Every finding on record at Artman Lutheran Home

Based on staff interviews and the review of facility documentation, it was determined that the facility failed to ensure a complete and through investigation for resident who sustained a fractured hip (Resident R37) for 1 out of 14 residents reviewed. (Resident R37) Findings include: Review of an incident dated March 14, 2026, submitted to the State Survey Agency reported that the resident's nurse aide found the resident sitting on the toilet in the bathroom located in (his/her) room, with (his/her) companion on the 7:00 a.m. through the 3:00 p.m. nursing shift. The reportable incident stated that the resident's companion reported that the resident fell off the toilet and she (the companion, Employee E8) picked the resident up and put him back on the toilet. The reportable event stated that the resident had severe cognitive impairment, non- ambulatory and needed the maximum assist of 2 people for transfers. According to the reportable event, the resident was assisted onto the toilet around 10:00 a.m. by his nurse aide and the nursing supervisor and was left on the toilet with his companion who was instructed to ring the call bell when he was ready to get up. Continued review of the reportable event indicated that the companion stated that she was standing outside of the bathroom when she saw the resident stand quickly and fall to the floor. The reportable incident indicated that the companion stated that she could not get to the resident in time to prevent the fall. Continued review of the reportable event indicated that the resident complained of hip pain, an x-ray was obtained at the facility and the results of the x-ray showed that the resident sustained an acute left femoral intertrochanteric fracture (left hip fracture). The reportable event stated that the resident was sent to the hospital emergency room for treatment. Review of a witness statement dated March 14, 2026, regarding the above-referenced incident from Employee E4 (nurse aide) stated that the nurse aide reported that both she and the licensed nurse (Employee E10) put the resident on the toilet and informed the companion to ring the call bell when the resident was finished. Continued review of the resident's statement indicated that the nurse aide walked in the bathroom and found the resident sitting on the toilet. Nurse aide reported that the companion told her that the resident fell and then she told the nurse. During an interview with the nurse aide, Employee E4 on April 30, 3036 at 1:08 p.m. the nurse aide reported that both she and the licensed nurse supervisor (Employee E10) put the resident on the toilet and that (he/she) fell off the toilet when (he/she) was left with the companion. The nurse aide reported that the companion was standing in the doorway of the bathroom after she and the license nurse put the resident on the toilet in the bathroom. Nurse aide reported that the companion told her that she took the resident off the floor and put him back on the toilet. Nurse aide reported that she told another nurse (Employee E9) what the companion had just told her about the resident falling off the toilet and the companion reporting that she picked the resident up from the floor and put him back onto the toilet. During an interview with licensed nurse (Employee E9) on April 30, 2026 at 1:34 p.m. licensed nurse reported that she the nurse aide (Employee E4) notified her that the resident fell off the toilet and that the resident's companion picked him put off the floor and put him back on the toilet so that he could finish using the bathroom. Licensed nurse, Employee E9 reported that she notified the nurse supervisor (Employee E10). Licensed nurse, Employee E9 reported that when she walked in the resident's room after the nurse aide called her in, the resident was sitting in his wheelchair next to the table in his room facing the door. Review of the facility's investigation did include a written statement from licensed nurse (Employee E9). Review of the facility's interview with the nurse aide (Employee E4) did not reveal a statement from her indicating that she had the companion assist her with transferring the resident from the toilet back to his wheelchair in his room. During a 2nd interview with the nurse aide (Employee E4) on April 30, 2026, at 1:45 p.m. the nurse aide reported that the resident was on the toilet when she went back into the bathroom to answer the call bell, and that both she and the companion transferred the resident from the toilet to his wheelchair. Review of a written statement from nursing supervisor (Employee E10) dated March 14, 2026, nursing supervisor reported that she assisted the nurse aide (Employee E4) with transferring the resident to the toilet. Nursing supervisor's reported in her statement that she instructed the resident's companion to ring the call bell when the resident was finished using the bathroomDuring an interview with nursing supervisor on April 10, 2026 at 1:47 p.m. nursing supervisor reported that she helped the nurse aide transfer the resident to the bathroom toilet located in the resident's room. Nursing aide reported that the companion was sitting on the chair across from the resident outside of the bathroom in his room when they left the room. Nursing supervisor reported that she instructed the companion to pull the call bell in his room when the resident was finished using the bathroom. Nursing supervisor reported that licensed nurse (Employee E9) came to her and informed her that the resident fell off the toilet and that the companion picked him up. Nurse supervisor reported that she went to the resident's room and he was sitting in his wheelchair. Nurse supervisor reported that she spoke with the companion and was notified by the companion that the resident stood up from the toilet and by the time she got to him he fell on the bathroom floor. Nurse supervisor reported that she was pretty sure that the nurse aide (Employee E4) and the companion transferred the resident from the toilet to the chair. Nursing supervisor reported that residents require two staff members for transfers and that companions are not allowed to assist staff with transferring a resident in the facility. Review of a written statement from the resident's companion (Employee E8) indicated that the companion stated that the resident was on the toilet and that she was waiting outside the bathroom when she saw him quickly stand. The companion reported in her statement that she tried to go towards him but the resident fell before she could get to him. Continued review of the companion's statement indicated that she picked him up from off the floor and sat him back on the toilet. During an interview with the companion on May 11, 2026, at 1:20 p.m. the companion reported that she works as a paid companion from an agency from 7:00 a.m. through 7:00 p.m. every other Saturday and reported that she is not allowed to provide care to or transfer residents. Continued interview with the companion regarding the incident on March 14, 2025 indicated that the resident was transferred to the toilet by two staff members at the facility and that she stood outside the bathroom door with the door open, to provide the resident with privacy. The companion reported that the resident stood up so quickly that she could not do anything about it. She reported that she ran to him as soon as she saw him stand. Companion reported that the resident then fell, and then picked him up from the bathroom floor and pulled the call bell in the bathroom for help. Companion reported that she did assist the nurse aide (Employee E4) with transferring the resident to his wheelchair once the nurse aide came in. Review of the facility's interview with the companion (Employee E8) did not reveal a statement from her indicating that she assisted the nurse aide (Employee E4) with transferring the resident from the toilet back to his wheelchair in his room. 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on observations and the review of clinical records it was determined that the facility failed to acknowledge a physician recommendation regarding a resident's positioning during meal times for 1 out of 14 residents reviewed (Resident R37).Findings include: Review of the April 2026 physician orders for Resident R37 included the following diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life); arthritis (the swelling and tenderness of one or more joints); macular degeneration (age related eye condition in which individuals cannot see things directly in front of them); difficulty walking; contracture of left hand, and fracture of unspecified part of neck of left femur and dysphagia (difficulty swallowing). Review of the resident's Comprehensive Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 18, 202,5 indicated that the resident was cognitively impaired. During an observation on April 29, 2026, at 12:30 p.m. the resident was observed eating lunch in (his/her) room in the bed with his companion present. Review of a note from nurse practitioner (Employee E11) dated April 14, 2026, at 1:00 p.m. stated that the resident was seen on the above referenced date with concerns from the resident's daughter that the resident had a coughing fit that last for over an hour. Continued review of the nursing note indicated that since the above referenced incident that the daughter described, the note documented that the resident continued to have an occasional moist, non-productive cough, and that this is chronic for the resident due to the resident's poor posture and difficulty in swallowing. Continued review of the above referenced documentation from the nurse practitioner documented that the resident was being fed lying in his bed. The nurse practitioner recommended for the resident to have all of his meals out of bed in his chair to reduce the risk of aspiration (occurs when something that's supposed to be in an individual's stomach - like food, water or gastric acid - or anything that isn't air gets into your airways which can lead to complications like airway blockage and infections). Review of the resident's April 2026 and May 2026 physician orders did not show evidence that the nurse practitioner's recommendations were acknowledged by the facility. During an interview with the nurse practitioner on April 30, 2026, at 1:00 p.m. the nurse practitioner reported that the family and the facility were both concerned about coughing and she was contacted by the facility to assess the resident. She reported that she made the above referred recommendation after her assessment to have the resident eat out of bed to the nursing staff. 