Every finding on record at Bryn Mawr Extended Care Center

Based on clinical record review and interview with staff, it was determined that the facility did not report an allegation of resident-to-resident abuse the State Survey Agency as required for one of eight records reviewed (Resident R1). Findings include:Review of clinical records for Resident R1 revealed that the resident was admitted to the facility on [DATE], with the diagnoses of quadriplegia (paralysis that affects of limbs), and schizophrenia (mental disease characterized by a loss of reality contact). Review of grievance logs for the facility revealed that Resident R1 had filed a complaint with the facility that (his/her) roommate, Resident R2, had hit (him/her) on May 1, 2026. Review of documentation submitted to the State survey agency for May 2026 revealed no documented evidence that State Survey Agency was notified or the allegation of resident to resident abuse.Interview with Employees E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on May 12, 2026, at 11:30 a.m. revealed that the facility conducted an investigation of the allegation immediately upon receiving the concern. They further stated that multiple witnesses to the incident were interviewed and confirmed that Resident R2 did not hit Resident R1. They stated that did not file a report as they were unaware that it was required, as the incident was so quickly unsubstantiated due to multiple staff and resident witnesses. 28 PA. Code 211.14(a) Responsibility of licensee

Based on observations, review of facility documentation and clinical records, and staff and resident interviews, it was determined the facility failed to ensure Resident R3, was adequately secured during transportation in the facility's contracted transportation service van. This failure resulted in actual harm to Resident R3 who sustained a fracture of right tibial plateau, for which the treatment involved surgical procedure for one of two residents reviewed (Resident R3) Findings Include: Review of Resident R3's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 9, 2026, revealed Resident R3's diagnoses included Hemiplegia (total paralysis of one side of the body) and Hemiparesis (weakness or partial loss of muscle movement on one side of the body, both resulting from brain or spinal cord damage), Cerebrovascular Accident (CVA-stroke), Psychotic Disorder (mental health condition that causes a person to lose touch with reality, making it difficult to distinguish between what is real and what is not), Seizure Disorder (chronic brain condition characterized by recurring, unexpected electrical storms in the brain, disrupting normal brain function, causing temporary symptoms like staring spells, uncontrollable shaking, confusion, or loss of awareness), End Stage Renal Disease (permanent stage of kidney failure), and Depression (mental health condition characterized by persistent sadness and a loss of interest in activities). Continued review of Resident R3's MDS assessment revealed the resident's BIMS (Brief Interview of Mental status) score of 15, which indicated the resident was cognitively intact. Further review of the MDS assessment indicated Resident R3 used a wheelchair for mobility. Review of Resident R3's care plan developed July 16, 2024, revealed the resident had impaired Activities of Daily Function related to impaired mobility, Right Hemiparesis/Hemiplegia secondary to CVA and History of Right Hip Fracture. Continued review of Resident R3's care plan revealed a care plan developed on October 28, 2024, related to the resident being at risk for falls related to impaired mobility. Review of information submitted to the Pennsylvania Department of Health by the facility on February 21, 2026, revealed Resident R3 sustained a fall on February 21, 2026, in the transportation van. [Resident R3] with BIMS score of 15 boarded .van a contracted transportation service of the facility, to be taken to (his/her) scheduled dialysis appointment, on February 21, 2026, at approximately 9 a.m. At approximately 9:30 a.m., Nursing staff, Employee E3 received a call from the contracted transportation service's van driver, (Employee E5). (Employee E5) informed the facility staff (Resident R3) sustained a fall to the floor of the van. (Van driver, Employee E5) made an abrupt stop of the van as vehicles in front of the van stopped unexpectedly, causing Resident R3 to fall out of (his/her) wheelchair and onto the floor of the van. (Van driver, Employee E5) stated that he was going to return the resident to the facility, and at that time the nurse of the facility advised the driver to take the resident to the ER (emergency room) for evaluation. MD (physician) and Responsible Party of [Resident R3] were made aware of [Resident R3's] then healthcare status along with the name and location of the hospital the resident was being taken to. Continued review of the information submitted to the Department revealed, Facility nursing staff has called the initial Hospital were [Resident R3] was taken, to obtain a follow up report. Facility Nursing staff was told by ER (Emergency room) Nurse of the hospital that [Resident R3] was being transferred to, a Major Hospital for surgery of the Right Tibia (shin bone). Administrator of the facility called the Contracted Transportation Service Company for their incident reports of the event. According to the Contracted Transportation Service Company driver's (Employee E5) statement, [Resident R3] was not secured in [Resident R3's] wheelchair in the van. Police was called and the incident report was given to Police Officer. The facility was looking for a new non-emergent transportation service. Review of Resident R3's clinical record revealed a nursing note dated February 21, 2026, confirming the same information as documented above. Review of Resident R3's hospital Emergency Department record, dated February 21, 2026, revealed Resident R3 arrived to the Emergency Department after a motor vehicle accident. The patient was sitting in (his/her) wheelchair on a transport on (his/her) way to Dialysis. Another vehicle cut them off and the driver slammed on the brakes. The patient fell out of the chair and struck (his/her) right side against the seats in front of them. Now having pain on the right side of (his/her) body which includes right shoulder, elbow, knee, and ankle. Also reports a headache with neck pain. No Loss of Consciousness. (He/she) is on Eliquis (anticoagulant). Review of Resident R3's hospital X-ray dated February 21, 2026, in the hospital Emergency Department record revealed; there was a fracture of the tibia. On March 9, 2026, at 12:54 p.m., an interview was conducted with Assistant Director of Nursing (ADON), Employee E3 regarding the incident involving Resident R3. Employee E3 (ADON) revealed received notification of the incident from the van driver, Employee E5, on February 21, 2026. During the interview, Employee E3 revealed the van driver (Employee E5) acknowledged Resident R3 was not secured with a wheelchair- seatbelt, Resident R3 fell inside the vehicle contracted by the transportation service company. Further interview on March 9, 2026, at 1:09 p.m. with Employee E3 (ADON), revealed on February 21, 2026, the van driver called to notify staff that he/she was bringing Resident R3 back to the facility because the resident had fallen out of his/her wheelchair after the van came