Every finding on record at Bedford Post Acute

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman (an independent, impartial official appointed to investigate and help resolve complaints) of a transfer to the hospital for five of 35 residents reviewed (Residents 1, 6, 9, 65 and 75). Findings include: A facility policy regarding transfer or discharge notices, dated January 7, 2026, indicated that residents (or resident representatives) are notified of an impending transfer or discharge and the reason for the move in writing and in a language and manner they understand. A copy of the notice is sent to the office of the State Long-Term Care Ombudsman. When a resident is sent emergently to an acute care setting, this is considered a transfer, not discharge, because the resident's return is generally expected. Notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 1, dated May 19, 2026, revealed that the resident was cognitively intact, required assistance from staff for some daily care needs, and had diagnoses that included heart failure (the heart can't pump blood well enough to meet the body's needs), pneumonia and respiratory failure (blood does not have enough oxygen and causes difficulty breathing). A nursing note for Resident 1, dated May 6, 2026, at 11:22 p.m., revealed that the resident had increased shortness of breath and the resident's pulse oximetry (measures blood oxygen levels) was 84 percent on oxygen at a rate of 3 liters per minute (LPM). His oxygen was increased to 5 LPM and his oxygen level increased to 89 percent. The physician was notified and the resident was sent to the hospital. There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 1's hospital discharge. A quarterly MDS assessment for Resident 6, dated May 12, 2026, revealed that the resident was cognitively impaired, was dependent on staff for all daily care needs, and had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth). A nursing note for Resident 6, dated April 24, 2026, at 3:11 p.m. revealed that the resident's feeding tube had come out and she was sent to the hospital. There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 6's hospital discharge. A quarterly MDS assessment for Resident 9 dated April 17, 2026, revealed that the resident was cognitively impairment, required assistance from staff for daily care needs, and had diagnoses that included cerebrovascular disease (conditions that affect blood flow and the blood vessels in the brain) and diabetes. A nursing note for Resident 9, dated April 3, 2026, at 11:04 a.m. revealed that the resident complained of numbness to her left hand that spread upwards to the shoulder during a doctor appointment and she was sent to the hospital. A nursing not for Resident 9, dated May 30, 2026, at 5:52 p.m. revealed that the resident had an episode of low blood sugar, was unresponsive, and had labored breathing and was sent to the hospital. There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 9's hospital discharges. An annual MDS assessment for Resident 65, dated April 15, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had recent falls, and had diagnoses that included dementia.A nursing note, dated March 29, 2026, at 6:50 p.m. revealed Resident 65 was witnessed sliding out of her chair onto the floor and had a skin tear to her right hand with bruising. At 10:45 p.m. the resident's wound was noted to have bled through the dressing. The physician was notified the excessive bleeding, and orders were received to send the resident to the hospital evaluation. There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 65's hospital transfer. A quarterly MDS assessment for Resident 75, dated June 13, 2026, revealed that the resident was cognitively intact. A nurse's note, dated June 2, 2026, revealed that the resident was sent to the hospital for difficulty in breathing and that she was admitted to the hospital. There was no documented evidence that a written notification of transfer was provided to the ombudsman for Resident 75's hospital transfer. Interview with the Director of Nursing on June 15, 2026, at 9:33 a.m. confirmed that there was no documented evidence that the ombudsman was notified of the hospital transfers for Residents 1, 6. 9, 65 and 75. She indicated that as of June 15, 2026, they had not been notifying the ombudsman of resident hospital transfers. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible for two of 35 residents reviewed (Residents 2, 37) and failed to ensure that each resident received assistance devices to prevent accidents for two of 35 residents reviewed (Residents 15, 53).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 2, 2026, indicated that the resident was mildly cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and epilepsy (brain condition that causes repeated seizures).Observation of Resident 2 on June 17, 2026, at 9:44 a.m. revealed that the resident was sitting in her recliner watching television. Interview with Director of Rehabilitation on June 17, 2026, at 9:50 a.m. stated that they have never done a recliner safety assessment on their residents. Interview with Nursing Home Administrator on June 16, 2026, at 2:42 p.m. confirmed that no recliner safety assessment was performed. The facility's air mattress policy, dated January 7, 2026, indicated that appropriate pressure redistribution support surfaces would be based on current recommended practices for device selection, as well as the resident's risk factors, clinical and functional needs, and preferences.A quarterly MDS assessment for Resident 37, dated February 26, 2026, revealed that the resident was cognitively intact, required assistance for staff with daily care needs, and had a pressure ulcer. Physician's orders, dated February 13, 2026, included orders for the resident to use an air mattress.A nursing note, dated February 20, 2026, at 7:12 p.m. revealed that Resident 37 was assessed by staff following a fall from her bed. She received skin tears to the left arm, right elbow and left knee. There was no documented evidence that the resident's air mattress was re-assessed for safety following the fall.Observations of Resident 37 on June 16, 2026, at 9:51 a.m. revealed that she was in bed with an air mattress in place.Interview with the Nursing Home Administrator on June 17, 2026, at 2:00 p.m. confirmed that there was no evidence that Resident 37's air mattress was re-assessed for safety following the fall on February 20, 2026. A comprehensive MDS assessment for Resident 15, dated May 8, 2026, revealed that the resident was cognitively impaired, used a wheelchair for transport, and had diagnoses that included dementia. Observations of Resident 15 on June 14, 2026, at 11:15 a.m. revealed that Nurse Aide 3 was pushing the resident in her wheelchair through the hall to the dining room with no leg rests on the wheelchair and staff telling her to keep her legs up while being pushed. Interview with Nurse Aide 3 on June 14, 2026, at 11:25 a.m. confirmed that Resident 15's leg rests were not on the wheelchair and should have been applied before transporting. A comprehensive MDS assessment for Resident 53, dated June 10, 2026, revealed that the resident was cognitively impaired, required extensive assistance for daily care needs including transfers and locomotion, and had diagnoses that included muscle weakness and gait abnormality. Observations of Resident 53 on June 14, 2026 at 11:24 a.m. revealed that she was being pushed in her wheelchair by Nurse Aide 4 with her feet hanging down able to touch the floor. Nurse Aide 4 was telling the resident to keep her feet up in the air as they went through the hall. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Nurse Aide 4 at that time confirmed that the resident should have had leg rests on her wheelchair to prevent injury during the transport. Interview with the Director of Nursing on June 14, 2026, at 3:02 p.m. confirmed that residents should have leg rests on their wheelchairs while being pushed by staff.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza and/or the pneumococcal immunizations for four of 35 residents reviewed (Residents 3, 13, 37, 42).Findings include:The facility's influenza and pneumonia vaccination policies, dated January 7, 2026 revealed that all residents would be offered the influenza and pneumonia vaccines.A quarterly Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 30, 2026, revealed that the resident was admitted to the facility on [DATE]. Section O0250 A (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in the facility for the year's influenza vaccination season, due to not being offered the vaccine. There was no documented evidence that the facility offered or administered the influenza vaccine to Resident 3. A quarterly MDS assessment for Resident 13, dated May 29, 2026 revealed that the resident was cognitively impaired, was admitted to the facility on [DATE], and that she was not offered the influenza or pneumonia vaccine. There was no documented evidence that Resident 13 was offered the influenza or pneumonia vaccine. A quarterly MDS assessment for Resident 37, dated March 31, 2026, revealed that the resident was admitted to the facility on [DATE]. Section O0300A (Pneumococcal Vaccination) revealed that the resident's pneumococcal vaccine was not up to date and that the resident was not offered the pneumococcal vaccine. A quarterly MDS assessment for Resident 42, dated May 14, 2026, revealed that the resident was admitted to the facility on [DATE]. Section O0250A (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in the facility for the year's influenza vaccination season, due to not being offered the vaccine.Interview with the Nursing Home Administrator on June 16, 2026 at 1:16 p.m. revealed that Residents 3, 13, 37, and 42 were not offered the influenza vaccine or the pneumonia vaccine and they should have been. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 35 residents reviewed (Residents 42 and 65). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415F1 Antibiotic Medications was to be coded if an antibiotic medication was taken by the resident at any time during the seven-day look-back period. Physician's orders for Resident 42, dated February 24, 2026, included an order for staff to apply 2% lidocaine/Nystatin/Silvadene /20% zinc topical cream (pain reliever/antifungal/ antibiotic/protective barrier) to the resident's sacrum (area located at the lower part of the spine) every day and evening shift for wound care. Review of the Medication Administration Record (MAR) for Resident 42, dated May 2026, revealed that staff had administered the 2% lidocaine/Nystatin/Silvadene /20% zinc cream to the resident's sacrum on May 1 through May 14, 2026. A quarterly MDS for Resident 42, dated May 14, 2026, revealed that section N0415F1 was not coded, indicating that the resident did not receive an antibiotic medication during the seven-day look-back assessment period. Physician's orders for Resident 65, dated April 3, 2026, included an order for the resident to receive 500-125 milligrams (mg) of Augmentin (an antibiotic) every twelve hours for seven days for cellulitis (bacterial skin infection). Review of the MAR for Resident 65, dated April 2026, revealed that staff had administered the Augmentin to the resident on April 3 through April 10, 2026. An annual MDS for Resident 65, dated April 15, 2026, revealed that section N0415F1 was not coded, indicating that the resident did not receive an antibiotic medication during the seven-day look-back assessment period. Interview with the Nursing Home Administrator on June 17, 2026, at 1:44 p.m. confirmed that the MDS was coded incorrectly for Residents 42 and 65. 28 Pa. Code 211.5(f) Medical records

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for one of 35 residents reviewed (Resident 13).Findings include: A quarterly MDS assessment for Resident 13, dated May 29, 2026, revealed that the resident was cognitively impaired, was admitted to the facility on [DATE], and that she was not offered the influenza or pneumonia vaccine. Review of Resident 13's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. Interview with the Nursing Home Administrator on June 16, 2026, revealed that Resident 13 was not offered the covid vaccination and should have been. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on review of the Nursing Assistant job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to five of five nurse aides reviewed (Nurse Aides 6, 7, 8, 9, and 10).Findings include: Review of the facility nursing assistant job description indicated that nurse aides were to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations. Review of Nurse Aide 6's personnel file revealed that she was hired on February 19, 2019. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 7's personnel file revealed that she was hired on August 21, 2017. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 8's personnel file revealed that she was hired on November 23, 2012. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 9's personnel file revealed that she was hired on June 24, 2021. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Review of Nurse Aide 10's personnel file revealed that she was hired on November 7, 1995. Review of her continuing education transcript revealed that she did not complete any annual education regarding Quality Assurance and Performance Improvement (QAPI) training. Interview with the Nursing Home Administrator on June 16, 2026, at 2:27 p.m. confirmed that Nurse Aides 6, 7, 8, 9, and 10 failed to complete the necessary education regarding Quality Assurance and Performance Improvement (QAPI) training. 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.20(a) Staff Development

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending July 2, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 17, 2026, identified repeated deficiencies related to failure to correct deficient practices related to quality care, safe environment free from accident hazards, and storage and labeling of medications. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending July 2, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending July 2, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards. The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during the survey ending July 2, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications. Refer to F684, F689, F761 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat as ordered by the physician for one of 35 residents reviewed (Resident 37).Findings include:The facility policy for assistive devices, dated January 7, 2026, indicated that certain devices and equipment that assist with mobility, safety, and independence were provided for residents. They may include specialized eating utensils and equipment, safety devices for the bathroom, and mobility devices.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 31, 2026, indicated that the resident was moderately cognitively impaired and required supervision from staff with eating. A care plan, dated May 22, 2026, revealed the resident was at risk for altered nutrition and was to have all foods in separate bowls for each meal.Observations of Resident 37 during the lunch meal on June 17, 2026, at 12:01 p.m. revealed that the resident was in bed eating lunch and she had a regular plate with her food items on it, she did not have a separate bowl for each food item. The resident's meal ticket for the noon meal indicated that she was to have all food items in separate bowls.Interview with Licensed Practical Nurse 1 on June 17, 2026, at 12:11 p.m. confirmed that Resident 37 did not have her food items in separate bowls and should have, according to the resident's meal ticket.28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for two of 35 residents reviewed (Residents 42, 63) and failed to label one multi-dose vial of Tubersol solution with the date it was opened in one of two medications rooms reviewed. