Every finding on record at Barclay Friends

Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interview, it was determined that the facility failed to electronically submit accurate direct care staffing information for one of the last four quarters (Quarter One of 2025). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). First quarter reporting includes data from October 1st through December 31st. Review of PBJ staffing data reports for fiscal year first quarter 2025 revealed the facility triggered for No RN hours on October 1, 2024, through October 31, 2024, November 1, 2024, through November 30, 2024, December 1, 2024, through December 31, 2024, and Failed to have Licensed Nursing Coverage 24 hours/day on October 1, 2024, through October 31, 2024, November 1, 2024, through November 30, 2024, and December 1, 2024, through December 31, 2024. Review of staffing documentation for October, November and December 2024, revealed the facility did have RN hours on October 1, 2024, through October 31, 2024, November 1, 2024, through November 30, 2024, and December 1, 2024, through December 31, 2024, the facility did have Licensed Nursing Coverage 24 hours/day, indicating the facility failed to submit accurate PBJ information as required by the ACA. During an interview on June 13, 2025, at 10:30 a.m., the DON confirmed that the PBJ report for Quarter One for 2025 was submitted inaccurately. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy, Weight of Resident, revised January 2018, revealed the Physician, Registered Dietitian, and Power of Attorney will be notified if there is a 5 lb. weight gain/loss in one month. Review of Resident 51's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 51's weights revealed a weight of 124 lbs on April 23, 2022, and a weight of 147 lbs on May 23, 2022 (a gain of 23 lbs in one month). Further review of the clinical record revealed no evidence that the Registered Dietitian nor the Physician was aware of the weight gain until July 14, 2022, and July 15, 2022, respectively. Interview with the Director of Nursing on August 12, 2022, at 12:53 p.m. confirmed the Physician and Registered Dietitian were not made aware of the weight increase in a timely manner. 28 Pa. Code 211.5(f) Clinical records Previously cited 7/23/21 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 7/23/21

Based upon clinical record review and observation, it was determined that the facility failed to accurately complete a Minimum Data Set assessment relating to restraints for one of 24 residents reviewed (Resident 37). Findings include: Review of Resident 37's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated June 9, 2022 revealed Resident 37 utilized a trunk restraint while in a chair or out of bed. Review of Resident 37's clinical record failed to reveal evidence that a trunk restraint was in use. Observations conducted of Resident 37 during the survey failed to reveal a trunk restraint in use. Interview with the Director of Nursing on August 12, 2022 at approximately 11:00 a.m. revealed Resident 37 did not use a trunk restraint at any time while staying at the facility. The facility failed to accurately assess and complete the MDS for Resident 37. 483.20 Resident Assessments Previously cited 7/23/21 28 Pa Code 211.5(f) Clinical records Previously cited 7/23/21 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observation, staff interviews, and a review of facility policies and documentation, it was determined the facility failed to ensure infection control and prevention practices were implemented on three of three units observed (Bradford, Birmingham, and Goshen). Findings include: A review of the facility's policy titled Infection Policy and Control Program last revised in September, 2019, revealed that it is the responsibility of all staff in each department to have knowledge of and implement infection control measures in accordance with job duties which includes proper cleaning and allocation of equipment and/or items used for residents during ADL (Activities of Daily Living) activities, and those with an infectious process who require transmission-based precautions. A review of the facility's policy titled Environmental Cleaning and Disinfecting During Pandemic, dated April, 2020, revealed that all environmental staff will follow the facility infection control and prevention policies including hand hygiene and use of PPE (Personal Protective Equipment) per facility policy. This includes: gown will be worn upon entry into the resident room or area for all suspected or confirmed cases of respiratory infectious disease. Immediately before leaving the room, remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. During the survey entrance conference with the Director of Nursing (DON) on December 7, 2020, at 9:10 a.m., it was revealed that everyone who enters all three units (Bradford, Birmingham, and Goshen Unit) in the facility must wear an N-95 respirator mask (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles), a face shield or an eye protector. A gown, a hair cover, a shoe cover, and gloves must be worn in addition to the N-95 mask and a face shield/eye protector when entering a resident's room. All PPE except for the N-95 mask and the face shield/eye protector must be removed before leaving the resident's room. An observation on December 7, 2020, at 10:15 a.m. on Bradford Unit, revealed Employee E4 entered a resident room (410) wearing an N-95 mask, an eye protector, a hair cover, and a shoe cover. Employee E4 was observed cleaning room [ROOM NUMBER]. At 10:22 a.m., Employee E4 was observed leaving room [ROOM NUMBER] still wearing a gown, a shoe, and a hair cover. Employee E4 walked in a hallway passing the living room and nurse station to get to another resident's room (412). The employee entered room [ROOM NUMBER] wearing the same PPE used in room [ROOM NUMBER]. An interview with Employee E4 on December 7, 2020 at 10:29 a.m., stated that she/he should have changed her/his PPE but did not do it in order to conserve the PPE, due to limited supplies. An observation of the Bradford unit on December 7, 2020 at 10:30 a.m. revealed an abundant supply of different PPE available for all staff. An observation on the Birmingham Unit on December 7, 2020, at 10:35 a.m., revealed Employee E5 without an eye protector. Upon seeing the surveyor, Employee E5 grabbed her/ his face shield hanging by the hallway rail and placed it on without sanitizing it. An observation on the Goshen Unit on December 7, 2020, at 11:00 in the presence of licensed nurse Employee E6, and the Infection Preventionist Nurse (IP) Employee E3 revealed a table with PPE supplies. The table was by a wall with rails. A gait belt (a device used to aid in the safe movement of a resident), and a used, unlabeled face shield were observed hanging by the rails where the PPE was located. An interview with Employee E6 on December 5, 2020, at 11:05 a.m., revealed that she/he was not aware of who the items belonged to, and was unable to confirm that it was clean. Further observation revealed a bedside commode with a chair cushion on top of it, and a two-transfer board on the right side of the PPE table. Employee E6 was unable to confirm if the equipment near the PPE table was cleaned. Also observed was a gallon of distilled water used for residents oxygen humidification, and an uncovered box with mask/helmets located on the floor under the PPE table. An interview with the IP on December 7, 2020 at 11:10 a.m., confirmed that the equipment mentioned above should have not been placed by the PPE set-up table. An observation on the Goshen Unit on December 7, 2020, at 11:00 a.m. revealed Employee E6 and Employee E7 wearing regular eyeglasses instead of an eye shield or eye goggles. An interview with the IP nurse on December 7, 2020, at 11:15 a.m., confirmed that regular eyeglasses were not considered PPE and stated that Employee E6 and E7 should have worn appropriate eye protection. The above was conveyed to the DON on December 7, 2020, at 1:30 p.m. The facility failed to ensure infection control and prevention practices were implemented on Bradford, Birmingham, and Goshen Unit. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(3(5) Nursing services. Previously cited 10/18/19

Based on clinical record review and staff interview, it was determined that the facility failed to respond to pharmacy recommendations for one of five residents reviewed (Resident #27). Findings include: Review of Resident #27's clinical record revealed a physician's orders [REDACTED]. Review of Resident #27's clinical record revealed a pharmacy recommendation dated (MONTH) 9, 2019 of The resident has an order for [REDACTED].g. oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis; pathological hypersecretory condition, or demonstrated need for maintenance treatment (e.g. due to failure of drug continuation trial or H-2 blockers) is considered to be potentially inappropriate therapy, secondary to the increased risk of [MEDICAL CONDITION] infection, bone loss, and fractures. Please consider a reduction in the current dosage, change to an H-2 blocker, or provide rationale for therapy continuation. The form does not contain physician response nor signature or date of review. Further review Resident #27's clinical record failed to reveal documentation of physician response to pharmacy recommendations dated (MONTH) 9, 2019 until (MONTH) 18, 2019. Interview on (MONTH) 18, 2019 at approximately 1:19 p.m. with licensed Employee E2, AIT, who confirmed that there was no documentation that the physician addressed the pharmacy recommendation dated (MONTH) 9, 2019. 28 Pa Code 211.5(f) Clinical records Previously cited on 11/29/18 28 Pa Code 211.12(d)(3) Nursing Services Previously cited on 11/29/18