28 Pa. Code 211.10(c)(d) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on staff interviews and the review of clinical documentation, it was determined the facility failed to ensure that a resident received supervision during toileting and was transferred by facility staff members after sustaining a fall incident in the bathroom for one of 14 residents reviewed. (Resident R37)Findings include: Review of Companion Services/Private Caregivers policy with a revision date of July 26, 2018, revealed it is the policy of the facility to obtain documentation of services to be provided by a companion or private caregiver from the resident representative or employer. Review of Resident R37's clinical record revealed April 2026 physician orders including the following diagnoses: Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life); Arthritis (swelling and tenderness of one or more joints); Macular Degeneration (age related eye condition in which individuals cannot see things directly in front of them); Dysphagia (difficulty swallowing); difficulty walking; contracture of left hand, and fracture of unspecified part of neck of left femur. Review of Resident R37's clinical record revealed Resident R37's Comprehensive Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated December 2, 2025, indicated the resident was cognitively impaired. Continued review of the MDS assessment revealed the resident was dependent on staff for toilet hygiene, sit to stand transfer, lower body dressing and toilet transfers. Review of Resident R37's Care Needs as noted by the companion agency who employed Resident R37's companion dated November 11, 2025, to current revealed, facility staff are to do all personal care for the resident. Additional review of same document revealed for Resident R37's personal care and toileting, the resident's Care Needs indicated [NAME] staff is responsible for all transfers and personal care. Continue review of the companion agency documentation revealed the companion agency staff were to alert facility staff when personal care is needed by the resident. Review of Resident R37's Activities of Daily Living (ADL's) as noted by the companion agency dated November 11, 2025, to current; revealed companion staff should request transfers from facility staff for the resident on all shifts. Review of information submitted March 14, 2026, by the facility to the Department, revealed Resident R37's nurse aide found the resident sitting on the toilet in the bathroom located in (his/her) room, accompanied by (his/her) companion from the 7:00 a.m. to 3:00 p.m. nursing shift. Continued review of information revealed the resident's companion indicated the resident fell off the toilet and (the companion, Employee E8) picked the resident up and put him back on the toilet. Further review of the documentation revealed Resident R37 had severe cognitive impairment, non- ambulatory and needed the maximum assistance of two people for transfers. Continued review of the information revealed the companion reported the resident was standing outside of the bathroom when she saw the resident stand quickly and fall to the floor. Additional review of the information revealed the companion indicated she could not get to the resident in time to prevent the fall. Further review of the information revealed the resident complained of hip pain. An x-ray was obtained at the facility, and the results of the x-ray showed the resident sustained an acute left femoral intertrochanteric fracture (left hip fracture). Continued review revealed the resident was sent to the hospital emergency room for treatment. Review of Employee E4's (nurse aide) witness statement dated March 14, 2026, regarding the above-referenced incident revealed the nurse aide reported both she and the licensed nurse (Employee E10) put the resident on the toilet and informed the companion to ring the call bell when the resident was finished. Nurse aide reported that the companion told her the resident fell and then she informed the nurse. During interview with the nurse aide, Employee E4 on April 30, 2026, at 1:08 p.m. the nurse aide revealed both she and the licensed nurse supervisor (Employee E10) put the resident on the toilet and the resident fell off the toilet when the resident was left with the companion. Nurse aide, Employee E4 revealed the companion was standing in the bathroom doorway after Licensed nurse, Employee E10 put the resident on the toilet. Nurse aide, Employee E4 revealed the companion told her that she took the resident off the floor and put the resident back on the toilet. Nurse aide, Employee E4 revealed she informed another nurse (Employee E9) what the companion had confided to her about the resident falling off the toilet and the companion picking the resident up from the floor and put the resident back onto the toilet. During interview with Licensed nurse (Employee E9) on April 30, 2026, at 1:34 p.m. revealed that nurse aide (Employee E4) notified her that the resident fell off the toilet and the resident's companion picked him off the floor and put him back on the toilet so the resident could finish using the bathroom. Licensed nurse, Employee E9 reported she notified the nurse supervisor (Employee E10). Licensed nurse, Employee E9 revealed when she walked into the resident's room after the nurse aide called, the resident was observed sitting in his wheelchair next to the table in his room facing the door. Review of the facility's investigation did include a written statement from licensed nurse (Employee E9). During follow up interview with nurse aide (Employee E4) on April 30, 2026, at 1:45 p.m. the nurse aide revealed the resident was on the toilet when she went back into the bathroom to answer the call bell, and that both she and the companion transferred the resident from the toilet to the resident's wheelchair. Review of written statement by nursing supervisor (Employee E10) dated March 14, 2026, revealed nursing supervisor indicated she assisted the nurse aide (Employee E4) with transferring the resident to the toilet. The nursing supervisor reported in her statement she instructed the resident's companion to ring the call bell when the resident was finished using the bathroom. Interview conducted with nursing supervisor (Employee 10) on April 10, 2026, at 1:47 p.m. nursing supervisor reported she helped the nurse aide transfer the resident to the bathroom toilet located in the resident's room. Nursing aide indicated the companion was sitting on the chair across from the resident outside of the bathroom in the resident's room when they left the room. Nursing supervisor reported she instructed the companion to pull the call bell in the resident's room when the resident was finished using the bathroom. Nursing supervisor revealed the licensed nurse (Employee E9) came to her and informed her that the resident fell off the toilet and the companion picked the resident up. Nurse supervisor indicated she went to the resident's room, and the resident was sitting in his wheelchair. Nurse supervisor reported, she spoke with the companion and was informed by the companion the resident stood up from the toilet and by the time she got to the resident, the resident fell to the bathroom floor. Nurse supervisor reported she was pretty sure the nurse aide (Employee E4) and the companion transferred the resident from the toilet to the chair. Nursing supervisor reported Resident R37 requires two staff members for transfers and companions are not permitted to assist staff with transferring a resident in the facility. Review of written statement by Resident R37's companion (Employee E8) revealed the companion reported the resident was on the toilet and she was waiting outside the bathroom when she saw the resident quickly stand. The companion reported in her statement she tried to go towards the resident but the resident fell before she could get to the resident. Continued review of the companion's statement revealed she picked the resident from the floor and sat the resident back on the toilet. Interview conducted with companion (Employee E8) on May 11, 2026, at 1:20 p.m. revealed she works as a paid companion from a nursing agency for shift times of 7:00 a.m. through 7:00 p.m. every other Saturday. Employee E8 reported that she is not permitted to provide personal care or transfer residents. Continued interview with the companion regarding the incident of March 14, 2025, revealed the resident was transferred to the toilet by two staff members of the facility and she stood outside the bathroom door with the door open, to provide the resident privacy. The companion revealed, the resident stood up quickly that she could not do anything about it. Resident R37's companion, Employee E8 reported that she ran to the resident as soon as she saw him stand. The companion revealed Resident R37 fell; then she picked the resident up from the bathroom floor and pulled the call bell in the bathroom for help. Companion reported that she did assist the nurse aide (Employee E4) with transferring the resident to his wheelchair once the nurse aide came in. During an interview with the Director of Rehabilitation on April 30, 2026. at 2:41 p.m. it was confirmed that the resident's transfer status at the time of his fall required the resident to have the assistance of two staff members. During an interview with the Director of Nursing (DON) on April 30, 2026, at 2:25 p.m., concerns for Resident R37's supervision and safety were discussed. Further it was discussed with the facility Director of Nursing that the resident was transferred off the floor after a fall incident in the bathroom and into a wheelchair by a companion. 