to an abrupt stop. Employee E3, reported to have instructed the van driver to take Resident R3 directly to the hospital but the van driver insisted on bringing Resident R3 back to the facility. Continued interview with Assistant Director of Nursing (ADON), Employee E3, revealed she was waiting at the front entrance when the van pulled up front with Resident R3 inside the van. Employee E3 (ADON), revealed Resident R3 was physically assessed and was observed to have redness on his/her face with fresh blood above the eyebrow. Resident R3 told Employee E3, that he/she fell forward out of the wheelchair and was in a lot of pain. Van driver reportedly informed Employee E3, that he/she only secured the resident's wheelchair in the van but failed to apply Resident R3's seatbelt. Assistant Director of Nursing (ADON), Employee E3, revealed Resident R3 remained in the vehicle, and he/she again directed the van driver to transport Resident R3 to the hospital for further evaluation. On March 9, 2026, attempts to interview the van driver, Employee E5, were unsuccessful as Employee E5 was no longer employed by the facility. Review of the New Hire-Training Acknowledgement Form of the Contracted Transportation Service Company for Employee E5 revealed Employee E5 completed the New Hire- Training on May 20, 2025. Further review of Employee E5's personnel file revealed; Employee E5 also received training on October 8, 2025, Passenger Assistance Safety and Sensitivity (Pass) 8 Basic Online Training Program. (The training is widely used in the U.S. for drivers who transport people with disabilities, seniors, or medical passengers (like paratransit or non-emergency medical transport.) During interview on March 12, 2026 at 2:07 p.m. with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, surveyor asked how the van driver should have responded to an injured resident in the van and if it was appropriate for the van driver to assist the resident off the floor and back into the wheelchair without direction from a medical provider. Continued interview with the Nursing Home Administrator, Employee E1, revealed he/she did not know how the van driver should have proceeded after Resident R3 fell out of the wheelchair. The facility failed to ensure that Resident R3 was adequately secured during transportation in the facility's Contracted Transportation Service Van. This failure resulted in actual harm to Resident R3 who sustained a fracture of right tibial requiring surgery. 28 PA Code 201.18(b)(3)(e)(1) Management 28 PA Code 211.10(d) Resident care policies

Based on review of facility policy, review of clinical records, observations, and interviews with staff and residents it was determined that the facility failed to review and revise resident care plans in accordance with resident needs for one of 33 residents reviewed (Resident R134). Findings Include: Review of Resident R134's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 13, 2026, revealed the resident had severe cognitive impairment and a diagnosis of aphasia (communication deficit). Review of Resident R134's comprehensive care plan dated August 27, 2025, revealed the resident had potential for falling related to limited mobility and impaired balance. Intervention dated August 10, 2025, specified scoop mattress in place. Observations and interview on March 12, 2026, at 11:00 a.m. with Registered Nurse, Employee E12, revealed Resident R134 did not have a scoop mattress. Resident R137 had a regular pressure reduction mattress in place. Interview on March 12, 2026, at 11:22 a.m. with Director of Nursing, Employee E2, revealed Resident R134 was seen by the wound practitioner in October 2025 after the resident sustained a skin tear to the thigh. Per the wound care communication log dated October 29, 2025, the wound practitioner recommended discontinuing the scoop mattress as he/she felt it would inhibit the turning and repositioning of Resident R134. Continued interview on March 12, 2026, at 11:22 a.m. with Director of Nursing, Employee E2, confirmed the facility failed to revise Resident R134's care plan to remove the scoop mattress intervention. Review of Resident R3's quarterly Minimum Data Set, dated [DATE], revealed Resident R3's diagnoses included Hemiplegia (total paralysis of one side of the body) and hemiparesis (weakness or partial loss of muscle movement on one side of the body, both resulting from brain or spinal cord damage), Cerebrovascular Accident (CVA-stroke), Psychotic Disorder (mental health condition that causes a person to lose touch with reality, making it difficult to distinguish between what is real and what is not), Seizure Disorder (a chronic brain condition characterized by recurring, unexpected electrical storms in the brain. These sudden bursts of electricity disrupt normal brain function, causing temporary symptoms like staring spells, uncontrollable shaking, confusion, or loss of awareness), End Stage Renal Disease (permanent stage of kidney failure), and Depression (mental health condition characterized by persistent sadness and a loss of interest in activities). Continued review of Resident R3's MDS assessment revealed the resident's BIMS (Brief Interview of Mental status) score of 15, which indicated that the resident was cognitively intact. Further review of the MDS assessment indicated Resident R3 used a wheelchair for mobility. Review of Resident R3's care plan developed July 16, 2024, revealed the resident had impaired Activities of Daily Function related to impaired mobility, Right Hemiparesis/Hemiplegia secondary to CVA and History of Right Hip Fracture. Continued review of Resident R3's care plan revealed a care plan developed on October 28, 2024, related to the resident being at risk for fall related to impaired mobility. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure a resident was provided the self-determination in regard to a room change for one of 33 residents reviewed (Resident 157).Findings Include: Review of facility policy Resident Rights and Facility Responsibilities Policy reviewed October 7, 2025, revealed it is the facility's policy to comply with all Resident Rights, and to communicate these rights to residents and their designated representatives in a language that they can understand. Review of Resident Rights Room Assignments & Changes revised July 2011, revealed during the course of a residents stay, room changes may be necessary for the welfare of each resident. The facility will try to give the Resident and Resident Representative reasonable notice, prior to change, including an explanation for the change. Review of Resident R157's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 28, 2026, revealed the resident was admitted to the facility on [DATE], and had diagnoses of muscle weakness, cognitive communication deficit, and need for assistance with personal care. Continued review of Resident R157's comprehensive MDS dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS - brief screener that aids in detecting cognitive impairment) score of 12 (moderately impaired). Observations on March 11, 2026, at 1:55 p.m. revealed Resident R157 was in the hallway, visibly upset, holding a few of his/her personal belongings. Interview on March 11, 2026, at 1:55 p.m. with Resident R157, the resident expressed being upset and frustrated because he/she was abruptly informed and subsequently transferred to a new room. Resident R157 stated he/she did not want to move rooms but indicated he/she felt a choice was not provided. Resident R157 stated he/she was only informed within the last 30 minutes, and his/her personal belongings were already moved with the assistance of nursing staff. Licensed Nurse, Employee E10, was present at the time of the interview with Resident R157 on March 11, 2026, at 1:55 p.m. Licensed Nurse, Employee E10, stated he/she was given instruction by the Admissions Director that Resident R157 needed move into a new room so a room could become available for a new male admission. Interview on March 11, 2026, at 2:08 p.m. with the Director of Nursing, Employee E2, revealed he/she was unaware Resident R157 was transferred to a new room. Interview on March 11, 2026, at 2:15 p.m. with Social Services Director, Employee E11, confirmed Resident R157 should not have been moved, as staff were also unable to get in contact with the resident's representative. 28 Pa Code 201.29(a) Resident rights

