Every finding on record at Allied Services Skilled Nursing Center

Based on observations, clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to assess and determine whether a resident could safely self-administer medications before permitting medications to be left at the bedside without staff supervision for one of 10 residents reviewed (Resident 1).Findings include: A review of the facility policy titled, Medication Administration, last reviewed August 20, 2025, revealed it was the facility's policy that medications were to be administered safely, timely, and as prescribed.A review of the facility policy titled Self-Administration of Medications, last reviewed August 20, 2025, revealed it was the facility policy that residents are reviewed on admission, when there is a change in status, and annually to determine a status for self-administration of medications. The policy revealed if it is determined by the interdisciplinary team that the resident is unable to carry out self-administration, the right to self-administer medications will be withdrawn. The policy further documented that each resident has the right to self-administer medications unless the interdisciplinary team has determined that the practice is unsafe. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including pneumonia (an infection that causes inflammation and fluid accumulation in the lungs, making breathing difficult) and sepsis (a life-threatening condition in which the body's response to an infection causes widespread organ dysfunction). A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 8, 2026, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). Clinical record review failed to identify documentation that the interdisciplinary team completed a self-administration of medications assessment upon admission or otherwise determined whether Resident 1 could safely self-administer medications. Observation conducted on July 28, 2026, at 8:46 AM revealed five medication tablets and capsules on the floor beneath Resident 1's bed next to the trash can. An empty medication cup was observed on the resident's bedside table. During an interview at the time of the observation, Resident 1 stated the nurse routinely placed medications on the bedside table and left the room before the medications were taken. Resident 1 stated he did not want to continue taking the medications because he did not know what they were for. The resident stated he attempted to throw the medications into the trash can but missed because of limited mobility. Employee 1, a Licensed Practical Nurse (LPN), confirmed she prepared the medications and brought them into Resident 1's room. Employee 1 stated she observed the resident begin taking the medications but could not confirm that she remained in the room until the resident swallowed them. Employee 1 could not explain why an empty medication cup remained on the bedside table or why the medications were found on the floor. During the interview, Employee 1 identified three white speckled oblong tablets as glucosamine-chondroitin (a dietary supplement commonly used to support joint health) and two yellow capsules as gabapentin (a prescription medication commonly used to treat nerve pain and certain seizure disorders). Review of the physician's orders revealed Resident 1 had an active order for glucosamine-chondroitin 500 milligrams/400 milligrams, four tablets by mouth every morning, and gabapentin 300 milligrams by mouth three times daily. Review of the July 2026 Medication Administration Record (MAR) revealed Employee 1 initially documented both medications as administered. After Employee 1 was informed that the medications had been found on the floor, she revised the MAR documentation to indicate Resident 1 refused both the glucosamine-chondroitin and gabapentin. The findings were reviewed with the Nursing Home Administrator on July 28, 2026, at 1:00 PM. The facility failed to ensure the interdisciplinary team assessed and documented whether Resident 1 could safely self-administer medications before permitting medications to be left at the bedside without staff supervision and without confirming the resident had taken the medications. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, clinical record review, select facility policy review, and staff interviews, it was determined the facility failed to ensure residents were free from foreseeable accident hazards related to the unattended placement and unsupervised administration of medications for 2 of 21 residents reviewed (Resident 116 and Resident 136) on 1 of 4 units observed.Findings included: A review of the facility policy titled, Medication Administration, last reviewed August 20, 2025, revealed it is the facility policy that medications are administered in a safe and timely manner and as prescribed. A review of the facility policy titled Self-Administration of Medications, last reviewed August 20, 2025, revealed it is the facility policy that residents are reviewed on admission, when there is a change in status, and annually to determine a status for self-administration of medications. The policy revealed if it is determined by the interdisciplinary team that the resident is unable to carry out self-administration, the right to self-administer medications will be withdrawn. The policy further documented that each resident has the right to self-administer drugs unless the interdisciplinary team has determined that the practice is unsafe. A clinical record review revealed Resident 136 was admitted to the facility on [DATE], with diagnoses to include dementia (a progressive, irreversible syndrome causing decline in memory, thinking, and daily functioning) and hypertension (high blood pressure, is a chronic condition where blood force against artery walls is consistently too high). A clinical record review revealed a Self-Administration of Medication assessment dated [DATE], documenting Resident 136 was unable to safely administer medications, because the resident could not state the purpose of the medications, could not identify the correct dosage, and could not identify the scheduled administration times. A clinical record review revealed Resident 116 was admitted to the facility on [DATE], with diagnoses of lymphedema (chronic condition characterized by the buildup of lymph fluid, usually in the arms or legs, causing swelling, discomfort, and skin changes) and muscle weakness. A clinical record review revealed a Self-Administration of Medication assessment dated [DATE], revealed Resident 116 was unable to safely administer medications, because the resident could not state the purpose of the medications, could not identify the correct dosage, and could not identify the scheduled administration times. During an observation of the medication pass on April 29, 2026, at 08:26AM, Employee 5, Licensed Practical Nurse (LPN), prepared medications for Resident 136 by pouring the medications into a medication cup. Employee 5 entered the resident's room, placed the medication cup on the bedside table, instructed the resident to take the medications, exited the room, and began preparing medications for another resident outside the room. Observation revealed Employee 5 turned away from Resident 136 and did not remain present to supervise administration or verify the resident safely swallowed the medications. Observation revealed Employee 5 LPN subsequently prepared medications for Resident 116, entered the resident's room, identified the resident, placed a medication cup containing five pills on the bedside table, and exited the room without supervising medication administration or verifying the resident safely swallowed the medications. Resident 116 was observed pouring the medications from the medication cup directly onto the bedside table and ingesting the pills individually without staff supervision. Employee 5 did not return to the room to observe completion of medication administration. During an interview conducted on April 29, 2026, at 08:39AM, Employee 5 stated both residents could self-administer medications without assistance despite facility assessments identifying both residents as unable to safely self-administer medications. The facility failed to ensure medications remained under staff supervision and failed to ensure residents assessed as unable to safely self-administer medications were protected from foreseeable accident hazards associated with unattended medications at the bedside. These hazards included the potential for improper administration, choking, incomplete ingestion, medication misuse, or access to medications by another resident. The above findings were reviewed with the Nursing Home Administrator on April 29, 2026, at 1:00PM. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of clinical records, employee personnel records, facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and demonstrated competencies necessary to safely initiate intravenous (IV) access for two of 37 residents reviewed (Resident 14 and Resident 290).Findings include: Federal regulation requires a facility to develop, implement, and maintain an effective training program for all new and existing staff. The training program must be based on the facility assessment (an evaluation conducted by the facility to identify the resident population and determine the knowledge and skills staff need to meet resident care needs). Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment (a comprehensive evaluation completed by the facility to determine the resident population served, the care and services residents require, and the staffing competencies, resources, and training necessary to meet those identified resident needs safely and effectively). Pennsylvania State Board of Nursing Regulations, Title 49, Chapter 21, require licensed nurses performing intravenous therapy to complete appropriate education, receive supervised clinical instruction, and demonstrate ongoing competency. Licensed Practical Nurses (LPNs) may only perform those nursing functions for which they have documented knowledge, skills, and abilities under appropriate supervision. A review of the facility policy titled Intravenous Therapy, last reviewed August 20, 2025, revealed it is the facility's policy to provide a means to maintain intravenous (IV) access (a small tube inserted into a vein to administer fluids or medications directly into the bloodstream) when necessary to carry out physician orders. The policy indicated a Registered Nurse (RN) may initiate an IV after completing three witnessed IV insertion attempts ( sticks). The policy also indicated an LPN may initiate an IV after successfully completing an approved IV course and completing three witnessed IV insertion attempts. Within the policy, the term sticks referred to attempts to start an IV. A review of Resident 14's clinical record revealed a physician's order dated October 24, 2025, to place a one-time IV due to an upper respiratory infection (infection involving the nose, throat, or airways) and elevated white blood cell levels, which can indicate infection or inflammation (the body's response to injury or infection). A review of the electronic Medication Administration Record (eMAR, the computer-based system used to document medications and treatments administered to residents) and interdisciplinary progress notes revealed Employee 3, RN, initiated intravenous access with a 24-gauge needle (a small diameter needle commonly used for IV access) on October 24, 2025, at 9:00 PM in Resident 14's right forearm. A review of Resident 290's clinical record revealed a physician's order dated January 5, 2026, to place a one-time IV for hydration (providing fluids to maintain normal body function and prevent dehydration). A review of the eMAR and interdisciplinary progress notes revealed Employee 4, LPN, initiated intravenous access with a 24-gauge needle on January 5, 2026, at 4:01 PM in Resident 290's right forearm. A review of employee personnel records revealed:Employee 3, RN, began employment at the facility on July 7, 2014. The personnel file did not contain documented competency validation demonstrating completion of the three supervised IV insertion attempts required by facility policy prior to initiating IV access for Resident 14. Employee 4, LPN, began employment at the facility on December 27, 2010. The personnel file did not contain documented competency validation demonstrating completion of the three supervised IV insertion attempts required by facility policy prior to initiating IV access for Resident 290. During an interview conducted on May 1, 2026, at 8:00 AM, the Nursing Home Administrator (NHA) acknowledged the facility could not provide documentation demonstrating the required IV competency validation outlined in the facility policy. Specifically, the facility was unable to provide evidence that Employee 3, RN, or Employee 4, LPN, completed the required three witnessed IV insertion attempts prior to independently initiating IV access for Resident 14 and Resident 290. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses administered medications according to physician ordered parameters for 2 of 21 residents reviewed (Resident 9 and Resident 258).Findings include: A review of the facility policy titled, Medication Administration, last reviewed August 20, 2025, revealed medications are to be administered as ordered by the physician and vital signs, including blood pressure and pulse, are to be obtained when ordered by the physician. Clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses including hypertension (high blood pressure that increases the workload on the heart and may damage organs over time) and presence of a cardiac pacemaker (a device implanted to help regulate the heart rhythm when the heart beats too slowly or irregularly). A review of Resident 9's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2026, revealed that Resident 9 was severely cognitively impaired with a BIMS score of 0 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment and the interview could not be conducted because the resident was unable to engage with the questions). Review of Resident 9's physician orders revealed an order dated June 1, 2023, for Metoprolol Succinate Extended Release 25 milligrams (medication used to lower blood pressure and slow the heart rate) to administer one half tablet by mouth every morning and at bedtime for hypertension. The order directed staff to hold the medication if the systolic blood pressure (the top number of a blood pressure reading that measures pressure in the blood vessels when the heart contracts) was less than 100 millimeters of mercury (mm/Hg) and the heart rate was less than 60 beats per minute. Review of the December 2025 electronic Medication Administration Record (eMAR, a computerized medication documentation system) revealed the medication was not administered on the following dates: December 23, 2025, Blood pressure was 108/52 mm/Hg, heart rate was 59 beats per minute. December 24, 2025, Blood pressure was 94/56 mm/Hg, heart rate was 74 beats per minute. December 25, 2025, Blood pressure was 99/60, heart rate was 79 beats per minute. Review of the January 2026 eMAR revealed the medication was not administered on January 29, 2026, when the blood pressure was 90/60 millimeters of mercury and the heart rate was not obtained. Review of the March 2026 eMAR revealed the medication was not administered on March 31, 2026, when the blood pressure was 98/60 mm/Hg and the heart rate was 63 beats per minute. The eMAR documented the medication was held because the resident's blood pressure and heart rate were reportedly outside the physician ordered parameters. However, review of the physician order revealed both the systolic blood pressure and heart rate were required to be below the ordered parameters before the medication was to be withheld. On the above dates, both conditions were not present, and the medication should not have been withheld according to the physician's order. Additionally, on January 29, 2026, staff failed to obtain and evaluate the resident's heart rate prior to withholding the medication. Clinical record review revealed Resident 258 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (long term loss of kidney function) and hypertensive urgency (a severe elevation in blood pressure that requires prompt medical evaluation and treatment). A review of Resident 258's Quarterly MDS, dated [DATE], revealed that Resident 258 was cognitively intact with a BIMS score of 15 a score of 13 through 15 indicates intact cognition. A review of Resident 258's physician orders revealed an order for Amlodipine Besylate 2.5 milligrams (medication used to lower blood pressure by relaxing blood vessels) by mouth twice daily for hypertension. The order directed staff to hold the medication if the systolic blood pressure was less than 110 mm/Hg or if the heart rate was less than 60 beats per minute. Review of the eMAR revealed facility staff administered the medication despite the resident's blood pressure readings falling below the physician ordered hold parameters on the following dates and times: February 10, 2026, at 8:00AM, blood pressure was 85/62 mm/Hg, and the heart rate was 80 beats per minute. February 15, 2026, at 8:00AM, blood pressure was 108/74 mm/Hg, and the heart rate was 88 beats per minute. March 22, 2026, at 8:00AM, blood pressure was 106/58 mm/Hg, and the heart rate was 91 beats per minute. April 6, 2026, at 8:00AM, blood pressure was 81/48 mm/Hg, and the heart rate was 82 beats per minute. April 11, 2026, at 8:00PM, blood pressure was 78/56 mm/Hg, and the heart rate was 90 beats per minute. April 19, 2026, at 8:00AM, blood pressure was 104/58 mm/Hg, and the heart rate was 88 beats per minute. Review of physician orders for Resident 258 revealed an order dated October 25, 2024, for Clonidine 0.1 milligrams (medication used to lower blood pressure) every 8 hours as needed for systolic blood pressure greater than 160 mm/Hg. Review of the eMAR revealed staff administered the as needed Clonidine to Resident 258 despite the resident's systolic blood pressure not exceeding the physician ordered parameter of greater than 160 on the following dates and times: February 9, 2026, at 10:00 PM, blood pressure was 108/58 mm/Hg. February 12, 2026, at 10:00 PM, blood pressure was 93/58 mm/Hg. February 13, 2026, at 06:00 AM, blood pressure was 131/81 mm/Hg. February 14, 2026, at 02:00 PM, blood pressure was 93/62 mm/Hg. March 8, 2026, at 10:00 PM, blood pressure was 134/68 mm/Hg. March 10, 2026, at 10:00 PM, blood pressure was 116/62 mm/Hg. March 16, 2026, at 10:00 PM, blood pressure was 102/56 mm/Hg. March 28, 2026, at 10:00 PM, blood pressure was 132/72 mm/Hg. April 3, 2026, at 10:00 PM, blood pressure was 152/74 mm/Hg. April 4, 2026, at 06:00 AM, blood pressure was 97/52 mm/Hg. April 25, 2026, at 06:00 AM, blood pressure was 124/64 mm/Hg. An interview with the Nursing Home Administrator conducted on April 30, 2026, at 1:30 PM reviewed the above findings related to the facility's failure to ensure nursing staff administered blood pressure medications according to physician ordered parameters. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure evidence-based diagnostic criteria and accepted professional standards of clinical practice were utilized to establish a diagnosis of schizophrenia for one of 37 residents reviewed (Resident 13).Findings include: According to the Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, 2022, Diagnostic Criteria (DSM-5-TR, the standard guidebook used by mental health professionals in the United States and worldwide to diagnose mental health conditions) to diagnose schizophrenia ( a chronic and severe mental disorder characterized by disturbances in thought processes, perceptions, emotional responsiveness, and social interactions), the following criteria must be met.Two or more of the following symptoms for a significant portion of time during a one-month period or less if successfully treated (at least one from 1 to 3 must be present):1. Delusions (false beliefs)2. Hallucinations (false perceptions)3. Disorganized speech (illogical communication)4. Grossly disorganized or catatonic behavior (impaired goal-directed actions or rigid body position)5. Negative symptoms (loss of normal emotional expression, flat affect)Functional impairment: Marked decline in work, interpersonal relations, or self-care. Continuous signs of disturbance for greater than 6 months, including greater than one month of active-phase symptoms. A clinical record review revealed Resident 13 was originally admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of a Pennsylvania Preadmission Screening Resident Review Identification form (PASRR, a federal screening requirement that prevents the inappropriate institutionalization of individuals with mental illness or intellectual disabilities by ensuring they receive specialized care in the most appropriate, least restrictive setting) dated October 8, 2020, revealed Resident 13 has one serious mental illness indicated, Personality Disorder (a mental health condition characterized by enduring, rigid patterns of thinking, feeling, and behaving that deviate significantly from cultural expectations, causing distress or functional impairment). A review of Resident 13's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care), Section I Active Diagnoses dated May 18, 2025, revealed that Resident 13 does not have a medical diagnosis of schizophrenia. A review of a Pennsylvania Preadmission Screening Resident Review (PASRR) Identification form dated May 11, 2025, revealed Resident 13 had a schizophrenia diagnosis added after admission. The PASRR form was signed by Employee 10, Social Services. A physician's order dated November 27, 2025, for Perphenazine Oral Tablet 4 mg (an antipsychotic medication commonly used to treat symptoms of serious mental illness) with directions to administer 4 mg by mouth two times daily for mood disorder was initiated on May 11, 2025, and discontinued on May 23, 2025. A physician's order for Perphenazine Oral Tablet 4 mg with directions to give 4 mg by mouth two times a day for a diagnosis of schizophrenia initiated on November 27, 2025. Review of Resident 13's quarterly MDS assessment dated [DATE], revealed schizophrenia was coded as an active diagnosis in Section I. The comprehensive clinical record review failed to reveal documented psychiatric evaluations, psychological evaluations, physician documentation, diagnostic testing, behavioral assessments, symptom documentation, or other clinical evidence supporting that Resident 13 met DSM-5-TR diagnostic criteria for schizophrenia. Comprehensive clinical record review failed to reveal documentation of delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative symptoms consistent with schizophrenia.During an interview on May 1, 2026, at 9:15 AM, the above findings were reviewed with the Nursing Home Administrator (NHA). The facility was unable to provide physician documentation, psychiatric evaluation, psychological evaluation, behavioral assessments, or other clinical diagnostic evidence supporting that Resident 13 met DSM-5-TR diagnostic criteria for schizophrenia. The facility failed to ensure evidence-based diagnostic criteria and accepted professional standards of clinical practice were utilized prior to identifying Resident 13 with schizophrenia. 28 Pa. Code 211.2(d)(3) Medical director. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records, care plan conference attendance documentation, facility policy, and staff interview, it was determined the facility failed to ensure comprehensive care plan conferences were conducted following Minimum Data Set (MDS) assessments for one of 37 residents reviewed (Resident 93).Findings include: The Resident Assessment Instrument (RAI) Manual (October 2025) is the federally issued instruction manual that provides guidance for completion of the Minimum Data Set (MDS, a federally mandated standardized assessment process conducted periodically to assess resident needs and guide care planning). According to the RAI Manual, the facility must develop a comprehensive care plan within seven days after completion of the comprehensive MDS assessment and must review and revise the care plan following each assessment. The RAI further indicates the facility is responsible for assisting residents to participate in the care planning process, including conducting care plan conferences for information exchange and decision-making. The RAI also requires the facility to provide advance notice of care planning conferences to the resident and resident representative, when applicable, to support participation in the process. A review of the facility policy titled Resident Centered Comprehensive Care Plan, last reviewed August 20, 2025, revealed the facility will provide a comprehensive care plan, initiated on admission and reviewed after completion of each comprehensive assessment and quarterly assessment for each resident. The policy indicated the care plan would include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive and quarterly assessments. The procedure reveals social services will be responsible for inviting residents, families or the resident representative to participate in the plan of care conference and encourage attendance. According to the procedure, each discipline will provide a brief update at the Plan of Care meeting. Clinical record review revealed Resident 93 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease without dyskinesia (a progressive disorder of the nervous system that affects movement and coordination, without abnormal involuntary body movements). A review of Resident 93's quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 93 was cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a range of 8-12 means moderate cognitive impairment indicating Resident 93 has noticeable problems with memory or thinking, but is not in the severe range). Review of the clinical record, including MDS assessments, revealed a quarterly MDS assessment was completed on November 23, 2025, and an annual MDS assessment was completed on January 20, 2026. Review of the clinical record, including interdisciplinary progress notes and care plan conference attendance/signature documentation, did not include evidence that care plan conferences were conducted following the November 23, 2025, quarterly MDS assessment or the January 20, 2026, annual MDS assessment. Review of the clinical record did not include evidence of care plan conference participation, information exchange, resident involvement in care planning, or documented efforts to engage Resident 93 and/or the resident representative in the care planning process following the November 23, 2025, and January 20, 2026, MDS assessments, as required by the RAI Manual and facility policy. During an interview conducted on April 30, 2026, at 11:07 AM, the Nursing Home Administrator (NHA) confirmed care plan conferences were not conducted following the November 2025 quarterly MDS assessment and the January 2026 annual MDS assessment for Resident 93. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(d)(3) Nursing services.

Based on clinical record review, review of facility policies, and staff interviews, it was determined the facility failed to develop and revise a resident-centered comprehensive care plan to accurately reflect current discharge planning goals and preferences for one of 37 residents reviewed (Resident 93).Findings include: A review of the facility policy titled, Planned Discharge, last reviewed August 20, 2025, revealed it is the policy to identify residents with the potential for discharge and develop an interdisciplinary (involving multiple professional disciplines working together) care plan to support transition to the next level of care. The policy revealed discharge planning would be discussed during care plan conferences with involvement of the interdisciplinary team. Review of the facility policy titled, Resident-Centered Comprehensive Care Plan, last reviewed August 20, 2025, revealed the care plan would be reviewed and revised promptly when changes occurred in the resident's physical or psychosocial (mental, emotional, and social) well-being. The policy indicated resident needs, goals, problems, and concerns would be updated by appropriate staff as frequently as necessary. Clinical record review revealed Resident 93 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease without dyskinesia (a progressive disorder of the nervous system that affects movement and coordination, without abnormal involuntary body movements). A review of Resident 93's (quarterly) Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 22, 2026, revealed that Resident 93 was cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a range of 8-12 means moderate cognitive impairment indicating Resident 93 has noticeable problems with memory or thinking, but is not in the severe range). A review of Resident 93's comprehensive care plan dated February 13, 2025, and in effect at the time of the survey, identified the resident as a potential discharge to home. Interventions included anticipating discharge needs such as medical equipment and home health services, involving the resident in discharge planning, providing written and verbal education, and evaluating community resources to support discharge. Review of the clinical record revealed social services progress notes dated September 3, 2025, and November 21, 2025, documenting Resident 93's intended goal to be discharged from the facility. Review of a social services progress note dated January 20, 2026, documented Resident 93's discharge plan had changed due to the resident requiring ongoing care and supervision in the facility. The note further documented Resident 93 declined referral to community discharge resources and planned to remain in the facility. Despite documentation indicating Resident 93's discharge goals had changed from discharge to home to long-term placement within the facility, the active comprehensive care plan in effect during the survey continued to identify discharge to home as the resident's goal and continued to include discharge planning interventions inconsistent with the resident's current preferences and needs. During an interview conducted on April 30, 2026, at 11:07 AM, the Nursing Home Administrator stated Resident 93 was initially considered for discharge to the community but was no longer able to be safely discharged and planned to remain in the facility. The Nursing Home Administrator acknowledged the active care plan had not been revised to reflect the resident's current discharge goals and preferences in accordance with facility policy. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of the Resident Assessment Instrument (RAI) Manual, Minimum Data Set (MDS) assessments, and staff interviews, it was determined the facility failed to ensure Minimum Data Set assessments accurately reflected the clinical status of three of 37 residents reviewed (Residents 273, 302, and 303).Findings include: The Resident Assessment Instrument (RAI) Manual is the federally issued instruction manual that provides specific coding guidance for each item on the Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care). Facilities are required to code the MDS according to the specific instructions outlined in the RAI Manual to ensure accuracy, consistency, and regulatory compliance. The Resident Assessment Instrument (RAI) Manual, October 2025, Section J, indicates a major injury related to a fall includes, but is not limited to, traumatic bone fractures (broken bones), joint dislocations, internal organ injuries, head injuries, spinal cord injuries, amputations, and crush injuries. A clinical record review revealed Resident 303 was admitted to the facility on [DATE], with diagnoses that included traumatic subdural hemorrhage (bleeding caused by trauma between the brain and its outer covering). A nursing progress note dated March 19, 2026, at 3:33 PM revealed Resident 303 was transferred from the facility to the community emergency department after being found on the floor in the resident's room. Documentation indicated the resident sustained a 3.0 centimeter (cm) by 3.0 cm by 0.3 cm laceration (a cut or tear in the skin) to the back right side of the head with a moderate amount of bleeding A review of emergency department records dated March 20, 2026, revealed Resident 303 was diagnosed with an acute-on-chronic subdural hematoma (a new area of bleeding occurring in addition to an older collection of blood between the brain and its outer covering). A nursing progress note dated March 20, 2026, at 10:00 AM revealed Resident 303 returned to the facility with three staples placed in the back of the head to close the wound. A review of Resident 303's discharge-return not anticipated MDS assessment dated [DATE], Section J, Health Conditions, revealed the assessment indicated the resident had not experienced a fall with major injury (head injury as defined in the RAI) since the prior assessment. During an interview conducted on April 30, 2026, at 11:06 AM, the Registered Nurse Assessment Coordinator (RNAC, the nurse responsible for coordinating and completing MDS assessments) confirmed Resident 303 sustained a fall with major injury, including an acute-on-chronic subdural hematoma and head laceration requiring staples. The RNAC confirmed the March 21, 2026, MDS assessment was not coded accurately. A clinical record review revealed Resident 302 was admitted to the facility on [DATE], with dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A nursing progress note dated November 9, 2025, at 10:00 PM revealed Resident 302 was transferred to the emergency department following a fall in the resident's room. A nursing progress note dated November 10, 2025, at 7:15 AM revealed Resident 302 returned from the hospital and refused use of a sling for the right arm. A nursing progress note dated November 13, 2025, at 10:35 AM revealed the resident sustained a non-operative right humerus fracture (a broken upper arm bone that did not require surgery) related to the fall. A review of Resident 302's discharge-return not anticipated MDS assessment dated [DATE], Section J, Health Conditions, revealed the assessment indicated the resident had not experienced a fall with major injury since the prior assessment. Review of the RAI Manual, October 2025, revealed fractures are considered falls with major injury for MDS coding purposes. During an interview conducted on April 30, 2026, at 11:06 AM, the RNAC confirmed Resident 302 sustained a fall with major injury, including a right humerus fracture. The RNAC confirmed the November 14, 2025, MDS assessment was not coded accurately. A review of Resident 273's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (commonly referred to as a stroke caused by blockage of blood flow to the brain resulting in brain tissue damage) and long-term anticoagulant use (ongoing use of blood-thinning medication to prevent harmful blood clots). Review of physician orders revealed an order initially dated December 15, 2025, directed staff to administer Eliquis (Apixaban, a blood-thinning medication used to reduce the risk of blood clots and stroke) 5 milligrams (mg) by mouth twice daily to Resident 273 related to a history of cerebrovascular accident (stroke).A review of Resident 273's January 2026, February 2026, March 2026, and April 2026 Medication Administration Records (MAR, a clinical record used to document medication administration) revealed staff administered Apixaban 5 mg twice daily as ordered by the physician. A review of Resident 273's quarterly MDS assessment dated [DATE], revealed the assessment indicated the resident did not receive anticoagulant medication during the seven-day look-back period (the observation period used for MDS coding prior to completion of the assessment). During an interview conducted on April 30, 2026, at 1:05 PM, the RNAC confirmed Resident 273 received anticoagulant medication during the seven-day look-back period and confirmed the March 25, 2026, quarterly MDS assessment was not coded accurately.28 Pa. Code 211.5(f)(x)(xi) Medical records. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, hospital records prior to admission, select facility policies and procedures, facility-provided investigative documentation, and staff interview, it was determined the facility failed to accurately assess pressure injury risk, failed to implement appropriate preventative interventions, and failed to conduct timely and thorough skin assessments to prevent the development of pressure injuries for one resident (Resident CR1) of five residents reviewed.Findings include: According to the US 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 the 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 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 considering possible surgical repair. A review of a facility policy titled Wound Management/Pressure Reduction last reviewed July 2025 revealed it is the policy of the facility to assess each resident's potential for skin breakdown based on clinical risk factors. The policy revealed upon discovery of a pressure ulcer, the investigation will be initiated, a plan of care will be established, the nurse will notify the wound nurse, and the residents will have a prevention or specialty mattress as needed. The policy further noted the Braden scale (a standardized assessment tool used to determine a resident's risk for developing pressure injuries by evaluating six risk factors including sensory perception, moisture, activity, mobility, nutrition, and friction/shear; scores range from 6-23, with lower scores indicating greater risk)will be done for every admission to the facility, and then every week for four (4) weeks. The policy details that weekly body checks will be done and recorded appropriately by certified nurse aides. The policy defines an unstageable pressure ulcer as ulcers that are covered with slough (a yellow, stringy material made of devitalized tissue, meaning dead tissue that has lost its blood supply) and eschar (a thick layer of dead tissue) and true depth cannot be determined. Once the ulcer is debrided (dead or damaged tissue removed) of slough and/or eschar such that the tissues involved can be determined, then the ulcer can be reclassified with proper ulcer stage (the true depth and extent of tissue damage can be determined). The ulcer does not have to be completely debrided or free of all slough and/or eschar in order to reclassify the stage. The policy detailed that if a skin area is identified, the information will reflect the type of skin impairment, the location, size, description, shape, drainage, odor, or necrosis. The policy indicated that if an unstageable pressure ulcer is identified, staff is to apply moist saline dressings every shift with dry sterile dressings, consult the wound care nurse, consult the physician, and consult the dietician for recommendations. A review of Resident CR1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included muscle weakness and difficulty walking. A review of Resident CR1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 8, 2025, revealed that Resident CR1 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). The MDS revealed Resident CR1 was dependent on staff for multiple activities of daily living including toileting, bathing, upper and lower body dressing, bed mobility, and transfers. The assessment documented the resident required maximal assistance to roll in bed and was dependent on staff for transfers between the bed, chair, toilet, and shower. A review of CR 1's clinical record revealed an admission nursing evaluation, completed on December 1, 2025, at 6:01 PM documented the resident used a wheelchair as the primary means of mobility and required others to push the wheelchair. The admission nursing evaluation revealed the resident to have flesh tone, warm, normal moisture, and good skin turgor (skin's elasticity, or its ability to change shape and return to normal). The assessment revealed the resident was observed to have bruising on the lower abdomen, redness and rashes on the penis, groin, buttocks, sacrum, coccyx area, and redness on the heel of the foot. However, the clinical record lacked documentation describing the type of skin impairment, size, drainage, odor, or tissue characteristics of the identified areas as required by the facility's wound management policy. A review of hospital records prior to admission revealed that on November 25, 2025, a wound care provider evaluated Resident CR1 and documented the presence of edema (swelling caused by fluid accumulation) and erythema (redness caused by inflammation or increased blood flow) to the penis and groin area. The wound care provider documented a moist and macerated skin area (skin that becomes soft and damaged due to prolonged exposure to moisture) with some bleeding present. The hospital wound care provider documented the resident's coccyx, buttocks, and gluteal folds were red and blanching, meaning the skin temporarily turned white when pressure was applied and then returned to red, indicating irritation and early skin compromise. The wound care provider further documented the resident was at high risk for further skin breakdown due to decreased mobility, friction, shear, moisture, respiratory compromise, and multiple medical conditions. The wound care provider recommended to continue the low air loss bed Citadel (these systems are designed to manage microclimate meaning heat and moisture, prevent pressure injuries, and support rehabilitation through alternating pressure and constant air), apply Desitin (treatment that uses Zinc Oxide to form a thick, protective barrier, instantly sealing out moisture and reducing redness) to the groins, penis, inner and posterior thighs, sacrum, coccyx, and buttocks twice daily. The provider recommended alternating with barrier cream (protective, often thick topical products that shield skin from moisture, irritants, and bacteria, helping to treat or prevent skin breakdown). The provider also documented to avoid adult briefs, reposition the resident every two hours while in bed and every one hour while located in the chair. The provider also recommended using a tan waffle cushion (seat cushion designed to redistribute weight and reduce pressure on the skin) when out of bed to the chair if the Braden score was below 14. A review of therapy assessments dated December 2, 2025, revealed that physical therapy documented Resident CR1 required extensive assistance to complete sit-to-stand transfers due to weakness and decreased activity tolerance. Occupational therapy documented the resident required maximal assistance for bed mobility and transfers. A review of admission documentation revealed a Braden Score Evaluation on December 1, 2025, at 6:02PM. The evaluation documented Resident CR1 had no impairment regarding sensory perception, was often moist, must be assisted to the chair or wheelchair, had no limitation making major or frequent changes in position, and was able to move freely and required minimal assistance scoring the resident at an 18 (low risk). The Braden assessment findings documented by facility staff were inconsistent with the resident's clinical condition. The clinical record documented that the resident required maximal assistance for mobility and transfers and could not independently reposition in bed or chair. A review of a second documented Braden Score Assessment completed on December 8, 2026, at 2:25PM, revealed CR1 had no impairment regarding sensory perception, was occasionally moist, was unable to walk, was able to make occasional changes in body or extremity position without assistance, and again the resident was able to move freely and required minimal assistance, documenting a score of 16 (low risk), despite therapy evaluations confirming the resident required maximal assistance for mobility and transfers. Based on the resident's documented functional status and the presence of a moisture-associated skin area identified upon admission, the Braden Scale categories for mobility, moisture, and activity would have reflected greater impairment than documented. Scoring the assessment consistent with the resident's documented condition would have resulted in a score of approximately 12, which indicates high risk for pressure injury development. A review of CR1s progress notes revealed a note dated December 17, 2025, documenting the resident was at risk for skin breakdown due to a documented moisture associated area, limited mobility, and incontinence. The progress note revealed the resident was educated about the need to frequently reposition himself to avoid skin breakdown, despite the clinical record confirming resident CR1 was cognitively impaired, and unable to reposition himself without assistance. A progress noted dated December 26, 2025, at 1:17PM, again documented Resident CR1 was at risk for skin breakdown due to a documented moisture associated area, limited mobility, and incontinence. The progress note revealed the resident was educated about the need to frequently reposition himself to avoid skin breakdown, despite the clinical record confirming resident CR1 was cognitively impaired, and unable to reposition himself without staff assistance. A progress note dated December 29, 2025, at 10:30AM revealed Resident CR1 was observed to have an unstageable pressure injury to the right gluteus (right buttock) measuring 3cm (centimeters) x 3cm x 0.1 cm. The wound bed was described as 100 percent purple with non-blanching tissue, meaning the skin did not turn white when pressure was applied, which indicates tissue damage and impaired blood circulation. The progress note then documented the resident was educated about the need to reposition frequently and offload (removing or reducing pressure from the area) the wound as often as possible to allow wound healing, the note documented a new order for a low-air loss mattress (a therapeutic support surface designed to redistribute pressure and circulate air to reduce moisture and heat helping to prevent and treat pressure injuries) and to continue repositioning the resident every two hours as previously ordered. The facility failed to accurately assess pressure injury risk and failed to implement recommended pressure-relieving interventions, which placed Resident CR1 at risk for pressure injury development. The clinical record later documented the presence of an unstageable pressure injury to the right gluteal area. An interview with The Nursing Home Administrator and Director of Nursing on March 11, 2026, at 1:15PM reviewed the above findings of the facility's related to the development of a pressure injury for Resident CR1. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to ensure staff followed appropriate infection control practices during the administration of medications for two of four residents observed during the administration of medications. (Residents 26 and 99) on the One North nursing unit. A review of facility policy titled Infection Control Policy and Procedure last reviewed by the facility on August 12, 2024, indicated the Infection Control Intervention Protocol is established and maintained for the detection, control and prevention healthcare associated infections. The elements of the protocol consist of infection criteria, standard and transmission-based precautions, hand hygiene, surveillance, infection control and prevention. On July 17, 2025, at 8:14 AM, an observation revealed that Employee 2, a Licensed Practical Nurse (LPN), was administering morning medications to Resident 99. While removing Vitamin D2 (1.25 mg capsule) from a medication package, the capsule fell onto the medication cart. Employee 2 picked up the capsule with his bare hand, without washing his hands or putting on gloves, and placed it into the resident's medication cup. The same observation revealed that a Senna 8.6 mg tablet fell onto the cart while being dispensed from a stock bottle. Employee 2 again picked up the tablet with his bare hand and placed it into the medication cup, without first washing his hands or using gloves. Lastly, Employee 2 pushed a Lorazepam 0.5 mg tablet from the medication card directly into his bare hand and placed it in the resident's medication cup, again without hand hygiene or glove use, before administering the medications to Resident 99. A subsequent observation at 8:35 AM revealed that Employee 2 was administering medications to Resident 26. A Furosemide 20 mg tablet fell onto the medication cart during preparation. Employee 2 picked up the tablet with his bare hand, without washing his hands or wearing gloves, and placed it into Resident 26's medication cup prior to administration. An interview was conducted with the Nursing Home Administrator (NHA) on July 17, 2025, at approximately 11:15 AM. The above findings related to Employee 2's failure to follow proper infection control practices during medication administration were reviewed at that time.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.28 Pa. Code 211.10(c)(d) Resident care policies.

Based on select facility policy, clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis and failed to ensure the physician orders were followed for one residents (Resident 166) of 35 residents reviewed. A review of the clinical record revealed that Resident 166 was admitted to the facility on [DATE], with diagnoses to include malignant neoplasm of the lung (a form of cancer affecting lung tissue). The resident had a current physician order initially dated June 4, 2025, for hydrocodone-acetaminophen ( a narcotic pain medication) 10-325 mg tablet one tablet every four hours as needed, for moderate pain, defined in the order as pain rated between 5 and 7 on a pain scale (a numeric rating tool commonly used in healthcare to measure a resident's self-reported level of pain. 0 indicates no pain and 10 indicates the worst possible pain).A review of the resident's June 2025 Medication Administration Record (MAR) revealed staff administered the narcotic pain medication 19 times for the month of June. Documentation showed that non-pharmacological interventions were not attempted or documented prior to any of these 19 administrations, as required by standard nursing practice and pain management guidelines.Additionally, the MAR documented the narcotic pain medication was administered outside the parameters of the physician's order on the following dates:June 5, 2025, administered for a pain level of 9 (which is categorized as severe pain, not moderate).June 17, 2025, administered for a pain level of 0 (indicating no pain).June 18, 2025, administered for a pain level of 2 (mild pain).A review of the resident's July 2025 MAR revealed staff administered the narcotic pain medication five times for the month of June. Again, none of the documented administrations included evidence that non-pharmacological interventions were attempted or proven ineffective prior to medication use.These findings were reviewed with the Nursing Home Administrator during an interview conducted on July 18, 2025, at approximately 2:00 PM. The review confirmed that the facility failed to ensure pain medications were administered in accordance with physician orders and that non-pharmacological interventions were not consistently attempted or documented prior to the administration of as-needed narcotic pain medications.28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services.

