Every finding on record at Brookline Nursing and Rehab

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to store indwelling urinary catheter equipment in a manner to prevent the potential for infection for one of one resident reviewed for catheter concerns (Resident 9).Findings include: Clinical record review for Resident 9 revealed that his diagnoses included urinary retention (inability of the bladder to empty completely after urination). Review of Resident 9's active physician orders revealed instructions for staff to change a Foley catheter (flexible tubing inserted through the penis into the bladder to drain urine) as needed for obstruction or dislodgement, and every thirty days for routine care of the indwelling urinary catheter. An active physician order instructed staff to place a leg bag (smaller urinary collection bag secured by straps onto the leg underneath clothing) on Resident 9 in the morning and a drainage bag (larger bag used to contain a larger amount of urine that is hung below the bladder on an item such as the side of the bed) for Resident 9 during hours of sleep. Observation of Resident 9 on February 24, 2026, at 3:26 PM revealed him in his wheelchair, fully clothed. Resident 9 stated that his Foley urine collection bag was underneath his clothing, secured to his leg. Observation of the storage of the larger urinary collection bag equipment that was not in use at the time on February 24, 2026, at 3:26 PM with Employee 1 (licensed practical nurse), revealed that the larger urine collection bag was stored in an open plastic bag that was tied to the toilet assist bar. The tubing connected to the larger urinary collection bag was not capped, which exposed the tip to potential contamination. The plastic bag containing the collection bag also contained a plastic graduate (container marked with units of measurement such as milliliters for accurate measurements of urinary output). Interview with Employee 1 at the time of the observation confirmed that Resident 9's roommate ambulates independently and utilizes the bathroom for his toileting needs. Interview with the Nursing Home Administrator and the Director of Nursing on February 25, 2026, at 2:00 PM indicated that the facility had no policy, procedure, or competency education materials that relayed to staff the appropriate storage of indwelling urinary catheter equipment to prevent potential contamination from the environment (e.g., ensure the ends of all tubing are capped, and store equipment outside the bathroom area where another resident/roommate could inadvertently contaminate the equipment) during non-use. The surveyor reviewed the above concerns regarding Resident 9's urinary catheter equipment storage during the interview. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 5, dietary manager, on February 24, 2026, at 10:20 AM revealed the following: Shelves in a cupboard that held drink pitchers adjacent to the food preparation sink were flaking and/or peeling. A large white pipe going into the ceiling near a corner of the kitchen had an accumulation of black-colored dust around it. The wall behind the refrigerators that held tray carts had an accumulation of dust on it. A baseball sized area of peeling paint on the ceiling above a food prep area. Two dry goods storage rooms contained a large gap surrounding the interior perimeter of the room where the ceiling meets the wall. Cobwebs were also observed in the area. The wall area behind the dishwasher had an accumulation of a black substance on the wall. The wall under the stainless-steel table to the right of the dishwashing machine had an accumulation of dried stains on it. Observation of an adjacent area (one foot by one foot) where pipes extend from the wall to a sink revealed a large open area on the wall exposing the wall joists and pieces of insulation. Observation on February 24, 2026, at 10:25 AM revealed the dishwasher was not in use. A manufacturer placard located adjacent to the temperature monitoring gauge noted the required operating wash temperature as a minimum of 155 degrees Fahrenheit. Concurrent observation of the dishwasher through several cycles revealed that the dishwasher temperature monitoring gauge only reached a maximum temperature of 152 degrees Fahrenheit during the wash cycle and not the minimum 155 degrees as specified by the placard. Observation on February 26, 2026, at 10:06 AM with Employee 5 revealed that the dishwasher was in use by two staff members. Two observations of the dishwasher cycle revealed that the maximum temperature reached for the wash cycle was 150 degrees Fahrenheit and not the minimum 155 degrees as specified by the placard. A concurrent interview with Employee 5 revealed that the dishwasher was a hot water sanitizing dishwasher. A review of the facility documentation titled, Dishwasher Temperature Log dated February 2026, revealed that staff are to record temperatures three times daily (after breakfast, dinner, and supper). The staff documentation revealed that staff documented the temperature as below the minimum 155 degrees specified by the manufacturer placard on the following: February 7, 2026, supper; 150 degreesFebruary 10, 2026, supper; 150 degreesFebruary 14, 2026, supper; 150 degreesFebruary 15, 2026, supper; 150 degreesFebruary 16, 2026, breakfast and dinner; 152 degreesFebruary 17, 2026, breakfast and dinner; 150 degreesFebruary 18, 2026, breakfast; 150 degreesFebruary 19, 2026, breakfast; 152 degreesFebruary 19, 2026, supper; 150 degreesFebruary 20, 2026, supper; 150 degreesFebruary 21, 2026, supper; 150 degreesFebruary 22, 2026; supper; 150 degrees The above information for the dishwasher was reviewed in a meeting with the Nursing Home Administrator on February 26, 2026, at 10:15 AM. The above information about the kitchen was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 2:10 PM. 483.60(i)(1)-(2) Food safety requirementsPreviously cited deficiency 3/21/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of select facility policy and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care for non-invasive ventilation consistent with professional standards of practice and develop a comprehensive and person-centered care plan for one of two residents reviewed (Resident 5) and maintain respiratory related equipment supplies in a safe and sanitary manor in two of two dining rooms observed (main dining room and restorative dining room). Findings include: Review of the facility policy titled CPAP (continuous positive airway pressure)/BiPAP (bilevel positive airway pressure) Support, revealed preparation for use included, in part, reviewing the physician's order to determine the oxygen concentration and flow and the PEEP (positive end expiratory pressure). Further review of the policy included a section on documentation that noted, in part, that mode and settings for the device should be