Every finding on record at Broad Acres Health and Rehabilitation

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions to prevent the development and the transmission of communicable diseases and infections for five of 20 residents reviewed (Residents 1, 5, 10, 22, and 27).Findings include: Review of a current facility document titled Infection Control-Enhanced Barrier Precautions states that the facility will place a trash can inside the room near the door for discarding PPE (personal protective equipment). Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Clinical record review for Resident 1 revealed an active physician order for Enhanced Barrier Precautions related to a surgical site to the left upper leg. Observation of Resident 1's room on August 18, 2026, at 10:10 AM revealed that they had a bin containing cloth PPE gowns in their room, sitting on the counter where the handwashing sink is located. The bin was noted to be uncovered and did not provide protection against potential environmental contaminants. No trash can was observed inside the room near the door for discarding PPE. Clinical record review for Resident 10 revealed an active physician order for Enhanced Barrier Precautions related to MDRO (multi-drug resistant organism). Observation of Resident 10's room on August 18, 2026, at 10:13 AM revealed that they had a bin containing cloth PPE gowns in their room, sitting on the counter where the handwashing sink is located. The bin was noted to be uncovered and did not provide protection against potential environmental contaminants. In addition, the gowns were not folded and were protruding from the bin. A gown was noted to be hanging over a discarded meal tray belonging to Resident 10's roommate, nearly touching the discarded food on the tray. No trash can was observed inside the room near the door for discarding PPE. Observation of Resident 10's room on August 19, 2026, at 10:37 AM with Employee 7 (registered nurse) revealed that the breakfast tray for Resident 10's roommate was again sitting next to the open bin of cloth PPE gowns. Interview with Employee 7 on the date and time of the observation confirmed that the storage of isolation gowns intended for use with Resident 10 failed to provide protection against potential environmental contaminants. Employee 7 removed the breakfast tray from the counter following the observation. Clinical record review for Resident 22 revealed an active physician order for staff to implement EBP related to urinary catheter (flexible tube inserted into the bladder to drain urine) use. Observation of Resident 22's room on August 18, 2026, at 9:56 AM revealed a sign on her door to implement EBP. An open bin behind a television on a counter in Resident 22's room contained unfolded reusable isolation gowns. There was no barrier to maintain the isolation gowns in a manner to protect them from potential environmental contaminants (e.g., dust, splashes, resident/visitor/staff inadvertent contact). Observation of Resident 22's room on August 19, 2026, at 10:29 AM with Employee 7 revealed that the open bin remained on Resident 22's counter with unfolded reusable isolation gowns. Employee 7 confirmed that the storage of the gowns failed to provide a cover or method to protect the gowns from potential environmental contaminants. Clinical record review for Resident 27 revealed an active physician order for staff to implement EBP related to urinary catheter use. Observation of Resident 27's room on August 19, 2026, at 10:34 AM with Employee 7 revealed an open bin on Resident 27's counter that contained unfolded reusable isolation gowns. Employee 7 confirmed that the storage of the gowns failed to provide a cover or method to protect the gowns from potential environmental contaminants. Clinical record review for Resident 5 revealed an active physician's order for staff to implement EBP related to a non-healing wound. Observation of Resident 5's room on August 19, 2026, at 10:24 AM with Employee 7 and Employee 2 (registered nurse assessment coordinator) revealed an open bin on Resident 5's counter that contained reusable isolation gowns. Interview with Employees 7 and 2 on the date and time of the observation confirmed that the storage of isolation gowns intended for use with Resident 5 failed to provide protection against potential environmental contaminants. The above findings related to EBP PPE storage were reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on August 20, 2026, at 9:30 AM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents reviewed for medication regimen review (Resident 22).Findings include: The facility policy entitled, Psychotropic Medication Use, last reviewed March 2, 2026, revealed that psychotropic medications will be prescribed at the lowest possible dosage for a limited period of time and are subject to gradual dose reduction (GDR, the tapering down and possible discontinuation of the dose of a medication) and re-review. The facility implements gradual dose reductions and non-pharmacological interventions unless contraindicated prior to initiating or instead of continuing psychotropic medication. The attending physician will identify, evaluate, and document with input from other disciplines and consultants as needed symptoms that may warrant the use of antipsychotic medications. Within the first year, a GDR will be attempted in two separate quarters, with at least one month separating, unless clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless contraindicated. Contraindication might be for, but not limited to, the target symptoms returning or worsening; the physician has documented a clinical rationale as to why the reduction could impair the resident function; and the continued use is in accordance with current standards of practice and the physician has documented the rationale as to how the reduction might impact the resident function or exacerbate a medical or psychiatric condition. Clinical record review for Resident 22 revealed her medication regime included the anti-anxiety medication Clonazepam 2 mg (milligrams) at bedtime since May 1, 2024; and the antidepressant medication Duloxetine 60 mg twice daily (120 mg total daily dose) since May 20, 2025. A consultant pharmacist recommendation dated November 20, 2025, requested that the physician evaluate attempting a gradual dose reduction of the Clonazepam and Duloxetine medications. The physician disagreed with the recommendation on December 8, 2025, with the rationale that Resident 22 had a recent reduction of her Sertraline (antidepressant) medication. Resident 22's clinical record indicated that the physician order for Sertraline 25 mg daily was discontinued almost three months earlier on September 18, 2025. Review of plans of care developed by the facility to address Resident 22's use of antianxiety psychotropic medications revealed interventions that included to, Monitor/record occurrence of/for target behavior symptoms and document per facility protocol (initiated January 9, 2024). The plan of care did not identify specific target behaviors (expressions or indications of distress), which have prompted the use of psychotropic medication. Review