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that a call bell system was functioning for one of 33 residents reviewed. (Resident R2) Findings include: Review of Resident R2's quarterly assessment dated [DATE], indicated Resident R2 was cognitively intact. The assessment also indicated that this resident required moderate assistance with toilet transfers, sit to standing positioning, chair to bed/ bed to chair transfers and to walk ten feet. This assessment said that Resident R2 was frequently incontinent of bowel and bladder. Review of Resident R2's nursing notes dated November 19, 2025, indicated Resident R2 was found sitting on the floor near the bed. The nursing note indicated that Resident R2 was asked to use the call bell system to alert the nursing staff to assist with transfer needs for toileting. Review of nursing note dated December 19, 2025, indicated Resident R2 was witnessed standing up from the wheelchair to proceed to transfer without assistance. Resident R2 complained of pain post fall. The physician sent the resident to the hospital for further evaluation. The hospital report indicated that Resident R2 was diagnosed with a right hip fracture post fall on December 19, 2025. The nursing progress notes indicated that Resident R2 was asked to use the call bell to request the assistance of staff for standing and transfer needs. Clinical record review for Resident R2 revealed a nursing progress note for January 3, 2026, that indicated the resident had experienced a fall, while trying to self-transfer from bed to wheelchair. The nursing note indicated that the resident sustained an injury a skin tear of the shin during the fall. The nursing progress note indicated that Resident R2 was asked to use the call bell system to notify the nursing staff of the resident's care needs for transfer assistance. Review of Resident R2's nursing notes dated January 25, 2026, indicated Resident R2 fell while attempting to transferring self to the wheelchair. The nursing progress note said the Resident R2 needs staff assistance to safely transfer from wheelchair to bed and bed to wheelchair. The nursing progress note indicated that Resident R2 was reminded to ask for staff assistance. The resident was asked to use the in room call bell system to alert the nursing staff of Resident R2's care needs. Interview with Resident R2 at 9:30 a.m., on March 10, 2026, revealed that the resident was reporting that staff do not answer the call bell system in a timely manner to provide assistance with care needs. Resident R2 was reporting that he prefers to get out of bed early after he eats breakfast. The resident verified needed assistance with standing, transferring and toileting. Observations at 10:00 a.m., on March 10, 2026, revealed that Resident R2's call bell system was not fully functioning. The call bell was pushed and activated in the resident's room however the light above the door and panel light at the nurse's station was not sounding or lighting to alert the staff of Resident R2's request for assistance with care needs. Interview with the registered nurse, Employee E6, at 10:15 a.m., on March 10, 2026, confirmed that the call bell system for Resident R2 was not operating according to manufacturer's specifications. Interview with the Director of Nursing, at 10:00 a.m., on March 11, 2026, revealed that a temporary three-way call system was purchased for Resident R2. The three-way call system rings at the nurse's station, vibrates on the person assigned to the resident and Resident R2 was given a press button call activator for the bedroom. 28 PA. Code 211.10(d) Resident care policies28 PA Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate infection control practices were maintained during wound care for one of 29 residents reviewed (Resident R12). Findings include:Review of the Pennsylvania Department of Health document Checklist for Infection Control, last updated January 2026, revealed that, Gloves should be changed and hand hygiene performed when moving from dirty to clean wound care activities (e.g. after removal of soiled dressings, before handling clean supplies, and Aseptic non-touch technique .aims to prevent the transmission of microorganisms to the wound. Review of Resident R12's clinical record revealed that the resident was most recently readmitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke caused by a blood clot or other obstruction in the brain), hemiplegia (paralysis of one side of the body) of the right dominant side, aphasia (inability to speak) following stroke. Review of wound treatment orders obtained March 9, 2026, revealed the following wound care orders: Cleanse right ischium (hip area) with NSS (normal saline solution), pack with calcium alginate (a special type of dressing that absorbs excess fluid to keep the wound dry) and cover with CDD (clean dry dressing) once a day.Cleanse sacrum (tailbone) with NSS, pack with calcium alginate and cover with CDD once a day. Observation of wound care for Resident R12 was conducted on March 12, 2026, at 10:10 a.m. During the care that was provided by Registered nurse, Employee E12, the nurse performed hand hygiene and donned gloves before preparing the clean field. The resident was rolled onto her left side. After placing an absorbent pad under the resident's hip and buttocks, the nurse removed the soiled bandages from the wound on the ischium and the wound on the sacrum, as well as uncovering an area on the left inner thigh.Employee E12 then removed her soiled gloves and donned clean gloves without performing hand hygiene. The nurse cleansed all three wounds with normal saline without changing gloves or performing hand hygiene between wounds. Before cleaning the thigh wound with a saline soaked gauze pad, Employee E12 noticed a drip coming from the sacral wound. She used the saline soaked gauze to wipe up the drip before using the same gauze to cleanse the thigh wound. Alginate was applied to all three wounds which were then covered with adhesive bordered gauze. The clean dressings were applied with the same gloves that were used to clean the wounds. After the resident's wounds were dressed, Registered nurse, Employee E12 gathered the soiled dressings and other trash, wrapping them into the absorbent pad, which she then placed on the resident's bedside table. The soiled draw sheet was removed from the bed and placed on the resident's chair. A clean draw sheet was placed, and the resident was repositioned.Continued observation revealed Employee 12 washing hands and donning clean gloves, Employee E12 picked up the bundle of soiled material and placed it into a biohazard bag which she took to the soiled utility room to dispose of in the biohazard bin. An interview with the Director of Nursing (DON), Employee E2, on March 12, 2026, at 11:20 a.m. confirmed that the nurse had missed many indications for hand hygiene, including moving between wounds and in between dirty and clean wound care activities. DON further confirmed that the nurse should not have had all three wounds open at the same time. She stated that the wound to the inner thigh was excoriation, which should have been treated with a moisture barrier cream, not alginate and a dressing. Employee E2 confirmed that the nurse should not have place soiled materials on the resident's bedside table or her chair. 