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated May 14, 2026, revealed that the resident was moderately cognitively impaired, had pain frequently, received routine and as needed pain medications, and received an opioid (narcotic pain reliever). Physician's orders for Resident 42 dated May 20, 2026, included an order for the resident to receive 5 milligrams (mg) of Oxycodone twice a day for pain and 5 mg of Oxycodone every six hours as needed for moderate/severe pain. A review of the controlled drug count record (tracks each dose of a controlled medication) for Resident 42, revealed that the routine dose of Oxycodone was signed out of the as needed Oxycodone medication card on June 3 through 8, 2026. Interview with the Director of Nursing on June 16, 2026, at 1:02 p.m. revealed that the pharmacy only sends one card of Oxycodone and the routine and as needed doses are signed out of the card despite the label instructions. The facility's policy regarding Medication Administration, dated January 7, 2026, revealed that medication labels should be checked three times for the right dose, right time, and right method of administration prior to administering. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated May 25, 2026, revealed that the resident was cognitively impaired and had diagnoses that included disorientation and depression. Physician's orders for Resident 63 dated March 26, 2026, included an order for the resident to receive 0.5 milligrams (mg) of Lorazepam (anti-anxiety medication) daily for depression (mood disorder). Observations on June 16, 2026, at 1:56 p.m. revealed that the label on the card of Lorazepam did not match the current physician's order. The label reads Lorazepam 0.5 mg give one table by mouth every eight hours as needed for agitation. Interview with the Director of Nursing on June 16, 2026, at 2:23 p.m. revealed that the label on Resident 63's Lorazepam should match the current physician's order for the medication and it did not. The facility's policy regarding medication labeling, dated January 7, 2026, revealed that multi-dose vials were to be labeled when opened. Manufacturer's instructions for Tubersol, undated, revealed that the vial of Tubersol is good for 30 days once opened. Observations in the TCU med room on June 15, 2026, at 12:38 p.m. revealed that there was an opened and undated vial of Tubersol solution in the fridge. Interview with Registered Nurse 2 on June 15, 2026, at 12:39 p.m. revealed that the Tubersol vial should have been labeled with the date when it was opened. 28 Pa. Code 2119(a)(1) Pharmacy Services

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand-washing techniques were used during medication administration for one of 35 residents observed (Residents 7).Findings include: The facility's policies regarding Medication Administration, dated January 7, 2026, indicated that staff should follow infection control procedures, including hand sanitization for administration of medications. Observations during medication administration on June 15, 2026, at 8:50 a.m. revealed that Licensed Practical Nurse 5 was preparing Resident 7's medications. Using her bare hands, Licensed Practical Nurse 5 took a pill out of the cup and broke it in half. She then administered the medication to Resident 7. Interview with Licensed Practical Nurse 5 on June 15, 2026, at 8:55 a.m. confirmed that she should not have touched the pill with her bare hands. Interview with the Director of Nursing on June 15, 2026, at 2:12 p.m. confirmed that Licensed Practical Nurse 5 should not have touched the pill with her bare hands and administer the medication to Resident 7. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 35 residents reviewed (Residents 51 and 59). Findings include: A facility policy related to psychoactive/psychotropic medication use, dated January 7, 2025, indicated that the resident or resident representative has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the Alternative or option he or she prefers. Prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a psychotropic medication and document the consent in the medical record. The facility must record the signed written consent in the resident's medical record. A new informed consent must be obtained for dosage increases of psychotropic medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 51, dated June 1, 2026, indicated that the resident was cognitively impaired, was dependent of staff for daily care needs, received psychotropic medications including antianxiety and antidepressant medications, and had diagnoses that included dementia, anxiety, and depression. Physician's orders for Resident 51, dated October 15, 2025, included orders for the resident to receive 10 milligrams (mg) of Paxil (an antidepressant) daily for depression. Physician's orders for Resident 51, dated January 8, 2026, included orders for the resident to receive 20 mg of Paxil daily for depression. Physician's orders for Resident 51, dated January 16, 2026, included orders for the resident to receive 5 mg of Valium (a psychotropic medication used to treat anxiety) every eight hours for worsening behaviors related to anxiety disorder. There was no documented evidence in Resident 51's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosages of Paxil and Valium. Interview with the Nursing Home Administrator on June 16, 2026, at 11:46 a.m. confirmed that there was no documented evidence in Resident 51's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosages of Paxil and Valium. A quarterly MDS assessment for Resident 59, dated April 20, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, received psychotropic medications including antidepressant and antipsychotic (used to treat mental health disorders) medications, and had diagnoses that included dementia, anxiety, and depression. A nursing note for Resident 59, dated November 14, 2025, at 2:42 p.m. revealed that the physician gave a new order to increase the resident's Seroquel (an antipsychotic medication) to 50 mg daily at bedtime. Physician's orders for Resident 59, dated November 14, 2025, included orders for the resident to receive 50 mg of Seroquel daily at bedtime for Behavioral and Psychological Symptoms of Dementia (BPSD). There was no documented evidence in Resident 59's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosage of Seroquel. Interview with the Nursing Home Administrator on June 17, 2026, at 1:11 p.m. confirmed that there was no documented evidence in Resident 59's clinical record to indicate that the resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dosage of Seroquel. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 35 residents reviewed (Resident 10), and failed to follow consultant recommendations to send a representative/staff member to an appointment for a resident unable to communicate causing the appointment to be canceled and a delay in treatment for one of 35 residents reviewed (Resident 68).