Every finding on record at Ball Pavilion, The

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety for one of six kitchen refrigerators, and three of three pantry refrigerator/freezers; and failed to monitor resident's personal refrigerators for temperatures for one of one residents reviewed with personal refrigerators (Resident R55).Findings include: Review of a facility policy entitled Cooler and Freezer Storage dated 2/19/26, revealed Leftover prepared foods will be discarded if not used within three days of preparation. Review of a facility policy entitled Pantry Stock of Nursing Units and Dining Rooms dated 2/19/26, revealed A server will stock the pantries on A, B, and C and dining rooms with food supplies each morning and evening; All outdated food items will be discarded; Leftover food items will be discarded if not used within three days; At your service items will be discarded if not used within 30 days. No policy was provided regarding Personal Refrigerators. Observations during a kitchen tour on 3/24/26, at 12:15 p.m. of cooler six revealed two pitchers of iced tea dated 3/17/26. During an interview with the Dietary Manager on 3/24/26, during the time of observation, he/she confirmed that the two pitchers of iced tea were past the use by date and should be discarded. Observation on 3/24/26, at 12:35 p.m. of resident refrigerator/freezer in A Hall pantry revealed three frozen prepared individually wrapped chicken breasts dated 10/22/25. During an interview with the Dietary Manager on 3/24/26, during the time of observation, he/she confirmed the three frozen prepared chicken breasts were expired and should be discarded. He/she further confirmed that the frozen chicken breasts were an at your service item and should be discarded if not used within 30 days. Observation on 3/24/26, at 12:40 p.m. of resident refrigerator/freezer in C Hall pantry revealed the following: one single serve yogurt cup with an expiration date of 2/5/26, one single serve yogurt cup with an expiration date of 2/17/26, two single serve yogurt cups with an expiration date of 3/9/26, one single serve yogurt cup with an expiration date of 3/17/26, five single serve yogurt cups with an expiration date of 3/19/26, two frozen prepared hamburger patties dated 2/10/26, one frozen prepared hamburger patty dated 10/23/25, and three frozen prepared hamburger patties dated 2/20/26. During an interview with the Dietary Manager on 3/24/26, during the time of observation, he/she confirmed the ten single serve yogurt cups were expired and should be discarded, and six frozen hamburger patties were expired and should be discarded. He/she further confirmed that the frozen hamburger patties were an at your service item and should be discarded if not used within 30 days. Observation on 3/24/26, at 12:50 p.m. of resident refrigerator/freezer in B Hall pantry revealed three frozen prepared hamburger patties dated 2/20/26, and seven frozen prepared hamburger patties dated 2/10/26. During an interview with the Dietary Manager on 3/24/26, during the time of observation, he/she confirmed the ten frozen hamburger patties were expired and should be discarded. He/she further confirmed that the frozen hamburger patties were an at your service item and should be discarded if not used within 30 days. Observation on 3/25/26, at 10:00 a.m. revealed Resident R55 had a personal refrigerator in his/her room. There was no evidence in the room of a temperature log sheet being present. During an interview on 3/25/26, at 10:45 a.m. the Nursing Home Administrator confirmed the facility lacked evidence of monitoring the refrigerator temperatures for Resident R55's personal refrigerator. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during the administration of intravenous (IV) medications for one resident (Resident R49); the administration of feeding tube medications for one resident (Resident R52); and the administration of oral medications for two residents (Residents R15 and R63) observed during medication administration.Findings include:A facility policy entitled, Enhanced Barrier Precautions dated 2/19/26, indicated that enhanced barrier precautions will be implemented for all staff who care for residents during high-contact care activities and included device care and/or use of central lines and feeding tubes. A facility policy entitled, StatSafe (on-site medication dispensing system) - Assigning and Removing Access dated 2/19/26, indicated that licensed nurses will re-dispense doses when medications are dropped. A facility policy entitled, Hand Hygiene Monitoring dated 2/19/26, included the Hand Hygiene Monitoring Procedure which indicated that staff are expected to use a towel to turn off the water faucet and discard the towel. Resident R52's clinical record revealed an initial admission date of 7/17/25, with diagnoses that included pleural effusion (excess fluid build-up around the lungs), pneumonia (infection in your lungs that can cause difficulty breathing, fever and cough), kidney disease, irregular heartbeat. Resident R52's clinical record revealed a physician's order dated 3/03/26, for infection control enhanced barrier precautions [EBP] d/t PICC line (long, flexible tube (catheter) that is inserted into a vein in your upper arm to administer medications), and an order to administer cefazolin sodium {Rocephin (antibiotic)] intravenously three times a day into a venous catheter. Observation on 3/24/26, at 1:49 p.m. revealed EBP signage posted outside of Resident R52's door that indicated all staff are to wear gloves and gowns to perform high-contact care, and a supply of personal protective equipment [PPE (gowns, gloves, etc.)] was present. Registered Nurse Employee E5 donned gloves, flushed the PICC line with 10 cc of normal saline, and administered IV Rocephin through the PICC line and failed to don a gown prior to the administration. Observation on 3/25/26, at 8:35 a.m. revealed that Licensed Practical Nurse (LPN) Employee E4 opened the medication cart drawer, and removed an opened clear plastic pharmacy pill pack, reached inside the drawer with a bare hand and retrieved three pills that were lying loose in the drawer, and placed them inside a medication cup. LPN Employee E4 continued to prepare and administer the medications to Resident R49. Resident R49's clinical record revealed an initial admission date of 1/09/24, with diagnoses that included dementia, pneumonitis (lungs are irritated or inflamed by various factors, such as medications, molds, chemicals, or