28 Pa Code 201.18(b)(1) Management28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of clinical records, observations, and interviews with staff, residents, and resident representatives it was determined that the facility failed to have available a thermometer to heat of food brought from home by a family member for one of 33 residents reviewed (Resident R162).Findings Include: Review of facility policy Food Brought in From Outside the Facility reviewed November 2024, revealed staff outside the dietary department will store and handle food in accordance with food safety standards when residents or their friends/family bring food into the facility. Further review of facility policy revealed if food needs to be reheated, reheat food in microwave so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit (F). After reheating the food, staff should take the temperature to confirmed food has reached an internal temperature of 165 degrees. Staff should allow food to cool to 130-155 degrees F when served to residents. Review of Resident R162's comprehensive care plan dated March 6, 2026, revealed the resident was at increased nutrition/hydration risk related to a diagnosis of severe protein-calorie malnutrition (insufficient intake of protein and calories, leading to muscle and fat loss and impaired bodily functions), and decreased food intake. Interventions dated March 4, 2026, included to respect/honor resident dietary choices and to provide assistance with meals as needed to encourage intake. Observations on March 11, 2026, at 11:45 a.m. revealed a resident family member was standing at the nurse's station and was visibly upset. Interview on March 11, 2026, at 11:45 a.m. with Licensed Nurse, Employee E10, revealed the family member was upset because he/she brought in food for Resident R162, but staff did not have a thermometer to reheat the food. Interview on March 11, 2026, at approximately 11:50 a.m. with Resident R162's family member revealed he/she brought in Resident R162's favorite homemade meal of spaghetti and meatballs to encourage meal intakes but the nurse, identified as Employee E13, refused to heat the food up. Interview on March 11, 2026, at approximately 11:50 a.m. with Resident R162 the resident expressed desire for spaghetti and meatballs, noting it was a favorite meal. Continued interview on March 11, 2026, at approximately 11:50 a.m. with Resident R162's family member revealed he/she had spoken with the Registered Dietitian earlier in the week who encouraged the family to bring in food items from home to encourage Resident R162's meal intakes and support nutrition status. Interview on March 11, 2026, at approximately 12:00 p.m. with Licensed Nurse, Employee E13, revealed Resident R162's food could not be reheated because a thermometer was unavailable and the kitchen was unable to heat up the food. Interview on March 11, 2026, at approximately 12:05 p.m. with Registered Dietitian, Employee E8, confirmed he/she encouraged Resident R162's family to bring in food from home. Further interview confirmed the nurse should have obtained/requested a thermometer to assist Resident R162 in consuming his/her meal from home. 28 Pa. Code 201.29 (a) Resident rights.

Based on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete dialysis records related to dialysis communication for two of two Dialysis-Residents reviewed (Residents R3 and R16).Findings include: Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident R3's physician order, dated August 14, 2024, revealed; Resident R3 received dialysis treatment at an outpatient dialysis facility on Tuesdays, Thursdays and Saturdays. The physician ordered a special instruction for the dialysis communication tool, to be completed. Review of Resident R3's Hemodialysis Communication Record named; Dialysis Communication Tool, revealed that on uncountable days, in the months of February 2026, January 2026, and December 2025, it was lacking the signature of the Dialysis Facility Nurse on the Part to be completed by the Dialysis Staff in the communication log. Review of Resident R16's clinical record revealed that resident R16 was diagnosed with of End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident R16's physician order, dated May 02, 2024, revealed; Resident R16 received dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays and Fridays. The physician ordered a special instruction for the dialysis communication tool, to be completed. Review of Resident R16's Hemodialysis Communication Record named; Dialysis Communication Tool, revealed that on uncountable days, in the months of February 2026, January 2026, and December 2025, it was lacking the signature of the Dialysis Facility Nurse on the Part to be completed by the Dialysis Staff in the communication log. Interview with the Director of Nursing, on March 12, 2026, at 11:14 a.m., confirmed incomplete Dialysis communication log of Residents R3, and R16. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(3) Nursing services

Based on review of facility records and interview with staff, it was determined that the facility failed to transmit the required initial comprehensive MDS assessment for one of 29 residents reviewed (Resident R153)Findings include:Review of MDS (Minimum Data Set- a periodic assessment of resident needs) transmission data for Resident R153 revealed an admission MDS was transmitted on October 28, 2025. A quarterly assessment was transmitted on February 28, 2026. An initial comprehensive assessment was not found to have been transmitted.An interview with Employee E1, the Nursing Home Administrator confirmed that no MDS assessment was transmitted between October 28, 2025, and February 28, 2026. 28 Pa. Code S 201.14(a) Responsibility of licensee