of a plan of care developed by the facility to address Resident 22's use of antidepressant medication revealed interventions that included to, Monitor/document/report to MD (physician) prn (as needed) ongoing s/sx (signs and symptoms) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. (negative) mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. A physician order dated July 29, 2025, instructed staff to, monitor and document behaviors r/t (related to) depression, anxiety, mood swings, paranoia, hallucinations, delusions, irritability, lack of motivation, and changes in sleep or appetite, as needed for Behavior Tracking. Resident 22's medical record did not include monitoring of individualized target behaviors as identified in her plan of care for the use of the antidepressant medication (e.g., attention seeking, concern with body functions, need for constant reassurance). Resident 22's medical record did not include monitoring of individualized target behaviors for the use of the antianxiety medication. Review of the behavior tracking documentation by licensed staff on the treatment administration record (TAR, electronic documentation completed by licensed staff for the completion of care) dated December 1, 2025, through August 18, 2026, revealed no occurrences of behavioral signs and symptoms. Resident 22's clinical record contained no evidence that the consultant pharmacist or physician evaluated the potential for a gradual reduction or discontinuation of Resident 22's antianxiety medication (taken at the same dose since May 1, 2024) or antidepressant medication (taken at the same dose since May 20, 2025) in the absence of distressing signs and symptoms. Interview with the Director of Nursing on August 19, 2026, at 3:35 PM and August 20, 2026, at 9:45 AM confirmed the above findings for Resident 22. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on closed clinical record review and staff interview, it was determined that the facility failed to provide the resident/resident's responsible party with complete information of resident's discharge needs and failed to set up home therapy services at time of discharge for one of three residents reviewed (Resident 93).Findings: Clinical record review revealed that Resident 93 was admitted to the facility on [DATE], with a diagnosis of urinary tract infection (bacterial infection in any part of the urinary system) and history of falling. Clinical record review for Resident 93 revealed an interdisciplinary team meeting note as well as an Initial Resident Discharge plan assessment completed on July 13, 2026. Both items of documentation included that this resident is in the facility for short term care with a plan to discharge home. Clinical record review for Resident 93 revealed that she discharged home on July 16, 2026, accompanied by her son. Clinical record review for Resident 93 revealed an Occupational Therapy discharge summary for dates of service of July 12, 2026, to July 15, 2026, that included discharge recommendations for home health physical and occupational therapy. Clinical record review for Resident 93 revealed a physical therapy discharge summary for dates of service of July 11, 2026, to July 16, 2026, that included discharge recommendations that the resident would benefit from home health therapy services to improve function in her home. Clinical record review for Resident 93 revealed a physician Discharge summary dated [DATE], that included an order given for discharge and staff to make necessary preparations for resident follow-up. There was no evidence Resident 93 received arrangements for home health therapy services prior to discharge. Interview with the Administrator and the Director of Nursing on August 20, 2026, at 9:05 AM revealed that the usual discharge process is the resident and/or responsible party receives a nursing discharge summary that would include information on medications, appointments, as well as referrals for home care. The Director of Nursing confirmed that there is no evidence that the facility attempted to arrange home care services for Resident 93. 28 Pa Code 201.29(a) Resident Rights 28 Pa Code 211.12(d)(3) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 20 residents reviewed (Residents 7 and 67).Findings include: Clinical record review for Resident 7 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated April 28, 2026, in which facility staff assessed the resident as having an active diagnosis of Schizophrenia (a mental health condition that impacts the way people think, feel, and behave). Further review of the clinical record revealed that Resident 7 had a diagnosis of Schizophrenia however, there was no evidence that Resident 7 was receiving medications, specialized services, or had any behaviors associated with the Schizophrenia. The MDS of Resident 7 was reviewed with Employee 2, registered nurse assessment coordinator, on August 19, 2026, at 12:58 PM. An interview with Employee 2 on August 19, 2026, at 1:49 PM revealed that the MDS for Resident 7 was marked in error. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on August 19, 2026, at 2:30 PM. A follow-up interview with Employee 2 on August 20, 2026, at 1:23 PM revealed the MDS was marked in error for Resident 7 and the resident should not have been marked on the MDS as having an active diagnosis of Schizophrenia since the resident was not receiving medications or had any associated behaviors related to the diagnosis. Clinical record review for Resident 67 revealed active physician orders that indicated she received the antidepressant Venlafaxine since April 14, 2026, for a diagnosis of anxiety associated with depression. A quarterly MDS assessment dated [DATE], indicated Resident 67 received antianxiety medication during the seven-day observation period. Resident 67's clinical record did not have evidence that she received an anxiolytic medication in July 2026. The resource provided (Med-Pass ASCP MDS 3.0 Drug Class Index) by the Director of Nursing on August 19, 2026, at 3:59 PM as the resource staff consistently used to identify pharmacological classification to support coding the MDS 3.0 revealed that Venlafaxine's pharmacological classification was an antidepressant, not an anxiolytic. Interview with the Director of Nursing on August 19, 2026, at 5:09 PM confirmed Resident 67's MDS anxiolytic medication coding on the quarterly MDS was an error. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure a dependent resident received assistance with dressing for one of two residents reviewed for activities of daily living concerns (Resident 49).Findings include: Interview with Resident 49 on August 17, 2026, at 12:13 PM revealed the resident was upset and tearful because she had not been dressed for the day. The resident was observed wearing a blue hospital gown. Resident 49 stated, I guess I will just have to wait until second shift and hope they will dress me. The resident stated that she would like to get dressed in the morning just like everyone else does. Observation of Resident 49 on August 18, 2026, at 10:18 AM, revealed that Resident 49 was in bed and in a night gown. The resident stated that she wanted to be dressed but again, nobody had offered to dress her again that morning. The surveyor later observed that the resident's door was closed at 12:40 PM, and an interview with Resident 49 at 4:05 PM revealed that staff had been dressing her during the previous observation of her door being closed at 12:40 PM. Review of a quarterly MDS completed August 6, 2026, for the resident revealed that the facility staff assessed Resident 49 as requiring partial/moderate assistance with dressing her upper body, and as dependent with dressing her lower body. Resident 49 did not receive the required assistance to be dressed per her preference. The surveyor reviewed the above concern regarding Resident 49 during an interview with the Nursing Home Administrator and the Director of Nursing on August 20, 2026, at 9:30 AM. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for one of 20 residents reviewed (Resident 2) and failed to meet the professional standards of practice for a pacemaker monitoring device for one of 20 residents reviewed (Resident 75).Findings: Clinical record review for Resident 2 revealed a physician order initiated on May 15, 2026, for levothyroxine sodium (a medication used to treat an underactive thyroid) 175 micrograms one time daily for hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet your body's needs). Review of Resident 2's medication administration record (MAR - electronic documentation by licensed staff to attest to the administration of medication) dated August 2026, revealed that the resident did not receive his scheduled dose of levothyroxine sodium on August 18, 2026, at 6:00 AM. The corresponding orders administration note dated August 18, 2026, at 5:08 AM noted that the medication was not available and was reordered at that time. Interview with the Director of Nursing on August 19, 2026, at 10:32 AM, revealed that the facility has an Omnicell (automated medication dispensing system) in the facility to obtain medications when needed. She provided an Omnicell item list which listed the available medication including four tablets of levothyroxine 25mcg, 8 tablets of levothyroxine 50mcg, and 4 tablets of levothyroxine 0.1mg tablets. The Director of Nursing confirmed that the facility had the needed medication available for Resident 2, but it was not administered. Clinical record review for Resident 2 revealed a nursing progress note dated August 14, 2026, at 9:20 AM noting the resident had a ten-pound weight gain since July 30, 2026, as well as increased shortness of breath with ambulation. The note also included that the resident had pitting edema (swelling caused by extra fluid trapped in your body tissues) to bilateral ankles. The physician assistant was notified, and new orders were placed for a chest x-ray (imaging to take pictures of the inside of your body), blood work, and an increase in his dose of metolazone (water pill used to treat fluid retention). Additional review of Resident 2's clinical record revealed the chest x-ray result dated August 14, 2026, included mild chronic congestive heart failure (a chronic condition where the heart muscle does not pump blood well), small right lower lobe linear infiltrate (an abnormal substance that accumulates in the tissue or air spaces of the lung) or atelectasis (a partial collapse of a lung or lobe of a lung) new since June 3, 2026. Continued review of Resident 2's clinical record revealed a physician and a physician assistant were notified of the chest x-ray result on August 14, 2026, and ordered doxycycline (an antibiotic that stops bacterial growth) 100mg (milligram) twice daily for seven days for pneumonia. Review of Resident 2's medication administration record dated August 2026 revealed no order for doxycycline. The above findings regarding Resident 2 were reviewed with the Director of Nursing on August 18, 2026, at 2:35 PM. Interview of the Director of Nursing on August 18, 2026, at 4:00 PM confirmed that the order for doxycycline on August 14, 2026, was not placed in the computer system resulting in the resident not receiving this medication. The physician was notified of the above omission, and an order was placed to initiate doxycycline 100mg twice daily for seven days. Facility Police titled, Pacemaker Check and Monitoring last reviewed without revision on March 2, 2026, states that if an electronic pacemaker device ([NAME] etc.) is in use, the facility with check placement and functioning routinely. Concurrent interview with Resident 75 and Employee 5 (licensed practical nurse) on August 18, 2026, at 12:05 PM revealed the resident had an implanted pacemaker (medical device placed under the skin near your collarbone to help control abnormal heart rhythms). The resident also had a pacemaker transmitter device, [NAME] Model EX1150, on her nightstand that is utilized to remotely monitor and transmit information from the resident's pacemaker. Interview with Employee 5 (licensed practical nurse) revealed that the device runs off Wi-Fi and they rarely lose their Wi-Fi. Medical provider documentation for Resident 75 dated August 17, 2026, at 10:53 AM noted the resident had a cardiac pacemaker. Clinical record review for Resident 75 revealed no evidence that the facility was checking placement and functioning routinely of her [NAME] device per their policy. Discussion with the Director of Nursing on August 19, 2026, at 3:29 PM confirmed that there was no evidence that the facility was checking placement and functioning routinely of Resident 75's [NAME] device. 28 Pa Code 211.12(d)(1)(2)(5) Nursing Services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to implement an intervention related to fall prevention for one of five residents reviewed for falls (Resident 9). Findings include: Clinical record review for Resident 9 revealed a diagnosis list that included: Alzheimer's Disease (a brain disease that causes progressive cognitive impairment), repeated falls, muscle weakness, lack of coordination, cognitive communication deficit, need for assistance with personal care, difficulty in walking, and unspecified dementia (a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons) moderate with mood disturbance. An annual Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 7, 2026, revealed that facility staff assessed Resident 9 as having a BIMS (Brief Interview for Mental Status) of 3, which indicated severe cognitive impairment. The resident was also noted as having an active diagnosis of repeated falls. A review of physician orders for Resident 9 revealed an order dated January 25, 2026, at 10:00 PM for a chair clip alarm - check activation and function every shift. The care plan for Resident 9 revealed that the resident has a safety device (clip chair alarm) for decreased safety awareness initiated on January 26, 2024, and revised on January 25, 2026. An intervention initiated on January 25, 2026, included a clip chair alarm when in her wheelchair; the medical symptom was listed as decreased safety awareness and impulsiveness. Further review of Resident 9's care plan revealed that the resident is a high risk for falls related to a history of falls and dementia. An intervention included