Based upon observation and clinical record review, it was determined that the facility failed to ensure residents receive the necessary care and services to prevent the development of pressure ulcers and failed to ensure timely identification of a pressure ulcer for two of eight residents reviewed (Resident #37 and Resident #65). Findings include: Review of Resident #37's [DIAGNOSES REDACTED]. Review of Resident #37's Quarterly Minimum Data Set Assessment (MDS - periodic assessment of resident needs) dated (MONTH) 2, 2019 revealed Resident #37 required the assistance of one staff member to turn and reposition while in bed, required the assistance of one staff member to transfer from bed to wheelchair and was at risk for developing pressure ulcers. Review of Resident #37's nursing progress notes dated (MONTH) 4, 2019 revealed MD/POA made aware of resident's acquired purple circular area on her left heel non-blanchable; denies pain or discomfort. But voices overall pain/discomfort to total body after care is provided and (resident) repositioned/transferred into a recliner. Which Tylenol is ordered PRN (as needed) and administered today with effectiveness but resident's facial grimacing, does not appear comfortable. Continuous repositioning until resident states (resident) is comfortable. Skin to sacrum intact. Resident is now two assist due to decline. Review of Resident #37's nursing progress notes dated (MONTH) 5, 2019 revealed (resident) is a long term resident with a BIMS of 10. (Resident) has [MEDICAL CONDITION] and has been dealing with exacerbation of [MEDICAL CONDITION] which she received extra doses of [MEDICATION NAME], as well as dealing with a [MEDICAL CONDITION] URI (upper respiratory infection), did not receive antibiotic for this. Resident did receive neb treatments to help with lung function. With this we have seen a decline in resident. Appetite is poor but has supplements for a nutritional supplement. (Resident) is now requiring oxygen. (Resident's) functional abilities has declined as well, (resident) is requiring more help from staff. Further review of this progress note reveals with these declines (resident ' s) skin integrity has declined as well due to lack of mobility, lack of nutrition, etc. Heels have been offloaded while resting in bed or chair. (Resident) now has plush heel booties to b/l (bilateral - both) feet to decrease further breakdown. Skin prep will be applied to b/l heels to protect skin from opening. Review of Resident #37's Initial Skin Evaluation dated (MONTH) 15, 2019 revealed initial wound team eval of darkened purple area to left heel - presents as DTI (deep tissue injury) and measures 3 cm (centimeters) x 4.5 cm. Further review of this Skin Evaluation revealed new intervention recommendations of pressure pump to mattress, offloading heel boot to left heel at all times. Review of the next wound team skin evaluation form dated (MONTH) 3, 2019 revealed Resident #37's left heel now presented as an unstageable eschar (dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed) measuring 2.5 cm x 3.5 cm. Review of Resident #37's Treatment Administration Record (TAR) dated (MONTH) 2019 revealed orders for skin prep to bilateral heels twice daily beginning (MONTH) 5, 2019 and failed to reveal any evidence of interventions and/or treatments in place to prevent the pressure ulcers from developing on resident's heels. Review of Resident #37's active care plan revealed Resident #37 had the potential for pressure ulcers related to muscle weakness/difficulty walking with interventions including elevate heels at rest and pressure reducing mattress to bed which were initiated in (MONTH) (YEAR). Further review of Resident #37's active care plan dated (MONTH) 15, 2019 revealed Resident #37 had a pressure ulcer of the left heel with interventions including offloading heel boot to left heel at all times. Further review of Resident #37's active care plan failed to reveal interventions to offload resident's heels at all times prior to Resident #37 developing the pressure ulcer to the left heel. Review of Resident #65's [DIAGNOSES REDACTED]. Review of Resident #65's Quarterly MDS dated (MONTH) 7, 2019 revealed Resident #65 had a Brief Interview for Mental Status Score of 4 indicating severe cognitive impairment, required the extensive assistance of one staff person for turning and repositioning in bed, required the extensive assistance of two staff persons for transferring between bed and wheelchair and was at risk for developing pressure ulcers. Review of Resident #65's Weekly Skin assessment dated (MONTH) 9, 2019 revealed resident had no issues - sacrum and feet intact - some discoloration. No open areas noted. Review of Resident #65's nursing progress notes dated (MONTH) 13, 2019 at 9:08 a.m. revealed Resident very sleepy this shift. Easily aroused but will return back to sleeping and leaning to the left in chair. Afebrile. No c/o burning with urination, no foul odor. Continue on antibiotic for UTI (urinary tract infection). [MEDICAL CONDITION] noted to BLLE (bilateral lower extremities). BLLE elevated in recliner chair in living area. Skin prep applied to bilateral heels. Heels intact, no discoloration noted. Review of Resident #65's nursing progress notes dated (MONTH) 13, 2019 at 10:25 p.m. revealed family brought attention to this nurse regarding b/l heels. Resident was in Goshen living area sleeping in recliner with legs elevated. BL lower extremities had +2 [MEDICAL CONDITION] present and BL heels had soft dark purple area with blanchable redness surrounding it. Resident was very lethargic and expressed pain with movement of legs. Family wanted resident to go to hospital for further evaluation due to skin and change in mental status. Review of Resident #65's clinical record revealed resident was transferred to the hospital on (MONTH) 13, 2019 at approximately 7:15 p.m. Review of Resident #65's emergency room history and physical dated (MONTH) 13, 2019 revealed Stage II breakdown on the heels greater on the left than the right. Review of Resident #65's Wound Team Skin Evaluation Form dated (MONTH) 18, 2019 revealed initial evaluation by wound nurse 9/18/19. DTI (deep tissue injury) to left heel, no open area. Dark purple non-blanchable area measures 4.5 cm x 5.0 cm. Surrounding tissue pink and blanchable. Resident denies pain to area. Heel protective booties in place. Further review of Resident #65's Wound Team Skin Evaluation Form dated (MONTH) 18, 2019 revealed initial evaluation by wound nurse 9/18/19. DTI to right heel, no open area. Dark purple non-blanchable area measures 3.0 cm x 3.5 cm. Surrounding tissue pink and blanchable. Resident denies pain to area. Heel protective booties in place. Review of Resident #65's Medication Administration Record [REDACTED] Review of Resident #65's Treatment Administration Record (TAR) dated (MONTH) 2019 failed to reveal any treatments or interventions to prevent Resident #65's bilateral heel pressure ulcers prior to (MONTH) 13, 2019 when resident's bilateral heel pressure ulcers were identified. Review of Resident #65's active care plan dated (MONTH) 13, 2019 revealed Resident #65 had pressure ulcers of bilateral heels with interventions including heel booties which was after Resident #65's pressure ulcers were identified. Interview with the Nursing Home Administrator, Administrator in Training and Acting Director of Nursing on (MONTH) 18, 2019 at approximately 12:30 p.m. confirmed that Resident #37 and Resident #65 had developed pressure ulcers of the bilateral heels and that interventions were put into place after the pressure ulcers were identified. 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/29/18 28 Pa. Code 211.12(d)(3) Nursing Services 28 Pa. Code 211.12(d)(5) Nursing Services