documented in the resident's medical record. Clinical record review for Resident 5 revealed a diagnosis list that included acute and chronic respiratory failure with hypercapnia (high levels of carbon dioxide in the blood) and obstructive sleep apnea (periods of breathing cessation during sleep). A review of current physician orders for Resident 5 revealed an order dated [DATE], for NIV (non-invasive ventilation) at night and with naps; make sure the machine is upright and not lying flat to prevent air intake from being blocked. There were no settings for the device in the physician order. A review of the February 2026 Treatment Administration Record (TAR) for Resident 5 revealed that staff were documenting the application of the device. A review of Resident 5's current care plan revealed that the resident was at risk for respiratory impairment related to the medical history. An intervention included NIV (CPAP) use per physician orders. The care plan did not address additional areas (i.e. settings, cleaning the device, resident assessment, and/or monitoring for complications). An interview with Employee 6, registered nurse, on February 26, 2026, at 10:05 AM revealed that the settings for the device should be located in the physician orders. Observation of the restorative dining room on February 26, 2026, at 9:40 AM revealed a suction unit on a countertop. The following packaged items kept with the suction were expired: connection tubing (expired February 1, 2024), connective tubing (expired [DATE]), and connection tubing 6' (expired [DATE]). Observation of the main dining room on February 26, 2026, at 9:55 AM revealed a suction unit on a countertop. The following packaged items kept with the suction were expired: connective tubing (expired [DATE]) and a yankauer suction tip (expired [DATE]). The Director of Nursing was notified of the expired items on February 26, 2026, at 10:05 AM. The above information for Resident 5 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 10:45 AM. 483.25(i) Respiratory/tracheostomy Care and SuctioningPreviously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff and family interview, it was determined that the facility failed to ensure assistance with activities of daily living for a dependent resident for one of one resident reviewed for activities of daily living concerns (Resident 66).Findings include: Interview with Resident 66's daughter on February 24, 2026, at 11:15 AM revealed that she believed that her father's fingernails were long, that his hair was long, and that she was upset by how he looked during her visit on February 12, 2026. Review of a plan of care developed by the facility on December 11, 2025, to address Resident 66's self-care deficits with activities of daily living (ADL) revealed that Resident 66 was dependent on staff for showering/bathing and personal hygiene needs. Observation of Resident 66 on February 25, 2026, at 8:50 AM revealed that his hair was cut short. Resident 66 stated that he was on his way to the therapy department where he was going to shave. Interview with Resident 66 on February 25, 2026, at 9:12 AM indicated that the barber cut his hair that morning. Observation of Resident 66's fingernails revealed that they were long (several millimeters beyond the tips of his fingers), uneven, and the fingernail of his right ring finger was broken. Resident 66 stated that he needed to cut his fingernails, however, he confirmed that he did not have clippers to cut his fingernails. Interview with Employee 4 (nurse aide) on February 25, 2026, at 9:11 AM indicated that staff should trim a resident's nails with each shower, however, Employee 4 confirmed that it appeared that Resident 66 did not have his fingernails trimmed with his shower. Employee 4 asked Resident 66's permission to cut his fingernails at that time and Resident 66 offered no resistance to the care. Review of Documentation Survey Report (electronic documentation completed by nurse aide staff to record completed assistance with ADL care) information for Resident 66 revealed that he had a shower on January 7, 14, 21, and 28, 2026. Staff documented that a shower was, not applicable, on February 4, 2026, and that he only had a bed bath on February 11 and 15, 2026. Staff initialed the completion of a shower for Resident 66 on February 22, 2026 (three days before the observation of his fingernails documented above). Although the documentation indicated that Resident 66 was to shower every Sunday, staff only referenced bathing for Resident 66 on Wednesdays; and that he only received one shower between January 28, 2026, and February 22, 2026. The surveyor reviewed the above concerns regarding Resident 66's showers and nail care during an interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to develop and implement a comprehensive, person-centered, trauma-informed care plan to meet a resident's mental and psychosocial needs for one of 18 residents reviewed (Resident 9). Findings include: Clinical record review for Resident 9 revealed nursing documentation dated [DATE], at 9:42 AM that Resident 9 was noted in his bed with a cord around his neck. Resident stated that he wanted to get staff's attention, so he decided to wrap it around his neck. Resident 9 then started with paranoid thoughts and stated that his daughter killed his wife and shot her in the chest. He stated that, (acquaintances' surname) was also in on it to help cover it up. Resident 9 continued with paranoid thoughts on how his daughter killed his wife and, .wants to try and kill him so she can get his pension and get all of his money. Resident 9 left the topic of conversation easily and was noted with scattered thought processes. Resident 9 stated that he could easily wrap his hands around someone's neck and just, snap, it and no one would ever know. Resident 9 had paranoid thoughts of his wife marrying him because of money, and that his mother cheated on his father and had a baby. Resident 9 stated that, they threw the (ethnic description) baby into the river, because no one wanted the baby. Resident 9 was described as very distraught with expressions of how people go away to the war and women, .just do what they want and cheat on people. Clinical record review for Resident 9 revealed psychiatry progress note documentation dated [DATE], that Resident 9 was a military veteran and his wife died three weeks before the assessment. Diagnoses listed by the practitioner included PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event). An active physician's order dated [DATE], admitted Resident 9 to skilled care for diagnoses that included PTSD. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], revealed that staff coded the MDS item for PTSD incorrectly as that Resident 9 did not have PTSD. Resident 9's clinical record did not include evidence that the facility identified the traumatic event that precipitated his PTSD, identified potential triggers that could worsen the symptoms of the disorder, implemented ongoing tracking of his distressing target behaviors, or established non-medicinal behavioral interventions used to reduce or eliminate distressing target behaviors. Review of plans of care developed by the facility to address Resident 9's care needs did not provide evidence of a plan of care to address his potential distressing behaviors or symptoms (e.g., hallucinations, aggression, self-harm, isolation, etc.). The surveyor reviewed the concern that the facility had not developed a plan of care for Resident 9's PTSD diagnosis during an interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 10:50 AM. The facility initiated a plan of care following the surveyor's questioning (dated February 26, 2026) to address Resident 9's potential to exhibit behaviors that are a result of past trauma, which may impact moods or behaviors, including his suicide attempt on [DATE]. The facility also obtained a physician's order (dated February 26, 2026) to monitor potential side effects of antipsychotic medication use (e.g., blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, hallucinations) every shift; and a physician's order (dated February 26, 2026) to monitor potential socially inappropriate or disruptive behaviors (self-injury, pacing/wandering, screaming/yelling out, suicidal ideations, physically abusive behavior: hitting, kicking, pushing, biting, etc.) every shift. Interview with the Director of Nursing on February 27, 2026, at 8:45 AM confirmed that staff failed to initiate a plan of care upon Resident 9's readmission to the facility following his in-patient psychiatric stay to incorporate his PTSD diagnosis, grief secondary to the recent death of his wife, and his suicide attempt. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received pneumococcal immunizations unless refused or clinically contraindicated for one of five residents reviewed for immunization concerns (Resident 12).Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed without changes on November 20, 2025, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. For residents who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. Clinical record review for Resident 12 revealed that he last refused a pneumococcal vaccine (Pneumovax 23) on November 16, 2018. Resident 12's clinical record contained no evidence that the facility offered Resident 12 a pneumococcal vaccine in the more than seven years after November 16, 2018. The surveyor requested any evidence of education provided to Resident 12 regarding the risks and benefits of pneumococcal vaccination administrations after November 2018 during an interview with the Director of Nursing on February 25, 2026, at 2:00 PM. Review of a Vaccination Consent Form, dated September 12, 2025 (provided after the surveyor's questioning), revealed an acknowledgement by Resident 12 that he understood the benefits and risks of a PCV20 (Prevnar 20 pneumococcal) vaccination, and that he requested that the vaccination be given to him. There was no evidence that the facility administered the PCV20 immunization to Resident 12. The surveyor reviewed the above concerns regarding Resident 12's pneumococcal vaccinations during an interview with the Director of Nursing on February 27, 2026, at 9:23 AM. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure an assessment accurately reflected the resident's status for one of 18 residents reviewed (Resident 9).Findings include: Clinical record review for Resident 9 revealed psychiatry progress note documentation dated [DATE], that Resident 9 was a military veteran and his wife died three weeks before the assessment. Diagnoses listed by the practitioner included PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event). An active physician's order dated [DATE], admitted Resident 9 to skilled care for diagnoses that included PTSD. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], revealed that staff coded the MDS item for PTSD incorrectly as that Resident 9 did not have PTSD. Interview with the Director of Nursing on February 27, 2026, at 8:45 AM confirmed that staff failed to code Resident 9's admission MDS to include his PTSD diagnosis. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview it was determined that the facility failed to provide written notice of transfer to the resident representative for three of six residents reviewed (Residents 5, 9, and 12) and written notice of the facility bed-hold policy for two of six residents reviewed for hospitalization (Residents 9 and 12).Findings include: Clinical record review for Resident 5 revealed the resident had an emergency contact listed. Nursing documentation for Resident 5 dated December 16, 2025, at 9:36 AM revealed the resident had a change in condition and the licensed practical nurse (LPN) evaluated the resident. Nursing documentation for Resident 5 dated December 16, 2025, at 10:19 AM revealed that a message was left for the responsible party and son. Nursing documentation for Resident 5 dated December 16, 2025, at 10:45 AM revealed that EMS (emergency medical services) arrived and care was transferred to EMS. Nursing documentation for Resident 5 dated December 16, 2025, at 5:00 PM revealed that the resident was being admitted to the hospital for bilateral kidney stones. Facility documentation titled, Notice of Transfer or Discharge, dated December 16, 2025, noted the resident was transferred to the hospital due to the medical condition. The resident signed and dated the document on December 16, 2025. There was no evidence of any documentation that the resident representative was notified in writing as soon as it was practicable of Resident 5's transfer to the hospital. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 27, 2026, at 1:08 PM. Clinical record review for Resident 9 revealed profile information that listed a daughter and a son as potential resident representatives.Nursing documentation dated December 23, 2025, at 9:42 AM revealed that Resident 9 left the facility via emergency medical services transport due to a mental health crisis.Review of a Bed-Hold Notification form dated December 23, 2025, indicated that Resident 9 signed the notice on December 23, 2025. The section of the notice for the resident's responsible party (representative) signature was blank.Review of a Notice of Transfer or discharge date d December 23, 2025, indicated that Resident 9 signed the notice on December 23, 2025. There was no documentation on the notice to indicate that the facility ensured that either of Resident 9's designated resident representatives received a written copy of the notice.Interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 2:00 PM confirmed that the facility had no evidence that Resident 9's resident representative received written notice of