infections), and gastrostomy status [g-tube (feeding tube inserted through the abdomen directly into the stomach to provide nutrition, fluids, and medications when oral intake is insufficient)]. Resident R49's clinical record revealed a physician's order dated 10/28/25, for infection control EBP d/t g-tube. Observation on 3/25/26, at 8:42 a.m. revealed EBP signage posted outside of Resident R49's door that indicated all staff are to wear gloves and gowns to perform high-contact care, and a supply of personal protective equipment [PPE (gowns, gloves, etc.)] was present. LPN Employee E4 washed his/her hands and then turned off the spigot using a bare hand. LPN Employee E4 then donned gloves and proceeded to administer medications through a g-tube and failed to don a gown. During an interview at that time, LPN Employee E4 confirmed that he/she should have used a towel to turn off the spigot and stated that gowns are worn when the resident has an infectious disease. Observation on 3/25/26, at 9:00 a.m. revealed that LPN Employee E4 poured five medications from the clear plastic pharmacy pill pack into a medication cup, then tipped the medication cup to drop the tablets into the clear plastic pill crushing sheath while holding the capsule inside the medication cup with his/her bare finger. He/she proceeded to prepare the medications and administer them to Resident R15. During an interview at that time LPN Employee E4 confirmed that he/she picked up the medications with his/her hands and then administered them to residents. Observation on 3/25/26, at 9:10 a.m. revealed that LPN Employee E3 removed a soft gel cap medication from the pharmacy bottle with his/her bare hand and placed it in the medication cup. He/she proceeded to prepare medications and administer them to Resident R63. During an interview at that time LPN Employee E3 confirmed that he/she should not have used their bare hand to touch the medication. During an interview on 3/25/26, at 10:05 a.m. the Director of Nursing confirmed that protective gowns should be worn while administering medications through an IV and g-tube, and medications should not be handled with bare hands, and loose medications should be discarded. During an interview on 3/25/26, at 11:20 a.m. the Infection Preventionist confirmed that staff should use a towel to turn off the spigot, and wear gowns during medication administration through an IV or g-tube. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of 15 residents reviewed (Residents R4, R5, and R62).Findings include:Review of facility policy entitled Transfer to Hospital/Emergency dated 2/19/26, indicated Transfer of resident with the necessary paperwork and notifications once decision is made to transport; Nurse is to inform Emergency Department of transfer and will make copies of Face Sheet, Living Will (if resident has one), out of facility DNR, print out resident transfer sheet, vaccine records, and any other resident clinical records deemed necessary to be sent.Resident R4's clinical record revealed an admission date of 12/9/18, with diagnos2s that included Cerebral Infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and High Blood Pressure.Resident R4's progress notes revealed notes dated 12/6/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.Resident R5's clinical record revealed an admission date of 7/8/24, with diagnoses that included gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed), and muscle weakness.Resident R5's progress notes revealed notes dated 1/29/26, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R62's clinical record revealed an admission date of 2/18/26, with diagnoses that included Acute Respiratory Failure, Heart failure, and Dementia.Resident R4's progress notes revealed notes dated 3/6/26, indicating a transfer to assisted living. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.During an interview on 3/27/26, at 10:00 a.m. the Director of Nursing confirmed that Residents R4, R5, and R62's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider.28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy and clinical records, observation, and staff interview it was determined that the facility failed to appropriately maintain respiratory care equipment to prevent the spread of infection regarding respiratory care equipment for one of 15 residents (Resident R1).Findings include: A facility policy entitled, Oxygen Concentrator (medical device that extracts oxygen from ambient air and delivers a concentrated oxygen supply to patients who need supplemental oxygen) Operation dated 2/19/26, indicated that oxygen tubing is be hung on the wall with specific label when not in use and/or change in deliver to portable oxygen. Resident R1's clinical record revealed an admission date of 2/27/26, with diagnoses that included congestive heart failure (chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts), spinal stenosis (narrowing of the spine, which puts pressure on the spinal cord & nerves & can cause pain) of the neck and mid-back, and high blood pressure. A physician's order dated 2/27/26, revealed to administer oxygen via oxygen concentrator/portable at two liters per minute every shift. Observation on 3/24/26, at 1:00 p.m. revealed Resident R1 sitting in his/her room with the supplemental oxygen tubing from the concentrator in his/her nose and the oxygen tubing cannula for his/her portable oxygen canister was hanging over the top of the canister that was attached to the back of the wheelchair. Interview with LPN Employee E2 at that time, confirmed that the tubing for the portable canister should not be hanging over the top of the canister on the back of the wheelchair. Observation on 3/25/26, at 11:10 a.m. revealed Resident R1 sitting in his/her wheelchair with his/her feet on top of the bed. The concentrator tubing was in his/her nose and the tubing from the portable oxygen canister was hanging over the top of the canister that was attached to the back of the wheelchair. Observation on 3/25/26, at 11:20 a.m. revealed Resident R1's tubing from concentrator was lying on the top of his/her bed and Resident R1 was no longer in the room. During an interview at that time, the Infection Control nurse confirmed that the tubing should be hanging on the hook on the wall when not in use. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policies, and staff interviews, it was determined that the facility failed to discard an outdated multi-dose vial of Tuberculin (solution used to test for Tuberculosis) in one of three medication room refrigerators (Unit B), and a multi-dose vial of insulin in one of four medication carts (Unit A-1).Findings include: Review of a facility policy entitled, Medication Storage dated 2/19/26, indicated that outdated medications are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy. Nighttime nurse will complete medication cart check sheet daily after checking med cart and remove all expired medications. Observation on 3/24/26, at 3:55 p.m. in the Unit B medication room refrigerator revealed a multi-dose vial of Tubersol with an expiration date of 3/22/26. During an interview at that time Licensed Practical Nurse (LPN) Employee E1 confirmed that the vial of Tubersol was expired and should have been discarded. Observation on 3/24/26, at 4:30 p.m. of Unit A-1 medication cart revealed a multi-dose vial of Humalog (fast-acting insulin) with an expiration date of 3/18/26. During an interview at that time, LPN Employee E4 confirmed that the Humalog insulin was expired and should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records regarding a gastrostomy tube [g-tube (feeding tube inserted through the abdomen directly into the stomach to provide nutrition, fluids, and medications when oral intake is insufficient)] per physician's order for one of 15 residents (Resident R49).Findings include: A facility policy entitled, Transcribing Physician's Orders dated 2/19/26, revealed the purpose is to ensure accurate recording of physician's orders on resident clinical record, enteral feeding orders include the amount of delivery to the resident and the amount of water in a 24-hour period, if indicated by the physician. Resident R49's clinical record revealed an initial admission date of 1/09/24, with diagnoses that included dementia, pneumonitis (lungs are irritated or inflamed by various factors, such as medications, molds, chemicals, or infections), and gastrostomy status. A physician's order dated 3/09/26, revealed for enteral nutrition via pump at 80 cc/hr., hang at 6:00 p.m. and take down at 6:00 a.m. two times a day and document input. A physician's order dated 2/11/26, revealed to flush the feeding tube with (140 cc) of water q (#4 of hours) hours and with (30 cc) of water before and after each medication administration. Resident R49's medication administration record (MAR) revealed staff documented feeding hung at 6:00 p.m. and removed at 6:00 a.m. and failed to document the amount of feeding Resident R49 received. Resident R49's MAR revealed staff documented every shift flush feeding tube with (140 cc) of water q (#4 of hours) hours and with (30 cc) of water before and after each medication administration and failed to record the amount of water administered in a 24-hour period. Review of a departmental progress note dated 2/8/2026, revealed the Registered Dietitian recommended nutritional feeding at 80 cc/hour running 6 pm - 6 am, 12 hours via pump and to run to complete 1000 cc bag. Water flush 140cc q 4 hours. Feeding provides 1500 calories, 69 gm protein and 764 cc free water, plus 744 cc from water flush, for a total of 1573 cc water. Estimated needs = 1200-1500 calories, 55-65 gm protein and 1200-1500 cc fluids. Feeding is meeting 100% of estimated needs for calories, protein, and fluid. Resident R49's clinical record lacked evidence that the nutritional needs outlined by the Registered Dietitian were being met and lacked evidence that staff were recording the amount of nutritional feeding and water provided. During an interview on 3/26/26, at 3:12 p.m. the Director of Nursing confirmed Resident R49's clinical record contained incomplete and inaccurate documentation regarding tube feeding amounts and flushes. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 211.5(f)(viii) Medical records28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for two of 15 residents reviewed (Residents R5, and R55).Findings include: Review of facility policy entitled Care Plans dated 2/19/26, revealed that the Interdisciplinary Team will formulate goals and approaches after identifying resident problems/conditions; goals should be measurable and have a time frame for completion or evaluation; periodic reviews and revisions of each resident will be done. Resident R5's clinical record revealed an admission date of 7/8/24, with diagnoses that included gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed), and muscle weakness. Review of Resident R5's comprehensive care plan on 3/25/26, revealed that of the 31 care plans present, 28 had an outstanding target date (an identified date a care plan should be reviewed/revised) of 12/31/25, and two had an outstanding target date of 3/4/26. The care plans included the problem categories of: anticoagulant therapy, diuretic therapy, congestive heart failure, risk for dehydration, risk for infection, risk for malnutrition, pressure ulcer, range of motion, antidepressant medication, enhanced barrier precautions (EBP), risk for urinary tract infection, cognition, urinary tract infection, pain, treatment, decreased cardiac output, personalized care, wound management, depression, pain control, EBP related to ESBL (type of bacteria infection), impaired physical mobility, coping, sensory perception, self-care, risk for bleeding, altered fluid balance, skin integrity, cardiac function, and fluid restriction. Resident R55's clinical record revealed an admission date of 10/30/25, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), kidney disease (the gradual loss of kidney function), and high blood pressure. Review of Resident R55's comprehensive care plan on 3/25/26, revealed that of the nine care plans present, six had an outstanding target date of 11/19/25. The care plans included the problem categories of: personalized care, risk for urinary tract infection, psychosocial wellbeing, skin tear, discharge planning, and pain. During an interview on 3/25/26, at 2:15 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R5 and Resident R55's care plans were not reviewed and/or revised as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of Title 49, Chapter 21 of the Pennsylvania Code and clinical records, observations, and staff interview, it was determined that the facility failed to provide services that adhered to accepted standards of practice for one resident's admission assessment (Resident R1) and one of seven residents observed during medication administration (Resident R63).Findings include: Review of Title 49 Pa. Code S 21.145. Functions of the