Based on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to complete a comprehensive nutritional assessment and monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement appropriate interventions to address weight loss for one of thirty-five residents reviewed for nutritional status and weight loss. (Resident 75).A review of the facility policy titled Weighing Residents/Reporting Significant Weight Changes, last reviewed in March 2025, indicated that when a resident experiences a weight change of 5% or more in one month, nursing and/or the dietitian will reweigh the resident within 48 hours to verify the change. If verified, the dietitian is expected to reassess the resident's energy and hydration needs, adjust the care plan as necessary, and document the assessment and interventions in the electronic medical record.A review of Resident 75's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including moderate calorie-protein malnutrition (a condition in which the body does not receive or absorb enough nutrients to function properly) and dementia (a group of symptoms that affect memory, reasoning, and daily functioning).A review of Resident 75's documented weights showed the following:04/02/2025: 96.8 lbs.05/05/2025: 90.5 lbs.This reflects a 6.5% weight loss over a 33-day period, meeting the facility's threshold for significant weight loss requiring reweigh, reassessment, and possible care plan revision.However, a review of the resident's comprehensive person-centered care plan, initiated on June 20, 2022, and last revised on March 25, 2025, revealed no updates or revisions to reflect the significant weight loss noted on May 5, 2025. The plan of care already identified the resident as at risk for nutritional deficits due to her diagnoses and history of weight loss. Interventions included periodic weight monitoring and notification to the registered dietitian (RD), physician, and family in the event of significant changes. Despite this, there was no evidence of reassessment, documented physician notification, or implementation of revised nutritional interventions following the documented May 5, 2025, weight.Further review revealed the Registered Dietitian did not document the resident's significant weight loss until July 17, 2025, over two months after the weight loss occurred. The July 17 RD note acknowledged the weight change from April to May but did not recommend new interventions, stating that weight had been stable since May, and that the current plan of care would be continued. This delay in identifying and responding to the resident's nutritional decline is inconsistent with the facility's policy and fails to demonstrate timely reassessment or mitigation of nutritional risk.In an interview conducted on July 19, 2025, the above findings were reviewed with the Nursing Home Administrator.28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to evaluate the clinical necessity of an indwelling urinary catheter and failed to follow its own policies for catheter removal and bladder assessment for one of 35 sampled residents (Resident 70).A review of the facility's policy titled Urinary Catheter Insertion, Care, Irrigation, and Removal, last reviewed August 2024, indicated that indwelling bladder catheterization may only be used to relieve urinary retention not treatable by other means or to collect a urine specimen when a resident is unable to provide one midstream. The facility will attempt catheter removal, if medically able, and establish a toileting plan to address incontinence or urinary frequency. The indwelling catheter assessment tool will be used to determine whether the resident has a clinical condition which indicates the need for the indwelling catheter. If the criteria are not met, nursing staff are to notify the physician for either an order to remove the catheter or rationale for its continued use. Discuss with the Physician alternate methods of continence management including intermittent catheterization, or a toileting plan. The procedure for removal of the indwelling catheter included, after catheter removal, a licensed nurse must complete a bladder assessment within three to seven days to determine whether the resident is a candidate for a toileting plan. Clinical record review revealed that Resident 70 was admitted to the facility on [DATE], with diagnosis to include, end stage COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease). The clinical record noted the presence of an indwelling Foley catheter at the time of admission. A review of a five-day, admission minimum data set assessment (Minimum Data Set a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 16, 2025, revealed a BIMS score (Brief Interview for Mental Status an assessment tool to assess cognitive function) of 13 (a score of 13 to 15 indicates the resident is cognitively intact). The assessment confirmed the presence of a Foley catheter (a plastic tube inserted into the bladder with an associated collection bag to collect urine) and indicated that the resident required assistance with activities of daily living and was receiving hospice care. A review of a nursing bladder assessment dated [DATE], indicated the resident had an indwelling Foley catheter but did not include a documented diagnosis or clinical rationale to support its continued use. A subsequent post-admission bladder assessment dated [DATE], documented no change in the resident's urinary status, and the indwelling catheter remained in place. There was still no documented clinical justification for its continued use. A review of the resident's care plan dated June 9, 2025, under Activities of Daily Living, included toileting with the assistance of one staff member. A nursing progress note dated June 26, 2025, at 12:57 PM, documented that the resident's hospice nurse recommended discontinuing the Foley catheter and initiating a voiding trial (the process of removing the urethral catheter and monitoring for spontaneous urination). The physician was contacted, and the Foley catheter was removed at 2:18 PM the same day. However, there was no documentation that nursing staff completed a bladder assessment or initiated a voiding trial following catheter removal, as required by facility policy. Following the removal of the Foley catheter, Resident 70 experienced three documented falls while attempting to get to the bathroom:June 29, 2025-fall from bed while attempting to get to the bathroomJuly 1, 2025-fall from bed while attempting to get to the bathroomJuly 2, 2025-fall from bed while attempting to get to the bathroom A bladder assessment dated [DATE], noted the resident exhibited mixed urinary continence and included a plan to offer toileting before and after meals, at bedtime (HS), and when awake during overnight (11 PM to 7 AM) rounds. However, there was no documented bladder tracker to support this continence pattern or care plan. During an interview conducted on July 18, 2025, at 11:00 AM, the Director of Nursing (DON) indicated Resident 70 had been admitted to the facility with a Foley catheter. She confirmed there was no documented diagnosis or clinical justification for the catheter and acknowledged the facility's policy for catheter removal and follow-up bladder assessment had not been followed.Cross refer F 68928 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility-provided investigation reports, staff interviews, and facility policies, it was determined the facility failed to implement and monitor planned fall prevention interventions for one of 32 sampled residents (Resident 70), resulting in multiple falls. Clinical record review revealed that Resident 70 was admitted to the facility on [DATE], with diagnosis to include, end stage COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease), and was receiving hospice services.A review of a five-day admission Minimum Data Set (MDS a federally required standardized assessment) dated June 16, 2025, documented a Brief Interview for Mental Status (BIMS a cognitive assessment tool) score of 13 (a score of 13 to 15 indicates the resident is cognitively intact). The MDS also identified that the resident had an indwelling Foley catheter (a plastic tube inserted into the bladder to drain urine) and required staff assistance with activities of daily living.A care plan-initiated June 10, 2025, identified the resident as being at risk for falls. Interventions included maintaining a hazard-free environment, ensuring bed in the lowest locked position, call bell and needed items within reach, reinforcing call bell use, and use of non-slip footwear. The care plan also addressed the resident's indwelling Foley catheter.A review of facility investigative documentation dated June 11, 2025, at 7:35 AM, Resident 70 documented that the resident was found kneeling on the floor on the right side of her bed. She stated she was reaching to get something off the floor. She sustained a skin tear to the right elbow area. The Physician was notified. She had an indwelling foley catheter in place at that time and was noted to be wearing non-skid socks. New interventions after the fall interventions included referrals to occupational and physical therapy and issuance of a reacher device.A review of a nurse's note dated June 26, 2025, 12:57 P.M. indicated the hospice nurse assigned to the resident made the recommendation to discontinue the foley catheter and complete a voiding trial (removal of the urethral catheter and an assessment of the patient's ability to urinate without it). The Physician was contacted and the foley catheter was removed June 26, 2025, at 2:18 PM. However, the nursing staff failed to complete a bladder assessment or initiate the voiding trial, as recommended.On June 29, 2025, at 12:45 AM, the resident was found on the floor between the beds in her room. She stated, I had to go to the bathroom. The intervention put in place post-fall was to offer toileting and out-of-bed assistance on the 11:00 PM to 7:00 AM shift. There was no documented evidence that a bladder assessment or voiding trial had been completed to support the appropriateness of this intervention.A review of a witness statement by Employee 1 (nursing assistant) dated June 29, 2025, at 2:00 AM, documented that the resident had been awake and sitting up in bed earlier that shift and declined assistance, including toileting. A review of a facility investigation dated July 1, 2025, at 7:30 AM revealed Resident 70 was again found on the floor in her room, between the two beds. She had been sitting on the edge of the bed. She stated, I was trying to get to the bathroom. New interventions implemented at the time of the fall included implementing a bowel and bladder tracker (assessment of bowel and bladder function in order to identify elimination issues and to formulate a plan to maintain or improve elimination continence).On July 2, 2025, at 12:30 PM, the resident was found seated on the floor outside of the bathroom door. She stated, I was going to do something. The planned intervention was to educate the resident on call bell use, and to continue the previously ordered bladder tracker. However, at the time of the survey, there was no documented evidence that this intervention had been implemented.There was no evidence at the time of the survey that the facility implemented and monitored the effectiveness of the planned interventions, including toileting schedules, elimination tracking, and post-catheter care, to prevent repeated falls.During an interview July 17, 2025, at 1:00 P.M., the Director of Nursing confirmed that planned interventions were not timely implemented to prevent falls for Resident 70.Cross refer F 69028 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observations, review of select facility policy and clinical records, and staff interviews it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs, and failed to follow physician orders for management of a PICC line for two residents out of 35 sampled (Residents 270, and 105). Findings include: Review of the facility policy titled Central Venous Catheter/PICC Care/Flush/Medication Administration last reviewed by the facility on July 24, 2024, revealed that it is the policy to provide dressing changes, medication and flushes to residents with a central venous catheter (CVC) or peripherally inserted central catheter (PICC a long catheter introduced through a vein in the arm, then through the subclavian vein into the superior vena cava or right atrium of the heart to administer parenteral fluids). Dressing changes are to be done weekly and PRN (as needed) with the extension tubing, stabilization device and cap change unless ordered otherwise by the physician. The dressing change is to be done by a Registered Nurse. During all dressing changes, assess the external length of the catheter to determine if migration (movement out of position) of the catheter has occurred. PICC external length is measured on admission or at the time of insertion, if after admission and documented on the care plan. Migration of any PICC line requires physician notification. A review of the clinical record revealed Resident 270 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis (inflammation of the bone caused by an infection), and immunodeficiency (failure or absence of elements of the immune system to fight infectious diseases). Review of Resident 270's hospital record dated August 8, 2024, revealed the resident underwent a procedure for a single lumen PICC placement in his left arm. The catheter (tubing) total length was 42 cm (no external catheter length was noted in the hospital records provided by the facility). The reason indicated for the PICC line was IV therapy for antibiotics. A review of physician orders dated August 15, 2024, revealed an order to change the PICC dressing weekly to include site care/extension tubing change/cap change/stabilization device every 7 days during day shift. The external length of catheter was to be measured during the dressing change or as needed (an increase in the external catheter length may indicate a problem with the PICC line). A review of Resident 270's plan of care, initially dated August 15, 2024, indicated that the resident required a PICC line. The PICC line external length measured 0 (zero) cm. Review of Resident 270's Medication Administration Record (MAR) for August 16, 2024, revealed nursing staff documented an X for the external catheter length measurement and documented a 7 above the nurse initials (according to the MAR coding, a 7 is not applicable). On August 20, 2024, nursing staff documented an external catheter length of 2 cm. Review of Resident 270's MAR for September 2, 2024, revealed that nursing staff documented an external catheter length of 1.5 cm. There was no documented evidence in the MAR or progress notes for the months of August and September 2024, that a weekly dressing change and external catheter length measurement was performed weekly as ordered. There was no documented evidence the physician was notified of the change in the measurement of the external catheter length from 0 cm on August 15, 2024, to 2 cm on August 20, 2024, and to 1.5 cm on September 2, 2024. Interview with the Director of Nursing on September 20, 2024, at approximately 9:40 AM was unable to provide documented evidence the facility performed weekly PICC dressing changes and measurement of the external catheter length as ordered by the physician. The DON confirmed there was no documented evidence that the physician was notified of the change in the external catheter length documented on August 20, 2024, and September 2, 2024. A review of Resident 105's clinical record revealed the resident was readmitted to the facility on [DATE], with diagnoses that include right AKA (above the knee) amputation (is a removal of all or a portion of a limb due to chronic disease or a traumatic injury), osteomyelitis (bone infection) right distal femur (thigh bone above the knee), and sepsis (is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). A review of Resident 105's readmission nursing evaluation completed by Employee 16, a licensed practical nurse (LPN), dated August 22, 2024, at 2:20 PM, revealed the resident returned to the facility with a peripherally inserted central catheter line in the right arm that was clean, dry, and intact. A review of physician's orders dated August 22, 2024, at 4:24 PM, indicated to change PICC dressing weekly with site care ,extension tubing change, cap change and stabilization device. May change dressing PRN (as needed) every day shift every 7 day(s) and measure the external length of catheter. A review of the resident's comprehensive person-centered plan of care that was initiated on August 23, 2024, identified the resident required a PICC line to the right upper arm, length: 46 cm, exposure: 0 cm(zero) with a resident goal it will remain patent and free of complications through next review. Planned interventions included to change dressing per policy or as ordered by physician and measure PICC line length if removing. A review of Resident 105's Medication Administration Record (MAR) dated August 22, 2024, through survey ending September 20, 2024, revealed the physician ordered weekly PICC line dressing changes and site care and external catheter length measurement were blank (no recorded documentation by staff) on August 23, 2024, and August 30, 2024, and September 6, 2024. The facility could not provide documented evidence that nursing staff completed physician ordered PICC line treatments or measurements as ordered. An interview with the Director of Nursing (DON) on September 20, 2024, at 9:40 AM, confirmed the facility could not provide documented evidence that PICC line treatments were performed and that the external catheter length was measured as ordered by Resident 105's prescribing physician. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of select facility policy, observation, and staff interview it was determined the facility failed to store drugs and pharmacy supplies in a safe manner and failed to remove medications awaiting final disposition in a timely manner in three medication storage rooms out of five medication storage rooms first floor, second floor, north, and third floor, south. Findings include: Review of facility policy titled Disposition of Medications: Discontinued Medications last reviewed by the facility July 24, 2024, indicated that medications discontinued by physician order, a resident is transferred or discharged and does not take the medication with him/her, or in the event of resident's death, the medications are marked as discontinued with a label closure. If a prescriber discontinues a medication, the medication container is marked appropriately (e.g. with a stop drug sticker) and the date of discontinuation is indicated along with the name of the nurse. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up for destruction by the pharmacy. Observation of the first floor medication storage room conducted on September 18, 2024, at 11:04 AM, in the presence of Employee 2 (registered nurse) revealed a clear storage bin on the countertop overflowing with discontinued resident prescription medication cards, pill packages, nebulizer treatments, vials of medications (heparin), IV bags, bottles of liquid medication, and insulin pens that were left unsecured. Interview with Employee 2 on September 18, 2024, at 11:15 AM, confirmed the prescription medications in the bin were discontinued medications removed from the medication carts and awaiting pharmacy pickup. Employee 2 was unsure of the procedure or frequency for pharmacy pickup. Observation of the second floor (2 North) medication storage room conducted on September 18, 2024, at 11:54 AM, revealed a clear storage bin, on the floor behind the door, with discontinued resident prescriptions of medication cards, pill packages, nebulizer treatments, and an IV bags that were left unsecured. An interview with Employee 27, a registered nurse (RN), on September 18, 2024, at 11:57 AM, confirmed the medications in the bin were discontinued medications awaiting pickup from the pharmacy. Observation of the third floor medication storage room (3 South) conducted on September 18, 2024, at 1:00 PM revealed a blue storage bin on the countertop overflowing with discontinued resident prescriptions lidocaine patches, medication cards, pill packages, nebulizer treatments, IV bags, bottles of liquid medication, and prescription lotions that were left unsecured. Interview with Employee 3 (licensed practical nurse) on September 18, 2024, at 1:15 PM confirmed the medications in the bin were discontinued medications awaiting pickup from pharmacy. During an interview with the Director of Nursing (DON) on September 19, 2024, at 10:20 AM she confirmed that discontinued medications should have been returned to pharmacy in a timely manner and the medications should have been stored in a secured manner to prevent unauthorized access and the potential for drug diversion. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records and staff interview it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address the resident's needs for adaptive equipment to ensure the prevention of the development of potential skin impairment for one out 35 residents sampled. (Resident 250). Findings include: Clinical record review revealed Resident 250 was admitted to the facility on [DATE], with diagnoses which included down syndrome (a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is usually associated with developmental delays, mild to moderate intellectual disability, and characteristic physical features), seizure disorder and severe intellectual disorder. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 13, 2024, revealed. the resident was severly, cognitively impaired, and unable to complete a BIMS test (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information), requires extensive staff assistance for activities of daily living, and was at risk for pressure sores. Nursing documentation indicated Resident 250 had a history of a deep tissue injury, (a deep tissue injury, DTI, is a type of pressure ulcer that affects the subcutaneous tissues under intact skin) on April 15, 2024. Interventions to prevent pressure injury included skin prep (a protective barrier film) applied to heels as well as to apply a Truvue boot (TruVue Heel Protector is a fabric pressure care boot that mirrors the natural shape of the leg. It securely holds the leg and foot in place while allowing for full range of motion. It provides support to the foot and lower limb for pressure care and comfort, helping to reduce the risk of pressure injuries by lifting the heel off the bed and minimizing the risk of pressure injury caused by rubbing against sheets) to both heels at all times, remove every shift for a skin check. The resident's bilateral heel DTI injuries were noted to be healed on May 9, 2024. A review of Physicians orders dated April 15, 2024 revealed off loading (suspending the heels in the air by placing on a pillow or other device to prevent pressure), Purvue boots to bilateral lower extremities (feet) at all times, and remove the boots on every shift for skin checks. A review of the residents care plane dated January 4, 2024 revealed the resident was to comply with the therapeutic regimen including preventative measures to prevent the potential for skin breakdown. The intervention for the bilateral TruVue boots to be worn at all times, was not noted on the care plan at the time of the survey. A corresponding nurse aide Kardex (an electronic summary of the residents care utilized by nursing staff to provide appropriate care and services to residents. It lists all the important information to get a quick summary of the resident needs) did not include the daily application of the TruVue boots. An observation September 18, 2024 at 9 AM revealed Resident 250 was lying in bed. The bilateral Purvue boots were not on the resident's feet. The boots were noted to be on the floor, behind his bed. During an interview September 18, 2024 at 9:15 AM Employee 4, a nurse aide, stated she was unaware that Resident 250 was to have the Purvue boots on his feet at all times. She stated she gave Resident 250 AM care prior to this interview and put nonskid socks on the resident. She stated that she does not work on this unit very often and is not familiar with the care required for this resident. She stated at the start of the shift, she looks at the resident's Kardex to receive care instructions for the resident. She stated the Purvue boots intervention was not on the resident's Kardex at the start of the shift. During an interview September 18, 2024 at 9:20 AM the assistant Director of Nursing confirmed that Resident 250's pressure sore preventative intervention, the bilateral Purvue boots were not put on to his care plan at the time of the Physicians order and it was not currently on the care plan. The failed to provide documented evidence the facility developed and implemented a care plan to assure this dependent resident is provided the necessary care to prevent the potential for skin impairment. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for three of six residents reviewed (Resident 334, 105 and 270). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145b. IV therapy curriculum requirements; (f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145a (relating to prohibited acts), and only under supervision as required under paragraph (1). (1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as a CRNP, physician, physician assistant, podiatrist or dentist). (g) An LPN who has met the education and training requirements of S 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145a and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. A review of a facility policy for LPN's-starting/discontinuing IV's; Administering/withdrawal of IV fluids revealed, Licensed Practical Nurses who have satisfactorily completed a Board approved educational program to start and discontinue an Intravenous infusion, administer and withdraw intravenous fluids may with a written physician's order, start and discontinue an IV, administer, and withdraw IV fluids. The LPN may not administer or withdraw fluids via a venous central line (PICC line). The LPN (who has completed the Board certified educational program) will attend a yearly in-service of administration of intravenous fluids and medications. Clinical record review revealed that Resident 334 was admitted to the facility on [DATE] with diagnosis to include, orthopedic aftercare and infection, and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). Physicians orders dated September 11, 2024 revealed, administer Vancomycin HCl (antibiotic medication) Solution Reconstituted 750 MG, intravenously (IV) one time a day for MRSA (a type of staphylococcus bacteria that is resistant to many antibiotics) until October 18, 2024. A review of a September 2024 Medication Administration Record (MAR) revealed that between September 11 through September 19, 2024, Employee 26, LPN, Employee 4, LPN and Employee 6, LPN signed the MAR as administering the IV antibiotic medication to Resident 334 through the PICC line. Clinical record review revealed that Resident 105 was admitted to the facility on [DATE] with diagnosis to include a MRSA infection. The resident was admitted with a PICC line. Physicians orders dated August 22, 2024 revealed, Vancomycin HCl Intravenous Solution 1000 MG/10ML, 1750 mg intravenously every 12 hours for osteomyelitis (infection of the bone) until September, 12, 2024. A review of a September 2024 Medication Administration Record (MAR) revealed that between September 1 through September 12, 2024, Employee 7, LPN, Employee 8 LPN Employee 9 LPN, Employee 10 LPN, Employee 11 LPN , Employee 12 LPN, Employee 13, LPN, Employee 14, LPN, Employee 15, LPN, Employee 16, LPN, and Employee 3, LPN signed the MAR as administering the IV antibiotic medication to Resident 105. Clinical record review revealed that Resident 270 was admitted to the facility on [DATE] with diagnosis to include, Osteomyelitis (an infection in the bone), admitted to the facility with PICC line. Physicians orders dated August 15, 2024 revealed, Zosyn (an antibiotic medication Intravenous Solution 4-0.5 GM/100 ML, administer 4.5 gram intravenously every 8 hours for osteomyelitis for 32 Days A review of a August 2024 Medication Administration Record (MAR) revealed that between August 15 through August 31, 2024, Employee 3 LPN, Employee 17 LPN Employee 14 LPN, Employee 18 LPN, Employee 19 LPN , Employee 20 LPN, Employee 10 LPN, Employee 21 LPN, Employee 22 LPN, Employee 12 LPN, Employee 23 LPN Employee 24 LPN, Employee 15 LPN, and Employee 8 LPN signed the MAR as administering the IV antibiotic medication to Resident 270. Interview on September 18, 2024, at approximately 10 a.m. with Employee 11 an LPN, stated she never administered medications through residents' PICC lines at the facility. She confirmed she was never educated on the administration of medications through the PICC line. She stated she would call the RN to administer the IV through the resident's PICC line. She stated she, the LPN, would sign out on the MAR that she had administered the medication when the RN actually administered the IV medication through the resident's PICC line. There was no evidence of any education or supervision regarding IV administration as well as PICC line usage for any LPNs working at the facility. During an interview on September 20, 2024, at approximately 9:30 AM the director of nursing confirmed that LPN's in the facility did not receive education regarding the administration of medications through PICC lines. She further confirmed that as per the facility policy, only RN's were allowed to administer medications through PICC lines. The DON further confirmed the facility policy indicates the nurse administering the medications are to sign the MAR indicating it was administered. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(5) Nursing services.

Based on clinical record review and resident and staff interview it was determined the facility failed to develop and implement an individualized discharge plan for one of 25 residents sampled (Resident 251). Findings Include: A review of the clinical record of Resident 251 revealed admission to the facility on [DATE], with diagnoses including heart disease. A quarterly Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated August 1, 2024, revealed the resident had a BIMS (brief interview to aid in detecting cognitive impairment) score of 15, indicating that her cognition was intact. Interview with Resident 251 on September 18, 2024, revealed the resident was hoping to return to the community to live independently. Review of Resident 251's comprehensive care plan revealed a focus area dated February 29, 2024, indicating the resident has been identified as a potential discharge to home and will require resident and/or caregiver training and instruction to assist with transitioning to home. This discharge plan was not revised or updated as of the time of the survey on September 20, 2024. A review of social service notes between Resident 251's admission February 29, 2024, and end of survey September 20, 2024, revealed no documented evidence that social services was working with the resident on a discharge plan to the community as the resident desired. There was no documented evidence the resident's discharge plan was updated with new goals and interventions for the resident to be discharged to the community. Interview with the Nursing Home Administrator on September 20, 2024, at approximately 1:30 PM confirmed the facility failed to revise and implement a discharge plan based on the resident's expressed desire to discharge to the community. 28 Pa. Code 201.25 Discharge policy.

Based on review of clinical records, observation, and staff interview, it was determined the facility failed to follow physician orders for oxygen therapy and failed to to maintain oxygen equipment in a functional and sanitary manner for two residents out of 35 sampled (Residents 227 and 176). Findings include: Review of Resident 227's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include respiratory failure (not enough oxygen passes from the lungs to the blood, making it difficult to breath), and dependence on supplemental oxygen (treatment that provides extra oxygen to breathe). The resident had a current physician's order, initially dated August 28, 2024, for continuous oxygen therapy administration via nasal canula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at three (3) liters per minute. An observation conducted on September 17, 2024, at 1:20 PM revealed that Resident 227 was lying in bed with supplemental oxygen in place via an oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) with the liter flow set at 2 liters per minute. An additional observation made on September 18, 2024, at 12:40 PM revealed that Resident 227 was lying in bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 2 liters per minute. Interview with Employee 1 (licensed practical nurse) at the time of the observation on September 18, at 12:40 PM confirmed that Resident 227 was prescribed three (3) liters of oxygen continuously, but the resident was currently receiving 2 liters of oxygen per minute. Review of Resident 176's clinical record revealed the resident was admitted the facility on June 24, 2020, with diagnoses to include acute respiratory failure, and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid or pus and cause breathing difficulties). The resident had a physician's order, initially dated August 26, 2024, for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (medication inhaled into the lungs using a nebulizer machine which is a small machine that turns liquid medicine into a mist that can be inhaled into the lungs) inhale orally via nebulizer four times a day for expiratory wheeze for 7 days. The physician's order end date for the nebulizer treatment was September 2, 2024. An observation conducted on September 17, 2024, at 1:46 PM revealed that Resident 176 was awake and lying in bed. The resident's nebulizer machine, including the tubing and mouthpiece, were placed on the bedside nightstand. Also present on the bedside nightstand were opened beverages and snack containers, pepper packets, toiletries, a reacher (adaptive device used to assist with picking up objects) and a telephone. The nebulizer mouthpiece was uncovered and not bagged. Interview with the Director of Nursing (DON) on September 19, 2024, at 10:14 AM confirmed that residents' respiratory equipment and supplies should be bagged when not in use to prevent contamination. The facility failed to maintain oxygen delivery equipment in a sanitary manner. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10 (a)(c) Resident Care Policies.