either the transfer or the bed-hold notices.Clinical record review for Resident 12 revealed profile information that listed an ex-wife as his first emergency contact and his daughter as his second emergency contact (potential resident representatives). Nursing documentation dated January 27, 2026, at 4:11 AM revealed that Resident 12 transferred out of the facility to the hospital for a surgical procedure. Nursing documentation dated February 6, 2026, at 5:12 PM indicated that Resident 12 returned to the facility following the surgical procedure. Review of a Bed-Hold Notification form dated January 27, 2026, indicated that Resident 12 signed the notice on January 27, 2026. The section of the notice for the resident's responsible party (representative) signature was blank. Review of a Notice of Transfer or discharge date d January 27, 2026, indicated that Resident 12 signed the notice on January 27, 2026. There was no documentation on the notice to indicate that the facility ensured that either of Resident 12's designated resident representatives received a written copy of the notice. Interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 2:00 PM confirmed that the facility did not take measures to ensure Resident 12's representative received a written copy of either the Bed-Hold Notification or Notice of Transfer in response to his January 27, 2026, transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 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 provide the highest practicable care regarding physician ordered pain medications and pain parameters for one of one resident reviewed for pain (Resident 3).Findings include: Clinical record review for Resident 3 revealed a diagnosis list that included pain in unspecified shoulder and myalgia (muscle pain). Resident 3's care plan revealed the resident has pain related to the medical history. An intervention included pain medications per physician orders. Review of the current physician orders for Resident 3 revealed the following medications for pain: Tramadol (a pain medication used to treat moderate to moderate severe pain) HCl oral tablet 50 milligrams (mg) give one tablet by mouth every four hours as needed for moderate to severe pain AND give one tablet by mouth two times a day for moderate to severe pain dated December 3, 2025, at 4:45 PM. Acetaminophen (Tylenol, a medication used to treat mild pain and reduce fever) tablet 325 mg give two tablets by mouth every four hours as needed for pain dated August 21, 2025, at 11:52 AM. The order did not specify the pain parameters for administration. Morphine Sulfate (an opioid medication used to treat moderate to severe pain) oral solution 20 mg/ml (milliliter) give 0.5 ml by mouth every one hour as needed for shortness of breath / pain dated February 24, 2026, at 11:30 AM. The order did not specify the pain parameters for administration. The above information for Resident 3 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 26, 2026, at 2:10 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to identify and monitor the medical symptoms that warranted the use of an antipsychotic medication and monitor for potential adverse consequences of antipsychotic medication use for one of five residents reviewed for potentially unnecessary medication (Resident 9).Findings include: Clinical record review for Resident 9 revealed active physician orders (dated January 9, 2026) for admission to the skilled care facility for diagnoses of: Major depressive disorder (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems)PTSD (Post Traumatic Stress Disorder, thoughts, avoidance behaviors, negative changes in mood and cognition, and intrusive thoughts related to a traumatic event)Suicidal attemptCKD (chronic kidney disease, loss of the kidney(s)' ability to filter waste and excess fluid from the blood)Vascular dementia (decreased blood flow to the brain resulting in loss of memory and cognition) Progress note documentation from the facility's psychological services provider dated January 13, 2026, noted that Resident 9 was in the hospital after a suicide attempt (put call bell rope around his neck) due to losing his wife. Review of active physician orders for Resident 9 revealed instructions to administer Abilify (Aripiprazole, an antipsychotic medication that alters brain chemicals) 5 mg (milligrams) at bedtime from January 28, 2026, until decreased on February 24, 2026, to Aripiprazole 2.5 mg at bedtime. Resident 9's medication regime also included active physician orders for the following antidepressants:Mirtazapine 15 mg at bedtimeSertraline HCL (Zoloft) 150 mg daily The medication reference, Drugs.com, noted that important warnings for the use of Aripiprazole include that there is increased risk for mortality in elderly patients with dementia-related psychosis and suicidal thoughts and behaviors with antidepressant drugs. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis, suicidal thoughts, and behaviors. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. The medication reference also noted potential physical symptoms while using Aripiprazole: convulsions (seizures), difficulty with breathing, a fast heartbeat, a high fever, high or low blood pressure, increased sweating, loss of bladder control, severe muscle stiffness, unusually pale skin, or tiredness. These could be symptoms of a serious condition called neuroleptic malignant syndrome (NMS). Resident 9's clinical record did not include evidence that the facility identified the traumatic event that precipitated his PTSD, identified potential triggers that could worsen the symptoms of the disorder, implemented ongoing tracking of his distressing target behaviors that warranted the use of the antipsychotic, or established non-medicinal behavioral interventions used to reduce or eliminate distressing target behaviors. Resident 9's clinical record also did not provide evidence that the facility monitored Resident 9's potential physical side effects from the use of the antipsychotic. Review of plans of care developed by the facility to address Resident 9's care needs and psychotropic medication use did not provide evidence of a plan of care to address his potential distressing behaviors or symptoms (e.g., hallucinations, aggression, self-harm, isolation, etc.). The surveyor reviewed the above concerns regarding inadequate monitoring and adequate indications for Resident 9's use of the antipsychotic medication during an interview with the Nursing Home Administrator and the Director of Nursing on February 26, 2026, at 10:50 AM. The facility initiated a plan of care following the surveyor's questioning (dated February 26, 2026) to address Resident 9's potential to exhibit behaviors that are a result of past trauma, which may impact moods or behaviors, including his suicide attempt on December 23, 2025. The facility also obtained a physician's order (dated February 26, 2026) to monitor potential side effects of antipsychotic medication use (e.g., blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, hallucinations) every shift, and a physician's order (dated February 26, 2026) to monitor potential socially inappropriate or disruptive behaviors (self-injury, pacing/wandering, screaming/yelling out, suicidal ideations, physically abusive behavior: hitting, kicking, pushing, biting, etc.) every shift. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate and report allegations of abuse and neglect for two of three residents reviewed (Residents CR1 and CR2). Findings include: The policy entitled, Abuse Investigation and Reporting, last reviewed without changes on November 20, 2025, indicated that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The policy indicated that if an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported the administrator will assign the investigation to an appropriate individual. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility administrator, or designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services, law enforcement, the resident's attending physician, and the facility's medical director. Review of a facility concern/grievance report dated January 8, 2026, communicated to the facility by Resident CR1, revealed that she had a concern that a girl that came into her room the night before (January 7, 2026) and was grumpy right away and stated, you asked for it, now you got it, after she ask for a wedge for behind her back. The form indicated that she had a pad laying on her spine and that she could not find the call bell to ring and she was scared. Attached to the concern form was a summary from the director of nursing that indicated her and the social service director met with Resident CR1 regarding her concern that someone was being rough with her during the night when they put her to bed. Resident CR1 also indicated that the person did not put a wedge under her back and she laid on her back all night. She said she had her call bell but was afraid to use it in case this person came back. The summary indicated that Resident CR1 could not identify who the person was because she had her eyes closed the whole time. The summary reviewed different staff members that the Director of Nursing spoke to and ruled out as perpetrators, and there were written statements from two-night shift nurse aides, regarding the event but no perpetrator was identified through those statements either. The director of nursing's summary indicated that the two night-shift nurse aides felt the resident was hallucinating. The summary was signed by the director of nursing on January 9, 2026. Further clinical record review for Resident CR1 revealed a progress note dated January 9, 2026, at 1:54 PM that indicated a purplish area was noted on her right flank/hip area that extended to just below her right abdominal fold. The certified nurse practitioner was notified and ordered and ultrasound of the area and also ordered Vitamin K (essential to help with blood clotting) be given related to Resident CR1 having an elevated PT INR (a blood test that measures how long it takes for blood to clot, used to check for bleeding problems). A progress note for Resident CR1 dated January 9, 2026, at 2:56 PM indicated an ultrasound of the discolored area was completed. A progress note for Resident CR1 dated January 10, 2026, at 10:51 indicated that the ultrasound results showed that Resident she had a hematoma in the right flank/hip and abdominal area. A progress note on January 11, 2026, at 8:01 AM indicated that Resident CR1 was sent to the emergency room. Review of the emergency room documentation dated January 11, 2026, revealed that she had a large bruise to her right abdomen and hip that staff at the nursing facility noted a few days ago. The report also indicated that they use a gait belt to assist Resident CR1 and are unsure if it is from that. The clinical impression specified in the emergency documentation, of the area was noted as a hematoma. The facility was unable to provide any information indicating that they investigated the cause of the hematoma on Resident CR1's right flank/hip and abdominal area to rule out abuse. Interview with the Director of Nursing and the Nursing Home Administrator on January 22, 2026, at 11:30 AM revealed that they did not report or more thoroughly investigate the above noted events because they did not feel they was any allegation of abuse. Closed clinical record review for Resident CR2 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that assessed Resident CR2 as frequently incontinent of both bowel and bladder and that she was dependent on staff for personal and toileting hygiene. Nursing documentation dated November 10, 2025, at 4:34 PM revealed that Resident CR2's granddaughter informed the nurse that no nurse aide staff had been in the room all day to do care. Per the nurse's documentation, a nurse aide went into the room at approximately 2:10 PM (no indication of staff providing care earlier that day) and was refused entry to provide care by Resident CR2's granddaughter. When the nurse aide returned to provide care after the granddaughter's report, Resident CR2 was noted to be, .soaked from incontinence through the sheets and the bed pads. Interview with the Nursing Home Administrator on January 22, 2026, at 2:35 PM revealed that the facility did not identify the report from Resident CR2's granddaughter (no care all day) as an allegation of neglect, did not obtain statements from staff who provided (or attempted to provide) care on the day in question to rule out the potential for resident neglect, and did not report the allegation to the appropriate agencies (e.g., the local field office for the Department of Health). The facility failed to report and thoroughly investigate allegations of abuse and neglect as noted above for Residents CR1 and CR2. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(a)(c) Resident rights

Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 1, 2, and 3). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 1, 2, and 3 (nurse aides). Interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 10:55 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 28 Pa. Code 201.19 (7) Personnel policies and procedures