28 Pa. Code 211.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on the review of clinical records, facility fall investigation, it was determined that the facility failed to implement a care plan intervention for Resident R1 by not providing a properly functioning chair alarm as specified in the resident's individualized care plan for one of five residents reviewed. (Resident R1).Findings Include:Review of Resident R1's care plan dated September 5, 2025, revealed an intervention requiring the use of an electronic chair alarm to alert staff of unassisted rising. Ensure the device is in place every shift.Review of Resident R1's fall investigation dated October 7, 2025, revealed that the resident was found lying on his right side in his room on the floor with his head against the wall and his legs still positioned on his leg rests.Further review of the investigation revealed that current fall preventions included: bed and chair alarm to alert staff of unassisted rising, hourly checks due to poor safety awareness and fall risk, nonskid socks while in bed, and staff to remain with resident at all times while in the bathroom. Continued review of the investigation revealed that Resident R1's chair alarm was not connected properly when fall occurred.Interview with the Director of Nursing, Employee E2, on October 14, 2025, at 12:00 p.m. confirmed that Resident R1's chair alarm was not connected properly as per the care plan when he fell on October 7, 2025.This deficiency was cited as past non-compliance.Review of facility Action plan/Follow up documentation revealed the following information.1. Resident R1's call bell was connected properly and interventions added to ensure functioning every shift.2. All residents with bed or chair alarms were checked immediately to ensure they were on and functioning.3. The Director of Nursing educated the nursing assistant responsible on 10/8/2025. The Unit Manager in-serviced the clinical team on all shifts; completed on 10/12/2025.4. Audits will be completed weekly on the household by the Unit Manager on residents that have alarms x 3 months and 100% compliance is achieved. Use of Bed and Chair alarms are very minimal in community. Plan of Correction will be reviewed by team in QAPI monthly meetings until completed.Facility date of compliance was October 12, 2025.A review was conducted of clinical records, facility documentation, staff education, and documentation of audits conducted by the facility. Interview with staff revealed that the staff was knowledgeable about the facility bed/chair alarm policy. It was determined that the plan of correction was implemented and identified as past non-compliance.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility provided documentation, review of clinical record, and interview with staff, it was determined that facility did not ensure to provide pneumococcal immunization according to professional standards of practice for one of 73 residents reviewed (Resident R165) Findings include: Review of facility provided policy 'Immunization Policy,' unknown date, indicates that All residents will be offered the Pneumococcal vaccine per Centers for Disease Control and Prevention (CDC) recommendations (age/timing of previous vaccine). According to CDC Epidemiology and Prevention of Vaccine-Preventable Diseases, revised on April 22, 2024, indicates that The key to preventing serious adverse reactions after vaccination is effective screening. Every patient should be screened for contraindications and precautions before administering any vaccine dose. Further review of facility's policy 'Immunization Policy,' unknown date, indicates that these vaccines will be administered by any appropriately qualified personnel who are following facility procedures, without the need for an individual physician evaluation or order other than the signed standing orders. Review of facility provided documentation on May 21, 2025, 12:00 p.m., revealed Resident R165, received pneumococcal immunization on August 27, 2024. Review of R165's clinical record revealed no evidence of completed screening prior to immunization. Interview with facility's infection preventionist, Employee E4, on May 21, 2025 at 2:00 pm, confirmed that facility does not complete screening for pneumococcal immunizations prior to administration. 28 Pa Code 210.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12 (c)(d) (10) nursing services

Based on interviews with residents and staff, observations, and review of facility policy, it was determined the facility did not ensure the residents' right to file a grievance anonymously was available for the residents for nine of nine residents interviewed (Resident R15, 16, 26, 28, 29, 39, 42, 43, and 159). Findings include: Review of the facility's policy titled Resident Concerns/Grievances not dated states, The resident or family has the right to file a grievance anonymously by using the locked boxes on the households which are routinely checked by the DON (Director of Nursing). During resident council on May 22, 2025, at 10:00 a.m. with nine alert and oriented residents (Resident R15, 16, 26, 28, 29, 39, 42, 43, and 159) all agreed that they were not aware it was their right to be able to file a grievance anonymously. During an interview and observation with Community Life Leader, Employee E6, on May 22, 2025, at 11:30 a.m., a sign posted in one of the three skilled nursing units titled Notice of Grievance Procedures indicated the residents had the right to file a grievance and may file a grievance anonymously. The surveyor did not observe a designated area where the anonymous grievance would be submitted. Employee, E6 pointed to the box labeled suggestion box. The Directof of Nursing confirmed On May 23, 2025, at approximately 11:30 a.m., there will be a box labeled for anonymous grievances. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)Resident rights

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one of 16 residents reviewed. (Resident R28) Findings Include: Review of the facility policy titled Abused or Neglected Residents revied 2023, states the resident has the right to freedom from neglect and protects residents from real or perceived abuse or neglect from any source. The policy defines neglect as deprivation by an individual, including caretaker, a facility, its employees, or service providers to provide good and services that is necessary to attain or maintain physical mental emotional psychosocial well-being. The same policy states that the investigation will include the witness(es) interview and signed statement will be obtained. Any suspected or alleged abuse will be reported to the Department of Health. Resident R28 was admitted to the facility on [DATE], with heart failure, and atrial fibrillation (irregular heartbeat causing increased risk for stroke). Review of nursing note dated February 5, 2025, stated the resident alerted the staff that she spilled coffee on herself. Upon the nurse's assessment the resident was noted with scattered intact blisters to the right abdominal area, under right breast and upper right thigh. Interview with Resident R28 on May 23, 2025, at approximately 1:00 p.m. indicated she was given her cup of coffee sitting up in bed and fell asleep with the cup in her hand. The resident stated, At first, I didn't realize it because it didn't hurt. I didn't tell nursing until later. Interview with the Director of Nursing on May 22, 2025, at approximately 9:30 a.m. stated the incident was not reported to State Survey Agency. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on clinical record review, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of abuse and neglect for one of 16 residents reviewed. (Resident R28) Findings include: Review of the facility policy titled Abused or Neglected Residents revised 2023, states the resident has the right to freedom from neglect and protects residents from real or perceived abuse or neglect from any source. The policy defines neglect as deprivation by an individual, including caretaker, a facility, its employees, or service providers to provide good and services that is necessary to attain or maintain physical mental emotional psychosocial well-being. The same policy states that the investigation will include the witness(es) interview and signed statement will be obtained. Any suspected or alleged abuse will be reported to the Department of Health. Review of Resident R28 was admitted to the facility on [DATE], with heart failure, atrial fibrillation (irregular heartbeat causing increased risk for stroke). Review of nursing note dated February 5, 2025, stated the resident alerted the staff that she spilled coffee on herself. Upon the nurse's assessment the resident was noted with scattered intact blisters to the right abdominal area, under right breast and upper right thigh. Review of facility investigation and interview with dining coordinator, Employee E7 May 22, 2025, at 12:00 p.m. who placed the coffee on the resident's breakfast tray and the aide Employee E8 on May 23, 2025, at 11:30 p.m., who served the coffee to Resident R28, confirmed the facility failed to obtain the written witness statement to rule out any possibility of neglect. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee

Based on review of facility provided documentation, review of clinical record, and interview with staff, it was determined that facility did not provide Covid-19 immunizations according to professional standards of practice for 35 of 73 residents reviewed (Residents R7, R26, R35, R27, R48, R43, R29, R18, R177, R15, R178, R20, R14, R38, R166, R167, R168, R169, R170, R171, R172, R173, R174, R8, R175, R176, R179, R180, R39, R37, R9, R46, R40, R22, R181) Findings include: Review of facility provided policy 'Immunization Policy,' unknown date, indicates that All residents, staff and volunteers will be offered covid-19 vaccine per the Centers for Disease Control and Prevention (CDC) recommendations. According to CDC Epidemiology and Prevention of Vaccine-Preventable Diseases, revised on April 22, 2024, indicates that The key to preventing serious adverse reactions after vaccination is effective screening. Every patient should be screened for contraindications and precautions before administering any vaccine dose. Further review of facility's policy 'Immunization Policy,' unknown date, indicates that these vaccines will be administered by any appropriately qualified personnel who are following facility procedures, without the need for an individual physician evaluation or order other than the signed standing orders. According to S483.80(d)(3) COVID-19 immunizations, The LTC facility must develop and implement policies and procedures to ensure all the following: When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized. (Screening individuals prior to offering the vaccination for prior immunization, medical precautions and contraindications is necessary for determining whether they are appropriate candidates for vaccination at any given time.) Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R7 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R26 was administered covid-19 immunization on October 14, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R35 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R27 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R48 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R43 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R29 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R18 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R177 was administered covid-19 immunization on December 17, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R15 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R178 was administered covid-19 immunization on October 26, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R20 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R7 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R14 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R38 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R166 was administered covid-19 immunization on November 8, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R167 was administered covid-19 immunization on February 22, 2025. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R168 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R169 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R170 was administered covid-19 immunization on October 15, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R171 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R172 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R173 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R174 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R8 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R175 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R176 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R179 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R180 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R39 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R37 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R9 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R46 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R40 was administered covid-19 immunization on April 24, 2025. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R22 was administered covid-19 immunization on October 11, 2024. Review of facility provided documentation, on May 21, 2025 at 12:00 pm, revealed Resident R181 was administered covid-19 immunization on October 14, 2024. Review of residents' clinical records revealed no evidence of completed screening prior to covid-19 immunizations. Interview with facility's infection preventionist, Employee E4, on May 21, 2025 at 2:00 p.m. confirmed facility did not complete screenings on the residents listed above as required. 28 Pa Code 201.18(b)(1) Management

Based on interviews review of clinical records and facility policy, it was determined the facility failed to have a scheduled maintenance for residents' bed rails to ensure safety for one of 16 resident records reviewed (Resident R28). Findings include: Review of the facility's undated policy titled Bed Rails states the facility will ensure individual bed rail assessments and evaluations are performed on a regular basis. Resident was admitted to the facility on [DATE], with heart failure, atrial fibrillation (irregular heartbeat causing increased risk for stroke). Review of Resident R28's nursing note revealed an incident on March 11, 2025, the resident was found on the floor with a hematoma (bruise) to the left side of the head. The nurse noted that the right-side bed rail was broken, right side rail was in up position but would not lock in place. Interview with the Director of Maintenance on May 22, 2025, at 9:00 a.m. stated the bed rails were checked only at the time that a room was prepare for a new admission. Since the incident the Director of Maintence stated we now check the bedrails monthly since the incident. 28 PA Code 201.18(b)(1) Management

Based on review of clinical record, review facility policy, and interview with staff, it was determined that the facility failed to ensure the residents were provided with education regarding the benefits and potential side effects of influenza immunization for two of two residents reviewed (Resident R29 and Resident R14). Findings: Review facility policy on Influenza and Pneumococcal Vaccination revealed that under section Policy, it is the policy of [NAME] that each resident is to be protected against the influenza virus. Influenza vaccine will be offered for each resident annually. Under section Purpose to control a potential outbreak and prevent residents, visitors, and employees from being infected by the influenza virus. Under section procedure #1. Up and admission, readmission and annually the residence medical record will be reviewed for a history of influenza pneumococcal vaccination. #3 Each year the influenza vaccination is offered in a high dose for residents over [AGE] years of age and if indicated, the resident will be offered pneumococcal vaccination. If the resident/resident representative declines education about risk and complications of not receiving the influenza or pneumococcal vaccine will be discussed. #5 An order to administer the influenza vaccination each year will be obtained. #6 The resident will receive the influenza vaccination as ordered. Review of Resident R29's clinical record revealed no documented evidence that before offering the influenza immunization, Resident R29 received education regarding the benefits and potential side effects of the immunization. Review of Resident R14's clinical record revealed no documented evidence that before offering the influenza immunization, Resident R14 received education regarding the benefits and potential side effects of the immunization. Interview with Director of Nursing Employee E2 conducted on August 23, 2024, at 10:46 AM revealed that residents and families are provided with consent forms for vaccinations upon admission only and only asks the residents verbally if they want the vaccines at the beginning of each flu season. Further, Employee E2 confirmed that there was no documented evidence that the residents or the resident representatives received education regarding the benefits and potential side effects of influenza immunization. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of facility documentation, and review of clinical records it was determined that the facility failed to develop a person-center, comprehensive care plan related to impaired skin integrity for one of 15 residents reviewed (Resident R26). Findings Include: Review of facility policy Care Planning, undated, revealed a care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs. The resident's comprehensive care plan is developed within 7 days of submission of the complete MDS (Minimum Data Set - federally mandated resident assessment and care screening) assessment. Review of Resident R26's quarterly MDS dated [DATE], revealed the resident had short and long-term memory problems and was at risk of developing pressure ulcers. Review of facility skilled wound report dated August 15, 2024, by Licensed Nurse, Employee E5, revealed Resident R26 had a deep tissue injury (DTI - localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) of the right fifth toe with an onset date of July 11, 2024. Review of Resident R26's care plan revealed no documented evidence the facility developed or implemented a person-centered, comprehensive care plan with measurable objectives and timetables to address the resident's impaired skin integrity. 211.10 (d) Resident care policies.