Based on a review of clinical records, select facility investigation reports, information submitted by the facility, and personnel records and staff and resident interviews, it was determined that the facility failed to ensure the competency of staff providing supervision and assistance with a resident's transfer to prevent a fall during transfer that resulted in fractured ribs and related pain for one resident out of five sampled (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include, diabetes, stage 5 kidney disease with dialysis and a history of a fall with thoracic vertibra 8 endplate fracture prior to the resident's admission to the facility. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 27, 2023, revealed that the resident was cognitively intact, with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 15 indicates cognitively intact). The resident required maximum assistance of staff for transfers, bed mobility and ambulation in his room. The resident had a history of falls and was identified to be at high risk for falls. The resident's baseline care plan for activities of daily living dated April 20, 2023, revealed Resident 1 required extensive assistance of two staff with a rollator walker for transfers. A facility incident investigation dated April 28, 2023, at 11:15 a.m. revealed that two staff members were transferring Resident 1 via a mechanical lift (Hoyer lift) from his wheelchair into the dialysis chair for treatment (The dialysis center is located on the same campus as the facility. The hoyer lift used in the transfer noted above is owned and maintained by the facility. Facility staff utilize this lift at the dialysis center). During this transfer attempt, the resident slid down in the hoyer pad and slid through the opening of the pad onto the floor. The resident was assessed and hoyered into the bed and transferred to the hospital for evaluation. A review of hospital documentation dated April 28, 2023, at 12:42 AM revealed that Resident 1 presents to the emergency room status post fall from the hoyer lift. The resident was noted to have complaints of pain located in the right ribs. X-ray results dated April 28, 2023, revealed that the resident sustained an acute buckle fracture (One side of a bone bends, raising a little buckle, without breaking the other side of the bone) at the right anteriolateral 7th rib and non-displaced (Non-displaced fractures are still broken bones, but the pieces weren ' t moved far enough during the break to be out of alignment) acute fracture of the right lateral 8th rib. In response to the resident's fall from the hoyer lift, after the incident, facility maintenance staff examined the lift, as well as, the lift pad utilized in the transfer with no defects noted. The facility investigation did not identify if the appropriate size pad was used for the resident's transfer since he was normally transferred with the rollator walker and assist of two staff. A review of an employee witness statement dated April 28, 2023, at 11:15 AM from Employee 1, a nurse aide, revealed We transported {Resident 1} in the wheelchair in the facility van into the dialysis. As we were transferring the resident from the wheelchair onto the dialysis chair with the hoyer lift. The hoyer lift was positioned correctly, cross under his legs. As the resident was up off the wheelchair, as soon as I removed the chair (from under him), the resident sipped through the hole of the hoyer pad onto the floor in front of the wheelchair. It happened so fast. We yelled for help. Dialysis staff was present and called the ambulance. A review of an employee witness statement dated April 28, 2023, at 12:33 PM from Employee 2, the van driver, revealed that Employee 2 (van driver) stated that {Employee 1, the nurse aide} and I hooked the hoyer pad to the lift. We checked to assure that the legs were crossed. I operated the lift. When {Resident 1} was high enough, {Employee 1} pulled the chair from underneath the resident. As I was about to move {Resident 1} to the dialysis chair, he slipped through the gap at the bottom of the pad. As I lifted {Resident 1} from the wheelchair, he was sitting correctly and did not seem to be sliding on the pad. As I was about to turn {Resident 1} into the dialysis chair, he suddenly slid through the gap in the pad. During an interview May 23, 2023, at approximately 1 PM with Employee 3, the RN on duty at the time of Resident 1's fall during transfer to dialysis on April 28, 2023, during the 7 AM to 3 PM shift, Employee 3 stated that the nurse aides providing AM care for Resident 1 reported that the resident appeared weak during morning care. Employee 3 (RN) assessed the resident at that time and determined that a Hoyer lift transfer was appropriate for the resident's transfer at that time. Nursing staff utilized the hoyer lift to transfer the resident from the bed to the wheelchair at that time prior to his dialysis treatment. A review of a facility dialysis communication form dated April 28, 2023, (no time indicated) revealed that the resident had increased lethargy, difficulty with two person transfer with a walker. A Hoyer transfer initiated for resident's safety. During an interview May 23, 2023 at 9 AM, Resident 1 was asked about his fall while at dialysis from the hoyer lift. He stated that They (facility staff) screwed up. They (Employee 1, the nurse aide, and Employee 2, the van driver) didn't criss cross the lift pad at the bottom and I slid through the hole on my bottom. I broke a couple of ribs. It really hurt. The van driver and an aide from the facility transferred me from my wheelchair to dialysis. A review of information dated April 29, 2023, submitted by the facility revealed that the facility concluded that Upon investigation, the resident was sitting properly in the w/c with the Hoyer pad legs crossed. The w/c was locked, and the transfer was performed properly. The resident stated, I just slid. (Resident 1) was wearing sheen nylon pants at the time of transfer. The Hoyer lift and pad was removed from service and inspected. No issues were found. A repeat demonstration was performed with both CNA'S and demonstrated the proper technique. Residents spouse aware and stated she will bring in other clothing. However, only one of the two employees involved was a CNA (certified nurses aide), the second employee was the facility's van transport driver, who was not a nurse aide. A review of Employee 2's personnel file revealed that he was hired on October 4, 2022, as the facility transport van driver. Employee 2, was not a nurse aide or other trained healthcare professional skilled in performing resident transfers and use of the mechanical lift. The employee's job description as the transport van driver indicated that the duties included: -under the supervision of the Staffing Efficiency Manager, the driver is responsible for pick-up and delivery of residents and materials/equipment as assigned. -the position involves driving facility vehicles in all weather and environmental conditions. -Transports residents via facility van to and from medical appointments and related appointments -assists in transferring of residents from one surface to another during medical appointments when applicable. During an interview May 23, 2023 at approximately 2 P.M, the Nursing Home Administrator confirmed that the facility van driver operated the mechanical lift during Resident 1's transfer and the resident fell sustaining fractured ribs. The NHA stated that the facility identified the cause of the resident's fall as slippery pants and requested that his wife bring in alternate clothing for him to prevent recurrence. The facility failed to ensure staff assisting residents with activities of daily living, including transfers with a mechanical lift used for Resident 1's transfer, demonstrated competency to provide this type of resident care to prevent accidents and injuries. The facility failed to ensure that Resident 1 was transferred by staff possessing the necessary skills, abilities and competencies to safely perform the resident's transfer using the mechanical lift. 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services 28 Pa. Code 201.19 Personnel policies and procedures

Based on review of clinical records and select facility investigative reports and resident and staff interviews it was determined the facility failed to provide necessary staff assistance as planned and utilize safe technique during a transfer from the wheelchair to bed, to prevent an accident resulting in a fractured leg for one out of five residents reviewed (Resident 267). Findings include: A review of the clinical record revealed that Resident 267 was admitted to the hospital on (MONTH) 6, 2019, from her apartment with difficulty walking. The resident was then admitted to the facility on (MONTH) 11, 2019, from the hospital with a [DIAGNOSES REDACTED]. [MEDICAL CONDITION] appears as a swollen, red area of skin that feels hot and tender. It can spread rapidly to other parts of the body), and muscle weakness, abnormality of gait (difficulty walking) [MEDICAL CONDITION] (sometimes called [MEDICAL CONDITION] joint disease or wear and tear arthritis, [MEDICAL CONDITION] (OA) is the most common chronic condition of the joints. It occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling). A review of Resident 267's most recent MDS (minimum data set-standardized assessment process conducted at periodic intervals to assess resident care needs) assessment dated (MONTH) 18, 2019, revealed that the resident required extensive assistance of two staff members for transfers which includes moving between surfaces including to or from bed, wheelchair or chair. The resident was unable to move from a seating to standing position without assistance. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status-a tool to assess cognitive function - a score of 13-15 indicates intact cognition). A review of the resident's bedside Kardex (information card utilized by nurse aides which is a quick reference to the specific needs of each resident) conducted during the survey of indicated that the resident required assistance of two persons for transferring from one surface to another and was non ambulatory. The resident utilized a brace (hinged knee orthosis- a brace to limit movement of knee and may reduce pain and pressure of arthritis) to her left leg when out of bed and to be removed when in bed and for hygiene. A review of information dated (MONTH) 23, 2019, submitted by the facility indicated that on (MONTH) 21, 2019, Capable resident, Resident 267 (Age 83), admitted to facility on 9/11/2019 with Dx: [MEDICAL CONDITION] of the Left Lower Limb. On 9/22/19 resident complained of pain in her left lower leg. An RN assessment was completed, resident was medicated for pain, and MD was notified with orders noted for Keflex and an X-ray of the left leg. X-Ray result revealed [MEDICAL CONDITION] and a fracture to LLE. Resident indicated she did not have an accident or a fall. MD was notified with orders noted to consult orthopedics. Resident and Representative were updated. On (MONTH) 23, 2019, the State Survey Agency received an allegation that a staff member was transferring Resident 267 into bed on (MONTH) 21, 2019, during which the resident sustained [REDACTED]. A review of the facility's variance report dated (MONTH) 22, 2019, at 3:13 AM written by the registered nurse (RN) supervisor, Employee 1, which indicated that upon rounds the licensed practical nurse (LPN) Employee 2 noticed that resident's left lower leg was red, swollen and warm to touch, with pain of a 7 on a scale of 1-10 with 10 being the worst amount of pain tolerable. A lump on the resident's leg was later noted on (MONTH) 22, 2019. On (MONTH) 22, 2019, the physician was called and was ordered to have an X-ray of the left leg and was placed on an antibiotic for the possibility of [MEDICAL CONDITION]. An X-ray of the resident's left leg was obtained at 11:00 AM on (MONTH) 22, 2019. At 12:23 p.m. on (MONTH) 22, 2019, the X-ray results revealed proximal tibia/fibula (both bones of lower leg) fracture. A physician order [REDACTED]. A review of the facility's variance report and interview with Employee 2, LPN, conducted on (MONTH) 25, 2019, at 3:30 PM revealed that this nurse had written a statement for the facility, as part of their review of the incident, indicating that she was in the resident's room at 9:00 PM on (MONTH) 21, 2019 discussing other care issues. Employee 2 stated during a telephone interview on (MONTH) 25, 2019 at 3:30 p.m. that she was at the nurses station getting report from the other staff nurses around eight-ish on (MONTH) 21, 2019. She stated that Employee 3, a nurse aide, informed her that Resident 267 wanted to see a nurse because she pops all over. Employee 2 stated she didn't think anything of it because she was not understanding what the aide meant by popping all over. Employee 2 stated she spoke to the resident at 9:00 PM on (MONTH) 21, 2019, about another issue. Employee 2 stated that the resident was already in bed at that time and did not convey concerns to her at this time. Employee 2 stated she was making rounds around midnight on (MONTH) 21, 2019, (into the early morning hours of (MONTH) 22, 2019) and saw Resident 267's light on in the resident's room, which was unusual. Employee 2 stated that she looked into the resident's room and the bed covers were off the resident exposing the resident's left leg and observed the resident was rubbing her leg. Employee 2 saw that the resident's leg was red, swollen, and warm to touch. Employee 2 thought it was [MEDICAL CONDITION] and applied ice and administered Tylenol to the resident. Employee 2 stated that she asked the resident what happened., and the resident stated she was not sure. Employee 2 stated that she was not concerned how it happened because she stated she was sure it was [MEDICAL CONDITION] due to the fact the resident was admitted to the facility with [MEDICAL CONDITION] of her left leg. Employee 2 further stated that around 1:45 a.m. on (MONTH) 22, 2019, she went back to check on the resident's leg and noticed a bump. Employee 2 then called the supervisor who contacted the physician and an order was received to obtain an X-ray and start Keflex, an antibiotic for what was potentially [MEDICAL CONDITION]. A review of a typed nurse aide statement by Employee 3, the nurse aide, obtained by the facility on (MONTH) 22, 2019, not time noted, indicated that Employee 3 had showered the resident on the evening of (MONTH) 21, 2019 (no time indicated). Employee 3 stated that she brought the resident back to her room, got her dressed in the bathroom and placed the resident's wheelchair next to her bed. Employee 3 stated that the resident was talking about laundry. Employee 3 stated she (Resident 267) just started to stand up. Before I could finish, she started to transfer herself to the bed. I stepped close to her and held on to her so she would not fall. After she scooted herself over to the bed, she stated the resident stated, she heard a pop, 'but I pop all over.' She stated she was having some discomfort in her left leg. After she was comfortable in the bed I went and told the nurse about her saying she heard a pop. Multiple attempts were made to interview Employee 3 at the time of the survey ending (MONTH) 25, 2019. The employee was not working at the time of this survey and the employee did not return telephone calls placed to her in attempt to interview the employee by phone. The resident was seen by the orthopedic surgeon on (MONTH) 23, 2019, and returned to the facility with a long leg cast in place and orders for no weight bearing on the left leg. An interview with the resident on (MONTH) 25, 2019, at 10:05 a.m. verified that Employee 