Based on observation, review of facility policy, and staff interviews it was determined that the facility failed to maintain good infection control techniques on one of three nursing units (Bradford Nursing unit). Findings include: Review of the facility's policy titled, Infection Control Guidelines for Patient Care Equipment last revised (MONTH) (YEAR), revealed that basins to be kept in bathrooms and bedpans are stored in a clean basin when not in use. Observation of(NAME)nursing unit on (MONTH) 26, and 27, (YEAR) at approximately 11:30 a.m. revealed the residents room [ROOM NUMBER], 405, 406, 407, 410, 412, 414, 420, 421, 423, and 424 having basins and/or bedpans lying on the floor of the bathroom. The bedpans in these bathrooms were lying directly on the floor of bathroom, some of them upside down. Basins were lying directly on the floor with no barrier between floor and bottom of basin. Interview with non licensed nursing staff, Employee E4 on (MONTH) 29, (YEAR) at approximately 10:00 a.m. revealed that the basins and bedpans should be kept in cabinet in residents' bathrooms. Additional interview with non licensed nursing staff, Employee E5 on (MONTH) 29, (YEAR) at approximately 10:20 a.m. revealed that basins and bedpans can be kept on the floor of residents' bathroom. Interview with Director of Nursing on (MONTH) 29, (YEAR) at approximately 11:00 a.m. revealed that typically basins are kept on floor though bedpans should be inside a clean basin not on floor. Additionally, the Director of Nursing stated, we have no where else to put them. 28 Pa Code 211.12 Nursing services (c)(d)(1)(2)

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 18 residents reviewed (Resident #6). Findings include: Review of Resident #6's clinical record revealed that the resident was admitted on (MONTH) 2, (YEAR). A progress note dated (MONTH) 3, (YEAR), indicated that the resident had a stage III pressure ulcer (ulcer involving full thickness of skin loss, exposing tissue) to the left heel Progress note of (MONTH) 29, (YEAR), indicated resident had a stage III pressure ulcer to the tip of the right great toe. Review of the significant change MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 22, (YEAR), section title- Skin Conditions indicated that the resident had two stage III pressure ulcers which were not present upon admission/reentry. Review of Resident #6's progress note dated (MONTH) 2, (YEAR), indicated that the pressure ulcer continues on the left heel. Progress note of (MONTH) 5, (YEAR), indicated that the area on the right great toe was healed. Review of the quarterly MDS assessment of (MONTH) 14, (YEAR), section title- Skin Condition indicated that the resident had one stage III pressure ulcer which was not present on admission/reentry. Interview with licensed staff, Employee E6, on (MONTH) 29, (YEAR), at 8:28 a.m. confirmed that the MDS was coded incorrectly and that one pressure ulcer was present on admission/reentry. 28 Pa. Code: 211.5(f) Clinical records Previously cited 10/19/17 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 10/19/17

Based on clinical record review, it was determined that the facility failed to notify the State Ombudsman's office of residents transferred to acute care facilities for three of four residents reviewed (Resident #30, Resident #70, and Resident #83). Findings include: Review of Resident #70's progress note dated (MONTH) 24, (YEAR), indicated that the physician ordered the resident to be sent to the emergency room (ER) for evaluation of abnormal labs, hematuria (blood in the urine), and [MEDICAL CONDITION]. The resident was readmitted (MONTH) 3, (YEAR), and subsequently sent to theER on (MONTH) 5, (YEAR), for a change in condition. The resident was again transferred to the hospital on (MONTH) 22, (YEAR), for an elevated white blood cell count. Further review of Resident #70's record revealed no evidence that the State Ombudsman's office was notified of the transfers to the hospital. Review of Resident #83's closed record revealed resident was admitted to the facility on (MONTH) 1, (YEAR) for skilled rehabilitation following cardiac surgery. Further review of Resident #83's closed record revealed that on (MONTH) 3, (YEAR) Resident #83 suffered acute onset of left sided weakness, left eye droop and left mouth droop and was sent emergently to an acute care facility. Further review of Resident #83's closed record failed to reveal evidence that the State Ombudsman's office was notified of Resident #83's discharge from the facility. Review of Resident #30's clinical record revealed resident was admitted to the facility on (MONTH) 11, (YEAR) for Alzheimer's and history of falls. Further review of Resident #30's clinical record revealed resident was transferred to hospital on (MONTH) 3, (YEAR) due to fall at the facility resulting in a fracture. Additional review of Resident #30's clinical record revealed the facility failed to contact Ombudsman's office to notify them of Resident #30's transfer to the acute care facility. Interview with DON on (MONTH) 29, (YEAR) at approximately 10:30a.m. revealed that the facility does not typically notify the Ombudsman for transfers to acute care facilities 28 PA Code 201.18(b)(1)(2) Management Previously cited 10/19/17

Based on clinical record review, it was determined that the facility failed to send all appropriate clinical documentation for residents transferred to acute care facilities for four of four residents reviewed (Resident #30, Resident #70, Resident #79, and Resident #83). Findings include: Review of Resident #70's progress note dated (MONTH) 24, (YEAR), indicated that the physician ordered the resident to be sent to the emergency room for evaluation of abnormal labs, hematuria (blood in the urine), and [MEDICAL CONDITION]. The resident was readmitted to the facility on (MONTH) 3, (YEAR), and subsequently sent to the emergency roiagnom on (MONTH) 5, (YEAR), for a change in condition. The resident was again transferred to the hospital on (MONTH) 22, (YEAR), for an elevated white blood cell count. Further review of Resident #70's record revealed no evidence that all appropriate documentation was sent to the acute care facility. Review of Resident #79's progress note dated (MONTH) 13, (YEAR), revealed that critical lab values were received, the physician was made aware, and ordered the resident be sent to the emergency room for evaluation/treatment. Further review of Resident #79's record revealed no evidence that all appropriate documentation was sent to the acute care facility. Review of Resident #83's closed record revealed resident was admitted to the facility on (MONTH) 1, (YEAR) for skilled rehabilitation following cardiac surgery. Further review of Resident #83's closed record revealed that on (MONTH) 3, (YEAR) Resident #83 suffered acute onset of left sided weakness, left eye droop and left mouth droop and was sent emergently to an acute care facility. Further review of Resident #83's closed record failed to reveal evidence that all appropriate documentation was sent to the acute care facility when Resident #83 was discharged . Review of Resident #30's clinical record revealed resident was admitted to the facility on (MONTH) 11, (YEAR) for Alzheimer's and history of falls. Further review of Resident #30's clinical record revealed resident was transferred to hospital on (MONTH) 3, (YEAR) due to fall at the facility resulting in a fracture. Additional review of Resident #30's clinical record revealed the facility failed to send appropriate documentation to the acute care facility Resident #30 was transferred to. Interview with DON on (MONTH) 29, (YEAR) at approximately 10:30a.m. revealed that the facility does not typically send the nursing care plan with resident when transferred to acute care facility. 28 PA Code 201.18(b)(1)(2) Management Previously cited 10/19/17