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 4, Dietary Manager, on [DATE], at 10:00 AM revealed the following: There was a large hole observed in the wall of the dishwashing area. Two wall tiles adjacent to the hole had fallen off the wall onto the ground. There was an extensive build-up of dust on the appliance that Employee 4 referred to as the air handler. A wall-mounted first aid kit held burn spray that expired in 2021 and eye wash that expired in 2023. A smaller pantry area located in the hallway outside of the main kitchen held hand wipes that expired in [DATE]. The pantry area also held a bottled drink that Employee 4 reported was used for colonoscopy (an exam where a flexible medical device is inserted into the colon to assess for abnormalities) preps. This drink was being stored in the same area as commercial sanitizer/cleaner. A review of the food temperature logs for February 2025, with Employee 4 on [DATE], at 11:50 AM revealed the dates of February 19 and 26 had no dinner food temperatures documented as assessed by kitchen staff. The findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:00 PM. 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 develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 18, 55, and 61). Findings include: Clinical record review for Resident 18 revealed the facility admitted him on July 13, 2018. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added on October 3, 2022. A review of Resident 18's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 9, 2025, indicated that the facility assessed Resident 18 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 18's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 55 revealed that the facility admitted her on May 15, 2022, with diagnoses including dementia. A review of Resident 55's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 55 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 55's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 61 revealed that the facility admitted her on May 27, 2023, with a dementia diagnosis added May 31, 2023. A review of Resident 61's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 61 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 61's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. These findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 20, 2025, at 2:00 PM for Residents 18, 55, and 61. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of one resident reviewed (Resident 19). Findings include: Clinical record review for Resident 19 revealed a diagnosis list that included acute and chronic respiratory failure (a condition that makes it difficult to breathe) with hypercapnia (elevated levels of carbon dioxide in the blood), chronic obstructive pulmonary disease (COPD, a lung disease that causes inflammation and restricted air flow into and out of the lungs), acute and chronic respiratory failure with hypoxia (low oxygen levels in the body), and pulmonary embolism (a blood clot in the lungs). Current physician orders for Resident 19 revealed an order dated September 17, 2024, for supplemental oxygen at five liters per minute (LPM) via nasal cannula (medical tubing that delivers supplemental oxygen to the nose) every shift to maintain pulse ox (pulse oximeter; a non-invasive measure of the body's oxygen level) greater than 90 percent. A review of the current care plan for Resident 19 revealed the resident is at risk for respiratory impairment due to the medical history. Observation of a wheelchair outside of Resident 19's room on March 18, 2025, at 1:02 PM and 2:25 PM; and March 19, 2025, at 12:10 PM revealed a nasal cannula attached to a portable supplemental oxygen cylinder. The nasal cannula was stuffed into the back canvas storage area of the backrest of the wheelchair. There were also two footrests for the wheelchair in this storage area. The nasal cannula tubing was not protected from contamination from the ambient environment or the footrests in the same storage compartment. An interview with Employee 5, registered nurse unit manager, on March 19, 2025, at 12:10 PM revealed the wheelchair belonged to Resident 19 and the findings were reviewed with Employee 5. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 19, 2025, at 1:45 PM. 483.25(i) Respiratory/tracheostomy Care and Suctioning Previously cited deficiency 3/22/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for two of five residents reviewed for hospitalizations (Residents 11 and 70). Findings include: Clinical record review revealed that Resident 11 was transferred to the hospital on March 17, 2025, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 9:10 AM. Clinical record review revealed that Resident 70 was transferred to the hospital on March 5, 2025, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The above information for Resident 70 was reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on March 21, 2025, at 10:24 AM. They confirmed the facility had no further documentation indicating Resident 70's representative received written notice of the facility bed hold policy at the time of transfer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for one of three residents reviewed for accident hazards (Resident 72). Findings include: Observation of Resident 72's room on March 18, 2025, at 2:02 PM revealed that there was a left one-quarter side rail observed on the bed. Clinical record review for Resident 72 revealed that the facility completed a side rail assessment, review of potential risks, and obtained consent on February 7, 2025. The facility also completed a side rail entrapment evaluation on February 7, 2025, which revealed that the facility assessed zone six (between the end of the enabler device and the side of the headboard). There was no documentation that the facility assessed the risk for entrapment posed in zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and inside of the rail, and four (between the top of the compressed mattress and the bottom of the rail at the end of the rail). The above information was reviewed during an interview with the Nursing Home Director and the Director of Nursing on March 20, 2025, at 2:00 PM. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of two nursing units (Unit 3; Residents 51 and 73). Findings include: Observation of the Unit 3 Nursing Unit on the following dates and times revealed the following: On March 18, 2025, at 1:54 PM the drywall was marred behind Resident 51's head of the bed and their recliner. On March 18, 2025, at 2:24 PM the drywall was marred behind Resident 73's head of the bed. The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM. 28 Pa. Code 201.18(b)(3) Management