Licensed Practical Nurse (LPN) stated (a) the LPN participates in the planning, implementation and evaluation of nursing care . (1) an LPN shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when: (i) the patient's care needs exceed the licensed practical nursing scope of practice. Resident R63's clinical record revealed an admission date of 3/24/26, with diagnoses that included spinal stenosis (narrowing of spaces within the spine, which can compress the spinal cord and nerves, leading to pain, numbness, or weakness), spondylolisthesis (degenerative condition that affects the spine and causes arthritis in the joints and disks), and radiculopathy of the middle back (pinching of a nerve root in the spine that can cause pain, weakness, numbness and tingling). Resident R63's clinical record lacked evidence that a self-medication assessment was completed and/or evidence of a care plan and/or physician's order to permit Resident R63 to administer his/her own medications. Observation on 3/25/26, at 9:10 a.m. revealed that Licensed Practical Nurse (LPN) E3 prepared and delivered medications to Resident R63, observed the resident self-administer his/her nasal spray and proceeded to exit the room and leave the resident's oral medications sitting on the tray table. During an interview at that time, LPN Employee E3 stated that Resident R63 was alert and oriented times four and so it is okay to leave his/her medications for them to take. During an interview on 3/25/26, at 10:05 a.m. the Director of Nursing confirmed that medications should not be left in resident rooms and that staff should observe residents take their medications. Resident R1's clinical record revealed an admission date of 2/27/26, with diagnoses that included bacterial pneumonia (infection of your lungs caused by certain bacteria), spinal stenosis, high blood pressure, and vertigo (sensation of spinning and feeling off balance). Resident R1's admission assessment revealed that his/her admission assessment dated [DATE], was completed by an LPN. Resident R1's departmental admission progress note dated 2/27/26, indicated that the admission assessment was completed by an LPN. During an interview on 3/26/26, at 11:15 a.m. Registered Nurse Employee E5 and the Infection Preventionist confirmed that Resident R1's admission assessment and following baseline care plan was completed by an LPN. During an interview on 3/26/26, at 11:38 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R1's admission assessment and baseline care plan was completed by an LPN. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility contract and policy, and clinical record review, and staff interviews, it was determined that the facility failed to ensure that monthly pharmacy drug regimen reviews were completed for five of five residents reviewed (Residents R11, R13, R17, R30, and R52). Findings include: A facility contract entitled Care Apothecary Consultant Pharmacy Retainer Agreement dated 6/07/24, indicated that: monthly reviews of the drug regimen of each resident at Ball Pavilion will be conducted; recommendations, plans for implementation, and continuing assessment regarding medication policies and use through dated, and signed reports will be provided to administrator; and the pharmacy agrees to be responsible for providing continuous Consultant Pharmacist Services to the facility through the term of the agreement. A facility policy entitled Pharmacy Consultant Report at Ball Pavilion dated 9/09/24, indicated that the Pharmacy Consultant will e-mail Director of Nursing, Administrator, RNAC (Registered Nurse Assessment Coordinator), and Rehab Director with monthly pharmacy summary. Resident R11's clinical record revealed an admitted [DATE], with diagnoses including Parkinson's Disease (disease of involuntary muscle movements) atrial fibrillation (irregular heart beat) and orthostatic hypotension (low blood pressure when in a standing position). Resident R13's clinical record revealed an admitted [DATE], with diagnoses including dementia, Type 2 diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood), irregular heartbeat, and anxiety. Resident R17's clinical record revealed an admitted [DATE], with diagnoses including dementia with mood disturbance, anoxic brain damage (occurs when the brain is deprived of oxygen, leading to brain cell death and potentially permanent brain damage or even death), heart disease and convulsions. Resident R30's clinical record revealed an admitted [DATE] with a diagnoses of Alzheimer's disease (a disease characterized by forgetfulness and confusion) Type 2 diabetes (condition of poor blood sugar control) and hypertension (high blood pressure). Resident R52's clinical record revealed an admitted [DATE], with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure. Residents R11, R13, R17, R30, and R52's clinical records lacked evidence that a Pharmacy Consultant review was conducted for October 2024, November 2024, and December 2024. During an interview on 3/20/25, at 2:20 p.m. the Registered Nurse Assessment Coordinator confirmed that the pharmacy did not provide a Pharmacy Consultant to conduct the monthly reviews of the drug regimen of each resident during October 2024, November 2024, and December 2024. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(x) Medical records 28 Pa. Code 211.9(f)(3) Pharmacy Services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record and policy review, and staff interview, it was determined that the facility failed to provide care regarding treatment, consistent with professional standards of practice, to an existing injury to facilitate wound healing for one of five residents reviewed (Resident R52). Findings include: A facility policy entitled Provide Treatment to Pressure Injury dated 9/09/24, indicated that residents with a Stage 2 (partial thickness loss of dermis [presenting as a shallow open ulcer without slough) be assessed for a positioning program and support devices. Resident R52's clinical record revealed an admitted [DATE], with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure. Review of assessments and documentation provided by the contracted wound care specialist revealed: -8/19/24, initial assessment of a partial thickness moisture associated skin damage (MASD- erosion or inflammation of the skin caused by long-term exposure to moisture); wound on the left buttock measured 8.6cm (centimeters) X 1.9cm X 0.1cm and included orders for side-to-side offloading while in bed. -10/21/24, partial