Based on observations, review of facility policy, and staff interviews it was determined that the facility failed to implement procedures to ensure food was served at safe, appetizing temperatures for one of six residents observed in the dining room (Resident R31). Findings Include: Review of facility policy Food Temperatures, undated, revealed microwave re-heating is appropriate and acceptable when a resident requests to have their food reheated. Upon removal of the food from the microwave, the food will be stirred or rotated and then allowed to stand covered for two minutes before served to assure that the temperature will be under 180 degrees Fahrenheit. Review of Resident R31's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) revealed the resident had moderate cognitive impairment and had diagnoses of muscle weakness and dementia (group of symptoms affective memory, thinking abilities, and social abilities). Observations on August 21, 2024, at 12:35 p.m. in the Park dining room revealed dietary aide, E4, heated up a plate of food (hot dog and beans) for Resident R31. Further observations revealed dietary employee, E4, removed the plate from the microwave and handed it directly to the nurse aide to serve to Resident R31 without checking the temperature or letting it sit to come down to the proper temperatures. Subsequent interview on August 21, 2024, at 12:35 p.m. with dietary aide, Employee E4, confirmed the temperature of the food was not checked to ensure it was being served at safe temperatures. 211.12 (d)(5) Nursing services.

Based on observations, review of clinical record, and staff interview it was determined that the facility failed to provide beverages consistent with resident needs for one of six residents reviewed with altered fluid consistency (Resident R17). Findings Include: Review of Resident R17's clinical record revealed a physician order dated August 18, 2024, that revealed Resident R17 was ordered nectar consistency liquids (beverages that are thicker than water and fall slowly from a spoon). Observations on August 21, 2024, at 10:00 a.m. revealed Resident R17's breakfast tray was sitting on the overbed table in the resident's room. Observations revealed the meal ticket indicated Resident R17 was to be provided nectar thick liquids. Further observations revealed Resident R17 was provided with orange juice that was of thin, regular, consistency. Interview on August 21, 2024, at 10:05 a.m. with Nurse Aide, Employee E3, confirmed Resident R17 was provided with the wrong beverage. 211.10 (c) Resident care policies. 211.12 (d)(5) Nursing services.

Based on review of facility policy/Infection Control Program Overview, interview staff, review of facility record, it was determined that the facility failed to designate one or more individual as the infection preventionist who work at least part time at the facility. Findings include: Review facility Infection Control Program Overview, under section Goals: The goals of the infection control program are to #a Decrease the risk of infection to residents and personnel #b Monitor for occurrence of infection and implement appropriate control measures. #c Identify and correct problems relating to infection control practices #d ensure compliance with the state and federal regulations relating to infection control. Under section Division of Responsibilities for Infection Control Activities: the administrator is ultimately responsible for the infection control program. #A. Infection control practitioner or designee Responsibility is delegated to a staff member acting as the infection control practitioner or to a trained infection control practitioner to carry out the daily functions of the infection control program. Those functions are described in the Infection Control practitioner job description. The infection control practitioner or designee has knowledge and interest in infection control. Interview with Director of Nursing Employee E2 conducted on August 21, 2024, at 12:45pm confirmed that Employee E2 was the full time Director of Nursing at the facility. Further interview with Employee E2 also revealed that while being the full time Director of Nursing, Employee E2 was also the infection preventionist for the facility and that she was the only employee in the facility with an infection control certification. Follow-up interview with Employee E2 conducted on August 23, 2024, at 10:46 am revealed that Employee E2 also revealed that she does not clock in because she is a salary employee. Further Employee E2 also revealed that there was no documented evidence that she also worked part time as an infection preventionist. 28 Pa. Code 210.18(e)(1) Management 28 Pa. Code 211.12(d)(1) Nursing Services

Based on observation, review of facility policy, clinical record review, resident and staff interviews, it was determined that the facility failed to provide appropriate Activity of Daily Living (ADL) for two of 6 residents reviewed who were unable to carryout ADL care independently. (Resident R1 & R3) Findings include: Review of MDS (Minimum Data Set-assessment of resident care need) for Resident R1 dated April 2, 2024, revealed that the resident was dependent on the staff for showers, transfers, and toileting. MDS also revealed that the resident had a BIMS (Brief Interview for Mental status) score of 8 which indicated that the resident's cognitive status for daily decision making was moderately impaired. Clinical record indicated that Resident R1 was scheduled for showers on Wednesday and Saturday from 7-3 shift. On June 13, 2024, at 2:35 p.m. a review of Shower Task Performance Documentation with the Director of Nursing revealed and confirmed that Resident R1 was not given showers on Wednesdays May 8, 15, 22, 2024 and June 5, 2024, as per her schedule. Review of Resident R3's clinical record review indicated that Resident R6 was admitted to the facility on [DATE]. Clinical record indicated that Resident R3 was scheduled for showers/bed baths on Tuesday and Fridays. On June 13, 2024, at 10:29 a.m. an interview and observation held with Resident R3 who was in lying in bed mid-size facial hair, long hair, and long nails. The long hair looked greasy and dead white flakes on the top of his/her hair. Resident when questioned if he/she desires to cut his hair, facial hair, and nails. Resident R3 responded yes but I'm unable to do it myself. Resident R3 prefers bed baths over shower as he/she has colostomy bag. This observation was confirmed by License Nurse, Employee E5. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed related to toileting program, tubi-grips, gel cushion to wheelchair, for one resident of six residents reviewed. (Resident R1) Findings include: Review of facility policy, Medication Order undated, revealed, it is the policy of [NAME] Lutheran to establish uniform guidelines in the receiving and recording of medication orders. To ensure safe and effective use of medications and that medication information on residents is captured, used and communicated. Review of active physician order for Resident R1 revealed an order dated December 11, 2023 toileting schedule: Take resident to the bathroom/offer toileting resident at around 8:00 a.m., 11:00 a.m., 2:00 p.m., 5:00 pm, 8:00 p.m. check and change as need while asleep. Order dated May 1, 2023 tubi-grips to bilateral lover extremities place on in am and remove at bedtime. On November 3, 2022, to gel cushion to wheelchair check placement and integrity every shift. A review of the Task Documentation for Toilet Use from May 1, 2024 -June 12, 2024, the following dates did not document 11:00 am toileting attempt: May 1, 2,3, 4,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25,26,27,28,29,30,31, 2024 June 2, 3,4,5,6,7, 8, 9, 10, 11, 12, 2024 On June 13, 2024, at 10:39 a.m. to 11:15 a.m. interview and observations were completed in the living room of Resident R1 participating in activities but was not taken to the complete a toilet program per the physician order at 11am. Further observations were completed during the same day from 12:22 p.m. to 2:05 p.m. with Resident R1 who as having lunch and then transitioned to the living room for activities. There was no implementation of toileting program at 2pm. On June 13, 2024, at 12:37 p.m. observations made with Rehabilitation Director, Employee E13 that Resident R1 was sitting in her wheelchair eating lunch and had wheelchair foot rest heel loops/strips which would prevent the resident's heel to slide backwards was broken off on the right side. Resident R6 was sitting at the same dining table with Resident R1 and had a foot rest loop broken off as well on the left side. Employee E13 replaced it with new [NAME] and reported that there was no need for the [NAME] loops to be attached. On June 13, 2024, at 1:05 p.m. observation was taken place that Resident R1 was sitting in the dining room with no tubi-grips per the physician order. License Nurse, Employee E5 confirmed the observation and reported I must have forgot. Employee E5 went into Resident R1's room to locate tubi-grips and there was nonavailable. Employee E5 stated I will have to order it. 