a tab alarm to wheelchair initiated on January 22, 2026. The task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 9 noted a task dated January 25, 2026, to check activation, function, and placement of clip chair alarm every shift. Review of the Task documentation for August 2026 revealed that staff were documenting this as being completed and also documenting chair clip alarm activations per shift. Clinical documentation titled, Fall Risk Evaluation - CHR, for Resident 9 and dated July 6, 2026, at 12:18 PM revealed the resident scored 25 which indicated a high risk for falls. A Health Status Note for Resident 9 dated August 17, 2026, at 11:00 PM noted the nurse aide overheard the resident calling for help reporting she had fallen. The resident was found lying on the floor in front of the wheelchair. The documentation further noted the clip alarm was not clipped to the resident and the third shift nurse aide reported she was unaware it was a clip alarm and not a chair alarm. The documentation noted the clip and bed alarm were functioning at the time of the fall, but the clip was not connected to the resident. A Health Status Note for Resident 9 dated August 17, 2026, at 11:30 PM noted the resident was laying on the floor next to bed one (another bed in the room). The documentation further noted that the alarm was not sounding at time of fall and not connected to the resident, however, were in working order. Facility documentation titled, Event Investigation Statement, for Resident 9 dated August 17, 2026, from Employee 3, nurse aide, noted that the resident was transferred again to her chair. Facility documentation titled, Event Investigation Statement, for Resident 9 dated August 17, 2026, from Employee 6, nurse aide, noted that the resident was on her back in front of her wheelchair. Facility documentation titled, Event Investigation Statement, for Resident 9 dated August 17, 2026, from Employee 4, nurse aide, noted that the resident was very confused while Employee 4 was doing care. The documentation further noted that another nurse aide had gotten the resident out of bed due to her trying to climb out of bed and was unaware the resident had a chair alarm, so it was not heard when the resident fell. An interview with the Director of Nursing on August 19, 2026, at 2:30 PM revealed that the facility investigation determined that the staff member (nurse aide) thought the alarm was a pressure alarm for Resident 9's chair and not a clip alarm which requires staff to clip the alarm to the resident. The alarm was not clipped to Resident 9. The facility failed to implement an intervention related to fall prevention for Resident 9. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1).Findings include: Review of Employee 1's (nurse aide) personnel file revealed a Performance and Development Review that indicated his date of hire was March 28, 2023. The surveyor requested evidence of Employee 1's in-service training records for evidence at least 12 hours of in-service training calculated by his employment date (not calendar year) during an interview with the Nursing Home Administrator and the Director of Nursing on August 18, 2026, at 2:00 PM. Review of the training record provided by the facility for Employee 1 revealed that he completed 8.08 hours of in-services training from March 2025 to March 2026. Employee 1 did not complete 12 hours of in-service training since March 28, 2026 (calculated as 4.25 hours of in-service training from April 2026 to the date of the onsite survey). The surveyor confirmed the above findings during an interview with the Director of Nursing and Employee 7 (registered nurse) on August 20, 2026, at 1:16 PM. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding ADL (activities of daily living) care for one of four residents reviewed (Resident 1).Findings include:Clinical record review revealed Resident 1 had a current care plan (outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) focus that stated ADL (Activities of Daily Living; refers to the basic self-care tasks that individuals perform daily to maintain personal health and independence), Self Care Performance Deficit related to weakness, decreased mobility, hemiplegia from stroke. An intervention for this stated focus that was revised on March 13, 2026, read, Eating - All food items to be cut into bite sized pieces prior to intake. Set food tray up as per resident's preference prior to leaving tray. FEED ASSIST AND ENCOURAGEMENT AS NEEDED.During an interview with Resident 1 on April 9, 2026, at 11:09 AM, the resident stated that staff do not always help with their meals, and it depends on who is working. They also indicated that if they drop their fork on the ground, they cannot pick it up, so they do not eat.Observation of Resident 1's lunch service on April 9, 2026, at 11:57 AM, revealed that the resident had pizza on their plate. The pizza was noted to be a whole slice of cheese pizza, with two bites eaten. During a concurrent interview, the resident stated that that they picked the pizza up by the crust and ate the pizza with their hand. Continued observation outside of Resident 1's room for the next five minutes revealed no staff member entered the resident's room to provide feeding assistance or encouragement. Interview with the resident at 12:10 PM, revealed that the resident had disposed of her lunch in her bedside trash can. The resident indicated that no staff had offered assistance with their meal.The above findings were reviewed with the Nursing Home Administrator and the Director of Nursing on April 9, 2026, at 1:30 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documents and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs on one of two nursing units (B unit), and three of four residents reviewed (Residents 2, 3, and 4). Findings include: In an interview with Resident 3 on May 28, 2025, at 11:11 AM she stated she completes a lot of her care needs herself but does have to ring the call bell for staff and occasionally must wait some time for them. The resident was not specific on dates or times. A review of electronic call bell activation and response time logs for Resident 3's room from May 15 to 28, 2025, revealed the following call bell response times greater than 15 minutes: May 15, 2025, activated at 10:22 AM, response time of 21 minutes. May 15, 2025, activated at 1:07 PM, response time of 20 minutes. May 15, 2025, activated at 10:26 PM, response time of 16 minutes. May 15, 2025, activated at 10:49 PM, response time of 28 minutes. May 16, 2025, activated at 4:57 AM, response time of 22 minutes. May 18, 2025, activated at 10:13 AM, response time of 28 minutes. May 19, 2025, activated at 8:12 AM, response time of 16 minutes. May 19, 2025, activated at 7:06 PM, response time of 21 minutes. May 20, 2025, activated at 10:20 AM, response time of 32 minutes. May 20, 2025, activated at 1:30 PM, response time of 22 minutes. May 31, 2025, activated at 6:00 PM, response time of 31 minutes. May 22, 2025, activated at 7:59 AM, response time of 21 minutes. May 26, 2025, activated at 7:55 PM, response time of 26 minutes. May 27, 2025, activated at 8:36 AM, response time