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 10, dated March 16, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had skin tears, received application of nonsurgical dressings (with or without topical medications) other than to feet, and had a diagnosis of Coronary Artery Disease (CAD-a disease that limits blood flow to the heart caused by plaque buildup in the arteries). A care plan for the resident, dated December 9, 2023, included an intervention to apply tubi-grips (compression bandage designed to provide support and even pressure to an injured or swollen limb) to the bilateral lower extremities for edema. A wound consultant note for Resident 10, dated May 18, 2026, indicated that the resident had wounds and edema to the bilateral lower extremities and included recommendations to apply tubi-grips to the bilateral lower extremities daily on in the a.m. and off in the p.m. for edema. A physician's order for Resident 10, dated May 19, 2026, included an order to apply tubi-grips to bilateral lower extremities for edema and to remove tubi-grips to bilateral lower extremities every evening shift. Observations of Resident 10 on June 14, 2026, at 11:40 a.m. revealed that the resident was sitting in her wheelchair with visible bandages on her bilateral lower legs and no tubi-grips applied. Observations of Resident 10 on June 17, 2026, at 10:28 a.m. revealed that the resident was sitting in her wheelchair with visible bandages on her bilateral lower legs and no tubi-grips applied. The tubi-grips were observed sitting on her overbed table and the resident stated that they don't put them on. Interview with Licensed Practical Nurse 1 on June 17, 2026, at 12:39 p.m. confirmed that Resident 10's tubi-grips were not applied and they should have been. Interview with the Director of Nursing on June 17, 2026, at 2:30 p.m. confirmed that Resident 10's tubi-grips should have been applied and they were not. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated May 13, 2026, revealed that the resident was severely cognitively impaired, was non-verbal, and had diagnoses that included aphasia (a disorder that affects how you communicate). Physician's orders for Resident 68, dated March 9, 2026, included an order for the resident to have a caregiver attend her next appointment with her due to her inability to communicate with others. Review of Resident 68's consultation record from her neurology (specialist) appointment dated June 14, 2026, revealed that the resident did not have a caregiver present for the appointment as ordered on March 9, 2026 and therefore the physician could not assess the resident. Interview with the Director of Nursing on June 15, 2026, at 2:12 p.m. confirmed that Resident 68 was unable to communicate and that an attendant should have attended her physician's appointments, but did not. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's and their family member's concern for one of three residents reviewed (Resident 2).Findings include: The facility's policy regarding complaint grievances, dated February 14, 2025, revealed that the facility ensures complaints regarding the community were resolved in a timely and appropriate manner for employees or residents who have concerns or complaints. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 16, 2025, revealed that the resident was understood, could understand others, was cognitively intact, and had a diagnosis of parkinsonism (syndrome that causes movement symptoms like tremor, stiffness, and slowness of movement).Interview with the Resident 2 on November 12, 2025, at 12:16 p.m. revealed that he was upset when a staff member got water out of the shared bathroom sink for him to drink. He said that he had reported it to staff and also told his power of attorney. Review of Resident 2's clinical record and the facility's grievance logs revealed no concerns related to Resident 2's complaints or the family's complaints about not wanting drinking water that was obtained from the shared bathroom.Interview with Nurse Aide 2 on November 12, 2025, at 3:13 p.m. indicated that she was aware that the family does not want water from the bathroom, and that she had reported the concern to her nurse at the time, but that had been a while ago. Nurse Aide 2 gets water for Resident 2 from the medication cart, medication room, or the pantry.Interview with Nurse Aide 1 on November 12, 2025, at 4:01 p.m. revealed that Resident 2's spouse was upset that water was being obtained from the shared bathroom and not from the kitchen. Management was informed regarding the concern about the water, but staff still have not been told where they should get the Resident's water.Interview with the Director of Nursing on November 12, 2025, at 4:32 p.m. revealed that the facility was permitted to obtain water from the shared bathroom sink. The Director of Nursing also indicated that there was no grievance because it was the resident's spouse who reported the concern with the water and felt it was a non-issue because the family has multiple complaints and this did not meet the level for a grievance. 28 Pa. Code 201.29(i) Resident Rights.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that fall/injury prevention interventions were in place for one of 3 residents reviewed (Resident 1).Findings include: A facility policy for fall management, dated February 14, 2025, indicated that the interdisciplinary team reviews falls. The team will discuss and care plan recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the care plan and progress note. The care plan will be reviewed and/or revised as indicated. The care Kardex will be updated as appropriate. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 23, 2025, revealed that the resident was cognitively impaired, was independent with transfers and ambulation, was occasionally incontinent of urine, received therapy, had one fall since her prior assessment with no injury, and had a diagnosis of Alzheimer's dementia. A nursing note for Resident 1, dated August 1, 2025, at 1:34 a.m., revealed that the resident was sitting on the floor at the foot of her bed. She stated that she slipped and landed on her buttocks. New interventions included recommendations to wear non-skid socks at bedtime. A nursing note for Resident 1, dated August 14, 2025, at 5:06 a.m., revealed that the resident was found in her room lying on the floor on her back with her legs pointed towards her recliner chair. A fall investigation revealed that the resident was unable to describe why she was ambulating so early in the morning. It was determined at the conclusion of the investigation that the resident was most likely ambulating to the bathroom, lost her footing and sustained a fall. A witness statement from Nurse Aide 1, dated August 14, 2025, at 5:06 a.m. revealed that on the morning of August 14, 2025, at approximately 4:43 a.m., she heard a crash in Resident 1's room. Upon entering the resident's room, she saw the resident lying on her back on the floor with her head against her rollator walker and her shoes were by her feet on the floor. There was no documented evidence that the resident was wearing non-skid socks at the time of her fall. Interview with the Director of Nursing on September 3, 2025, at 2:38 p.m. confirmed that Resident 1 was not wearing non-skid socks at the time of her fall on August 14, 2025.