Based on a review of facility policy, residents group interview, and staff interview, it was determined that the facility failed to make certain residents were notified of the procedure for filing grievances anonymously on three of three nursing units (Bradford, Goshen and Birmingham Nursing units). Findings include: Review of the facility policy dated (MONTH) (YEAR), titled, Resident Grievance Policy stated that the policy is provided to residents during the admission process and are available at the following locations in the facility: social service office, bulletin board, and receptionist desk. During a residents group interview conducted on (MONTH) 28, (YEAR) at approximately 11:30 a.m. with eleven alert and oriented residents residing on the(NAME) Goshen and Birmingham Nursing Units, revealed that these residents were asked if they knew how to file a grievance or a concern and how they would file anonymously. All eleven residents were unclear on how to file anonymously and they were unaware of the location of Grievance/Concern forms. Review of an admission packet provided to surveyor from facility revealed there was no grievance forms in packet for residents upon admission. Observation of a bulletin board located in the main entrance hallway of the facility revealed a folder with the grievance policy inside and one grievance form stapled to the back of policy. The folder was attached to very top of bulletin board which was not easily accessible to wheelchair residents. During an observation on the(NAME)Nursing Unit on (MONTH) 28, (YEAR) at approximately 12:00 p.m. noted that the process of filing a grievance anonymously was not displayed and no Grievance/Concern Forms were visible on the unit. During an observation on the Goshen Nursing Unit on (MONTH) 28, (YEAR) at approximately 12:15 p.m. the process of filing a grievance anonymously was not displayed and no Grievance/Concern Forms were visible on the unit. During an observation on the Birmingham Nursing Unit on (MONTH) 28, (YEAR) at approximately 1:15 p.m. the process of filing a grievance anonymously was not displayed and no Grievance/Concern Forms were visible on the unit. During an interview on (MONTH) 29, (YEAR) at approximately 1:15 p.m. the Director of Nursing confirmed that although the grievance policy was displayed on a bulletin board near the main entrance explaining the grievance process, there was no way for a resident or family to file an anonymous grievance and grievance/concern forms are not accessible to resident or families without asking a staff member. Pa. 28 Code: 201.29(i) Resident Rights. Pa. 28 Code: 201.18(e)(4) Management.

Based on a review of facility policy, record review and interview with staff, it was determined that the facility failed to provide a bed-hold notice to the resident or responsible party upon transfer to the hospital for two of three residents reviewed (Residents #70 and #79). Findings include: Review of facility policy Bed Hold Policy revised (MONTH) (YEAR) indicated that written notice of the bed hold policy is given to the resident by nursing within 24 hours of a transfer. Review of Resident #70's progress notes revealed that the resident was sent to the emergency room (ER) on (MONTH) 24, (YEAR). The resident was readmitted to the facility on (MONTH) 3, (YEAR), and subsequently transferred to the hospital on (MONTH) 5, (YEAR). The resident was again transferred to the hospital on (MONTH) 22, (YEAR). There was no documented evidence to indicate that notification regarding the bed-hold policy was provided to Resident #70 or their responsible party before the transfer to the hospital on any of the above dates. Review of Resident #79's progress note revealed that the resident was transferred to the hospital on (MONTH) 13, (YEAR). There was no documented evidence to indicate that notification regarding the bed-hold policy was provided to Resident #79 or their responsible party before the transfer to the hospital. Interview with Employee E3 on (MONTH) 29, (YEAR), at 10:28 a.m. revealed that bed-hold notices are signed on admission. A copy is kept at the nursing station to be sent with the resident when they are transferred to the hospital. Employee E3 confirmed that there was no evidence that a bed-hold notice was sent with the residents. Pa. Code. 211.5(f) Clinical records Previously cited 10/19/17 Pa. Code. 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review and review of facility documentation, it was determined tht the facility failed to ensure that one of 20 residents reviewed was free of neglect during a transfer which resulted in actual harm to a resident who sustained a non-displaced [MEDICAL CONDITION] humerus (Resident E12). Findings include: Review of the facility policy titled, Resident Abuse, Neglect, or Misappropriation of Property, last revised on September 2016, defined neglect as the failure of the facility employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect also refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment and care including but not limited to: nutrition, medication, therapies and activities of daily living. Review of Resident E12's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quaterly Minimum Data Set assessment (MDS - a periodic review of resident needs) completed on January 11, 2017, revealed that the resident scored a 12 out of 15 on the Brief Interview of Mental Status (BIMS) which identified the resident with moderate cognitive impairment. The resident required extensive assistance of one person for bed mobility and transfer. Review of the facility's reportable event investigation revealed an interview with Resident E12 regarding a shoulder injury that occurred on Friday, February 24, 2017. Resident E12 said, she was in the wheelchair and was ready to get into bed and the nursing assistant was assisting her. The resident also stated that the nursing assistant helped her sit on the side of the bed and when he went to put her legs onto the bed, she placed her left arm on the bed and said wait there is a bug and looked back over her shoulder as he swung her legs up onto the bed. The resident stated, that it all happened so quickly that she didn't have time to move her arm and it got caught on the blanket and she felt a pull and tear in her shoulder. The resident complained of pain and was evaluated by the nurse. Review of nursing documentation dated February 28, 2017, at 3:08 p.m. noted a late entry from February 24, 2017, which stated that the nursing assistant asked the licensed nurse to go into the resident's room because he hurt the resident's arm. The resident was complaining of left shoulder pain. The nursing note further indicated, Resident arm injured during transfer into bed. Review of Resident E12's clinical record revealed a nursing progress note dated February 25, 2017, at 7:59 a.m. which stated, Resident expressed that while being assisted to bed last night she strained her left shoulder to left elbow. Resident complaining of pain. Tender to touch. Review of Resident E12's nursing progress note dated February 25, 2017, at 8:45 a.m. revealed She stated she strained her left arm getting into bed last night. She heard crunchies in her arm followed by pain. Today complaining of pain in her biceps area, poor range of motion. Call placed to Medical Doctor. Review of Resident E12's nursing progress note dated February 25, 2017, at 1:26 p.m. revealed Tylenol given at 8:30 a.m. for left shoulder and elbow pain. Minimal range of motion to left arm. New Physician's order given [MEDICATION NAME] milligram tablet every eight hours whenever necessary for severe pain and get x-ray on Monday, 2/27/17, if pain continues. Further review of Resident E12's nursing progress note dated February 25, 2017, at 11:01 p.m. revealed that the Resident requested and received Tylenol for left shoulder pain. Tender to touch. On Sunday February 26, 2017, on the evening shift, Resident E12 complained of increased pain in her left shoulder. The physician was called approximately 5:20 p.m. and an X-ray was ordered of the left shoulder. Review of the X-ray report dated February 26, 2017, revealed that the resident was diagnosed with [REDACTED]. On February 27, 2017, Resident E12 was sent to the local hospital for evaluation and to determine if the fracture observed on the portable X-ray was new or from a previous shoulder injury. Review of the hospital documentation dated February 27, 2017, noted that the resident had a deformity from old fracture in 2010, however there appears to be cortical discontinuity and lucency raising the possibility of superimposed acute fracture. There is no radiopaque foreign body. Nursing note date February 28, 2017, at 6:00 p.m. revealed that the resident was encouraged to get out of bed after breakfast but the resident was reluctant due to pain on movement. Offered and accepted PRN (as needed)[MEDICATION NAME] some relief soft splint wrap and ace to left upper ext (extremities) in place . new order for [MEDICATION NAME] 50 mg (milligrams) PRN for pain . Resident has othrth (orthopedic) apt (appointment) tomorrow. Review of the orthopedic (branch of medicine dealing with the bones or muscles) documentation revealed that Resident E12 was seen by the orthopedic surgeon on March 1, 2017. A verbal report was called into the facility on [DATE], by the orthopedic physician who stated he believes the fracture may be acute due to the patient's symptoms, however it is difficult to confirm given the deformity from a previous injury. On March 3, 2017, the final dictated report received from the orthopedic physician revealed a nondisplaced fracture of proximal end of the left humerus, unspecified fracture morphology, initial encounter, Acute. Review of the findings of the facility investigation revealed that it was determined that the facility found that the nursing assistant failed to properly transfer the resident into the bed and did not check the placement of the resident's arms before lifting her legs onto the bed causing her torso to twist and a strain to the left shoulder. Further review revealed that while the nursing assistant was providing care and assisting the resident into bed the resident asked the nursing assistant to stop lifting her legs and turning her into bed. The nursing assistant failed to listen to the resident when she said the motion he was assisting with was causing pain. As a result of the nursing assistant's actions, the resident sustained [REDACTED]. The facility failed to ensure that Resident E12 was free of neglect by the nursing assistant continuing to lift and turn resident into bed causing pain, which resulted in actual harm when the resident sustained [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 02/08/17, 09/30/16, 09/12/16, 08/21/15 28 Pa. Code 201.18(b)(1) Management Previously cited 02/08/17, 09/30/16, 09/12/16, 08/21/15 28 Pa. Code 201.18(e)(1) Management Previously cited 08/21/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/30/16, 08/21/15 28 Pa. Code 211.12(c) Nursing services Previously cited 09/30/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/08/17, 09/30/16, 08/21/15