thickness MASD wound on the left buttock measured 6.2cm X 0.6cm X 0.1cm, condition improving, and included orders for side-to-side offloading while in bed. -12/09/24, partial thickness MASD wound on the left buttock measured 1.5cm X 0.2cm X 0.1cm, condition improving, and included orders for side-to-side offloading while in bed. -2/17/25, partial thickness MASD wound on the left buttock measured 1.5cm X 1.3cm X 0.2cm, condition deteriorating, and included orders for side-to-side offloading while in bed. Review of Resident R52's Minimum Data Set (MDS- standardized assessment tool that measures health status in nursing home residents) revealed: -Quarterly MDS dated , 8/14/24, Section GG0170, Mobility was coded as requiring substantial/maximal assistance to roll left and right. -Quarterly MDS dated [DATE], Section GG0170, Mobility was coded as requiring partial/moderate assistance to roll left to right. -Quarterly MDS dated [DATE], Section GG0170, Mobility was coded as requiring substantial/maximal assistance to roll left and right. -Annual MDS dated [DATE], Section GG0170, Mobility was coded as requiring partial/moderate assistance to roll left to right. Further review of Resident R52's clinical record lacked evidence of a physician's order for side-to-side offloading (turn and position) in bed as recommended by the wound care specialist; the care plan entitled potential/actual impairment to skin integrity dated 2/21/24, lacked evidence of an intervention side-to-side offloading in bed, and lacked documentation that Resident R52 was provided side-to-side offloading while in bed. During an interview on 3/21/25, at 11:46 a.m. the Registered Nurse Assessment coordinator confirmed that Resident R52 should have an offloading side-to-side program in place to prevent worsening of his/her wound. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for three of 24 residents reviewed (Residents R35, R51, and R52). Findings include: Resident 35's clinical record revealed an admitted [DATE], with diagnoses including dementia, stroke with right-sided weakness, Schizophrenia (a serious mental health condition that affects how people think, feel and behave, and may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), and intellectual disabilities. Review of R35's Quarterly MDS dated [DATE], under Section M0300, Skin Conditions revealed it was coded as having a Stage Three (full thickness tissue loss). Resident R35's clinical record revealed assessment documentation provided by the contracted wound care specialist as follows: -11/11/24, initial examination of moisture associated skin damage (MASD- erosion or inflammation of the skin caused by long-term exposure to moisture) partial thickness wound to the gluteal cleft. -11/25/24, follow-up assessment MASD partial thickness wound to the gluteal cleft. Resident R51's clinical record revealed an admitted [DATE], with diagnoses including sepsis (the body's immune system has an extreme response to an infection, causing organ dysfunction), Stage Four pressure ulcer of the right buttock (full-thickness tissue loss with exposed bone, tendons, or muscle), and quadriplegia (paralysis that affects all a person's limbs). Review of Resident R51's Quarterly MDS dated [DATE], under Section M0300, Skin Conditions revealed it was coded as a Stage Four, not present on admission. Resident R51's clinical record revealed assessment documentation provided by the contracted wound care specialist dated 12/09/24, and indicated that his/her Stage Four wound was not acquired at the facility. Resident R52's clinical record revealed an admitted [DATE], with diagnoses including stroke with left-sided weakness, Type 2 diabetes, dementia, and high blood pressure. Review of Resident R52's Quarterly MDS's dated 10/23/24, and 12/11/24, and Annual MDS dated [DATE], Section M Skin Conditions, was coded as having a Stage Three pressure ulcer. Resident R52's clinical record revealed assessments and documentation provided by the contracted wound care specialist as follows: -8/19/24, initial assessment of a partial thickness moisture associated skin disorder wound on the left buttock measured 8.6 cm (centimeters) X 1.9 cm X 0. 1cm and included orders for side-to-side offloading while in bed. -10/21/24, partial thickness moisture associated skin disorder wound on the left buttock measured 6. 2cm X 0.6 cm X 0. 1cm, condition improving, and included orders for side-to-side offloading while in bed. -12/09/24, partial thickness moisture associated skin disorder wound on the left buttock measured 1. 5cm X 0. 2cm X 0. 1cm, condition improving, and included orders for side-to-side offloading while in bed. -2/17/25, partial thickness moisture associated skin disorder wound on the left buttock measured 1. 5cm X 1.3 cm X 0. 2cm, condition deteriorating, and included orders for side-to-side offloading while in bed. During an interview on 3/21/25, at 11:56 a.m. the Registered Nurse Assessment Coordinator confirmed that the wound staging on the above MDS's for Residents R35, R51, and R52 were coded incorrectly. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(11)(iv)(ix) Medical records

Based on observations and staff interviews, it was determined that the facility failed monitor the sanitizing functions of the dish machine in the main kitchen, and store food and food containers in a safe and sanitary manner in one of three nourishment refrigerators (B wing). Findings include: Review of a facility policy entitled, Dish Machine Temperatures dated July 2022, indicated that dish machine temperatures will be taken at the beginning of breakfast, dinner, supper dish runs, and any temperature that is below regulation (160-180 Fahrenheit degrees (F) wash, 180-200 F final rinse) will be reported immediately to the supervisor/coordinator on duty, and in the event that a dish machine is not working properly, paper products will be used for meal service. Review of a facility policy entitled Pantry Stock of Nursing Units and Dining Rooms dated July 2022, indicated that storage areas will be cleaned and organized as necessary. Observation on 5/09/23, at 2:00 p.m. the dish washer washing cycle reached 146 F, and final rinse cycle reached 156 F. Review of the High Temp Dish Log for May 2023, revealed that the wash cycle temperature failed to reach the minimum 160 F for the following meals; supper on 5/02/23, 5/04/23, and 5/07/23: the final rinse cycle failed to reach the minimum required 180 F on the following meals; dinner on 5/01/23, 5/03/23, 5/06/23, 