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to complete safety assessments for three of 25 residents reviewed (Residents 9, 17, 36) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated May 30, 2025, revealed that the resident was cognitively impaired, required assistance with daily care needs, had a Stage 3 pressure ulcer (pressure wound that forms as a result of prolonged pressure involving the fat layers beneath the skin), and had diagnoses that included dementia and Parkinson's Disease (a degenerative brain condition that affects muscle control and movement). Physician's orders for Resident 9, dated December 3, 2024, included an order for the resident to have a low air flow mattress (an inflated mattress for pressure relief) to promote skin integrity. Observations on June 30, 2025, at 11:11 a.m. revealed that Resident 9's bed was equipped with an air mattress; however, there was no documented evidence in the resident's clinical record that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. Interview with the Director of Nursing on July 2, 2025, at 1:30 p.m. confirmed that Resident 9 did not have an air mattress safety assessment completed regarding potential safety hazards prior to the air mattress being place on the resident's bed. A quarterly MDS assessment for Resident 17, dated May 5, 2025, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included Parkinson's (a progressive neurological disease that affects movement), stroke, sarcopenia (a medical condition where there is a loss of muscle mass). Observations on June 30, 2025, at 12:13 p.m. revealed that Resident 17's bed was equipped with an air mattress; however, there was no documented evidence in the resident's clinical record that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. Interview with the Director of Nursing on July 2, 2025, at 10:15 a.m. confirmed that Resident 17 did not have an air mattress safety assessment completed regarding potential safety hazards prior to the air mattress being place on the resident's bed. A quarterly MDS assessment for Resident 36, dated May 31, 2025, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included a hip fracture and contractures (a shortening and hardening of muscles and tendons) of the left hand and right hip. Observations on June 30, 2025, at 11:13 a.m. revealed that Resident 36's bed was equipped with an air mattress; however, there was no documented evidence in the resident's clinical record that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. Interview with the Director of Nursing on July 2, 2025, at 10:55 a.m. confirmed that Resident 36 did not have an air mattress safety assessment completed regarding potential safety hazards prior to the air mattress being place on the resident's bed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and observations, as well as interviews with staff, it was determined that the facility failed to maintain the confidentiality of medical information for one of 25 residents reviewed (Resident 46). Findings include: The facility's policy regarding general dose preparation and medication administration, dated February 14, 2025, indicated that employees are to observe each resident's privacy and rights in accordance with applicable law (including blocking unnecessary access to the Medication Administration Record). Observations during medication administration on July 2, 2025, at 8:04 a.m. revealed that Registered Nurse 1 walked away from the medication cart in the hallway between rooms [ROOM NUMBERS] to administer medications to Resident 46 in room [ROOM NUMBER], and left the laptop on top of the medication cart open and the Medication Administration Record (MAR) for Resident 46 was visible to staff, residents, and visitors in the hallway. Interview with Registered Nurse 1 on July 2, 2025, at 8:16 a.m. confirmed that he did not minimize or close the laptop screen to protect Resident 46's confidential medical information from being viewed by unauthorized people and he should have. Interview with the Director of Nursing on July 2, 2025, at 11:09 a.m. confirmed that laptop screens with confidential medical information should not be left open and visible to staff, residents, and visitors in the hallway. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.5(b) Clinical Records.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for two of two nurses reviewed (Registered Nurse 2, Licensed Practical Nurse 3), and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 4). Findings include: The facility's policy regarding Abuse, neglect, exploitation, and Misappropriation Prevention prom, dated February 14, 2025, indicated that the facility would conduct employee background checks and would not knowingly employ or otherwise engage any individuals who have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The personnel file for Registered Nurse 2 revealed a start date of June 25, 2025. However, there was no documented evidence that her license was verified with the state board. The personnel file for Licensed Practical Nurse 3 revealed a start date of May 12, 2025. However, there was no documented evidence that her license was verified with the state board. The personnel file for Nurse Aide 4 revealed a start date of June 23, 2025. However, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified until June 28, 2025. Interview with the Human Resources/Payroll Director on July 2, 2025, at 10:57 a.m. confirmed that Registered Nurse 2's start date was June 25, 2025, and that the license was not verified with the State Board of Nursing, but used a contracted company to perform background/licensure checks. She confirmed that License Practical Nurse 3's start date was May 12, 2025, and that the license was not verified with the State Board of Nursing, but used a contracted company to perform background/licensure checks. She also confirmed that Nurse Aide 4 had a start date of June 23, 2025, and that there was no documented evidence that a registry verification was completed prior to her start date, but used an contracted company to perform background/registry checks. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 25 residents reviewed (Resident 45). Findings include: A facility policy for bowel protocol, dated February 14, 2025, indicated that the facility was to ensure that residents are free from complications secondary to constipation. This would be accomplished through adequate assessment tracking, and treatment as indicated. The evening shift nurse would provide medication as ordered according to the following bowel protocol: Give Milk of Magnesia (MOM - an oral laxative) one time if there is no bowel movement after three days at bedtime. If Milk of Magnesia is ineffective, on day four, give a Dulcolax suppository (a laxative inserted rectally). If both Milk of Magnesia and Dulcolax suppository are ineffective, on day five give a saline enema (a liquid inserted rectally to stimulate a bowel movement). The day shift nurse would monitor the daily bowel record to ensure the residents had received successful bowel care results. The day shift supervisor would assess the resident and notify the physician for the residents that did not have successful results for other means of providing bowel relief. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated May 18, 2025, indicated that the resident was cognitively intact, was frequently incontinent of bowel and urine and required partial to moderate assistance for transfers from chair to bed, sitting and standing, and toilet hygiene. A care plan, dated May 15, 2025, for Resident 45 indicated that she was at risk for complications with the gastrointestinal system due to constipation. Interview with Resident 45 on June 30, 2025, at 10:33 a.m. revealed that she had recently been constipated. Physician's orders for Resident 45, dated May 14, 2025, included orders for staff to administer 30 milliliters (ml) of Milk of Magnesia as needed for no bowel movement after three days; a 10 milligram (mg) Dulcolax suppository as needed if Milk of Magnesia was not effective, to be administered on Day 4 if no bowel movement; and to administer a saline enema as needed if Milk of Magnesia and Dulcolax suppository are ineffective, to be administered on Day 5 of no bowel movement. Review of the bowel record for Resident 45, dated March 2025, indicated that the resident did not have a bowel movement on June 3 through June 8, 2025, a total of six days. Review of the Medication Administration Record (MAR) for Resident 45, dated June 2025, indicated that 30 ml of Milk of Magnesia was administered to the resident on June 6 with ineffective results. Review of the MAR revealed no documented evidence that Dulcolax was administered when Milk of Magnesia was ineffective on Day 4 of not having a bowel movement as ordered, and no documented evidence that a saline enema was administered on Day 5 of no bowel movement, as ordered. Interview with the Director of Nursing on July 2, 2025, at 10:15 a.m. confirmed that bowel protocol was not followed for Resident 45 on the above-mentioned dates. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 25 residents reviewed (Resident 17). Findings include: The facility's policy regarding medication administration, dated February 14, 2025, indicated that documentation of narcotic administration will be done in accordance with applicable law including documenting necessary medication administration treatment information on appropriate forms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 17, dated May 5, 2025, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnosis of Parkinson's (a progressive neurological disease that affects movement), stroke, sarcopenia (a medical condition where there is a loss of muscle mass). Physician's orders for Resident 17, dated September 9, 2024, included an order for the resident to receive 5-325 milligram (mg) of oxycodone-acetaminophen (a narcotic pain medication) to be administered every four hours as needed for pain. Review of the controlled drug record (tracks each dose of a controlled medication) for Resident 17 for May and June 2025 revealed that a 5-325 mg dose of oxycodone-acetaminophen was signed out on May 9, 2025, at 6:30 p.m.; June 4, 2025, at 5:11 a.m.; June 13, 2025, at 5:30 a.m.; and June 16, 2025 at 6:36 p.m. However, a review of the resident's Medication Administration Record (MAR) revealed no documented evidence that the medication was actually administered to the resident on the dates and times listed. Interview with the Director of Nursing on July 2, 2025, at 10:15 a.m. confirmed that there was no documentation of medication administration on the MAR for Resident 17 on the above dates and times and there should have been. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's recommendations for brace application were followed for one of 25 residents reviewed (Resident 25). Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated May 21, 2025, indicated that the resident was cognitively impaired, required moderate assistance for dressing and hygiene, and utilized a walker and a wheelchair. Interview with Resident 25 on June 30, 2025, at 1:29 p.m. revealed that he was to receive a back brace after he had fallen at the facility and broke his back, but he never received it. Hospital discharge records for Resident 25, dated January 5, 2025, revealed that the resident was to have a TLSO Brace (a brace that supports the back and pelvis area to reduce pain and prevent further injury) due to a back fracture. A nursing note for Resident 25, dated January 7, 2025, at 11:27 a.m., revealed that the hospital recommended the TLSO brace, but they did not require a specific company. The facility was unable to obtain a TLSO brace from one medical supplier and another supplier would not be able to provide the brace in a timely manner. The physical therapy department was to obtain a TLSO brace for the resident. Nursing Note for Resident 25, dated January 7, 2025, at 12:15 p.m., revealed that therapy was not able to obtain a TLSO brace and that his daughter would like him to be seen by a brain and spine specialist to obtain his brace. Interview with the Nursing Home Administrator on July 2, 2025, at 1:38 p.m. revealed that Resident 25 did not receive his TLSO brace because his daughter was to take the resident to a brain and spine specialist and purchase the brace but never did. Interview with the Director of Therapy on July 2, 2025, at 12:50 p.m. revealed that she would have been able to purchase the correct brace for Resident 25 and was told not to purchase it. Physical therapy was delayed for several months since he did not have the brace for support. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from mental abuse for one of nine residents reviewed (Resident 5), resulting in Immediate Jeopardy to the resident's mental health and safety. Findings include: The facility's abuse policy, dated February 10, 2021, included that staff were not to mentally abuse residents, which included humiliation, threats of punishment, or deprivation. Prevention of abuse regarding photographs and audio/video recordings indicated that residents had the right to be free from abuse that may occur from unauthorized taking of pictures or recordings that are demeaning or humiliating. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 14, 2021, indicated that the resident was admitted to the facility on [DATE], had severe cognitive impairment, was able to make herself understood and to understand others, was ambulatory (could walk) with limited assistance in the corridors, was frequently incontinent of bowel and bladder, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of information submitted by the facility, dated April 15, 2021, indicated that Licensed Practical Nurse 3 took a picture of Resident 5 on her phone while Resident 5 was in the hall without clothing on and was using a urine-soaked brief to wipe down surfaces. Licensed Practical Nurse 3 then showed the picture of the resident to multiple staff. Investigative interview statements from Licensed Practical Nurse 3, dated April 15, 2021, revealed the nurse indicated that she took the picture of Resident 5 because Registered Nurse 4 told her to take it and to show it to Licensed Practical Nurse 5. She indicated that Registered Nurse 4's [NAME] was, You can't make this s**t up, and the photo was taken at the request of Registered Nurse 4. Licensed Practical Nurse 3 confirmed that she was aware that it was inappropriate to take the picture of Resident 5, she had no idea why she took it, that she was tired, but did not know why. She stated that she showed the photo to Licensed Practical Nurse 5, Nurse Aide 6, and Licensed Practical Nurse 7. Licensed Practical Nurse 3 indicated that the picture did not show anything, just the resident's backside and not her face. Investigative interview statements from Licensed Practical Nurse 5, dated April 15, 2021, revealed that when he arrived at the nursing station, Licensed Practical Nurse 3 said, Look, we have a new cleaning lady. Licensed Practical Nurse 5 got her phone out and showed him a picture of Resident 5. The resident was 100 percent disrobed, had removed her incontinent brief, and used the soiled brief to, clean the chair. He indicated that the picture was very inappropriate, showed the resident naked, and was used as an insult to the resident's condition. He confirmed that the resident in the photograph was Resident 5. Investigative interview statements from Licensed Practical Nurse 7, dated April 15, 2021, revealed that she was receiving report from the nurse regarding a resident who was found in the hallway naked. As the report continued, Licensed Practical Nurse 3 said, Look, and when Licensed Practical Nurse 7 turned, Licensed Practical Nurse 3 had her phone out and showed her a picture of Resident 5, who was naked. Licensed Practical Nurse 7 indicated that she was shocked that Licensed Practical Nurse 3 would take a picture and that Licensed Practical Nurse 3 thought it was funny. Licensed Practical Nurse 7 indicated that she was embarrassed and saddened for the resident, and that the most upsetting thing was that Licensed Practical Nurse 3 did not even see what was wrong with taking such a picture. Investigative interview statements from Registered Nurse 8, dated April 15, 2021, revealed that when she arrived to work, she and Licensed Practical Nurse 3 began report, and Licensed Practical Nurse 3 said that she had something funny to show her. Licensed Practical