Based on review of a facility policy and procedure and clinical record review, it was determined the facility failed to complete accurate assessments and ensure that care and services were provided to assist residents in restoring as much bladder control as possible for four of 20 residents reviewed (Resident D2, Resident D4, Resident D9 and Resident D10). Findings include: Review of facility policy and procedure titled, Toileting Program, revised March 2017, revealed upon admission to the facility, the resident's toileting habits (bladder assessment diary) will be tracked for three days by the charge nurse and the nursing assistant. The charge nurse and nursing assistant's will develop an individualized toileting trial program utilizing the three-day Bladder and Bowel Assessment diary, the admission assessments and resident history. The policy further stated that the toileting program will thereafter be evaluation on an as needed basis and at least every 90 days. At any point that the resident has had a decline in their continence, the resident, according to policy will be placed back on a toileting trial program to assess the need of additional interventions to ensure their toileting needs are met. Review of Resident D2's [DIAGNOSES REDACTED]. Review of Resident D2's Quarterly Minimum Data Set assessment (MDS - periodic assessment of a resident's needs) dated May 17, 2017, revealed that Resident D2 was frequently incontinent of bladder. Review of Resident D2's Annual MDS dated [DATE], revealed that Resident D2 was always incontinent of bladder. Review of Resident D2's clinical record failed to reveal that an individualized toileting trial program was initiated and failed to reveal that Resident D2 was placed on a toileting trial program after a decline in Resident D2's bladder continence was identified as indicated in the facility's policy. Review of Resident D4's [DIAGNOSES REDACTED]. Review of Resident D4's Annual MDS dated [DATE], revealed that Resident D4 was frequently incontinent of bladder. Review of Resident D4's Quarterly MDS dated [DATE], revealed that Resident D4 was always incontinent of bladder. Review of Resident D4's clinical record failed to reveal that an individualized toileting trial program was initiated and failed to reveal that Resident D4 was placed on a toileting trial program after a decline in Resident D4's bladder continence was identified as indicated in the facility's policy. Review of Resident D9's [DIAGNOSES REDACTED]. Review of Resident D9's Quarterly MDS dated [DATE], revealed that Resident D9 was occasionally incontinent of bowel and frequently incontinent of bladder. Review of Resident D9's Quarterly MDS dated [DATE] revealed that Resident D9 was frequently incontinent of bowel and always incontinent of bladder. Review of Resident D9's clinical record revealed that incontinence evaluations were completed in May 2017 and August 2017 with no recommendations indicated. Further review of Resident D9's clinical record failed to reveal that an individualized toileting trial program was initiated after the above-mentioned evaluations were completed and failed to reveal that Resident D9 was placed on a toileting trial program after a decline in Resident D9's continence was identified per the facility policy. Review of Resident D10's [DIAGNOSES REDACTED]. Review of Resident D10's Quarterly MDS dated [DATE], revealed that the staff completed a Brief Interview for Mental Status (BIMS- interview to determine a resident's cognitive level). The resident scored a 13 out of 15 on the BIMS which indicated that the resident was cognitively intact. Further review of the MDS identified the resident as frequently incontinent of bladder and always incontinent of bowel. Review of Resident D10's Quarterly MDS dated [DATE], revealed that the resident was always incontinent of bladder and bowel. Review of Resident D10's clinical record failed to reveal that an individualized bowel and bladder toileting trial program was initiated after a decline in Resident D10's bowel and bladder continence was identified per the facility policy. Interview with the Director of Nursing on October 19, 2017, at approximately 12:00 p.m. confirmed that the above-mentioned residents were not placed on individualized toileting trial programs per the facility policy. 28 Pa. Code 211.5(f) Clinical records Previously cited 02/08/17, 09/30/16, 08/21/15 28 Pa. Code 211.10(c) Resident care policies Previously cited 09/30/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/30/16, 08/21/15 28 Pa. Code 211.12(c) Nursing services Previously cited 09/30/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/08/17, 09/30/16, 08/21/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 02/08/17, 09/30/16

Based on review of clinical records and staff interview, it was determined that the facility failed to timely act upon the pharmacy recommendation for one of 20 residents reviewed (Resident F2). Findings include: Review of Resident F2's [DIAGNOSES REDACTED]. Review of Resident F2's current physician's orders [REDACTED]. Further review of Resident F2's current physician's orders [REDACTED]. Further review of Resident F2's current physician's orders [REDACTED]. Review of Resident F2's clinical record revealed a Consultation Report by the pharmacy consultant dated July 11, 2017, which recommended discontinuation of the medications Loperamide, Clotrimazole Cream, and Benadryl. Further review of the consultation report revealed a physician response which indicated, accepted the recommendations, implement as written. The physician's signature was noted as well as date of signature of July 18, 2017. Further review of Resident F2's clinical record revealed a pharmacy Consultation Report dated August 10, 2017, which stated, prescriber accepted pharmacy recommendation to discontinue Loperamide, Clotrimazole Cream, and Benadryl but the order has not yet been processed. Interview with the Director of Nursing on October 17, 2017, at approximately 12:43 p.m. confirmed the above-mentioned recommendations from the consultant pharmacist were not acted upon in a timely manner. The facility failed to timely act upon the pharmacist recommendations. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.12(c) Nursing services Previously cited 09/30/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 02/08/17, 09/30/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/08/17, 09/30/16, 08/21/15