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, resident and staff interviews, it was determined that the facility failed to implement individualized approaches to restore normal bladder function and prevent continued decline of bladder continency for one of one resident reviewed for bowel and bladder management (Resident R38). Findings include: Interview with Resident R38 on October 11, 2023, at 11:54 a.m. stated she was continent 6 weeks ago, now she was incontinent after her recent hospitalization . Resident stated she was not using her bathroom or staff did not make any toileting plan. A review of Resident 38's admission assessment dated [DATE], revealed an assessment of resident's genitourinary system review which indicated that the resident was incontinent of urine, and she had a new onset of incontinence. Further review of the assessment revealed that the resident also had bowel incontinence. A review of Resident 38's bladder elimination record from September 19, 2023, to October 13, 2023, revealed the resident had 58 documented occurrences of incontinence. It was also revealed that continent of bladder was documented 6 times. Review of Resident R38's admission MDS (Minimum Data Set- assessment of resident care needs) dated September 26, 2023, revealed that the resident was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Further review of the MDS revealed that there was no trial of a toileting program (e.g. Scheduled toileting, prompted voiding, or bladder training) been attempted on admission or reentry or since urinary incontinence was noted in the facility. Review of the resident's plan of care dated September 20, 2023, revealed that the resident was noted with new onset of urinary incontinence with interventions included, evaluate if resident was aware of the need to void, evaluate for urinary complaints, evaluate medication schedule and possible pharmacological causes of new urinary incontinence, and evaluate resident's ability for toileting self-care. Review of clinical record for Resident R38 revealed no documented evidence that the staff assessed and implemented interventions to restore urinary continence or to prevent further decline in urinary continence. Interview with the Director of Nursing on October 13, 2023, at 11:00 a.m. confirmed that the facility did not implement interventions to restore urinary continence or to prevent further decline in urinary continence for Resident R38. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, clinical record review and interviews with staff, it was determined that the facility failed to implement psychiatry recommendations in a timely manner for one of two residents reviewed for behavioral health services (Resident R26). Findings include: Review of nursing progress note for Resident R26 dated August 18, 2023, revealed that the resident refused repositioning and at times refused care despite of continuous education and encouragement. Review of nursing progress notes for Resident R26 dated September 1, 2023, September 4, 2023 and September 10, 2023 revealed that the resident refused shower and at times refused care. Further review of nursing progress note for Resident R26 dated September 10, 2023, revealed that the resident was combative during treatment, and he was rolling nurses aide's wrist. The resident repeatedly hit the nurse. Review of resident's care plan for Resident R26 dated June 6, 2023, revealed that the resident had behavioral problem with interventions included, administer medications as ordered. Monitor/document for side effects. Review of Psychiatry Note for Resident R26 revealed that the staff stated resident was irritable and at times uncooperative. It was also revealed that the psychiatrist recommended to increase resident's Bupropion (It can treat depression) to 100 milligrams (mg) in the morning and 50 mg in the evening for irritability and low motivation. Review of physician orders for Resident R26 revealed an active physician's order, dated August 15, 2023, for Bupropion 50 mg twice daily. Continued review of physician orders revealed that there were no orders to adjust the dosage of the Bupropion as per the psychiatrist's recommendations. Interview on October 13, 2023, at 11:00 a.m., with. Employee E2, Director of Nursing, confirmed that there was no documented evidence that the psychiatrist recommendation was addressed by the staff or attending physician. 28 Pa Code 211.2(a) Physician services 28 Pa Code 211.12(d)(3) Nursing services

Based on observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for one of two medication carts observed. (Second floor medication cart). Findings Include: Review of manufacturer's guidelines for Humalog Insulin (insulin lispro) (medication used to treat high blood sugar levels) revealed that Humalog must be discarded 28 days after opening. Review of manufacturer's guidelines for Lantus Insulin(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Basaglar(insulin glargine) revealed that the medication must be discarded 28 days after opening. Review of manufacturer's guidelines for Novolog Insulin (insulin aspart) revealed that the medication must be discarded 28 days after opening. Unopened vials should be refrigerated unit use. Observation on October 11, 2023, at 9:20 a.m. of the second-floor medication cart with Registered Nurse, Employee E11, revealed open and undated vials of insulin pen, Basaglar, Humalog, Lantus and Novolog in room temperature. Further observation of the mediation cart revealed opened Refresh eye drops, Tobramycin eye drops, Latanoprost eye drops, and Timolol eye drops with no open date or expiration date. Interview with Licensed nurse, Employee E11, on October 11, 2023, at 9:20 a.m. stated staff label insulin pens and eye drops with open dates and expiration dates. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on the review of clinical records, review of facility documentation and interviews with resident and staff, it was determined that the facility failed to ensure that the appropriate assistive devices were provided during wheelchair transport to one of 27 residents reviewed which resulted in actual harm to the resident who sustained a fractured right ankle as a result (Resident R38). Finding Include: Review of clinical record for Resident R38 revealed that the resident was admitted to the facility on [DATE], with diagnoses including: fractured (broken) femur (thigh bone), [CONDITION(S)] (systemic, progressive [CONDITION(S)] disorder which causes damage to joints), fall, muscle weakness, difficulty walking and unsteadiness on the feet. Review of Resident R38's admission MDS (Minimum Data Set-Assessment of resident care needs) dated August 24, 2021, revealed that the resident had a BIMS-(Brief Interview for Mental Status) score of 9 which indicated that that the resident's cognitive status was moderately impaired. Continued review of the MDS revealed that the resident required one person assistance for locomotion off the unit and that the resident used a wheelchair for mobility. Review of an orthopedic consult dated September 10, 2021, revealed that the resident had a weight of 272 lb and a BMI (Body Mass Index- a measure of body fat based on height and weight that applies to adult men and women) of 42.60 which indicated that the resident was obese. Further review of the consult indicated that the resident had a history of a prior fall and sustained a right [CONDITION(S)] which required surgical repair on July 1, 2021. Review of physical therapy initial evaluation dated August 26, 2021, revealed that the resident's right lower extremity strength was impaired. Upon muscle grading assessment (This method involves testing key muscles from the upper and lower extremities against the examiner's resistance and grading the patient's strength on a 0 to 5 scale accordingly) the resident scored 3- (Three minus-Gradual release from test position) out of 5 for right hip, 3- for right knee extension and 3+(Three plus-Hold test position against slight pressure). The resident also had a pain level of 4 out of 10 to the right groin with hip flexion. Interview with Resident