Nurse 3 proceeded to play the child's song, Do Your Ears Hang Low? on her phone and then showed her a picture that she took of Resident 5. The picture showed the resident naked in the hallway with only one sock on and nothing else. The picture was of the resident's entire backside and in the picture she was shown wiping a chair with a urine-saturated brief. She stated that her immediate reaction was disgust and heartbreak, as the resident had cognitive impairment and no understanding of what she was doing, and the picture was a major infringement upon the resident's dignity and privacy. She told Licensed Practical Nurse 3 that the picture needed deleted and Licensed Practical Nurse 3 responded that she would delete it after she showed Licensed Practical Nurse 5. Investigative interviews for Registered Nurse 4 and Nurse Aide 6, dated April 15, 2021, revealed that they did not see the picture of Resident 5 on Licensed Practical Nurse 3's phone. Interview with Licensed Practical Nurse 5 on April 19, 2021, at 3:30 p.m. revealed that when he arrived to work (on April 15, 2021), Licensed Practical Nurse 3 said that she was waiting for him to get to work and wanted to show him that they had a new cleaning lady. He confirmed that he saw a picture of Resident 5 on Licensed Practical Nurse 3's cell phone that showed the resident using a saturated brief to clean a chair. Resident 5 had no clothing on and he could see her buttocks. He stated that Licensed Practical Nurse 3 thought it was funny, and that she deleted the picture after showing him. He reported the incident to the Director of Nursing. Interview with Licensed Practical Nurse 7 on April 19, 2021, at 4:15 p.m. revealed that when she came in to work (on April 15, 2021), Resident 5 was naked in the hallway and was wiping stuff down. She confirmed that Licensed Practical Nurse 3 said, Look at this, and showed her a picture of Resident 5 on her cell phone. Resident 5 was naked and she could see the resident's buttocks in the picture and could recognize the resident. She indicated that Licensed Practical Nurse 3 thought it was hysterical and did not think that she did anything wrong. She was not sure if the picture was deleted and stated that she reported the incident to Human Resources. Interview with Licensed Practical Nurse 3 on April 19, 2021, at 4:55 p.m. revealed that she was not familiar with Resident 5 and did not work with her. She confirmed that she took a picture of Resident 5 on her personal cell phone and indicated that she did this because Registered Nurse 4 told her to take the photo, and so she did like an idiot. She stated that she was tired and was not thinking. She confirmed that Resident 5 did not have clothes on, was wiping seats with a wet brief, and she showed other staff members the picture that she took. Interview with the Social Service Director on April 19, 2021, at 8:15 p.m. revealed that she was present with Resident 5 when Protective Services interviewed the resident, and when they asked the resident how she would feel if someone would take a picture of her naked, Resident 5 replied, I would punch them. Interview with the Nursing Home Administrator on April 19, 2021, at 5:28 p.m. revealed that employees were not to take pictures of residents on their cell phones without the residents' consent. On April 19, 2021, at 9:00 p.m. the Nursing Home Administrator was given the required Immediate Jeopardy Template and informed that the mental health and safety of Resident 5 had been placed in Immediate Jeopardy, due to the failure of the facility to ensure that Resident 5 was not subjected to mental abuse by Licensed Practical Nurse 3, who mentally abused the resident by taking a photograph of her while she was naked. The facility submitted and implemented an immediate action plan to ensure residents' privacy and protection from mental abuse by completing a facility-wide screening of residents to ensure that their privacy was not compromised, providing education regarding abuse, including the use of electronic devices and social media, to all employees prior to the start of their next shift, and completing observational and interview audits to ensure that the staff education was effective and that staff were not using their personal electronic devices while working. The facility educated all of their employees on April 19 and 20, 2021, completed audits following the education, and the Immediate Jeopardy was removed on April 20, 2021, at 5:35 p.m. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policies, information provided to staff upon hire, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained for one of nine residents reviewed (Resident 5), resulting in Immediate Jeopardy to the resident's mental health and safety. Findings include: The facility's abuse policy, dated February 10, 2021, included that staff were not to mentally abuse residents, which included humiliation, threats of punishment, or deprivation. Prevention of abuse regarding photographs and audio/video recordings indicated that residents had the right to be free from abuse that may occur from unauthorized taking of pictures or recordings that are demeaning or humiliating. The facility's policy regarding protecting resident privacy and prohibiting mental abuse related to photographs and audio/video recordings, February 10, 2021, indicated that any time that an employee, volunteer, consultant, contractor, or other caregiver take pictures or recordings of residents, this may be a HIPAA violation, but it also may constitute abuse. These instances should thoroughly be investigated in light of both of these considerations, examples included taking a photograph or recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, toileting, providing perineal care, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part without the resident's face, or showing the resident in a compromised position. Licensed Practical Nurse 3 acknowledged this policy on June 5, 2019. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 14, 2021, indicated that the resident was admitted to the facility on [DATE], had severe cognitive impairment, was able to make herself understood and to understand others, was ambulatory (could walk) with limited assistance in the corridors, was frequently incontinent of bowel and bladder, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of information submitted by the facility, dated April 15, 2021, indicated that Licensed Practical Nurse 3 took a picture of Resident 5 on her phone while Resident 5 was in the hall without clothing on and was using a urine-soaked brief to wipe down surfaces. Licensed Practical Nurse 3 then showed the picture of the resident to multiple staff. Investigative interview statements from Licensed Practical Nurse 5, Licensed Practical Nurse 7, and Registered Nurse 8, dated April 15, 2021, confirmed that Licensed Practical Nurse 3 showed them a photograph of Resident 5 on her cell phone, and that Resident 5 had no clothes on and was recognizable in the photo. Interview with Licensed Practical Nurse 3 on April 19, 2021, at 4:55 p.m. revealed that she was not familiar with Resident 5 and did not work with her. She confirmed that she took a picture of Resident 5 on her phone, and indicated that Registered Nurse 4 told her to take the photo, so she did, like an idiot. She confirmed that Resident 5 did not have clothes on and was wiping seats with a wet brief, and she showed the picture to other staff members. Interview with the Social Service Director on April 19, 2021, at 8:15 p.m. revealed that she was present with Resident 5 when Protective Services interviewed the resident, and when they asked the resident how she would feel if someone would take a picture of her naked, Resident 5 replied, I would punch them. Interview with the Nursing Home