Based on facility policy and clinical record review, it was determined that the facility failed to provide adequate and safe supervision during a transfer for one of 20 residents reviewed (Resident C2). Findings include: Review of the facility policy titled, Lift Policy, revised February 2017, revealed that two staff are to be utilized when performing a mechanical lift procedure on a resident. Review of Resident C2's clinical record revealed the resident had a fall on May 1, 2017, at 9:30 p.m. Review of Resident C2's nursing note dated May 1, 2017, revealed that the fall occurred due to the nursing assistant utilizing the sit-to-stand lift (a lift designed to help patients with some mobility but who lack the strength or muscle control to rise to a standing position. It uses straps, vests, or belts to make the transition possible.) by herself. The nursing assistant strapped the resident in the sit-to-stand lift and began to move the resident toward the bathroom and the resident started to move her arms out of position, so the nursing assistant grabbed the resident and lowered her to the floor from the lift. Interview with the Nursing Home Administrator and Director of Nursing on October 19, 2017, at approximately 1:45 p.m. confirmed that the nursing assistant should not have been utilizing the sit-to-stand lift by herself. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 09/30/16, 08/21/15 (At 42 CFR 483.25(h)) 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 02/08/17, 09/30/16, 09/12/16, 08/21/15 28 Pa. Code 201.18(b)(1) Management Previously cited 02/08/17, 09/30/16, 09/12/16, 08/21/15 28 Pa. Code 211.12(c) Nursing services Previously cited 09/30/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/08/17, 09/30/16, 08/21/15 28 Pa. Code 211.12(d)(2) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide a discharge summary for one of 20 residents reviewed (Resident CL3). Findings include: Review of Resident CL3's clinical record revealed the resident was discharged to an assisted living facility on August 3, 2017. Further review of Resident CL3's clinical record revealed there was no discharge summary signed by the physician. Interview with the Nursing Home Administrator and Director of Nursing on October 19, 2017, at approximately 1:45 p.m. confirmed that there was no discharge summary for Resident CL3. 28 Pa. Code 211.5(d) Clinical records 28 Pa. Code 211.5(f) Clinical records Previously cited 02/08/17, 09/30/16, 08/21/15

Based on review of facility documentation and interview with facility staff, it was determined that the facility failed to report an alleged incident of serious physical injury to the State Department of Aging for one resident reviewed (Resident E13). Findings include: Review of the Older Adults Protective Services Act (OAPSA), which was amended by Act 13 of 1997, mandates reporting requirements of serious physical injury (an injury that causes a person severe pain or significantly impairs a person's physical functioning, either permanently or temporarily). If serious physical injury occurs, as defined under OAPSA, the law requires additional reporting to the Department of Aging and local law enforcement. Review of an investigation of an injury which was discovered on December 30, 2016 revealed that Resident E13 sustained a [MEDICAL CONDITION] femoral neck (top of large bone in the thigh near the hip) and an investigation was completed by the facility. Interview with the Director of Nursing on February 9, 2017 at approximately 11:30 a.m. revealed that the facility did not notify the Pennsylvania Department of Aging of the serious physical injury as required by state law. The facility failed to notify the Pennsylvania Department of Aging of serious physical injury involving Resident E13. PA Chapter 51: Code: 51.3(g)(6) Notification 28 PA Code 201.14(a)(c) Responsibility of Licensee Previously cited 9/30/16 28 PA Code 201.18(b)(1)(d) Management Previously cited 9/30/16

Based on clinical record review, facility documentation and staff interview, it was determined that the facility failed to follow physician's orders to ensure the safety of one resident during meals for one of 18 residents reviewed, which resulted in actual harm to the resident (Resident CL3). Findings include: Review of Resident CL3's [DIAGNOSES REDACTED]. Review of Resident CL3's clinical record revealed that Resident CL3 received speech therapy from December 24, 2015, up to and including January 28, 2016, to promote the resident's eating and drinking abilities in an effort to avoid choking and/or aspiration (the accidental sucking of food particles or fluids into the lungs). Review of Resident CL3's January 2016 physician's orders revealed that the resident was ordered a mechanical soft diet (food that is made easier to chew and swallow). Review of Resident CL3's active plan of care dated December 22, 2015, revealed that the resident required a mechanically altered diet related to chewing and swallowing impairments and related to a history of a choking episode prior to admission. Review of facility documentation in relation to a description of an incident and Resident CL3's clinical record review revealed that on January 28, 2016, at approximately 12:45 p.m. Resident CL3 was in the dining room and the nursing assistant was called over to the Resident CL3's table by another resident. The other resident told the nursing assistant that Resident CL3 appeared to be choking. The nursing assistant asked Resident CL3 if he was choking but the resident was not able to answer. The nursing assistant described the resident as, his eyes were open, he looked a little red and sweaty. Further review of the facility documentation revealed that the nursing assistant then assumed that the resident was choking and performed the [MEDICATION NAME] maneuver (an emergency procedure for removing a foreign object lodged in the airway that is preventing a person from breathing) repeatedly. Two licensed nursing staff arrived and continued the process and also used an Ambu bag (a resuscitator bag used to assist ventilation's) to attempt to aid the resident's breathing. The emergency mdical technicians were called and started CPR (CPR - a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing). The resident subsequently expired. Review of the facility's investigation into this incident revealed that the nursing assistant confirmed that while serving the lunch meal to Resident CL3, the nursing assistant looked at the wrong resident's name and diet on the resident assignment sheet (report sheet instructing the nursing assistant in the specific care and needs of each resident that the nursing assistant is assigned to on a daily basis.) Review of the facility documentation revealed that the caregiver assigned to Resident CL3 provided a meal inconsistent with the diet that was ordered by the physician and recommended by the speech therapist. An interview on September 30, 2016, at approximately 12:00 p.m. with the Speech Therapist, Employee E3, revealed that the nursing staff received education on all of the residents who are being seen and treated by speech therapy, regarding the appropriate diet with accompanying precautions that are to be put into place for the safety of each resident. An interview with the Nursing Home Administrator on September 30, 2016, at approximately 12:30 p.m. confirmed that the nursing assistant served the wrong meal consistency to Resident CL3 which ultimately led to the resident choking on the food and subsequently expiring. The facility failed to ensure that Resident CL3 was provided with a meal consistent to the diet ordered by the physician which resulted in actual harm to Resident CL3 who choked and subsequently died . 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/29/14, 08/21/15, 09/12/16 28 Pa. Code 201.18(b)(1) Management Previously cited 09/29/14, 08/21/15, 09/12/16 28 Pa. Code 201.18(b)(3) Management Previously cited 09/29/14 28 Pa. Code 211.10(c) Resident care policies Previously cited 09/29/14 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/29/14, 08/21/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 09/29/14, 08/21/15