of 16 minutes. May 27, 2025, activated at 11:25 AM, response time of 16 minutes. May 27, 2025, activated at 3:54 PM, response time of 18 minutes. In an interview with Resident 2 on May 28, 2025, at 11:20 AM she stated that she waits an hour at times for staff to answer her call bell when she wants to transfer between her bed and chair or when she needs them to reach something she can't get. Resident 2 stated she waited a while for staff to answer her call bell as recent as this morning. A review of electronic call bell activation and response time logs for Resident 2's room from May 15 to 28, 2025, revealed the following call bell response times greater than 15 minutes: May 16, 2025, activated at 11:00 AM, response time of 16 minutes. May 17, 2025, activated at 7:38 AM, response time of 18 minutes. May 17, 2025, activated at 11:23 AM, response time of 17 minutes. May 17, 2025, activated at 1:19 PM, response time of 17 minutes. May 17, 2025, activated at 9:47 PM, response time of 28 minutes. May 19, 2025, activated at 7:42 AM, response time of 18 minutes. May 19, 2025, activated at 9:39 PM, response time of 18 minutes. May 22, 2025, activated at 8:38 AM, response time of 21 minutes. May 28, 2025, activated at 9:16 AM, response time of 25 minutes. In an interview with Resident 4 on May 28, 2025, at 1:15 PM, he pointed to a call bell lying on his tray table when asked how he got a hold of staff if he needed help. Resident 4 stated staff come to help him in an hour or in minutes, I just deal with it. A review of electronic call bell activation and response time logs for Resident 4's room from May 15 to 28, 2025, reveled the following call bell response time greater than 15 minutes: May 17, 2025, activated at 5:03 PM, response time of 41 minutes. May 17, 2025, activated at 6:43 PM, response time of 31 minutes. May 17, 2025, activated at 8:02 PM, response time of 47 minutes. May 17, 2025, activated at 8:52 PM, response time of 1 hour and 9 minutes. May 18, 2025, activated at 12:03 PM, response time of 22 minutes. May 19, 2025, activated at 11:42 PM, response time of 25 minutes. May 21, 2025, activated at 4:33 AM, response time of 24 minutes. May 21, 2025, activated at 6:56 PM, response time of 26 minutes. May 21, 2025, activated at 7:50 PM, response time of 16 minutes. May 23, 2025, activated at 7:07 PM, response time of 24 minutes. May 26, 2025, activated at 8:48 PM, response time of 22 minutes. May 26, 2025, activated at 9:11 PM, response time of 24 minutes. May 28, 2025, activated at 4:45 AM, response time of 19 minutes. The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing on May 28, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Residents 7). Findings include: Clinical record review revealed the facility admitted Resident 7 on April 19, 2024, and added a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on May 1, 2024. Review of Resident 7's social history and evaluation completed on April 23, 2024, revealed a trauma screening questionnaire (a group of questions related to symptoms that may occur due to a traumatic event) that indicated Resident 7 had difficulty concentrating at least twice in the past week. The questionnaire did not include questions related to her diagnosis of PTSD or triggers that may mitigate re-traumatization. Review of Resident 7's current care plan revealed a history of depression, PTSD, and anxiety. The care plan indicated that the PTSD was related to her husband's death and that she had panic attacks at times. The care plan did not identify what triggers her panic attacks related to her husband's death that occurred approximately [AGE] years ago or how she deals with them. Further review of Resident 7's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to identify triggers to develop and implement individualized interventions to prevent re-traumatization. Resident 7's care plan was revised on September 13, 2024, and a progress note was entered into her clinical record on September 12, 2024, at 7:57 PM indicating a conversation was held with her to determine her potential triggers. This was after the surveyor made the facility aware that her clinical record failed to identify her potential triggers on September 12, 2024, at 2:00 PM. These findings were confirmed with the Director of Nursing on September 13, 2024, at 2:00 PM. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to ensure daily nurse staff data was posted for both nursing units (A and B wing). Findings include: Observation on September 11, 2024, at 1:46 PM revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. Subsequent observations on September 12, 2024, at 2:48 PM, and September 13, 2024, at 11:12 AM again revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. The posting did not include the facility's name. Interview with the Director of Nursing on September 13, 2024, at 11:42 confirmed these findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for five of nine residents reviewed (Residents 11, 16, 24, 30, and 50). Findings include: Clinical record review for Resident 16 revealed that they were transferred to the hospital on August 31, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Clinical record review for Resident 30 revealed that they were transferred to the hospital on January 27, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party as required regarding the transfer that included the required contents listed above. Clinical record review for Resident 50 revealed that they were transferred to the hospital on December 29, 2023, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above. The surveyor reviewed the above information for Residents 16, 30, and 50 during an interview with the Nursing Home Administrator and Director of Nursing on September 12, 2024, at 2:20 PM. Clinical record review for Resident 11 revealed that she was transferred to the hospital on January 30, 2024, after there was a change in her condition. There was no documentation that the facility provided written notification to her responsible party as required regarding the transfer that included all the required contents as listed above. Clinical record review for Resident 24 revealed that they were transferred to the hospital on June 13, 2024, after there was a change in his condition. There was no documentation that the facility provided written notification to his responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above. Interview with Employee 1 (business office manager) on September 13, 2024, at 9:16 AM confirmed these findings. 