Based on observation, review of clinical documentation and interviews with staff, it was determined that the facility did not ensure physician orders were followed related to wound treatment for one of 29 residents reviewed (Resident R12). Findings include: Review of Resident R12's clinical record revealed that the resident was most recently readmitted to the facility on [DATE], with diagnoses of cerebral infarction (stroke caused by a blood clot or other obstruction in the brain), hemiplegia (paralysis of one side of the body) of the right dominant side, aphasia (inability to speak) following stroke. Review of March 2026 physician orders revealed wound treatment orders obtained March 9, 2026 toCleanse right ischium (hip area) with NSS (normal saline solution), pack with calcium alginate (a special type of dressing that absorbs excess fluid to keep the wound dry) and cover with CDD (clean dry dressing) once a day.and Cleanse sacrum (tailbone) with NSS, pack with calcium alginate and cover with CDD once a day. Observation of wound care for Resident R12 was conducted on March 12, 2026, at 10:10 a.m. During the care that was provided by Registered nurse, Employee E12, removed the soiled bandages from the wound on the ischium and the wound on the sacrum, as well as uncovering an area on the left inner thigh. The nurse cleansed all three wounds with normal saline. Alginate was applied to all three wounds which were then covered with adhesive bordered gauze. An interview with the Director of Nursing (DON), Employee E2, on March 12, 2026, at 11:20 a.m. confirmed that the wound to the inner thigh was excoriation, which should have been treated with a moisture barrier cream, and that the resident did not have an order for alginate and dressing for the thigh wound. 28 Pa Code 201.18(b)(1) Management28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical record, and review of facility policy, it was determined that facility did not ensure that residents received treatment in accordance with professional standards of practice related to medication administration for one of one residents reviewed (Resident R16)Findings include:Review of facility policy 'General Dose Preparation and Medication Administration,' revised November 15, 2024, indicates that prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.Review of Resident R16's audit electronic medication administration record (e-MAR), revealed artificial tears drops are scheduled to be administered at 8:00 a.m. and were administered at 12:34 p.m. on October 1, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 4:00 pm but not administered until 6:28 pm on October 1, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 8:00 pm but were not administered until 9:59 pm on October 1, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 4:00 pm but were not administered until 6:56 pm on October 2, 2025.Further review of e-MAR indicates artificial eye drops were scheduled to be administered at 8:00 pm but were not administered until 10:08 pm on October 2, 2025.Further review of e-MAR indicates Biotene dry mouth oral rinse is to be administered three times a day; Oral rinse was scheduled to be administered at 9:00 am on October 1, 2025 but was not administered until 12:35 pm.Further review of e-MAR indicated Escitalopram oxalate tablet, 20 mg, was scheduled to be administered at 9:00 am but were not administered unitl12:35 pm on October 1, 2025.Further review of e-MAR indicates Levothyroxine, 25 mcg, was to be administered at 6:00 am, with no indication that it was administered on October 2, 2025 and October 3, 2025. Further review of e-MAR indicates that Pregabalin schedule V capsule, 100 mg, is to be administer at 9:00 am but was administered until 12:37 pm on October 1, 2025.Further review of e-MAR indicates Restasis (cyclosporine) Dropperette; 0.5% - eye drops are to be administered at 9:00 am but were not administered until 12:37 pm on October 1, 2025.Further review of e-MAR indicates Restasis (cyclosporine) Dropperette; 0.5% - eye drops are to be administered at 8:00 pm but were not administered until 9:59 pm on October 1, 2025.Further review of e-MAR, revealed Ziprasidone HCL capsule, 20 mg, was to be administered at 9:00 am but was not administered until 12:37 pm on October 1, 2025.28 Pa Code 211.10(c ) Resident care policies28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of facility policies, clinical record reviews, and interviews with residents and staff, it was determined that the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests and physical, mental and psychosocial well-being on two of two nursing units. (1st and 2nd Floor) Findings include Review of facility policy titled Life Enrichment Programming Policy last revised May 4, 2023 revealed that it is the facilities policy to maintain an ongoing resident centered life enrichment program based on comprehensive assessments and care plans. The program will be designed to meet the interest including hobbies and preferences, and the abilities of each resident including their physical common mental, emotional, social, spiritual, psychosocial and leisure needs. This life enrichment (activities) program will create opportunities for each resident to have a meaningful life by supporting his or her domains of wellness. The life enrichment director will involve residents in all aspects of programming delivery planning preparation implementation cleanup evaluation, incorporating the residents expressed interest and preferences. Programs offered will reflect the spiritual and cultural diversity of all residents' programs will be designed to appeal to both genders as well as all age groups of residents residing in the community programs will be scheduled and offered 7 days a week including evening and weekend programs. Review of facility document life enrichment director job description revealed the primary purpose of this job is to enhance resident wellness and the quality of life through planning, organizing, developing, implementing and directing the overall life enrichment program and operation of the department in accordance with current federal, state and local standards, guidelines and regulations and established policies and procedures. Essential functions of this position are planned, develop, organize, implement, evaluate, supervise, and direct the life enrichment program of the community including providing adaptive life enrichment programs techniques equipment and materials as related to each resident specific needs. Review of facility activities calendar, the scheduled activities for April 8, 2025, include: morning greeting at 09:00a.m. follow by Daily chronicles at 10:00a.m. Brain Games at 11:00 a.m., Room visits at 1:00p.m., Taco Tuesday at 2:00p.m., and Fresh air break at 3:00 p.m. Review of facility calendar scheduled activities for April 9, 2025, morning greeting at 9:00 a.m., daily chronical at 10:00 a.m., [NAME] fitness at 11:00 a.m., room visits at 1:00 p.m., quarter bingo at 2:00 p.m., and fresh air brake at 3:00p.m. Review of facility calendar scheduled activities for April 10, 2025, revealed at morning greeting at 9:00 a.m., daily chronical at 10:00 a.m., room visits at 1:00 p.m., sunshine ministry at 2:00 p.m., and fresh air brake at 3:00 p.m. Further review of the facility April 2025 Activities Calendar revealed that daily chronicles, greeting, room visits and fresh air brake are offered daily with bingo repeated on ten days, activities of dining (taco Tuesday and ice cream social) offered every Tuesday. Review of grievances from December 2024 the resident wanted to be included in activities. The result of this concern was resident was educated on the services and activities of the facility Interview with Resident R9 on April 9, 2025, at 12: 22 p.m. revealed the resident stated there are never any activities, only bingo, I don't like bingo. We have never been out of the facility on an activity, and never are allowed outside. Interview with Resident R84 on April 9 , 2025, at 12:25 p.m., confirmed her roommate allegation that there are never any activities, and stated the calendar is