Based on clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to ensure that interventions to prevent falls were implemented for two of 18 residents reviewed (Resident A11 and Resident CL2) resulting in actual harm to Resident CL2. Findings include: Review of Resident CL2's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident CL2's Fall Risk Assessment (assessment to determine the risk level of falling) completed on August 21, 2016, revealed a score of 9 which placed the resident at a moderate risk for falls. Review of Resident CL2's September 12, 2016, Minimum Data Set assessment (MDS - a periodic assessment of resident needs) revealed that the resident required a one person assist for transfers and ambulated using a rolling walker. Review of Resident CL2's interdisciplinary nursing notes revealed that on September 4, 2016, at 6:55 a.m. nursing assistant, Employee E10, reported to the licensed registered nurse that, she was helping the resident into bed when the resident hit her head on the wall. Review of Resident CL2's nursing interdiscilinary notes dated September 4, 2016, at 3:41 p.m. noted that the resident was lethargic (sluggish) and complained of left leg pain. The physician was notified and the resident was transferred to the hospital by emergency services (911). Further review of the nursing interdisciplinary notes dated September 4, 2016, at 8:00 p.m. indicated that the resident was admitted to the hospital with [REDACTED]. Review of the facility's investigation into the fall sustained by Resident CL2 on September 4, 2016, revealed that nursing assistant, Employee E10, summoned the charge nurse to the resident's room where the resident was found sitting in the upright position on the floor. Nursing assistant, Employee E10, who witnessed the fall stated that the resident hit her head on the wall. Further review of the facility's investigation into the fall revealed that nursing assistant, Employee E10, was providing incontinence care to the resident while the resident was holding on to the nightstand for support. During the incontinence care, the resident fell to the floor. During the fall, the resident struck her head on the wall. An interview with the Nursing Home Administrator, the Director of Nursing, and the Interim Director of Nursing on September 30, 2016, at approximately 10:00 a.m. confirmed that on September 4, 2016, Resident CL2 fell while nursing assistant, Employee E10, was providing incontinence care at the bedside. The Nursing Home Administrator, the Director of Nursing, and the Interim Director of Nursing further confirmed that nursing assistant, Employee E10, had Resident CL2 standing next to the bed holding onto the night stand. The facility failed to ensure that Resident CL2 was provided with proper safety during incontinence care which ultimately resulted in the resident sustaining a fall and actual harm of a left hip fracture. Review of Resident A11's clinical record revealed that Resident A11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].) Further review of Resident A11's clinical record revealed that between September 1, 2015, and September 25, 2016, Resident A11 sustained a total of twenty-two falls. Review of Resident A11's active plan of care revealed that beginning October 30, 2015, the staff were to keep the resident within sight while the resident was awake. Further review of Resident A11's clinical record revealed that on six occasions since October 30, 2015, the resident fell out of the wheelchair onto the floor while the resident was in the resident lounge on the following dates: December 20, 2015, found by staff on the floor next to the wheelchair; January 6, 2016, and June 14, 2016, fell on the floor; June 27, 2016, the resident slipped onto the floor out of wheelchair; July 26, 2016, the resident slid and fell from wheelchair and September 25, 2016, the resident was found by staff on the floor. There was no evidence that the facility had consistently supervised and monitored Resident A11 to ensure the resident's safety in the lounge area, while awake as indicated on the resident's care plan. The facility failed to ensure that proper supervision was being implemented to prevent falls and injury. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 09/29/14, 08/21/15 28 Pa. Code 201.18(b)(1) Management Previously cited 09/29/14, 08/21/15, 09/12/16 28 Pa. Code 211.5(f) Clinical records Previously cited 09/29/14, 08/21/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/29/14, 08/21/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 09/29/14, 08/21/15

Based on record review and staff interview, it was determined that the facility failed to implement interventions to prevent the development of a pressure area for one resident out of 18 residents reviewed (Resident CL1), resulting in actual harm to Resident CL1. Findings include: Review of Resident CL1's [DIAGNOSES REDACTED]. cells for nourishment and energy) and an open reduction and internal fixation of the right (a surgery to fix a broken bone) hip. The resident was admitted to the facility on [DATE], and the admission Minimum Data Set assessment (MDS - a periodic assessment to determine resident care needs) revealed that the resident had a BIMS (a Brief Interview for Mental Status - structured cognitive test used to determine a residents cognitive status) score of 7 out of 15 indicating severe cognitive impairment (thinking and reasoning ability). The MDS also revealed that the resident required extensive assistance of two persons to move in bed. MDS Section M0150 title -Risk of Pressure Ulcers revealed that the resident was at risk for developing pressure ulcers. MDS Section M1200 title- Skin and Ulcer Treatment did not reveal that any pressure relieving devices were in place. Review of the Resident CL1's care plan initiated July 26, 2016, identified the resident with the potential for pressure ulcer development due to a decrease in mobility. The interventions documented in the care plan included, relieve pressure on affected areas, observe risk areas during care for skin redness, full body skin check weekly with showers, notify the nurse of any new changes in skin integrity. A skin risk assessment completed on August 6, 2016, indicated that the resident was at high risk for skin breakdown and had [MEDICAL CONDITION] (fluid accumulation) in the lower extremities. A skin assessment completed on August 9, 2016, revealed that there was no impairment of the skin. A nursing interdisciplinary note dated August 11, 2016, revealed that a 3 centimeter by 3 centimeter blister (a small bubble on the skin filled with serum (fluid) and caused by friction, burning, or other damage) was identified on the resident's right heel. Nursing interdisciplinary note dated August 12, 2016, at 10:30 a.m. revealed that the resident's right heel blister had been identified as fluid filled and closed. The resident's heels were off loaded (elevated to relieve pressure) and a treatment had been started to the area. Skin Prep (a [MEDICATION NAME] solution) was applied to the right heel twice daily beginning August 11, 2016, and Skin Prep was applied to the left heel for protection against breakdown starting August 13, 2016. Further review of the resident's clinical record revealed that there was no further tracking of the right heel blister as the resident was discharged from the facility on August 16, 2016. An interview with the Director of Nursing on September 30, 2016, at 11:00 a.m. confirmed that all residents on that unit were provided with a pressure reducing mattress but could not provide documentation of any additional measures implemented for this resident's heels who had been assessed as at risk for pressure ulcer development, had lower extremity [MEDICAL CONDITION] and required staff assistance to move in bed. The facility failed to ensure that interventions to prevent the development of blisters to the heels were provide for a resident who was assessed with [REDACTED]. 42 CFR 483.25(c) Treatment/Services to Prevent /Heal Pressure Sores Previously cited 08/21/15 28 Pa. Code 211.5(f) Clinical records Previously cited 09/29/14, 08/21/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/29/14, 08/21/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 09/29/14, 08/21/15

Based on staff interview, clinical record review and review of the facility's policies and procedures, it was determined that the facility failed to ensure the safety of a resident during a transfer for one out of 17 residents reviewed, which resulted in actual harm to Resident CL4. (Resident CL4) Findings include: Review of facility policy titled Lift Policy dated August, 2015 revealed that All staff will use the lifts for designated residents, as well as to lift any residents that the staff feels would be safely lifted using the lift. The policy further states For resident as well as staff safety, two staff are to be utilized when performing a lift procedure on a resident. Two staff will be actively involved in preparing resident for lift procedure; one staff will maneuver the lift while second staff will observe the resident and guide the resident and staff safely during transfer-transport, keeping in mind that resident limbs are in a safe position to prevent bruising, abrasions, and skin tears. Review of Resident CL4's Quarterly MDS Assessment (Minimum Data Set - periodic assessment of resident needs) dated July 9, 2015 revealed a BIMS score (Brief Interview for Mental Status) of 9 out of a possible 15. A score of 9 indicated moderately impaired cognition. The MDS also indicated that the resident required extensive assistance of one person for transfers and no limitation on range of motion. Review of Resident CL4's medical record revealed [DIAGNOSES REDACTED]. Review of this resident's care plan dated July 14, 2015 revealed that a sit to stand lift was to be used for all transfers. Review of Resident CL4's interdisciplinary notes dated July 31, 2015 revealed that the resident sustained [REDACTED]. The facility's investigation into the incident revealed that at approximately 7:30 a.m. on July 31, 2015, the resident was being transferred from a wheelchair to a shower chair by Employee E6. At that time the resident sustained [REDACTED]. plan. Employee E6 reported the skin tears to Employee E8 and the resident's injuries were assessed. The facility's investigation into the incident did not reveal the size or severity of the two skin tears. Further review of the facility's investigation into the incident revealed that on July 31, 2015 at approximately 4:30 p.m., Employee E7 brought the resident to the nurses' station because the resident was complaining of left leg pain. Review of licensed staff, Employee E9's clinical notes for that date revealed the resident's left leg was swollen more than usual, the resident was yelling out in pain when movement was attempted and the left knee was internally rotated. After contacting the physician, the resident was transferred to the emergency room for evaluation and diagnosed with [REDACTED]. Interview with licensed staff, Employee E2 on August 19, 2015 at approximately 11:00 a.m. confirmed that Employee E6 failed to follow facility's policy for transferring this resident. During this interview Employee E2 stated that the facility concluded that the fracture was linked to the transfer and Employee E6 did not transfer the resident with two people per facility's policy. A subsequent interview with Licensed Employee E2 on August 21, 2015 at approximately 9:30 a.m. confirmed that the facility did not assign two CNAs to any residents requiring mechanical lifts for transfers and that Resident CL4 should have been re-evaluated for physical and mental ability to comply with the use of a mechanical lift. The facility f ailed followed the established facility's policy for the transfer of a resident via a mechanical lift with resulted in actual harm to Resident CL4 sustaining a fracture to the left tibia. During the initial tour of the Bradford nursing unit on August 17, 2015 at approximately 12:00 p.m. a plastic container was noted on the floor at the entrance to the nursing station. This box was not secure and contained 3 cards containing Glucosamine (a dietary supplement) tablets and 3 medication cards containing Pantoprazole (a medication used for esophagitis) tablets. The NHA confirmed on August 17, 2015 at 6:00 p.m. that this box with unsecured medications should not have been left in a resident area and confirmed that there were residents on that unit who were confused and had compromised safety awareness. The pharmacy confirmed on August 19, 2015 that the count from the cards was a total of 169 pills. 483.25(h) Fee of Accidents Hazards/ Supervision/Devices Previously cited 9/29/2014 28 PaC ode: 201.14(a) Responsibility of licensee Previously cited 9/29/2014 28 Pa Code: 201.18(b)(1) Management Previously cited 9/29/2014 28 Pa Code: 211.10(d) Resident care policies 28 Pa Code: 211.12(d)(1)(5) Nursing services Previously cited 9/29/2014