3 gave her a shower on the evening of (MONTH) 21, 2019. When she (the resident) returned to her room via wheelchair, she wanted to be placed in bed on the right side of her bed. However, Employee took her to the left side of the resident's bed. The resident stated that she had to hang on to the bedside table. Resident 267 stated that Employee 3 swung her into bed. The resident stated at the she heard a very loud pop. During this interview the resident stated that she did not write a statement for the facility as part of the facility's incident review nor did any facility staff member question her about what happened on that evening when her leg was fractured. The resident stated that the nurse aide (Employee 3) was supposed to tell the nurse what happened that she heard a pop. The facility provided a type written statement dated (MONTH) 23, 2019, no time identified, which reportedly had been signed by Resident 267 when the resident was interviewed regarding her injury. This typed statement, allegedly signed by the resident noted I didn't have any accident or fall. No one hit me or did anything to hurt me. I have had many problems with my left leg. Ever since I had a hysterectomy, I have had bone trouble, I know I have [MEDICAL CONDITION]. I have felt for a long time I am going to have a broken bone sooner or later. I am not in a lot of pain, I can lift my leg and it doesn't hurt. I slept good last night. This typed written statement varied from the account the resident reported to the surveyor on (MONTH) 25, 2019. The written statement was reviewed with this resident along with her signature during the survey on (MONTH) 25, 2019, at 11 AM. The resident stated that she did not provide that statement and it was not her signature. The resident proceeded to demonstrate her signature to the survey and signed her signature underneath the signature on the typed statement. The resident's signature was not similar to the signature signed on the statement. A review of the resident's clinical record also revealed notations of the resident's signature on admission paperwork, which were consistent with the signature written in the surveyor's presence and inconsistent with the signature noted on the facility's typed written statement. The resident's account of the incident and her injury also differed from Employee 3's account of the incident according to the Employee 3's typed written statement. At 1:00 p.m. on (MONTH) 25, 2019, the NHA and director of nursing (DON) accompanied by the surveyor, with the resident's permission, interviewed the resident regarding her account of the injury she sustained and incident of (MONTH) 21, 2019. During this interview Resident 267 repeated the account she had provided to the surveyor earlier that morning. The resident stated that after her shower that evening, Employee 3, the nurse aide, put me in bed on the left side of my bed, I usually go into bed on the right side since it is easier for her. The resident further stated that she had to stand up and hold on to the furniture (bedside table) and Employee 3 swung her around and sat her on the bed. The resident stated, I wanted to tell her it did not move (left leg), but she twirled me around and I sat on the bed and I heard a loud, loud pop. The resident confirmed that it was only Employee 3 assisting her with the transfer. The resident stated that she does require two persons for transfers because she has difficultly moving her left leg. The resident was shown her statement (typed written statement) and her signature during this inteviews. The resident confirmed that this was not her statement nor her signature. She then signed below the signature on the statement and it differed from the signature on the paper, in the presence of the NHA, DON and surveyor. The signature she signed in front of the surveyor, DON and NHA was comparable to documentation in her clinical record. After the interview with the resident on (MONTH) 25, 2019. the NHA stated ooh, that sounded like a different story. During interview with the DON on (MONTH) 25, 2019, at 1:20 PM he stated that he had spoke to resident, but she did not tell him what happened. The DON stated that he typed out the statement and sent it back to the nursing unit. The DON did not address the resident's signature on the statement during this interview. During a follow-up interview with the resident after the DON and NHA left the room on (MONTH) 25, 2019 at 1:30 p.m. the resident verified that the DON did come to her room after the fracture was confirmed. The resident stated that he (DON) just stood in front of me for a few minutes and asked me if I had pain, he did not ask me any of those other questions. There was no evidence that Employee 3 had attempted to summon the assistance of another staff member, as planned and necessary for the resident's transfer after the resident's shower on the evening of (MONTH) 21, 2019. Employee 3 provided care to Resident 267 without the assistance of another staff member as the resident required and the resident sustained [REDACTED]. The facility failed to ensure that the resident was consistently provided the assessed level of staff assistance necessary to safely perform transfers. The facility further failed to thoroughly and accurately investigate the resident's injury to identify potential causative factors to plan the resident's care and prevent similar incidents and injury to the resident. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services. Continuing deficiency of 9/4/19 Previously cited 4/18/19, 6/13/19, 2/21/19, 10/26/18

Based on review of clinical records and select abuse investigations and staff and family interviews it was revealed that the facility failed to identify one resident's risk (Resident 289) for abusive behavior and devise and implement sufficient measures necessary to protect residents from sexual harassment and abuse for one out of 14 residents reviewed (Resident 141). Findings include: A review of the clinical record revealed that Resident 289 was admitted to the facility on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. The resident was placed on the unit designated as the facility's dementia unit. A review of nursing progress notes dated (MONTH) 5, 2019, revealed that the resident paced in the hallway looking for his family and pictures. On (MONTH) 6, 2019, nursing documented that the resident was wandering on the unit looking to go home and looking for his wife. Staff documented that he needed to be redirected from other residents. Staff documented on (MONTH) 7, 2019 that the resident continued to confuse another facility resident with his deceased wife. The resident was noted to tell the female resident he loved her and when the staff attempted to redirect him, Resident 289 would sometimes become angry. According to review of interdisciplinary progress notes dated (MONTH) 11, 2019, the resident was identified as mistaking other female residents for his wife. The resident was described as resistive to care and combative with staff. A behavioral note dated (MONTH) 14, 2019, revealed that the resident was wandering into other resident rooms. The resident required frequent redirection and emotional support. A behavioral progress note dated (MONTH) 16, 2019, revealed that the resident was ambulating on the unit with his rollator walker. The resident was described as restless. He was approaching female residents and mistaking them for his wife. The resident was described as being agitated when redirected and very forgetful. The resident was combative with care and was not receptive to diversional activities for long periods of time. On (MONTH) 21, 2019, staff documented that the resident was wandering in and out of other resident rooms. He transferred a resident out of her wheelchair and left her standing at the handrails in the hallway. When the staff attempted to sit this resident into her wheelchair, Resident 289 began wheeling himself in the opposite direction. He was removing other resident's belongings from their rooms. He also packed all his belongings in plastic bags. A behavior note dated (MONTH) 23, 2019, revealed that the resident was wandering into other resident rooms and was combative when staff attempted to redirect him. The resident hit a nurse with a wet floor sign. According to documentation dated (MONTH) 24, 2019, the resident was wandering in and out of other resident rooms. He was described as very agitated and combative, when the staff attempted to redirect him. On (MONTH) 25, 2019, staff documented that the resident was wandering into other resident rooms throughout the shift. A behavioral note dated (MONTH) 27, 2019, revealed that the resident was walking in the halls, in and out of other resident rooms. He was described as turning tables and his walker upside down. Staff noted that he kicked the medication cart. The resident was attempting to remove other residents from their rooms. He was described as angry and combative at times. Additionally the resident was making sexual comments to staff members and was attempting to pull them onto his lap. Staff documented that the resident was wandering in and out of resident rooms and upsetting female residents. On (MONTH) 28, 2019, staff noted that the resident was pacing up and down the hallway and in and out of resident rooms. He was described as angry and difficult to redirect. Nursing progress notes dated (MONTH) 5, 2019, revealed that the resident was attempting to stand other residents up. On (MONTH) 7, 2019, the resident was wandering in and out of resident rooms. He was looking for his truck and his daughter to take him home. Staff documented that the resident was sliding his mattress on the floor in the hallway on (MONTH) 8, 2019. According to documentation, the resident was trying to hit staff and was punching and accusing male staff members of sleeping with his wife. The resident was pacing the floor and roaming into other resident rooms on (MONTH) 10, 2019. On (MONTH) 11, 2019, staff documented that the resident was repeatedly wandering in and out of resident rooms. According to documentation the resident was entering other resident rooms and looking to help them on (MONTH) 12, 2019. On (MONTH) 16, 2019, the resident attempted to throw a towel out the window. The resident was very aggressive and combative towards the staff, when they attempted to redirect him out of another resident's room. He was later found lying in another resident's bed and began punching and twisting the fingers of staff members when attempts were made to redirect him. On (MONTH) 19, 2019, the resident took his pillow and blanket and placed them in the hallway and laid down on the floor. The resident was described as hard to redirect when he was wandering in and out of residents' rooms on (MONTH) 20, 2019. The resident was stripping his and other resident beds on (MONTH) 25, 2019, according to documentation. According to a review of employee statements completed as part of a facility investigation into a resident incident, Employee 1, RN (registered nurse) was attempting to administer medications to Resident 289 at 8:45 p.m., on (MONTH) 2, 2019, and was unable to locate him. A search of the unit revealed he was in Resident 141's (female resident) room. A review of Resident 141's clinical record revealed she had a [DIAGNOSES REDACTED]. The resident's most recent MDS (minimum data set-federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated (MONTH) 20, 2019 revealed that the resident was severly cognitively impaired with a BIMS (brief interview of mental status-test for cognition) score of 4 out of 15 (,[DATE] equals severe cognitive impairment). Employee 1 indicated that she observed Resident 289 in Resident 141's room. Resident 289 was naked and lying on top of female Resident 141. Employee 1 stated that it appeared the resident was having sex, with her (Resident 141). Employee 1 had difficulty redirecting and physically removing Resident 289 from Resident 141. Employee 1 stated she left the room (leaving Resident 289 and Resident 141 unattended) in an attempt to find another staff member. When she returned to Resident 141's room, she observed Resident 289, with his finger inside Resident 141 (vagina). A review of Employee 2's (LPN - licensed practical nurse) statement revealed that when she entered Resident 141's room, she also observed Resident 289 with his fingers in Resident 141's vagina. Employee 2 stated that when she told Resident 289 to stop, he became angry and combative and stated who are you to stop me from having sex with my wife. Employee 2 stated she had to pick Resident 289 up by his arms and around the chest to stand him up and get him away from Resident 141. A review of Resident 289's comprehensive plan of care dated (MONTH) 4, 2019, revealed that the facility identified the resident's inappropriate behaviors of yelling out, refusal of care, wandering in other rooms and physical aggression towards staff. The planned interventions were limited to involving the resident in activities of choice (not specified), providing ordered medications, psychiatric evaluations, redirection as needed, emotional support and reassurance. There was no documented evidence that the facility had identified the resident's interest in female residents he had mistaken for his wife and his sexual comments/behaviors toward the staff. On (MONTH) 20, 2019, the facility added the problem of non-complaint behaviors of refusing to follow his plan of care, including putting his bedding on the floor and lying on the floor. The only interventions developed, for this severely impaired resident, was to encourage the resident to verbalize his reason for his non-complaint behavior and to notify the physician for possible alternatives to treatments, medications, care plan recommendations, etc and to offer the resident appropriate alternatives when possible, which were not identified. When interviewed on (MONTH) 18, 2019 at 9:45 a.m. the Unit Manager from the unit on which Residents 141 and 289 resided on at the time of the sexual abuse, stated that Resident 289 wandered throughout the unit and into other resident rooms. She stated that the resident did wander into both male and female rooms, but was frequently searching for his wife and Resident 141 seemed to remind him of her. Resident 141's family member/representative was interviewed on (MONTH) 18, 2019, at 2:10 p.m. She expressed anger over the incident of sexual abuse by Resident 289. The resident's representative stated that her mother would not have the physical or cognitive ability to call out for help or consent to the sexual advances of Resident 289. The resident's representative further stated that her mother's room was a distance from the nurses station and her roommate also did not have the physical ability to call for staff assistance for Resident 141 at the time of the incident. The resident's family member stated that she was currently seeking alternate placement for her mother because she was no longer comfortable with her placement at the facility. The facility failed to adequately supervise Resident 289 and implement effective safety measures to deter Resident 289's intrusive wandering and manage the resident's behavioral symptoms, including those of a sexual nature, mistaking female residents for his wife and searching for his wife, to prevent the sexual abuse of Resident 141. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management Previously cited: [DATE] 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 201.29(c)(d) Resident Rights 28 Pa. Code 211.12(a) Nursing Services Previously cited:[DATE],[DATE],[DATE] 28 Pa. Code 211.12(c) Nursing Services Previously cited: [DATE],[DATE],[DATE] 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited:[DATE],[DATE],[DATE] .