incorrect, the activities listed are never actually happening. Interview with Resident R8 on April 9, at 12:40 p.m. revealed that the facility has not asked what she would like to do and does not have any activities of interest. This resident does not like bingo and the only activity offered is bingo. The activities listed are never actually happening. Resident R8 would really enjoy activities if they were offered and provided. Interview with Resident R502 on April 10, 2025, at 9:20 a.m. revealed there are no activities. There is nothing to do in the facility. No one has ever come in the room to provide any activities or ask of any activities Interview with Resident R132 on April 10, 2025, at 9:20a.m. revealed no one has come to the room except nurses. Interview with Resident R501 on April 10, 2025, at 09:20a.m. revealed no activities that are of interest to this resident, no one has come in to discuss any activities or hobbies or any books or games. Interview with Resident R499 on April 10, 2025 at 9:20 a.m. revealed resident does not leave the room, there has been no one from the activities department to see him and or provide him with any activity or one to one time and conversation. Observation of activity Taco Tuesday on April 8, 2025, at 02:02 p.m. in the facility main dining room, ten resident were all seated side by side facing forward toward the front of the room where an employee was preparing the tacos. Residents were the served by Life Enrichment Assistant, Employee E10. The only activity observed were residents watching Employee E10 plate tacos and residents eating. Which is not providing the interests and physical, mental and psychosocial well-being of the residents. Observation on April 9, 2025, at 11:07 a.m. on the second-floor dining/ activity room where the activity [NAME] fitness was scheduled, four residents were observed seated at a table, one resident coloring in a coloring book, the other three residents observed just sitting at the table along with the Life Enrichment Assistant, Employee E14. The residents were seen not performing any activity specifically not exercising. Interview with Life Enrichment Assistant, Employee E14 at time of the above observation, stated that [NAME] was finished, this activity was held when she arrived at work that morning. Observation of First floor nursing units A and B on April 9, 2025, at 1:00 p.m. through 1:25 p.m. revealed that there was no activity staff observed on the floor. According to the facility activity calendar, the activity room visits were scheduled. Continued observation on April 9, 2025, at 1:25 p.m. of the first-floor nursing units A and B revealed Life Enrichment Assistant, Employee E10 propelling a cart filled with snacks down the corridor. Interview with Life Enrichment Assistant, Employee E10 at time of the above observation revealed that as her life enrichment task, she offers the residents and employees the opportunity to purchases snacks. Employee E 10 confirmed that this is included as room visits for resident activity. Observation on April 10, 2025, at 9:00a.m. through 09:30 a.m. of First floor nursing units A and B revealed no activity staff observed on the floor. According to the facility activity calendar, the activity Morning Greeting was scheduled to take place at this time. Observation on April 10, 2025, at 9:40 a.m. revealed Life Enrichment Assistant Employee E10 supervising residents smoking at designated outside area. Interview with Life Enrichment Assistant, Employee E10 at the time of above observation revealed that Employee E10 was responsible for the first-floor unit A activity of greetings. Employee E10 confirmed that she had not conducted that activity as of this time. Asked what the activity greetings entailed, Employee E10 stated I go to all the resident on the unit and just check in with them, tell them about the day events, sometimes plays cards or does manicures Interview with Director of Life Enrichment, Employee E4 April 9, 2025, at 2:00 p.m. this employee stated that she speaks with the residents and attends resident meeting, the only activity she is aware of the residents request is bingo which has been added for additional days. A lot of the resident don't want to leave their room or participate in activities. This employee stated that the residents go outside and those on the second flood really enjoy the parachute game. Employee is not sure why there was a discrepancy of the timing of observed activities or does not know of any complaints of activities. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10 (d) Resident care policies

Based on interviews, review of clinical records, and the review of facility documentation and policy, it was determined that the facility did not ensure residents were free from verbal abuse for one of 28 resident records reviewed (Resident R46). Finding includes: Review of the facility's policy titled Abuse, Neglect and Exploitation revised on July 11, 2024, states that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents. The same policy defines verbal abuse as a use of oral language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance , regardless of their age, ability comprehend, or disability. Resident R46 was last admitted to the facility on [DATE], diagnosed with high blood pressure chronic kidney disease, type II diabetes, dementia with other behavioral disturbance, cognitive communication deficit, history of transient ischemic attack (TIA- cerebral infarction) without residual deficits, delusional disorder, unspecified psychosis not due to a substance or known physiological condition. Review of a facility's reported incident dated, February 21, 2025, revealed Resident R46 was overheard to keep his f*cking' tongue in his mouth from a staff member, Nursing Assistant (NA), Employee E6. Interview with Unit Manger Employee E5 on April 8, 2025, at 1:30 p.m. stated it was the resident's family member (RP) that overheard the NA say that to the resident. Review of the facility documentation revealed that the facility concluded the incident of verbal abuse verbal abuse and Employee E6 was terminated. 28 Pa Code 201.29(a)(c) Resident rights 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and documentation, clinical record review, interview with staff, and observations, it was determined that the facility failed to ensure that a licensed nurse maintained professional standards of quality of care for one of four residents reviewed. This failure resulted in delay of medical treatment relating to one resident not receiving medications timely. (Resident R 41) Findings include: Review of facility document titled General Dose Preparation and Medication Administration revised April 4, 2024, revealed that prior to medication administration , the facility staff should take all measures required by the facility policy and applicable law, including but not limited to verifying each time a medication is administered and that it is the correct medication, correct dose correct route at the correct rate, at the correct time and for the correct resident. Further review of this policy states that medication must be administered within timeframes specified by the facility policy or manufacturers information. Review of facility policy titled Administering medications revised January 18, 2025, revealed that medications shall be administered in a safe and timely manner and in