Based on observation and resident and staff interview, it was determined that the facility failed to provide a reasonable accommodation of needs in response to call bell activations for one of two nursing units observed (Unit 2; Residents 14 and 57). Findings include: Clinical record review for Resident 57 revealed a diagnosis list that included dementia (a loss of cognitive function that is caused by the permanent damage or death of the brain's nerve cells, or neurons). Resident 57's annual Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 14, 2025, noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. An interview with Resident 57 on March 18, 2025, at 11:31 AM revealed he was sitting in a chair next to the bed. The resident reported concerns that staff do not answer the call bell activations timely and sometimes take an hour or longer to respond and this occurs all the time. Clinical record review for Resident 14 (Resident 57's roommate) revealed a significant change MDS dated [DATE], that noted a BIMS of 13. Nursing documentation for Resident 14 dated March 9, 2025, at 1:31 PM revealed Resident noted with cognitive decline. An attempted interview with Resident 14 on March 18, 2025, at 11:40 AM revealed the resident was asleep and unable to be interviewed. An interview with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM revealed the facility can review call bell logs; however, the logs are not specific to the resident and account for the entire room. A review of the facility documentation titled Room Event Report, for Residents 14 and 57 revealed the following call bell activation dates/times with an elapsed time greater than 20 minutes: March 7, 2025, at 2:16 PM; elapsed time 20 minutes, 33 seconds March 8, 2025, at 8:14 PM; elapsed time one hour, 16 minutes, 48 seconds March 9, 2025, at 10:14 AM; elapsed time 47 minutes, 55 seconds March 9, 2025, at 11:08 AM; elapsed time 23 minutes, eight seconds March 9, 2025, at 7:25 PM; elapsed time 29 minutes, 15 seconds March 9, 2025, at 8:25 PM; elapsed time 54 minutes, 46 seconds March 10, 2025, at 5:23 AM; elapsed time 20 minutes, 24 seconds March 10, 2025, at 9:28 AM; elapsed time 46 minutes, 15 seconds March 10, 2025, at 10:42 AM; elapsed time 52 minutes, 29 seconds March 10, 2025, at 12:44 PM; elapsed time one hour, eight minutes, 53 seconds March 11, 2025, at 5:29 PM; elapsed time 38 minutes and 27 seconds March 12, 2025, at 6:03 AM; elapsed time one hour, 11 minutes, 52 seconds March 12, 2025, at 8:35 AM; elapsed time one hour, nine minutes, seven seconds March 13, 2025, at 6:17 AM; elapsed time 44 minutes and 59 seconds March 13, 2025, at 9:54 AM; elapsed time one hour, 40 minutes, three seconds March 13, 2025, at 8:15 PM; elapsed time one hour, 12 minutes, 32 seconds March 14, 2025, at 8:52 AM; elapsed time one hour, 28 minutes, 29 seconds March 14, 2025, at 4:54 PM; elapsed time 21 minutes, 43 seconds March 15, 2025, at 12:35 PM; elapsed time one hour, 41 minutes, 26 seconds March 15, 2025, at 6:19 PM; elapsed time one hour, 34 minutes, 35 seconds March 15, 2025, at 8:02 PM; elapsed time 41 minutes, 31 seconds March 16, 2025, at 6:35 AM; elapsed time 23 minutes, and five seconds March 16, 2025, at 8:38 AM; elapsed time 23 minutes, 13 seconds March 16, 2025, at 10:46 AM; elapsed time 33 minutes, 44 seconds March 16, 2025, at 1:10 PM; elapsed time one hour, 27 minutes, six seconds March 16, 2025, at 6:36 PM; elapsed time 30 minutes, two seconds March 16, 2025, at 7:30 PM; elapsed time 51 minutes, 21 seconds March 17, 2025, at 8:58 AM; elapsed time 24 minutes, 23 seconds March 19, 2025, at 11:43 AM; elapsed time 20 minutes, 41 seconds March 19, 2025, at 6:15 PM; elapsed time 28 minutes, 16 seconds An interview with the Nursing Home Administrator and Director of Nursing during a meeting on March 21, 2025, at 10:45 AM revealed the facility was unable to provide an explanation for the extended call bell times as noted in the resident interview and on the Room Event Report. A follow-up interview with Resident 57 on March 21, 2025, at 10:59 AM reiterated the extended wait time when he sometimes rings the call bell. The resident further noted he sometimes rings the call bell for Resident 14 (the roommate) since that resident has been confused recently. Another attempted interview with Resident 14 revealed that the resident was not interviewable due to confusion. The facility failed to provide a reasonable accommodation of needs in response to call bell activations for Residents 14 and 57. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to promote bladder continence for one of one resident reviewed for incontinence (Resident 31). Findings include: The policy entitled Urinary Continence and Incontinence- Assessment and Management, last reviewed on November 16, 2024, indicates as part of the initial and ongoing resident assessments, the nursing staff and physician will screen residents for information related to urinary incontinence. As part of the facility's assessment, nursing staff will seek and document details related to continence (relevant details include voiding patterns, associated pain or discomfort, and types of incontinence). The nursing staff and physician will identify risk factors for becoming incontinent, or for worsening of the resident's current incontinence. The evaluation will include a review for medications that might affect continence. The staff and physician will summarize the individual's continence status. The staff and physician will identify residents with complications of existing incontinence, or who have risk for such complications. The physician and staff will also address treatable causes, or contributing factors related to urinary incontinence. If the resident remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. The staff will document the results of the toileting trial in the resident's medical record. The staff and physician will evaluate the effectiveness of interventions, and implement additional pertinent interventions as indicated. Review of Resident 31's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 8, 2025, that indicated that the facility assessed him as being frequently incontinent of bladder, and that a urinary toileting program has not been attempted. The facility also assessed Resident 31 using a BIMS (brief interview for mental status) assessment, with a score of 15 (cognitively intact), and as being able to understand others, be understood, and having adequate vision and hearing. The MDS dated [DATE], also indicated that the facility assessed Resident 31 as requiring extensive assistance of two staff for toileting. There was no documented evidence in Resident 31's clinical record to indicate that the facility's physician or nursing staff assessed Resident 31 to determine the type of urinary incontinence, or to develop an individualized toileting program or plan of care. Interview with the Nursing Home Administrator and the Director of Nursing on March 21, 2025, at 10:30 AM confirmed the above findings for Resident 31. 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 a review of clinical records, select facility policies, facility investigation reports, and staff interviews, it was determined that the facility failed to maintain a resident's environment free from accident hazards which resulted in harm, a suicide attempt and hospitalization for one of three residents reviewed (Resident 3). Findings include: Review of the facility's policy, Suicide Threats last reviewed on (MONTH) 2, (YEAR), revealed Resident suicide threats shall be taken seriously and addressed appropriately. Additionally, the policy revealed Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing of such threats. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. Review of Resident 3's clinical record on (MONTH) 28, 2019, revealed [DIAGNOSES REDACTED]. Review of a facility's report following a suicide attempt on (MONTH) 25, 2019, revealed at 4:55 PM on (MONTH) 25, 2019, Resident 3 stated to a staff member I would be better off dead. The staff member called Registered Nurse Supervisor (RNS) to report resident's statement. The RNS arrived at Resident 3's room at 5:00 PM and resident was noted to be lying in bed resting with eyes closed, no signs of distress noted, did not awaken to answer questions. Resident's area checked for any possible hazard's and verified resident's safety. Resident 3 was placed on 15-minute checks at that time. Further review of the facility's submitted report revealed Resident 3 was checked at 5:15 PM and 5:30 PM on (MONTH) 25, 2019. At 5:39 PM Resident 3's roommate came into the hall and reported that Resident 3 broke a vase and was bleeding and needed help. Licensed Practical Nurse (LPN) 1, entered the room and found Resident 3 had her oxygen tubing wrapped around her hands and a broken vase on the floor and bleeding noted to her bilateral wrist. Also noted in the report Reddened area noted around her (Resident 3) neck possibly from the oxygen tubing. With Resident 3 stating I want to die. The report continues that Resident 3 sustained superficial lacerations to both wrists, was transferred to an acute care hospital for evaluation, and then admitted to a behavioral unit for treatment. The report states Resident's area checked for any possible hazard's and verified resident's safety. The facility failed to secure the area of potential accident hazards, including oxygen tubing, and her roommate's vase, after a suicide threat. This resulted in a suicide attempt, transfer to the hospital and admission in a behavioral unit. During an interview on (MONTH) 28, 2019, at approximately 3:35 PM with Nursing Home Administrator, when asked why the room was not cleared after the threat of suicide she revealed, that's a good question with no further comment. The facility failed to maintain a resident's environment free from accident hazards which resulted in harm, a suicide attempt and hospitalization for Resident 3. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/27/18, 8/21/18, 10/5/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 8/21/18, 8/3/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 3/15/19. 28 Pa. Code 201.29(d) Resident rights. Previously cited 3/20/19. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 9/27/18. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 8/21/18, 8/3/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 4/5/19, 9/27/18, 8/21/18, 8/3/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 3/20/19, 9/27/18, 10/19/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/27/18, 8/21/18, 10/19/17, 8/3/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/20/19, 9/27/18, 8/21/18, 4/3/18, 10/19/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/5/19, 3/20/19, 9/27/18, 8/21/18, 4/3/18, 10/19/17, 8/3/17.

Based on review of facility policy, clinical record review and interviews with staff it was determined that the facility failed to ensure that each resident received adequate supervision and monitoring of alarms to prevent accident hazards for one of 16 residents sampled (Resident 10). Findings include: Review of Resident 10's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 10's Guardian Elder Care Event Report dated December 12, 2013 at 1:15 a.m. revealed resident was on back half in the bathroom and half in the room complaining of back and left hip pain. Documentation revealed resident was being toileted when the event occurred. Resident was sent to the hospital and admitted with a hip fracture. Brookline Documentation Notice dated December 10, 2013 resident was walked to the bathroom and was told someone is ringing a bell across and would be right back, she was to wait and not get up alone. Resident fell and when employee returned, Resident 10 was on the floor. Interview March 18, 2014 at 10:00 a.m. with RN 1 revealed Resident 10 should not have been left unattended in the bathroom. 28 Pa. Code: 201.18 (e) (1) Management. Previously cited 5/9/2013 28 Pa. Code: 201.29 (d) Resident Rights. Previously cited 5/9/2013 28 Pa. Code: 211.10 (d) Resident Care Policies Previously cited 5/9/2013 28 Pa. Code: 211.12 (d) (2)(3)(5) Nursing Services Previously cited 5/9/2013

Based on clinical record review and interviews with staff it was determined that the facility failed to ensure adequate supervision and monitoring to prevent accident hazards for 13 of 19 residents (Resident 2, 3, 6, 9, 11, 12, 13, 14, 15, 16, 17, 18 and 19) and the subsequent investigation of accidents for 1 of 10 residents reviewed (Resident 9). Findings include: Review of the clinical record for Resident 9 revealed she was admitted to the facility on [DATE] following a fall at home with a traumatic vertebrae fracture. Review of the Fall assessment dated [DATE] revealed a score of 16 equaling at risk for falls. Review of the Care Plan dated May 22, 2014 revealed a problem of falls with interventions of call bell, remove obstacles, assess medications, and therapy. Review of the Incident Report dated May 26, 2014 revealed resident was found on the floor of the bathroom at 4:00 a.m. There was no investigation of the fall to review. The immediate interventions added to the care plan following the fall included grippy socks while in bed and toilet every 2 hours. Review of the Post Event Nursing Note dated May 27, 2014 revealed head injury was checked yes. Review of the Resident Care Plan Updated form dated May 26, 2014 revealed interventions added to the care plan included grippy socks in bed, toilet every 2 hours, and chair sensor alarm. Review of the staff signatures acknowledging the additions to the care plan revealed staff did not sign on 6 shifts following the fall on May 26, 2014, acknowledging the new interventions. During an interview on May 30, 2014 at 2:00 p.m., the DON acknowledged there was no investigation of the fall, and staff were not signing acknowledgement of the care plan updates. She stated the resident did not injure herself and staff were not documenting correctly. Additionally, review of the facility ' s Guardian Elder Care Event reports dated May 7 thorough 30, 2014, revealed a total of 13 Residents experienced 18 falls in that time period. Residents 3, 6, 9, 11, 12, 13, 16, 17, 18 and 19 had one fall each; Residents 2 and 14 had two falls each; Resident 15 had four falls. Interview with the DON and NHA on May 30, 2014 at 2:30 a.m. indicated that the facility continues to trend resident falls and has seen a decrease in them.