R38 on December 6, 2021, at 11:37 a.m. revealed that the resident had sustained a fracture to her right lower extremity when staff pushed her in the wheelchair six weeks ago. She stated staff did not use a leg rest during the transport to an activity which was held in the atrium, a distance of 522 feet from resident's room. Resident R38 stated she had requested the leg rest on her way back from the activity, but the staff member told her that she would push her fast so that she did not have to hold the leg up for a long time. Resident stated that she dropped her foot because of the pain and her right foot went underneath the wheelchair. Review of facility investigation dated October 15, 2021, revealed that Resident R38 was escorted to an activity by community life, during transport back from the activity the resident was unable to hold her legs up and her right leg was caught under the wheelchair. Resident complained of mild discomfort afterwards and x-ray obtained which revealed an acute fracture of the distal right fibula (ankle). The resident was sent to the ER for evaluation and treatment and returned with immobilizer/ace wrap in place and orders to follow up with ortho as outpatient. Review of a statement completed by Employee E12, Community Life staff, dated October 15, 2021, revealed that on the way to the happy hour activity Resident R38 asked for a break and took a rest at that time. Employee 12 asked the resident if she should get her leg rest and resident declined because they were near the atrium. Employee E12 said she would get the leg rest for their way back. After the activity Employee E12 took someone else to their room and she saw Resident R38 taking herself back to her room. Employee E12 told Resident R38 that she would get her leg rest and take her back. But resident stated her daughter was there and wanted to return to her room. Resident stated they would take break like last time. Employee E12 stated they took one break when the resident was tired and started moving again. Employee E12 stated that she told the resident that I will try to get you back quickly so that you don't have to hold your leg up long. Resident dropped her leg suddenly when they were in front of the security desk and Resident stated, I think I broke my ankle. Interview with Employee E12 on December 7, 2021, at 12:51 p.m confirmed that she had picked up the resident in her room for a happy hour activity which was scheduled in the atrium on the other side of the facility. Employee E12 stated she did not offer the wheelchair leg rest prior to the transport. On her way to the atrium, Resident R38 asked for a break when they approached close to the atrium. After the activity was finished, Employee E12 dropped someone else to their room. Employee E12 stated on her way back to the atrium, she saw Resident R38 wheeling herself back to her room. Employee E12 stated she offered her the leg rest but Resident R38 replied that her daughter was in her room and she needed to go right away. Employee E12 further stated Resident R38 took a break at the door before the security desk for some time. When they approached the security desk, Employee E12 saw someone passing by and looked at the person. Employee E12, stated suddenly she realized the wheelchair stopping and she looked at the resident and saw her right leg under the wheelchair. Employee E12 also stated that she was not familiar with Resident R38 and did not usually take Resident R38 to the atrium because she was not the regular activity staff on Resident R38's unit. Employee E12 confirmed that she was not aware of Resident R38's medical history and ambulation status other than the wheelchair use prior to October 15, 2021. Employee E12 also confirmed that she did not ask for the charge nurse and the nursing assistant scheduled for Resident R38 about resident's status. A distance measurement was requested to the administrator on December 6, 2021. Administrator reported the following measurements. 522 feet from Resident R38's room to the atrium. 282 feet from atrium to security desk. 254 from where Employee E12 picked up Resident R38 to double doors before the security desk. 23 feet from where Employee E12 and Resident R38 took break to location of the incident. Interview with Employee E10, Director of Therapy, on December 7, 2021, at 10:59 a.m., revealed if a person with cognitive impairment, contractures and unable to sequence need a wheelchair leg rest because most cases they are on therapy due to a weakness issue. Employee E10 stated a wheelchair leg rest would be used every time a resident was brought to therapy. Employee E10 stated if a resident refused leg rests staff should educate the resident about safety. Employee E10 also stated every resident that used a wheelchair received leg rests on admission and should be utilized if a resident has muscle weakness. Employee E10 confirmed that the risk for injury increases if staff pushes the wheelchair faster when the resident could not hold their leg up in wheelchair. Interview with Employee E11, Director of Recreational Therapy, on December 7, 2021, at 1:00 p.m. revealed when a resident is transported long distances leg rests were always used. Employee E11 stated activity staff were not trained on transport or wheelchair safety. Employee E11 further indicated that staff should look at the medical record or notify the charge nurse or nursing assistants if a resident refuses the leg rest before transporting a resident without the wheelchair leg rest. Review of clinical record for Resident R38 revealed no documented evidence that Employee E12 notified the nurse or the nursing staff when Resident R38 refused the wheelchair legs rests on October 15, 2021. There was also no documented evidence that the staff requested or obtained Resident R38's wheelchair leg rest to the atrium. Review of clinical record also revealed that there was no documented evidence that the staff educated Resident R38 about the importance of using leg rests or safety risk associated with not using leg rests when transporting by staff for long distances. Interview with Director of Nursing, Employee E2, on December 6, 2021, at 2:00 p.m. confirmed that Employee E12 did not use wheelchair leg rests to transport Resident R38 with documented history of right [CONDITION(S)] and surgical intervention, muscle weakness and obesity. Employee E2 also confirmed that staff was expected to utilize wheelchair leg rests when transporting resident off the unit or long distances. 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of clinical records and interview with facility staff, it was determined that the facility failed to monitor and supervise a resident to prevent injury for one of 14 residents reviewed, which resulted in actual harm (Resident R21). Findings include: Review of the clinical record for Resident R21 revealed a quarterly Minimum Data Set assessment (MDS-an assessment of resident care needs) dated August 29, 2016, indicated the resident had [DIAGNOSES REDACTED]. The resident's Braden Scale, for Predicting Pressure Sore Risk, dated June 6, 2016, revealed a score of 14, indicating the resident was a moderate risk for developing pressure sores. Resident R21 presented with two full thickness wounds (FTW - a deep tissue wound involving all layers of the skin) on the inside of the lower left leg. Review of facility documentation/investigation dated August 1, 2016, revealed that the resident sustained [REDACTED].(Certified Nursing Assistant per facility definition). The resident was transferred from the wheelchair to the bed. After the transfer, the CNA noticed a laceration on the resident's shin. The resident was sent to the hospital and received 11 sutures on the left inner calf. Documentation stated that after the facility investigation, the facility concluded the spiral cord on the bed controller had some frayed plastic, which caused sharp edges. The physician's orders [REDACTED]. Observation by the surveyor of the wound care on the two identified lacerations on the resident's left lower calf was completed on September 16, 2016, at 11:20 a.m. with Licensed Practical Nurses, Employee E3 and Employee E4. The Employees both explained, days after the 11 sutures were removed, blisters started forming at the wound site and the site got infected. Two wounds were observed on the lower left leg. The smaller wound which was proximal (closer to the body) measured 3.0 centimeters (cm) in length x 6.0 cm in width x < (less than) 0.1 cm (less than 0.1 cm) depth with moderate serosanguineus drainage (composed of serum and blood), with 90% granulated tissue (new tissue) and 10% slough (dead tissue, usually cream or yellow in color, such tissues impedes healing). The distal (farthest from the body) wound measured 10.0 cm in length x 6.0 cm in width x 0.3 cm in depth, with 20% granulated tissue, 60% slough and 20% eschar (dry, black, hard necrotic tissue, such tissue impedes healing), with moderate serosanguineus drainage. The above information was confirmed with the Nursing Home Administrator and the Director of Nursing at 2:00 p.m. on September 16, 2016. The facility failed to monitor and supervise a resident, during a transfer with a Hoyer lift, to prevent injury for one resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/25/14, 10/01/15