accordance with the physician order. Review of Resident R41's medication orders revealed orders for the following medication to be administered at 9:00 a.m.: Allopurinol 100 milligrams (mg) once a day, Amlodipine 10 mg, Cholecalciferol, Dorzolamide, Metoprolol 100 mg and Metoprolol 50 mg. Observation of Licensed nurse, Employee E15 on the first-floor nursing unit B on April 9, 2025 at 10:50 am, two hours after scheduled medication administration revealed Employee E15 appeared to be viewing a video playing on the facility computer on the med cart. Interview with Licensed nurse, Employee E15 at time of this observation, confirmed that she was watching the video on the computer, stating just catching up with Relias training (continuing education, compliance training for healthcare professionals). Asked if she was conducting medication pass, Employee E15 stated yes. Employee E15 shut off the playing of the video and then began preparation of medication to administer to Resident R 41. Employee 15 confirmed that the medications that she was preparing were Resident R41's morning medications which were due two hours prior. Employee E 15 stated she still had a few more residents to give medications to. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy, review of clinical records, resident and staff interview and observation, it was determined that the facility failed to provide an environment that is free from accident and hazards relating to adequate supervision and smoking safety. Findings include: Review of facility policy titled resident smoking policy last revised December 20, 2022 revealed facility has established residents smoking processes that take into account both smoking and non-smoking residents and that comply with applicable federal, state and local laws and regulations regarding smoking areas and smoking safety. Review of facility policy reveal resident who smoke will be required to sign a safe smoking and agree to abide by the rule regarding safe smoking or they will forfeit the privilege. Residents may only smoke on designate locations. Required supervision will smoke only at designated times independent smokers may smoke at any time but must sign out. Residents who smoke or desire to smoke will be required to sign a safe smoking contract and agree to abide by the rules regarding safe smoking or they will forfeit their smoking privileges residents may only smoke on premise in designated locations. Those requiring supervision will only smoke at designated times. Review of resident safe smoking agreement revealed rules and regulations including residents required supervision may smoke only a designated times and then designate locations when on facility grounds. Review of facility documented resident smoking list revealed resident R131, R14, R132, R51, R15, R88, R139, R19, R6, R66, R81 Review Residents' R131, R14, R51, R15, R88, R19, R66, R81 care plan revealed the following interventions: Educate as to the benefits of quitting and the risks associated with smoking, smoking items to be kept at nurse's station or per specific routine. Provide supervision at times of smoking, and smoking apron to be worn when smoking. Observation on April 8, 2025 at 2:00 p.m. revealed the facility main dining room first floor the designated smoking was viewed. Observation of five resident outside smoking, there was no staff member outside supervising the smoking activity . Interview with Life Enrichment Director, Employee E4 at the time of the observation revealed that some of the employees did not like to go outside so they watch from the window. Interview with Resident R14 at time of the observation revealed that they never have staff outside, they do not need a babysitter. Observation April 10, 2025 at 9:40 a.m. of the facility designated smoking area revealed 7 residents outside smoking and no staff present with these residents who were smoking. 28 Pa. Code 201.18 (b)(1)(e) Management 28 Pa. Code 211.12 (d)( 1)(5) Nursing services

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for one of five residents reviewed (Resident R63). Findings Include: Review of facility policy on Medication Regimen Review (MRR) Section Procedure, #9 revealed that the facility should encourage the physician/provider or other responsible parties receiving the MRR (Medical Record) and the Director of Nursing to act upon the recommendations contained within the MRR. #9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MMR and provide an explanation as to why the recommendation was rejected. #9.2 The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what if any action is taken to address it. #9.2.2 If the attending physician prescriber decided to make no change in the medication, the attending physician document the rationale in the resident's health record. Review of Pharmacy Consultation Report for Resident R63 with recommendation date of December 17, 2024, revealed that under section comment: Resident R63 has received Eszopiclone 2 milligrams at bedtime for insomnia since 5/2024. Under section Recommendation: Please consider if a gradual dose reduction could be attempted at this time. Further review f the Pharmacy Consultation Report revealed an illegible undated, initial on the report. Further the word decline was written below the undated signature. Further review of the Pharmacy Consultation Report revealed no documented evidence that the pharmacist's recommendation has been reviewed by the physician. Further there was no documented evidence of any, action taken by the physician to address the recommendation including rationale if there is to be no change in the medication. Interview with DON (Director of Nursing) Employee E2 conducted on April 10, 2025, at 11:19AM confirmed that the Pharmacy Consultation Report for Resident R63 with recommendation date of December 17, 2024, had an undated initial, did not have documented evidence that the pharmacist's recommendation has been reviewed by the physician. Further Employee E2 also confirmed that there was no documented evidence of any, action taken by the physician to address the recommendation including rationale if there is to be no change in the medication. Review of Pharmacy Consultation Report for Resident R63 with recommendation date of February 18, 2024, revealed that under section comment: Resident R63 has received Cyclobenzaprine5 mg three times daily since 10/1/2024 and may be at risk for or experiencing adverse effects related to the anticholinergic properties of this medication. Under section Recommendation: Please reevaluate ongoing use of Cyclobenzaprine and consider if dosing reductions could be attempted. Under section physician's response, the section for I decline the recommendation above and do not wish to implement any changes due to the reasons below was checked off however section Rationale was not filled out. There was no rationale documented in the resident's clinical record. Interview with DON Employee E2 conducted on April 10, 2025, at 11:19AM confirmed that the Pharmacy Consultation Report for Resident R63 with recommendation date of February 18, 2025, had a pharmacy recommendation to reevaluate ongoing use of Cyclobenzaprine and consider if dosing reductions could be attempted and there was no documented rationale for the declination of the pharmacy recommendation. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.12 (d)(5) Nursing Services.