Administrator on April 19, 2021, at 5:28 p.m. revealed that employees were not to take pictures of residents on their cell phones without the residents' consent. On April 19, 2021, at 9:00 p.m. the Nursing Home Administrator was given the required Immediate Jeopardy Template and informed that the personal privacy and mental health of Resident 5 had been placed in Immediate Jeopardy, due to the failure of the facility to ensure that Resident 5's personal privacy was not violated by Licensed Practical Nurse 3, who took a photograph of her while she was naked. The facility submitted and implemented an immediate action plan to ensure residents' privacy and protection from mental abuse by completing a facility-wide screening of residents to ensure that their privacy was not compromised, providing education regarding abuse, including the use of electronic devices and social media, to all employees prior to the start of their next shift, and completing observational and interview audits to ensure that the staff education was effective and that staff were not using their personal electronic devices while working. The facility educated all of their employees on April 19 and 20, 2021, completed audits following the education, and the Immediate Jeopardy was removed on April 20, 2021, at 5:35 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policies, information submitted by the facility, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of one resident reviewed (Resident 1), which resulted in a fractured leg bone for the resident. Findings include: The facility's policy regarding mechanical lifts (devices that use hydraulic power to lift and transfer a person from surface to surface), updated (MONTH) 2019, indicated that two staff were required to assist with transfers using a mechanical lift. The facility's policy regarding abuse and neglect, dated (MONTH) 14, (YEAR), indicated that staff education regarding abuse and neglect was completed with orientation and annually. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 7, 2019, indicated that the resident had severe cognitive impairment, required the extensive assistance of two persons for transfers, and had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 23, 2019, indicated that she was at risk for falls related to impaired balance and poor coordination. A therapy discharge communication for Resident 1, dated (MONTH) 23, 2019, indicated that the resident required two-person physical assistance for transfers from bed to chair, from wheelchair to a standard chair, from chair to bed, and to and from the shower. An incident investigation report and nursing note, completed by a registered nurse and dated (MONTH) 5, 2019, indicated that Resident 1 was lying on her back on the floor with the sit-to-stand mechanical lift (a type of mechanical lift that requires the resident to bear some weight with the legs while the upper body is supported in a sling) at her feet. The nurse aide stated that the resident was in the sit-to-stand lift when she buckled her legs, slid out, and was lowered to the floor. An assessment revealed swelling to left ankle, redness to the left calf, and the resident grimaced (facial expression indicative of distress) upon palpation (touch) to the left ankle joint. The physician was notified and ordered an x-ray of the left ankle that was scheduled for the following day. An x-ray report of the left ankle, dated (MONTH) 6, 2019, revealed that Resident 1 had an acute [MEDICAL CONDITION] distal fibula (the lower portion of a bone in the lower leg). An orthopedic (bone specialist) consultation report, dated (MONTH) 11, 2019, indicated that the resident was to wear a tall fracture boot at all times (except for hygiene) to the left lower leg and was to be non-weight bearing to the left lower leg. A written statement from Nurse Aide 1, dated (MONTH) 8, 2019, indicated that Resident 1 has always been transferred using a sit-to-stand lift when providing care, as she is very lethargic, and on (MONTH) 5, 2019, he transferred the resident using a sit-to-stand mechanical lift, and was going to guide her to the shower chair. Before getting to the shower chair, he lowered her to the floor. Nurse Aide 1 indicated that the transfer was done without a second caregiver, and that he understood that there were to be two staff present for mechanical lift transfers. Investigation information submitted by the facility, dated (MONTH) 15, 2019, indicated that Nurse Aide 1 was hired on (MONTH) 18, (YEAR). Training records, dated (MONTH) 28, (YEAR), revealed that the nurse aide had competencies (skills testing to demonstrate the knowledge and ability to perform a skill or task) completed on mechanical lift transfers. Interview with the Director of Nursing on (MONTH) 16, 2019, at 2:15 p.m. confirmed that Nurse Aide 1 had training on the facility's lift policy and should have followed the policy to perform transfers with the assistance of two staff instead of one. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/24/19. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/30/19, 1/24/19.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for one of 15 residents reviewed (Resident R1). Findings include: The facility's Weight Management Flowchart, dated 10/2/13, revealed that when a weight loss was identified, the registered dietitian and other disciplines (as needed) were to be contacted, a care plan was to be developed or revised as applicable, weight management strategies were to be implemented, and the resident and staff were to be educated. The facility's Weight Change Calculations policy, dated 10/2/13, revealed that a 5 percent weight loss in one month, a 7.5 percent weight loss in three months, and a 10 percent weight loss in six months were considered significant weight losses, and anything greater than these percentages was considered severe. Admission information, dated 8/2/13, for Resident R1 revealed that the resident was admitted to the facility on that day and weighed 186 pounds. An initial comprehensive assessment, dated 8/9/13, revealed that the resident was alert and oriented, able to make herself understood, could understand others, and required assistance for eating. Weight records revealed that when the resident returned from a hospitalization on [DATE], she weighed 162.8 pounds; a 12.4 percent (severe) weight loss in one month. Following this severe weight loss, there was no documented evidence that the registered dietitian was notified or that new weight management strategies were implemented until 9/17/13, 11 days later, when a nutritional supplement was ordered by the physician. Weight records revealed that the resident then lost another 9.8 percent in two months (severe) when her weight dropped from 162.8 pounds on 9/6/13 to 146.8 pounds on 11/18/13. Intake records, dated 9/19/13 through 11/18/13, revealed that the resident refused a nutritional supplement at least 26 percent of the time it was offered. Following this second severe weight loss, and despite the resident's refusal of the nutritional supplement at times, there was no documented evidence that the registered dietitian was notified or that new weight management strategies were implemented until 12/3/13, 15 days later, at which time the resident weighed 137.4 pounds; an additional 6.4 percent (severe) weight loss in less than one month. Intake records showed that the resident refused a nutritional supplement 80 percent of the time it was offered, and her meal intake averaged less than 50 percent between 11/19/13 and 12/3/13. Interview with the registered dietitian on 12/6/13 at 2:05 p.m. revealed that she was notified timely of Resident R1's weight losses and felt that she had done what was necessary to prevent further weight loss. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.