Based on a review of clinical records and select resident incident reports and staff interviews, it was determined that the facility failed to provide adequate staff supervision and the use of safe technique during resident transport to prevent a fall with serious injuries, head injury and multiple fractures, for one of 30 sampled residents (Resident CR2). Findings include: A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated August 5, 2017, revealed that the resident was cognitively intact and did not ambulate at the time of assessment. The resident was independent moving on and off the unit in his wheelchair, with staff supervision. The resident's Fall Risk assessment evaluation dated August 8, 2017, revealed a score of 2, which indicated he was at low risk for falls. Review of information dated September 20, 2017, at 6 AM submitted by the facility revealed that the resident sustained [REDACTED]. Review of Risk Management File Report (facility report of resident incidents) dated September 20, 2017, at 6 AM revealed that Resident CR2 left the (nursing) unit to attend dialysis via wheelchair accompanied by the facility's Van Transporter, Employee 1, through the ambulance entrance/exit. Employee 1 stated that she had asked the resident if he would like a blanket due to chilliness of the morning. The resident replied yes and proceeded to self-propel his wheelchair out of the doorway and down the (18 foot) ramp (of the ambulance exit). Employee 1 stated that she tried to grab him/his wheelchair, but the resident fell forward onto the pavement, striking his head. The resident sustained [REDACTED]. He complained of shoulder and arm pain. The report also noted that the resident's wheelchair was unlocked at the time of the accident. The resident's physician and guardian were notified of the incident and on September 20, 2017, at 6:30 AM the Resident was sent to the hospital for evaluation and treatment. A review of the fall interventions in place for Resident CR2 at the time of the fall revealed nonskid footwear and the use of a foam cushion applied to his wheelchair seat. Subsequent to the resident's fall on September 20, 2017, the facility added the approach that the resident Resident to be supervised and escorted out the door, down the ramp and to the van, until reviewed by PT/OT (physical/ occupational therapy) to prevent similar occurrences. Further review of the resident's clinical record revealed that the resident was admitted to the hospital on September 20, 2017, with [DIAGNOSES REDACTED]. Interview conducted with Employee 2, the Occupational Therapist Director, on November 14, 2017, at 10:30 AM revealed that Resident CR2 self-propelled independently throughout the facility. Employee 2 stated that residents are accompanied by a staff member when exiting the ambulance exit, because you need a code to get out of the building; it is not something residents would do on their own. Review of Facility's Job Description for Van Transporter revealed this position requires ability to transport self throughout facility, while pushing a wheelchair. In addition the Duties & Responsibilities of Job included the responsibility of the employee to Transports residents to and into the van. During interview conducted with Employee 1 on November 15, 2017, at 10:30 AM she stated that she accompanied the resident to the ambulance exit and used the keypad to open the locked exit door (on the day of the resident's fall). She held the door open with her foot and reached into resident's bag, which hung on the back of his chair, for his blanket. The resident pulled himself out of the door and he rolled down the hill (ramp) in his wheelchair. Employee 1 stated that she tried to grab him, but couldn't hold him and he fell forward out of his wheelchair, onto the pavement. Employee 1 stated that the resident never locked his wheelchair and so she did not lock his wheelchair at the time Employee 1 also stated there are usually two Transport Aides to assist residents out of the ambulance exit on dialysis days, one staff member to hold the door open and the other to escort residents down the ramp, but there was only one aide (herself) working on this day. Employee 1's written Witness Statement from Person Witnessing a Fall dated September 20, 2017, revealed that the employee noted the same scenario as stated above. An interview conducted with Employee 3, Transport Van Driver, on November 17, 2017, at approximately 12:00 PM revealed he was in the van supervising a different resident at the time of this resident's fall and he did not witness the incident. However, Employee 3 also stated there are usually two staff members to assist residents out of the ambulance exit on the mornings of dialysis, but there was only one staff member with Resident CR2 the day of his fall. Employee 1 opened the door to exit the facility, with the resident seated in an unlocked wheelchair, but failed to maintain control of the resident's wheelchair to safely transport the resident from the facility to the van. The facility was aware that the resident self-propelled himself in the wheelchair and failed to provide sufficient staff assistance and/or use safe technique to maintain the resident's safety and control of the resident's wheelchair during this transport. Interview with Director of Nursing (DON) on November 14, 2017, at approximately 1:00 PM revealed that the facility was unable to provide evidence of the provision of sufficient staff assistance and reasonable precautionary measures during wheelchair transport to prevent this accident with serious injuries. 28 Pa Code 207.2(a) Administrator's responsibility Previously cited 1/6/17, 2/23/16 28 Pa. Code 211.12(a) Nursing Services. Previously cited 8/26/17, 1/6/17, 10/5/16, 5/17/16, 4/13/16, 5/17/16, 12/18/15 28 Pa. Code 211.12(c) Nursing Services. Previously cited 8/26/17, 1/6/17, 10/5/16, 5/17/16, 4/13/16, 5/17/16 28 Pa. Code 211.12(d)(3) Nursing Services. Previously cited 8/26/17, 1/6/17, 5/17/16, 4/13/16, 5/17/16, 12/18/15 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited 8/26/17, 1/6/17, 10/5/16, 5/17/16, 4/13/16, 5/17/16, 12/18/15 Based on a review of clinical records and select resident incident reports and staff interviews, it was determined that the facility failed to provide adequate staff supervision and the use of safe technique during resident transport to prevent a fall with serious injuries, head injury and multiple fractures, for one of 30 sampled residents (Resident CR2). Findings include: A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated August 5, 2017, revealed that the resident was cognitively intact and did not ambulate at the time of assessment. The resident was independent moving on and off the unit in his wheelchair, with staff supervision. The resident's Fall Risk assessment evaluation dated August 8, 2017, revealed a score of 2, which indicated he was at low risk for falls. Review of information dated September 20, 2017, at 6 AM submitted by the facility revealed that the resident sustained [REDACTED]. Review of Risk Management File Report (facility report of resident incidents) dated September 20, 2017, at 6 AM revealed that Resident CR2 left the (nursing) unit to attend dialysis via wheelchair accompanied by the facility's Van Transporter, Employee 1, through the ambulance entrance/exit. Employee 1 stated that she had asked the resident if he would like a blanket due to chilliness of the morning. The resident replied yes and proceeded to self-propel his wheelchair out of the doorway and down the (18 foot) ramp (of the ambulance exit). Employee 1 stated that she tried to grab him/his wheelchair, but the resident fell forward onto the pavement, striking his head. The resident sustained [REDACTED]. He complained of shoulder and arm pain. The report also noted that the resident's wheelchair was unlocked at the time of the accident. The resident's physician and guardian were notified of the incident and on September 20, 2017, at 6:30 AM the Resident was sent to the hospital for evaluation and treatment. A review of the fall interventions in place for Resident CR2 at the time of the fall revealed nonskid footwear and the use of a foam cushion applied to his wheelchair seat. Subsequent to the resident's fall on September 20, 2017, the facility added the approach that the resident Resident to be supervised and escorted out the door, down the ramp and to the van, until reviewed by PT/OT (physical/ occupational therapy) to prevent similar occurrences. Further review of the resident's clinical record revealed that the resident was admitted to the hospital on September 20, 2017, with [DIAGNOSES REDACTED]. Interview conducted with Employee 2, the Occupational Therapist Director, on November 14, 2017 at 10:30 AM revealed that Resident CR2 self-propelled independently throughout the facility. Employee 2 stated that residents are accompanied by a staff member when exiting the ambulance exit, because you need a code to get out of the building; it is not something residents would do on their own. Review of Facility's Job Description for Van Transporter revealed this position requires ability to transport self throughout facility, while pushing a wheelchair. In addition the Duties & Responsibilities of Job included the responsibility of the employee to Transports residents to and into the van. During interview conducted with Employee 1 on November 15, 2017, at 10:30 AM she stated that she accompanied the resident to the ambulance exit and used the keypad to open the locked exit door (on the day of the resident's fall). She held the door open with her foot and reached into resident's bag, which hung on the back of his chair, for his blanket. The resident pulled himself out of the door and he rolled down the hill (ramp) in his wheelchair. Employee 1 stated that she tried to grab him, but couldn't hold him and he fell forward out of his wheelchair, onto the pavement. Employee 1 stated that the resident never locked his wheelchair and so she did not lock his wheelchair at the time Employee 1 also stated there are usually two Transport Aides to assist residents out of the ambulance exit on dialysis days, one staff member to hold the door open and the other to escort residents down the ramp, but there was only one aide (herself) working on this day. Employee 1's written Witness Statement from Person Witnessing a Fall dated September 20, 2017, revealed that the employee noted the same scenario as stated above. An interview conducted with Employee 3, Transport Van Driver, on November 17, 2017, at approximately 12:00 PM, revealed he was in the van supervising a different resident at the time of this resident's fall and he did not witness the incident. However, Employee 3 also stated there are usually two staff members to assist residents out of the ambulance exit on the mornings of dialysis, but there was only one staff member with Resident CR2 the day of his fall. Employee 1 opened the door to exit the facility, with the resident seated in an unlocked wheelchair, but failed to maintain control of the resident's wheelchair to safely transport the resident from the facility to the van. The facility was aware that the resident self-propelled himself in the wheelchair and failed to provide sufficient staff assistance and/or use safe technique to maintain the resident's safety and control of the resident's wheelchair during this transport. Interview with Director of Nursing (DON) on November 14, 2017, at approximately 1 PM revealed that the facility was unable to provide evidence of the provision of sufficient staff assistance and reasonable precautionary measures during wheelchair transport to prevent this accident with serious injuries. 483.25 (h) Free of Accident Hazards/Supervision/Devices 28 Pa Code 211.12 (a) (c) (d) (3) (5) Nursing services Previously cited: 1/6/17, 8/26/17 28 Pa Code 207.2 (a) Administrator's responsibility Previously cited: 1/6/17

Based on review of clinical records and select fall and event reports, observation, resident, staff, and family interview, it was determined that the facility failed to ensure that nurse aides demonstrated competency in the provision of safe personal care and resident services to prevent serious injury to one resident (Resident 287) out of 12 sampled residents. Findings include: A review of the clinical record revealed that Resident 287 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to her quarterly Minimum Data Set assessment dated [DATE] (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) the resident had a BIMS of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). The MDS assessment also indicated that the resident required staff assistance with bed mobility (changing position in the bed, turning from side to side and moving to and from a lying position according to the MDS Resident Assessment Instrument). A physical therapy evaluation dated January 27, 2016, indicated that the resident had muscular contraction of the right leg, impairment to both legs and utilized a mechanical lift for transfers out of bed or transferred to a chair due to decreased strength in her trunk area. The PT evaluation indicated that the resident required maximum assistance for rolling to her left side with one person and she required two persons maximum assistance for repositioning and boosting her (i.e., in bed). A review of an event reported to the State Survey Agency and the facility's fall investigation, both dated May 9, 2016, revealed that Employee 2, a nurse aide, was beginning to provide morning care to the resident. Employee 2 informed the resident that she had to go for more towels. When Employee 2 returned to the resident's room the resident had rolled out of bed on her left side. The resident sustained [REDACTED]. Further review of the facility's fall report and statement from Employee 2, revealed that the employee noted that while providing morning care for Resident 287, she had to get more towels; so she told the resident she would be right back. Employee 2 noted that she positioned the resident in the middle of her bed on her back with bed in lowest position and call bell in reach. Employee 2 heard the resident state I am going, I am falling and Employee 2 witnessed the resident rolling out of bed landing on her right knee. An interview with Employee 2 on May 17, 2016, at 12:45 PM revealed that this nurse aide repeated her account that she left the resident in the center of the bed on her back. She further stated that the resident's left arm was around the left siderail and the resident had pulled herself over and landed on her right knee. Employee 2 stated that she began the resident's morning care and the resident had been incontinent of stool. Employee 2 stated that the privacy curtain was drawn around the resident and she went to get towels. When Employee 2 returned, she observed the resident falling to her left side and could not reach her in time. An interview with Resident 287 on May 17, 2016, at 11:30 AM revealed that the resident described the circumstances of the fall from bed on May 9, 2016, by stating that I was on that side in the bed. The resident was pointing to the left side of her bed as the location from which she had fallen from bed. Observation and interview with the resident at this time revealed that the resident was unable to move her right arm and leg. An interview conducted on May 20, 2016, at 10:17 AM with the resident's son revealed that the facility had informed him that his mother swung her right leg over her left and the momentum pulled her out of bed. The resident's on also stated that the facility told him that they had caught her and protected her head so she did not injure it. The resident's son also stated that his mother has lived at the facility for the past seven years and she would never want to get anyone in trouble. However, the resident had told him that at the time of the fall, Employee 2 had been trying to change the resident's bedsheets by herself because the resident had stated that she did not want to get out of bed. Resident 287 told her son that Employee 2 pulled the resident's bedsheets and the resident rolled out of bed and hurt her leg. Interview with the ADON (assistant director of nursing) on May 17, 2016, at 1:00 PM revealed that the facility had concluded that the resident had apparently pulled herself out of bed with her left hand. When asked about the resident's functional limitations and ability to pull the right side of her body, the ADON stated her left hand is strong. Observation of the resident, review of the resident's clinical record and interview with the resident's son revealed no evidence that the resident had demonstrated the ability to move her right side, by use of her left side, prior to this fall. Additionally, Employee 2 stated during interview on May 17, 2016, that the resident's privacy curtain was drawn around the resident when she left the room to obtain more towels; leaving the resident reportedly in the middle of the bed after having been incontinent of bowel. The resident resides in the bed next to the window, which is farthest from the entry door. It could not be determined how Employee 2 witnessed the resident falling from the bed upon returning to the room with the resident's privacy curtain closed. Employee 2 did not have sufficient personal care supplies prepared to provide the resident's morning care and did not call for assistance when it was determined that the resident had been incontinent of stool and she was without adequate supplies or assistance in changing the resident's bed linens while the resident remained in bed. There was no documented evidence in the resident's clinical record that the resident possessed the functional capabilities to pull herself to the unaffected side without staff assistance. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services Previously cited 12/18/15 28 Pa. Code 201.20(a) Staff development

Based on review of the clinical records and facility follow up to resident accidents and staff interview it was determined that the facility failed to implement planned safety interventions, assistance devices and the supervision necessary to prevent an accident with serious injury for one resident out of six sampled (Resident A1). Findings include: A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], for rehabilitation subsequent to a fractured ankle. A review of the resident's admission minimum data set assessment dated [DATE], revealed that the resident was assessed as independent in all decision making with no long or short term memory problems. A review of the resident's comprehensive plan of care which was initiated on July 30, 2010, and updated on August 11, 2010, revealed that the resident was to receive the assistance of two staff members for all transfers. According to the resident's clinical record, on August 21, 2010, the resident was assisted into the bathroom by Employee 1, a nursing assistant. A raised toilet seat was placed on the toilet. When interviewed by the facility as part of their investigation, both the resident and the involved staff member stated that as the resident was sitting on the toilet, the seat became loose and the resident slid off and fell to the ground, landing on her left side. Employee 1 admitted that she had not reviewed the resident's comprehensive plan of care prior to caring for the resident and was unaware that the resident required two persons for transfers A review of nursing progress notes revealed that the resident complained of pain to the left side, left shoulder, and left hip. It was noted at that time, that the resident's left leg was shortened with a slight outward rotation and the resident was diagnosed with [REDACTED]. When interviewed on September 20, 2010 at 1:15 p.m. the resident confirmed that Employee 1 assisted her to the bathroom by herself and placed the raised toilet seat on the toilet. The resident stated that she did not think that the seat was attached to the toilet securely, which caused it to tip. The resident stated that the staff member was unable to prevent her from falling. An interview with the Director of Nursing Services on September 20, at 1:45 p.m. revealed that she and another staff member had attempted to recreate the incident numerous times and they were unable to do so, with the conclusion being that the use of two staff members could likely have prevent the resident's fall and significant injury. 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing Services. Previously cited: 10/30/09, 3/5/10, 4/21/100 . .