Based on clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to accurately monitor and assess and provide treatment to one resident for the development of a pressure ulcer that resulted in actual harm to the resident (Resident CL1). Findings include: A review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an MDS (Minimum Data Set-a periodic assessment of needs) dated May 22, 2013, indicated that the resident had severe impairment of cognitive skills (BIMS-Brief Interview for Mental Status score of 5/15) and required extensive assistance with one or two staff members for transferring, ambulation and bathing. A skin assessment (Baden Scale) dated May 6, 2013 indicated that the resident was at a low risk of developing a pressure sore. Review of nursing progress noted dated May 16, 2013 at 11:00 p.m., indicated that the resident was identified with blood blisters on both heels. The pressure ulcer report dated May 17, 2013 indicated that the deep tissue wound (DTI - skin damage of underlying soft tissue) on the resident's left heel measured 4.5 cm x 6.5 cm and the DTI on the right heel measured 3.5 cm x 7.5 cm. A review of nursing progress notes dated June 1, 2013 at 5:10 p.m., indicated that the physician was notified of the resident's poor intake of food and fluids and a low grade temperature and the physician gave a verbal order to send the resident to the emergency room the next day for an evaluation. Another nurse's progress note dated June 1, 2013 at 8:00 p.m. revealed that the resident was observed with skin failure on the sacrum. The area measured 3.5 cm.(centimeters) x 6.0 cm. that was deep purple in color and had an opening that measured 3.5 cm. x 2.5 cm. x 0.3 cm. deep with 70% slough (dead tissue separated from living tissue) and 30% brown tissue (necrotic - dead tissue) with a small amount of drainage. The physician was notified and ordered to treat the wound with Santyl (a [MEDICATION NAME] agent to remove dead skin). Nursing progress notes dated June 2, 2013 indicated that the resident was transferred to the hospital the next morning. A review of the physician's orders indicated that there had been no preventative measures implemented for the resident at admission or during the stay to reduce the risk of pressure ulcer development. A review of the resident's care plan indicated that a skin risk care plan was developed on May 29, 2013 related to the DTI on both of the resident's heels but there was no indication that a care plan had been developed to help reduce the risk of pressure ulcers for the resident. There was no evidence that the facility was turning or repositioning the resident to relieve pressure on the sacrum or that the facility was applying any preventive skin prep to the residents body. A review of the facility policy "Pressure and Venous Wound Care Management" indicated that nursing is to conduct weekly wound rounds to evaluate and document assessments. A nursing wound assessment progress note dated May 30, 2013 indicated that the only wounds being monitored were the wounds on the residents heels. Interview with Employee E1 on June 14, 2013 at 1:30 p.m. confirmed that there had been no preventative measures or treatment in place for the resident prior to the discovery of the Stage III ( Full-thickness loss of skin with serosanguineous drainage )pressure ulcer of the sacrum. The facility failed to accurately monitor and assess the resident that resulted in actual harm to the resident with the development of a pressure wound. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously Cited 5/31/13

Based on clinical record review, staff interviews and review of facility policy and procedure it was determined that the facility failed to complete comprehensive resident assessments and failed to notify the physician, timely, with a change of condition for two of 16 residents reviewed, resulting in actual harm to Resident R48 (Residents R24 and R48). Findings include: Review of Resident R48's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nursing admission assessment revealed that the resident's weight was recorded as 172.8 pounds, skin was intact with a blister noted on the front groin. No other skin issues were indicated. A nurse's note dated October 1, 2011 indicated the resident returned from the community with family at 11:00 p.m. and was noted to have plus 2 [MEDICAL CONDITION] (swelling) in his bilateral lower extremities. There was no evidence that the [MEDICAL CONDITION] in the lower extremities was assessed or monitored or that the physician was made aware. On October 6, 2011, the resident's weight was documented as 192.2 pounds, indicating a 19.4 pound weight gain in one week. Again, there was no evidence that the physician was made aware of this significant weight gain. A nurses note dated October 7, 2011, at 8:00 p.m., indicated that the nurse noted redness and [MEDICAL CONDITION] (swelling) in the resident's testicles, penis and groin area and that an odor was apparent. [MEDICATION NAME], a topical powder used to treat a fungal infection was ordered. On October 9, 2011, a nurses note at 8:00 p.m. indicated that a family member had reported that the resident was having difficulty breathing earlier that day. There was no evidence the physician was notified. The resident's condition continued to worsen and on October 12, 2011, 11 days after initially developing [MEDICAL CONDITION], nursing documented that the resident was transferred to the hospital for increased [MEDICAL CONDITION] in his bilateral lower extremities and was admitted to the hospital with [REDACTED]. An interview with Employee E1, licensed nurse, on October 13, 2011, at 2:25 p.m., confirmed that the resident's significant change in condition was not adequately assessed and monitored. Review of Resident R24's periodic assessment dated [DATE] revealed that the resident's [DIAGNOSES REDACTED]. Review of the nursing progress note dated February 27, 2011 at 5:00 p.m. revealed that Resident R24 had vomited three times and had loose stools. The resident was given a liquid diet and medications were not administered due to the nausea and vomiting, there was no evidence that the resident's vital signs were recorded or that a lung assessment or abdominal assessment was completed or that the physician was notified of the change in the resident's condition. The nursing progress note dated February 28, 2011 at 2:30 a.m. revealed that Resident R24 continued with watery stool, the next nursing progress note on February 28, 2011 at 10:25 a.m. and 10:30 a.m. revealed that the resident's pulse oximetry (measurement of oxygen percentage of red blood cells. normal 92-100%), was 83% on room air and that the respiratory rate was >24 and that the resident was very lethargic (decreased level of consciousness) and very diaphoretic (sweating) and that a blood pressure could not be heard/obtained, there was no evidence that temperature or a pulse rate was obtained. Resident R24 was then sent to the hospital emergency room for an evaluation. The nursing progress note dated March 8, 2011 revealed that the resident was readmitted to the facility and the nursing progress note dated March 10, 2011 revealed that the resident's hospital [DIAGNOSES REDACTED]. An interview with Employee E2, licensed nurse, on October 13, 2011 at 12:45 p.m. confirmed that he physician was not notified of the resident's change in condition until February 28, 2011 at 10:30 a.m. An interview with Employee E1, licensed nurse, on October 13, 2011 at 1:30 p.m. revealed that there was no hospital records available for review. Review of the facility's policy and procedure titled "Change in a Resident's Condition or Status" not dated, revealed that the resident's physician will be promptly notified of a significant change in condition and that a comprehensive assessment will be completed by the charge nurse for a significant change in condition. 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services.