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to obtain physician ordered medications for two of five residents reviewed (Residents 1 and 3). Findings include: Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], at 3:36 PM. Review of Resident 1's admission physician orders for medications to be administered to the resident revealed the following medication were ordered on April 19, 2024: Bupropion HCL ER 150 mg (milligrams) tablet two times a day for depression to start April 19, 2024, at 8:00 PM Phos-NaK oral packet 280-160-250 mg (Potassium and Sodium Phosphate) one packet with meals to start April 19, 2024, at 6:00 PM A review of Resident 1's medication administration record for April 2024, revealed no evidence the above medications were administered as ordered. The medication administration log was blank for the administration dates and times indicated. There was no evidence to indicate why the doses were not administered. Clinical record review for Resident 3 revealed the resident was admitted to the facility on [DATE], with nursing admission assessment completed at 2:00 PM. A review of Resident 3's admission physician ordered medications revealed the resident was ordered the following medications on May 3, 2024, to start at 9:30 PM: Amitriptyline HCL 25 mg to be given at bedtime for depression. Calcium-Vitamin D 600-200 mg unit two times a day for supplementation Diclofenac Potassium 50 mg one tablet three times a day for back pain Lorazepam tablet 1 mg at bedtime for anxiety Pregabalin capsule 100 mg three times a day for pain management. A review of Resident 3's medication administration record for May 2024, revealed no evidence Resident 3 was administered the above medication for the dosage and time indicated above. The medication administration record was left blank for the dates and times indicated for the above medications. There was no documented evidence as to why Resident 3 should not have received the medications as ordered. In an interview with the Nursing Home Administrator and Director of Nursing on May 8, 2024, at 12:30 PM the Director of Nursing indicated all medication orders are sent to the facility's pharmacy via the electronic record and medication deliveries arrive twice a day between 3:30-4:30 PM, and midnight - 2 AM. The Director of Nursing indicated since the pharmacy deliveries for the afternoon are already in route, residents admitted to the facility during the day have medications arrive on the midnight - 2 AM delivery. The Director of Nursing indicated some medications are available in the facility pharmacy stock, but not all that are ordered are available to utilize until medication deliveries arrive at the facility. In a follow up interview with the Director of Nursing on May 8, 2024, at 2:30 PM it was confirmed Residents 1 and 3 were not administered the above medications as ordered. 28 Pa. Code 211.9 (f)(4)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the main kitchen. Findings include: Observation of the facility's kitchen on October 3, 2023, at 11:07 AM revealed the following in the facility's dry storage area: Two unopened double chocolate boxed cake mixes with a manufacture's date of August 13, 2022 An unopened bag of vanilla wafers/cookies with a use by date of April 7, 2023 Three-quarters of a case of individual servings of Jiff peanut butter with a use by date of June 29, 2023 Four unopened containers of thickened orange juice with a use by date of April 23, 2023. Interview with Employee 3, dietary manager on October 3, 2023, at 11:07 AM and again on October 5, 2023, at 9:30 AM confirmed the items in the dry storage were out of use by dates and should not be available for resident use. Employee 3 also indicated that the double chocolate cake was to be used within one year of the manufacture's date (August 13, 2023). This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on October 4, 2023, at 1:00 PM. 28 Pa. Code 211.6(c)(f) Dietary services

Based on observation and staff interview, it was determined that the facility failed to provide dignity with dining for one of two main dining rooms (Assisted Dining Room, Residents 21 and 22), and for one of one resident reviewed for dignity in toileting (Resident 41) Findings include: Observation of the dining area on October 3, 2023, from 11:55 AM to 12:20 PM revealed that the staff failed to provide resident dignity based on the following: Observation of Employee 1, registered nurse, revealed that she attempted to feed Resident 21 with a spoon while standing up on the resident's left side. The surveyor briefly left the dining room where residents were being fed or assisted with feeding to observe the adjacent dining room where residents feed themselves. On return to the assisted dining room, Employee 1, was standing up attempting to feed Resident 22 with a spoon on the left side of the resident. Employee 1 voiced that is all she could get the resident to take. It is undignified for staff to stand over a resident to feed them. The surveyor reviewed the findings for Residents 21 and 22 with the Nursing Home Administrator and Director of Nursing during a meeting on October 4, 2023, at 1:15 PM. Observation on October 4, 2023, at 2:33 PM revealed that the door to Resident 41's room was open. Resident 41 resided in the semi-private room next to the window. The surveyor entered Resident 41's room after receiving permission from the responsible party. The bathroom door was open, and Resident 41 was sitting on the toilet with the lower part of her body undressed. Employee 2, nurse aide, was bending over and was removing the resident's incontinent brief, which was down to her feet at the time. Resident 41 was visible to the surveyor, responsible party, and roommate. During an interview with Employee 2 on October 4, 2023, at 2:40 PM she confirmed that she should have closed the door to Resident 41's room to provide her privacy and dignity. The surveyor reviewed the findings for Resident 41 during a meeting with the Director of Nursing on October 5, 2023, at 9:00 AM. 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for one of one resident sampled for activities of daily living (Resident 74). Findings include: Resident 74 was unable to be interviewed due to his current cognitive status. A clinical record review revealed the facility admitted Resident 74 on August 2, 2023. A review of Resident 74's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 8, 2023, indicated nursing staff assessed Resident 74 as requiring extensive physical help from one staff for bathing. A review of Resident 74's task documentation (ADL, activities of daily living charting) revealed he has not received a shower since August 5, 2023. Nursing staff documented Resident 74 refused showers since August 5, 2023. Further review revealed that 74's bathing preference was identified as preferring a shower once a week. A review of Resident 74's plan of care revealed no documentation that the facility addressed or implemented individualized interventions for Resident 74's refusal to shower. The facility failed to provide activities of daily living as scheduled and per their preference for Resident 74. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of five residents reviewed (Resident 65). Findings include: Clinical record review revealed the facility admitted Resident 65 on November 10, 2022. Further review of Resident 65's clinical record revealed the following weight assessments: August 26, 2023, 147 pounds September 12, 2023, 141 pounds September 15, 2023, 137 pounds October 2, 2023, 135 pounds (a 12-pound, 8.16 percent significant weight loss) A review of a nutrition progress note dated September 18, 2023, confirmed significant weight loss, and the dietician's intervention included a re-weight to confirm Resident 65's significant loss, and to notify Resident 65's physician. There was no evidence that staff obtained a re-weight or notified Resident 65's physician. Interview with the Director of Nursing on October 6, 2023, at 9:44 AM confirmed she was unable to provide any documentation that the facility obtained a re-weight or notified Resident 65's physician of his significant weight loss. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement interventions to maintain a resident's continence status for one of four residents reviewed (Resident 1). Findings include: The MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) Resident Assessment Indicators (RAI) 3.0 Manual, Section H indicated that each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. Clinical record review for Resident 1 revealed that the facility admitted him on August 11, 2023. Upon admission, the facility identified that Resident 1 was capable, with a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; 13-15 indicates cognitively intact) of 15, was continent of bowel, and aware of the need to defecate. Resident 1 was ordered to be non-weight bearing on his right lower extremity due to a recent hip fracture with surgical repair, therefore requiring staff assistance for toileting. Review of Resident 1's task interventions (an action intended to improve the resident's health and comfort) revealed that he frequently needed limited to extensive assistance from one staff member with his toileting needs. Further review from August 11, 2023, through August 30, 2023, revealed that Resident 1 was incontinent of bowel 13 times, with evening and night shift incontinence occurring for 11 of the 13 times. Resident 1 had loose stool from August 12, 2023, to August 18, 2023. Review of Resident 1's nursing and physician documentation dated August 16, 2023, revealed that Resident 1 was complaining of diarrhea almost every time he eats with nine episodes over the past several days. The physician ordered Imodium for the diarrhea, with noted positive results and Resident 1's diarrhea ceased on August 18, 2023; however, Resident 1's incontinence continued. Interview with Resident 1 on August 30, 2023, at 12:49 PM confirmed that he was continent of bowel prior to admission and that he becomes incontinent of bowel when staff fail to respond to his call bell, especially on the evening and night shifts. He revealed that he notified staff after supper on August 29, 2023, of the need to defecate. Staff indicated that they could not provide assistance at that time. Resident 1 indicated that he waited over an hour for staff to return. By that time, he had become incontinent of bowel and was forced to sit in it while in his wheelchair, until staff returned to provide care. Resident 1 indicated that he could not access his call bell because of being in his wheelchair at the time of staff notification and while awaiting staff return. He did reveal that when he does ring his call bell it sometimes takes staff over an hour to respond and provide incontinence care. Review of nursing documentation dated August 29, 2023, at 10:56 PM (the time of the entry) revealed that Resident 1 was out of bed in his wheelchair and went down to the dining room for supper. Resident 1 informed staff that he was not going again because he always needs the bathroom after he eats, and they told him they would get him back after he ate, and they did not. Review of facility call bell logs for Resident 1's room revealed the following call bell response times: August 12, 2023, 7:03 PM until 8:06 PM, 1 hour, 3 minutes until staff responded August 12, 2023, 10:02 PM until 10:44 PM, 41 minutes until staff responded August 13, 2023, 7:13 PM until 8:19 PM, 1 hour 6 minutes until staff responded August 17, 2023, 1:56 PM until 2:28 PM, 31 minutes until staff responded August 17, 2023, 2:36 PM until 3:14 PM, 36 minutes until staff responded August 19, 2023, 7:07 PM until 7:45 PM, 37 minutes until staff responded August 23, 2023, 6:17 PM until 7:02 PM, 45 minutes until staff responded August 25, 2023, 6:51 PM until 7:26 PM, 34 minutes until staff responded Review of Resident 1's continence documentation revealed that staff documented bowel incontinence on the following dates, potentially due to lengthy call bell response times noted above: August 13, 2023, evening shift August 17, 2023, evening shift August 25, 2023, evening shift Review of the facility's nursing time and staff ratios revealed that the facility failed to meet the following: On August 13, 2023, the facility did not meet the licensed practical nurse (LPN) state required ratio of one LPN to 25 residents on day shift and one LPN to 30 residents on evening shift. On August 13, 2023, the facility did not meet the state required nursing time of 2.87 direct nursing care on August 13, 2023. Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census: August 13, 2023, 6 NAs for a census of 81, requires 7 NAs. August 18, 2023, 6 NAs for a census of 86, requires 8 NAs. August 19, 2023, 7 NAs for a census of 85, requires 8 NAs. August 23, 2023, 7 NAs for a census of 87, requires 8 NAs. August 24, 2023, 7 NAs for a census of 87, requires 8 NAs. August 25, 2023, 7 NAs for a census of 85, requires 8 NAs. This surveyor reviewed the above information with the Nursing Home Administrator on August 30, 2023, at 1:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding wound assessments and diabetes management for three of three residents reviewed (Residents 2, 40, and 55). Finding include: Review of the policy entitled Admission and Weekly Skin Observations, indicates that the facility should monitor skin impairment, which can include abrasions, excoriations, skin tears, and surgical wounds weekly on the Open Lesion progress note until healed. Review of Resident 2's clinical record revealed a nursing note dated September 29, 2022, at 3:07 PM indicating that Resident 2 had an area between buttocks 6 cm (centimeters) by 0.25 cm. Review of the facility's investigation into Resident 2's open wound dated September 30, 2022, at 4:00 PM indicated that Resident 2 had an open area 6 cm by 0.25 cm on his coccyx. The Director of Nursing added a comment to the investigation on October 3, 2022, that Resident 2's sacral slit was moist, red, and open. There was no documented evidence in the facility's investigation to indicate that the facility determined a clinical basis for Resident 2's wound for differentiating type of wound. A nursing note dated September 30, 2022, at 9:55 PM indicated that Resident 2's crease of 6 cm by 0.25 cm in the coccyx area was cleaned, and A&D ointment applied. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no clarification in the order to indicate what nursing staff were to clean Resident 2's open area with. An In-service Training Record, dated October 4, 2022, indicated that the facility provided education to staff regarding Resident 2's gluteal fold skin tear, educating staff to utilize a pull sheet with repositioning and turning in bed to prevent shearing and/or tearing of the skin. Review of the facility's Skin Observation sheets dated October 5, 12, 19, and 26, 2022, revealed that an assessment was completed on Resident 2 to determine if any new skin alterations were present. The Skin Observation assessments did not include any documented evidence to indicate that the facility reassessed Resident 2's open wound to his gluteal crease. There was no documented evidence in Resident 2's clinical record to indicate that the facility monitored his open wound using the Open Lesion report. The last documented assessment of Resident 2's open wound was October 3, 2022. The facility continued to provide wound care to Resident 2's open wound until October 26, 2022, when this surveyor questioned the assessments and treatments. Interview with the Director of Nursing on October 27, 2022, at 10:40 AM, confirmed the above findings. Clinical record review for Resident 55 revealed current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Check Resident 55's blood glucose twice daily Notify Resident 55's physician if her blood greater than 400 mg/dL Review of Resident 55's blood glucose revealed that her levels on the following dates were: August 17, 2022, 4:00 PM, 408 mg/dL (Milligrams per Deciliter) September 14, 2022, 4:00 PM, 530 mg/dL September 20, 2022, 4:00 PM, 413 mg/dL September 23, 2022, 4:00 PM, 436 mg/dL October 16, 2022, 4:00 PM, staff indicated NA (not applicable) October 18, 2022, 4:00 PM, 461 mg/dL There was no documentation that staff notified Resident 55's physician after identifying a blood glucose level greater than 400 mg/dL. Clinical record review for Resident 40 revealed current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (insulin for high blood glucose) mix 75/25 suspension 100 u/ml (units per milliliter) inject 60 units SQ (subcutaneously, just under the skin) in the morning and inject 46 units SQ in the evening for diabetes If Resident 40's blood glucose was 60 to 80 mg/dL give 120 ml (milliliters of juice and recheck the blood glucose in 15 minutes. Repeat treatment if her blood glucose was less than 80 mg/dL. Notify Resident 55's physician if her blood glucose is greater than 400 mg/dL Review of Resident 40's blood glucose revealed that her levels on the following dates were: August 6, 2022, 5:00 PM, 433 mg/dL August 19, 2022, 7:00 AM, 80 mg/dL September 11, 2022, 5:00 PM, no documentation of Resident 40's blood glucose level October 8, 2022, 7:00 AM, 80 mg/dL October 14, 2022, 7:00 AM, 60 mg/dL There was no documentation that staff notified Resident 40's physician after identifying a blood glucose level greater than 400 mg/dL. On August 19, 2022, at 7:00 AM, and on October 8, 2022, at 7:00 AM, staff administered 60 units of [MEDICATION(S)] 75/25 insulin for Resident 40's blood glucose level of 80 mg/dL. There was no documentation that they provided 120 ml of juice or rechecked Resident 40's blood glucose per her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On September 11, 2022, at 5:00 PM there was no documentation indicating that staff administered Resident 40's [MEDICATION(S)] 75/25 insulin. On October 14, 2022, at 7:00 AM staff administered 60 units of [MEDICATION(S)] 75/25 insulin for Resident 40's blood glucose level of 60 mg/dL. There was no documentation that they provided 120 ml of juice or rechecked Resident 40's blood glucose per her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The surveyor reviewed the above information during an interview on October 27, 2022, at 2:05 PM with the Nursing Home Administrator and Director of Nursing. 483.25 Quality of Care Previously cited 11/5/21 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policy and procedures, clinical record review, and staff and resident interviews, it was determined that the facility failed to prevent an accident with injury for one of 23 sampled residents (Resident 9). Findings include: The facility policy entitled, "Falls and Injuries," last reviewed July 26, 2012, revealed that the facility is obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident's environment. The facility admitted Resident 9 on August 5, 2012, for rehabilitation post right knee replacement performed at an acute care hospital on August 2, 2012. The resident's [DIAGNOSES REDACTED]. Clinical record review for Resident 9 revealed an admission nursing note dated August 5, 2012, at 10:30 AM indicating that she was alert and oriented and required the assistance of two staff and a walker for ambulation. Review of the "Nursing Comprehensive Admission Data Collection and Assessment" (a form used by nursing at the time of admission to collect information about the resident and assess their needs), dated August 5, 2012, indicated that Resident 9 required extensive assistance of two staff for transfer and toilet use. Review of the "Resident Lifting, Transferring and Repositioning Data Collection" (a form used by nursing at the time of admission to determine a resident's functional ability) dated August 5, 2012, revealed that Resident 9 required extensive assistance (resident performs part of the activity with weight bearing support) with partial weight bearing capabilities and the assistance of two staff. The admission "Fall/Injury Assessment: Prevention and Management Plan of Care" (a form used to document individualized resident care), indicated that Resident 9 required the assistance of two staff for ambulation and transfer. Nursing documentation dated August 6, 2012, revealed that staff called the registered nurse to Resident 9's room. The nurse found Resident 9 face down in the bathroom with bleeding from her right knee. The nurse aide who was present during the fall stated that she was unable to reach the resident, the resident's knees buckled, and she fell . An x-ray report dated August 7, 2012, revealed a nondisplaced fracture of Resident 9's distal metaphysis left fibula (ankle). Review of the facility's investigation into the incident revealed a statement from the nurse aide indicating that she had just gotten Resident 9 off the toilet. The nurse aide indicated that she had her hand on the resident and turned to open the door. The nurse aide felt Resident 9 start to fall but could not grab her fast enough to stop her from falling. An interview with Resident 9 on August 29, 2012, at 10:00 AM revealed that on August 6, 2012, a staff member helped her to the bathroom. After she stood up from the toilet and was fixing her clothes, her legs gave out and she fell . During the same interview, the surveyor asked if at any time there was another staff member assisting her. She indicated that there was one nurse aide who helped her get out of bed and into the bathroom. There was no other staff in the room at the time. An interview with the Director of Nursing on August 29, 2012, at 11:25 AM confirmed that nursing had assessed Resident 9 as requiring two staff for assistance with ambulation and transfer. At the time of Resident 9's fall, there was one staff member in the bathroom with her. The facility failed to provide Resident 9 with two staff assistance according to her assessed needs resulting in a fall with a fracture one day after admission to the facility. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/8/11 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/8/11 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 7/8/11