5/08/23, and 5/09/23; supper on 5/02/23, 5/03/23, 5/04/23, and 5/07/23, or 12 of 26 meals documented. During an interview on 5/09/23, at 2:00 p.m. the Dietary Manager confirmed that the recorded dish washer temperatures for the above mentioned meals did not reach the minimum required 160 F for the wash cycle and 180 F for the final rinse cycle, and that dietary staff failed to notify the manager/coordinator and that meals were not provided the residents on paper products. Observations on 5/09/23, at 3:37 p.m. and 5/10/23, at 11:30 a.m. of the B wing nourishment revealed a brown dried substance splashed on middle and bottom shelves and down the left side panel of the internal refrigerator wall, and a yellow dried substance on the top door shelf. Interview on 5/10/23, at 11:30 a.m. with Registered Nurse Employee E3 confirmed the brown and yellow dried substances in the refrigerator and that the condition did not meet appropriate sanitary conditions, he/she believes that dietary staff clean it daily when they stock the refrigerator and take temperatures, and nursing staff are to clean up spills if they notice them. Interview on 5/10/23, at 12:20 p.m. with the Dietary Manager confirmed that whoever spills food/liquids in the refrigerators or finds the spilled substance should clean it up. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on observations and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for two of two resident neighborhoods (A and B Wings). Findings include: Observations between 5/09/23, and 5/11/23, of eight resident wheelchairs (Residents R1, R2, R4, R25, R32, R34, R36, R39, and R50) revealed wheelchairs with dried solid/food substances, dried liquid, and a build-up of dust and debris on the wheelchair armrest, seats, wheels, and frames. One resident wheelchair was observed to have a torn armrest that had been taped with black plastic electrical tape, and one resident wheelchair to have an armrest in disrepair. During an interview on 5/11/23, at 11:00 a.m. the Director of Nursing confirmed the presence of dried solid/food substances, dried liquid, and a build-up of dust and debris on the wheelchair seats, wheels and frames, and one wheelchair with a torn armrest that had been taped with black plastic electrical tape, and one wheelchair with an armrest in disrepair on B-Wing. During an interview on 5/11/23, at 11:50 a.m. Registered Nurse Employee E1 confirmed the presence of dried solid/food substances, dried liquid, and build-up of dust and debris on the wheelchair armrest, seat, wheels and frame on A-Wing. 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for six of 17 residents reviewed (Residents R7, R55, R30, R14, R25, and R15). Findings include: Review of facility policy entitled, Care Plan dated 11/2022, revealed that .each time a resident's condition indicates; a new care plan will be done to address the most current problem/concern and The care plan will include measurable objectives and timetables to meet each resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Review of Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, pressure ulcer of the sacral region, bone infection of the sacral region, dementia and high blood pressure. Review of Resident R7's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated March 22, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care,complained of constant pain and had an indwelling urinary catheter (a tube placed and held in the bladder to drain urine). Review of Resident R7's comprehensive care plan on 5/11/23, lacked reference to Resident R7's urinary catheter and pain status. Review of Resident R55's clinical record revealed an admitted [DATE], with diagnoses that included chronic kidney disease, urinary tract infection, diabetes (high blood sugar) and heart failure. Review of clinical record documentation revealed Resident R55 was started on an antibiotic on 4/23/23, for a urinary tract infection. Review of Resident R55's comprehensive care plan on 5/11/23, lacked reference to Resident R55's urinary status or urinary tract infection. Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia (difficulty swallowing food and/or liquids), dementia, and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Review of clinical record documentation revealed Resident R30 had a significant weight loss (weight loss of 5% in the last 30-day and/or 10% in the last six months) of 12.98% in the last six months. Review of physician's orders revealed Resident R30 was on a pureed diet (texture modified diet) and utilized a divided plate and [NAME] cup (light weight spill proof drinking cup with straw) Review of Resident R30's comprehensive care plan on 5/11/23, lacked reference to Resident R30's nutritional status, diet orders, or adaptive equipment required for meals. Review of Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart). Review of Resident R14's clinical record revealed physician's order dated 9/28/22, for Eliquis (medication to prevent blood clots) 5 milligrams (mg) by mouth twice a day, Insulin Lispro (medication used to control high blood sugar) 4 units subcutaneous (sq) four times a day before meals and at bedtime, and Lantus (medication used to control high blood sugar) 18 units sq once a day at 9:00 p.m. and physician orders dated 10/11/22, for Lantus 14 units sq once a day at 6:00 a.m. Review of Resident R14's comprehensive care plan on 5/11/23, lacked reference to Resident R14's diabetes or usage of Insulin Lispro or Lantus as well as reference to Resident R14's atrial fibrillation and usage of Eliquis. Review of Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included dementia, high blood pressure, and right leg deep vein thrombosis (blood clot that formed in the leg). Review of Resident R25's clinical record revealed a physician's order dated 6/29/22, for Xarelto (medication to prevent blood clots) 10 mg by mouth daily. Review of Resident R25's comprehensive care plan on 5/11/23, lacked reference to Resident R25's history of blood clots or usage of Xarelto. Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses including stroke with left-sided weakness, Type 2 Diabetes (affects how the body uses glucose (sugar)), dementia, mood disturbance, and high blood pressure. Review of Resident R15's clinical record revealed a physician's order dated 3/15/22, for oxygen at two liters per minute. Review of Resident R15's comprehensive care plan on 5/11/23, lacked reference to providing supplemental oxygen. Observations on 5/09/23, and 5/12/23, revealed Resident R15 lying in bed with supplemental oxygen being administered through a nasal cannula (tubing that delivers supplemental oxygen through the nose). During an interview on 5/12/23, at 11:38 a.m. Registered Nurse Assessment Coordinator confirmed that care plans had not been developed to address Resident R7's pain or indwelling catheter, R55's urinary tract infection, R30's nutritional status, R14's insulin, or anticoagulant, R25's anticoagulant, and R15's oxygen usage. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update and/or individualize care plans for two of 17 residents reviewed (Residents R11 and R23). Findings include: Review of facility policy entitled, Care Plan dated 11/2022, indicated that .each time a resident's condition indicates; a new care plan will be done to address the most current problem/concern. Review of Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included fractured right femur, anxiety, dementia and history of falling. Review of clinical record documentation and fall investigation tool for Resident R11, revealed that he/she fell on [DATE], at 7:00 p.m. resulting in a right femur fracture requiring hospitalization . There was no evidence that the care plan was updated to reflect the fall and interventions. Review of Resident R23's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, fractured right femur, and dementia. Review of clinical record documentation and fall investigation tool for Resident R23, revealed that he/she fell on [DATE], at 7:45 p.m. resulting in a right femur fracture requiring hospitalization and surgical intervention. Review of Resident R23's care plan on 5/11/23, related to fall's reflected that resident was found on the floor on 9/9/22, and failed to reflect the 1/9/23 fall that resulted in a fracture or interventions implemented as a result of the 1/9/23, fall and/or fracture. During an interview on 5/12/23, at 11:38 a.m. the Registered Nurse Assessment Coordinator confirmed that Resident R11 and R23's fall care plan was not updated to reflect most recent fall and/or fracture. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of 17 residents reviewed (Resident R7). Findings include: Review of Resident R7's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated March 22, 2023, revealed that the resident was cognitively impaired, required extensive assistance for daily care, and had an indwelling urinary catheter Observations in Resident R7's room on May 10, 2023, at 9:12 a.m. and again on May 11, 2023, at 10:00 a.m. revealed that the resident's urinary drainage bag and tubing were lying on the floor without a cover over the drainage bag. Interview with the Nursing Home Administrator on May 11, 2023, at 10:10 a.m. confirmed that Resident R7's urinary drainage bag and tubing should not have been on the floor and should have a cover over the drainage bag. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and prevent the potential spread of infection regarding respiratory care equipment according to physician orders, and failed to administer supplemental oxygen as ordered for two of 17 residents reviewed (Residents R7 and R15). Findings include: Review of a facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen for you to breathe) Operation dated November 2022, indicated that oxygen will be administered to residents at the rate ordered by the physician and per oxygen concentrator with humidifier unless otherwise ordered. Review of Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, pressure ulcer of the sacral region, bone infection of the sacral region, dementia and high blood pressure. Resident R7's physician's orders dated 3/03/23, included an order for Albuterol Sulfate (medication used to open airways via nebulizer mask) nebulization solution four times a day. Resident R7 also had an order for a wound vac (vacuum machine used to remove drainage from a wound). Observations on 5/10/23, at 9:00 a.m. revealed Resident R7's wound vac machine and drainage tubing resting on top of Resident R7's nebulizer mask. During an interview on 5/10/23, at 9:35 a.m. the Director of Nursing confirmed that the nebulizer mask should be stored in a bag while not in use and the wound vac machine and drainage tubing should not have been resting on Resident R7's nebulizer mask. Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included stroke with left-sided weakness, Type 2 Diabetes (affects how the body uses glucose (sugar)), dementia, mood disturbance, and high blood pressure. The clinical record also revealed a physician's order dated 3/15/22, for oxygen at two liters per minute via concentrator and to change the distilled water in the humidifier bottle every day on night shift. Observations on 5/09/23, and 5/12/23, revealed that Resident R15's supplemental oxygen concentrator was set at three liters per minute continuously, and that the humidifier bottle lacked distilled water. During an interview on 5/12/23, at 8:40 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R13's oxygen concentrator was not set at the correct liters per minute as ordered by the physician and that the humidifier bottle was empty. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of two residents with pressure ulcers requiring wound care reviewed (Resident R7). Findings include: Review of the facility policy entitled, Dressings/Prevention of Infection, dated 11/15/2022, indicated to remove the soiled dressing, remove soiled gloves and then wash hands. Review of Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, pressure ulcer of the sacral region, bone infection of the sacral region, dementia and high blood pressure. Review of Resident R7's physician's orders dated 3/03/23, included an order to cleanse the sacral wound and apply a wound vac (vacuum machine used to remove drainage from a wound). Observation of wound care on 5/10/23, at 9:00 a.m. revealed that the Director of Nursing moved the garbage can closer to Resident R7 with their gloved hands and then proceeded to remove the soiled dressing without removing gloves or washing hands and then continued to cleanse the wound without removing gloves or washing hands. During an interview on 5/10/23, at 9:35 a.m. the Director of Nursing confirmed he/she did not change gloves and did not complete hand hygiene when indicated. 