Based on observation, review of facility policy, review of the clinical record and interview with staff, it was determined that the facility failed to implement preventative measures and regularly assess a resident at risk to prevent the development of a pressure area for one out of 17 residents, which resulted in actual harm to Resident E11. (Resident E11). Findings include: Review of facility policy entitled Pressure Ulcer Management (reviewed 8/15) revealed that the nursing staff would utilize their assessment skills, treatment interventions and products ordered by the physician to provide optimum wound care prevention and management for each resident. During the first bath of the week, a skin assessment would be completed. The Preventative Skin Care Policy (reviewed 8/13) revealed that areas that are prone to pressure would be protected via the use of protective cushions, pressure relieving mattresses and elevating heels off the bed with pillows. Review Resident E11's [DIAGNOSES REDACTED]. Review of interdisciplinary notes dated December 27, 2014 revealed that Resident E11 was readmitted to the facility following surgery to repair a fractured right hip after a fall. Review of resident E11's MDS assessment (minimum data set: a regular assessment completed to identify resident care needs) dated April 16, 2015 revealed that the resident was at risk for pressure ulcer development. Review of interdisciplinary notes dated May 2, 2015 indicated that the resident had bilateral ankle swelling which would increase the risk of skin breakdown. Review of Resident E11's weekly skin assessment dated [DATE] did not identify any skin issues. The next skin assessment was completed June 2, 2015, 14 days after the previous assessment was completed which identified a deep tissue injury to the right heel (discolored intact skin or blood filled blister due to damage to underlying soft tissue from pressure or shear). An interdisciplinary note dated May 30, 2015 revealed that the nurse was going to contact the wound nurse concerning the resident's heels, however there was no note from the wound nurse until after the wound was identified. There was no evidence that any additional pressure relieving measures were initiated at that time as stated in the facility's policy. Wound documentation for Resident E11 dated June 2, 2015 indicated a full thickness wound (a wound that indicates that damage extends through all layers of skin to the subcutaneous tissue or beyond) measuring 4 centimeters by 4 centimeters was identified on the right heel. Wound documentation of June 11, 2015 indicated an unstageable /stage 4 wound (unable to visualize the wound bed secondary to eschar- dark, dead tissue covering the wound) measuring 4 centimeters by 4 centimeters on the right heel. Review of Resident E11's current physician orders [REDACTED]. On June 3, 2015 the physician ordered ace wraps to bilateral lower extremities on in am and off at bedtime with heel exposed to address [MEDICAL CONDITION]. Interview with the Director of Nursing on August 19, 2015 at approximately 10:00 a.m. revealed that pressure relieving measures were not provided in the lounge chair when the resident was out of bed and that the skin assessment of May 26, 2015 per facility policy. The facility failed to follow established policy by timely monitoring the resident's skin to prevent pressure ulcer and providing protective equipment to relieve pressure for a resident at risk for skin breakdown which resulted in actual harm to Resident E11 with the development of a deep tissue injury on the right heel. 28 PaC ode: 201.14(a) Responsibility of licensee Previously cited 9/29/2014 28 Pa Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 9/29/2014 28 Pa. Code 211.10(d)Resident care policies Previously cited 9/29/2014 28 Pa code 211.12(d)(1)(5) Nursing services Previously cited 9/29/2014

Based on a review of clinical records, facility abuse investigation documentation and staff interviews, it was determined that the facility failed to implement abuse policies that prohibit mistreatment, neglect and abuse of residents, resulting in actual harm to one of 19 residents reviewed (Resident F5). Findings include: Review of facility policy and procedure for abuse and neglect, revised July 2011, indicated that anyone who witnesses or has reasonable cause to suspect or believe that resident abuse or neglect had occurred, is to report it immediately to his or her immediate supervisor. Further review of the policy revealed that a caregiver alleged to have been abusive to a resident should be immediately suspended or reassigned. Review of facility documentation for October 14, 2011, revealed that the nurse on the 11:00 p.m. to 7:00 a.m. shift completed an assessment of Resident F5 after the caregiver reported that she had to lower the resident to the floor. Upon arriving at the resident's room, Resident F5 was observed to be scared and told the nurse that the caregiver had beaten her up. Facility documentation related that the resident was observed to have a 0.5 centimeter opening on her head. There was redness to the right eyelid as well as some redness on her right cheek. The facility documentation revealed that Resident F5 told the nurse that the caregiver slapped her on both sides of her face and head. Later during this shift, the resident's ear was noted to be turning blue and there was a bump noted on the resident's head. The nurse advised the caregiver to take care of other residents but not to provide care to Resident F5 any more that night. The nurse failed to suspend or reassign the caregiver as per policy and failed to notify the supervisor until 8:30 a.m. on October 14, 2011. Further review of facility documentation revealed that on September 28, 2011, this same nurse heard the same caregiver call the resident an old white [***] . Another resident, Resident F11 also complained to this nurse on that date, indicating that the caregiver was rough and wouldn't listen to her about her broken arm. The nurse failed to report these allegations, as per facility policy, to the supervisor until 16 days after the witnessed verbal abuse and the allegation of rough treatment. Review of nursing notes for Resident F5, dated October 14, 2011 through October 17, 2011, revealed that the resident's account of alleged abuse was consistent from when first reported. Review of Resident F5's care plan dated October 14, 2011, revealed interventions for the resident due to the resident experiencing distress from alleged physical assault. The resident was sent to the emergency roiagnom on [DATE], for evaluation for her injuries. Interview with the Director of Nursing and the Social Service Director on October 27, 2011, at 9:00 a.m., confirmed that if the nurse had followed the facility policy for the reporting of abuse and protection of residents after the allegation is reported, that the caregiver, who was an agency caregiver, would have been put on the do not return list and would not have been allowed to return to the facility. The nurse's failure to follow facility abuse policy resulted in actual harm to Resident F5 201.18(b)(1)(e)(1) Management Previously cited 9/27/2010, 9/15/2009 211.5(f) Clinical records Previously cited 9/27/2010 211.10(d) Resident care policies Previously cited 9/27/2010 211.12(d)(1)(5) Nursing services Previously cited 9/27/2010, 4/12/2010, 9/15/2009