28 Pa. Code 201.18 (b)(2) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of the Resident Assessment Instrument (RAI-manual that guides facilities with completing resident Minimum Data Set [MDS-periodic assessment of resident care needs] assessments), clinical records, facility documentation, and staff interviews, it was determined that the facility failed to complete the MDS to accurately reflect the resident's status at the time of the assessment for eight of 16 residents reviewed (R6, R8, R22, R27, R28, R45, R47, and R54). Findings include: Review of the October 2019 RAI Manual revealed that restraints (a device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) used in the seven-day assessment look-back period were to be documented in Section P (Restraints and Alarms) of the MDS, coding 0 for not used, 1 for used less than daily, and 2 for used daily. Review of Resident R6's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS dated [DATE], under Section P0100A, revealed that Resident R6's bed rails were coded as a restraint used daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations between 6/13/22, and 6/15/22, revealed Resident R6 had two quarter-sized rails on the bed and used his/her bed rails to assist with positioning during care. Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS dated [DATE], under Section P0100A, indicated that Resident R8's bed rails were coded as a restraint used daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, through 6/15/22, revealed Resident R8 had two quarter-sized rails on the bed. Review of Resident R22's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS dated [DATE], under Section P0100A, indicated that Resident R22's bed rails were coded as a restraint used daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, through 6/15/22, revealed Resident R22 had two quarter-sized rails on the bed. Review of Resident R27's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, and 6/16/22, revealed Resident R27 did not have bed rails. Review of Resident R28's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS dated [DATE], under Section P0100A, indicated that Resident R28's bed rails were coded as a restraint used daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, through 6/15/22, revealed Resident R28 had two quarter-sized rails on the bed. Review of Resident R45's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS dated [DATE], under Section P0100A, indicated that Resident R45's bed rails were coded as a restraint used daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, through 6/15/22, revealed Resident R45 had two quarter sized rails on the bed. Review of Resident R47's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, and 6/16/22, revealed Resident R47 used his/her bed rails to assist with positioning during care. Review of Resident R54's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section dated 5/25/22, under Section P0100A, indicated that Resident R54's bed rails were coded as a restraint used daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observations between 6/13/22, through 6/15/22, revealed Resident R54 had two quarter-sized rails on the bed. During an interview on 6/14/22, at 12:07 p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R6, R8, R22, R27, R28, R45, R47, and R54 MDS's Section P0100A as listed above were coded incorrectly and the quarter-sized rails were not used as restraints. 28 Pa. Code 211.5(f) Clinical records

Based on review of clinical record, observations, and staff interview, it was determined that the facility failed to develop a comprehensive care plan regarding an assistive device for one of 16 residents reviewed (Resident R23). Findings include: Review of Resident R23's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident R23 from 6/13/22 through 6/15/22, revealed he/she was wearing a seatbelt while in their electric wheelchair. During an interview on 6/15/22, at 10:30 a.m. Resident R23 indicated that they were able to remove the seatbelt without difficulty. Resident R23's current plan of care did not include a care plan to address Resident R23's assistive device of the seatbelt on their electric wheelchair. During an interview on 6/14/22, at 2:50 p.m. Registered Nurse Assessment Coordinator confirmed that Resident R23 lacked a care plan to address the use of the seatbelt on their electric wheelchair since Resident R23's admitted on 4/15/21. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, a facility event report and staff interviews, it was determined that the facility failed to provide adequate supervision or implement any effective safety interventions to prevent a fall with resultant injuries for one resident (Resident R1). Findings include: Resident R1's clinical record indicated that the resident was admitted from the hospital on [DATE], after a surgical repair of a hip fracture, following a fall at the facility's Personal Care Unit. The resident's face sheet included [DIAGNOSES REDACTED]. An event report submitted to the State Department of Health, dated 9/17/14, detailed an event that occurred on 9/15/14, at 1:10 p.m. It stated that Resident R1 had previously resided at the facility and had a long history of anxious behavior, was extremely confused and disoriented with "no safety awareness." The report detailed the following: after admission to the facility from the hospital, the resident was placed in a room and left unattended in bed without staff supervision or measures in place to protect her/him from injury. A short time later a staff member entered the room and found Resident R1 lying on the floor at the bedside where she/he had fallen. The resident was transported to the hospital where a new hip fracture was discovered. The additional fracture was not surgically repairable. During an interview on 9/22/14, at 11:30 a.m., the Nursing Home Administrator (NHA) confirmed that Resident R1 had fallen and fractured her/his hip while in the Personal Care Unit prior to admission to the facility, was very confused, was known to be restless, was at a very high risk for falls and at the time of admission, required constant supervision. The NHA also confirmed that when Resident R1 fell from the bed, the resident had been left without supervision in her/his room without any fall precautions, safety devices or alarms. The facility failed to provide adequate supervision to Resident R1 to prevent the risk of additional falls and to ensure this resident's safety, resulting in an inoperable hip fracture. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/12/2013. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/12/2013. 28 Pa. Code 211.12 (a)(c)(d)(1)(4)(5) Nursing services.