Based on review of clinical records, facility policy and interviews with staff, it was determined that the facility failed to ensure that a follow- up appointment was scheduled with an urologist for a resident with an an indwelling urinary catheter for one of 28 resident records reviewed (Resident R121). Findings include: Review of the facility's policy titled, Continence Management Program revised on June 7, 2023, states the facility will provide services to restore or improve normal bladder function. Resident R121 was admitted to the facility on [DATE], diagnosed with benign prostate hyperplasia with lower urinary tract symptoms (an enlarge prostate gland that can cause various urinary problems). Review of Resident R121's nursing note dated December 14, 2024 stated Resident R121 failed to urinate for eight hours on the 7-3 shift. The nurse assessed the resident's abdomen noting it was distended and painful when palpated. The nurse received orders to straight catherize Resident R121 (to manually insert a tube to the bladder for voiding). No urine was produced and the resident was sent to the hospital diagnosed with urinary retention, a urinary tract infection and a catheter was inserted for voiding. Review of Resident R121 documentation revealed a urinary consults with the urologist dated January 17, 2025 reminding of an upcoming appointment on January 28, 2025 for a cystoscopy (using a small telescope to look at the bladder). Additional visits to the urologist were made until the last appointment, dated February 19, 2025 that indicated to refer to the doctor for discussion of two treatment options. Continue review of Resident R121's clinical record did not reveal this appointment was scheduled. Unit Manager, Employee E5 confirmed the facility failed to follow-up with Resident R121 regarding the resident's treatment options for the indwelling urinary catheter. 28 Pa. Code 201. 18(b)(1) Management. 28 Pa code:211.10(c)(d) Resident care policies.

Based on observations, interviews with resident and staff and review of clinical records and facility policy, it was determined the facility did not ensure a baseline care plan was developed with interventions to prevent pressure injury or trauma for one resident diagnosed with diabetes of 28 residents reviewed. (Resident R86) Findings include: Review of the facility's policy for Comprehensive Care Planning revised March 2025 states, The facility will develop a comprehensive person centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy further states that a baseline care plan will be developed within the first 48 hours of admission to ensure the residents needs are met until the comprehensive care plan is completed. Review of Resident R86's Admission Minimum Data Set (MDS- is a standardized assessment tool used to evaluate resident functional status, cognitive abilities, and health conditions to develop care plans for the residents' needs) dated February 26, 2025, assessed the resident as cognitively impaired with fluctuating inattention, and disorganized thinking, bilateral lower extremity impairment, used a wheelchair to ambulate, incontinent of bowl and bladder, depended on staff for toileting and maintaining toileting hygiene, needed substantial assistants for hygiene (able to do less than half the effort), and needed partial or moderate assistance with bed mobility. Resident R86's MDS included diagnoses of a progressive neurological condition, high blood pressure, diabetes mellitus, cerebrovascular accident (CVA, stroke) dementia, malnutrition, Parkinson disease, and Psychotic disorder. The resident's MDS revealed a weight loss of 5% or more in the past month (Nutritional assessment on admitted d February 26, 2025 noted a significant weight loss of 8.5% in the past month, related to the resident not receiving any nutrition for four or more days in the hospital due to a bowel obstruction). The resident's MDS using Braden (a formal assessment tool) and clinical assessment indicated Resident R86's was at risk for developing a pressure ulcer noting no unstageable or unhealed pressure ulcer was found during the assessment. The MDS indicated the skin and ulcer treatments were in place, that include a pressure reducing device for chair and bed, noting there was no turning/repositioning program in place nor any application of dressings to feet were implemented at the time of admission. Continue review of the MDS revealed that the resident was assessed at risk for pressure ulcers. The MDS assessment indicated this care need was addressed in Resident R86's care plan. Further review of Resident R86's clinical record did not reveal a care plan for pressure ulcers nor was a care plan developed for the resident's risk of developing an open area to the skin, or heels, by injury, pressure and/or ulcer due to the resident's diagnosis of uncontrolled diabetes, decreased bed mobility, and substantial weight loss. 28 Pa Code 211.10(a) Resident care policies 28 Pa Code 211.10(c) Resident care policies

Based on review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to timely provide assistance with incontinence care for one of 35 residents reviewed (Resident R9). Findings Include: Review of Resident R9's clinical record revealed a quarterly Minimum Data Set Assessment (MDS - federally mandated resident assessment and care screening) dated February 28, 2025, that indicated the resident was able to make her needs known, cognitively intact, and had diagnoses of anxiety, depression, and muscle weakness. Further review of Resident R9's MDS dated [DATE], revealed the resident was always urinary/bowel incontinent (loss of bowel and bladder control) and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). Interview on April 8, 2025, at 10:33 a.m. with Resident R9 revealed the resident had a bowel movement after breakfast and was waiting to be assisted with incontinence care. Resident R9 reported staff had been informed multiple times. Interview on April 8, 2025, at 10:36 a.m. with Resident R9's assigned nurse, Employee E7, revealed this nurse was aware Resident R9 was waiting to be assisted with incontinence care. Licensed Nurse, Employee E7, indicated Resident R9 informed the employee not that long ago and that Resident R9's nurse aide was informed and would be in when done helping a different resident. Interview on April 8, 2025, at 11:01 a.m. with Licensed Nurse, Employee E7, revealed the nurse just got done providing incontinence care for Resident R9 because the nurse aide was still assisting other residents. Observations on April 10, 2025, at 11:15 a.m. revealed the call light for Resident R9's room was engaged. Subsequent interview on April 10, 2025, at 11:15 a.m. with Resident R9 revealed the resident had a bowel movement and was in need of incontinece care. Observations on April 10, 2025, at 11:23 a.m. revealed Resident R9's call bell was off. Interview on April 10, 2025, at 11:23 a.m. with Resident R9 revealed a nurse aide came in and turned off the call bell and told the resident she would be back after done assisting another resident. Observations on April 10, 2025, at 11:48 a.m. revealed Resident R9's call bell was still turned off. Interview on April 10, 2025, at 11:48 a.m. with Resident R9 revealed the resident was still waiting for incontinence care. Observations on April 10, 2025, revealed the nurse aide did not provide incontinence care to Resident R9 until 11:50 a.m. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation, interviews with resident and staff, review of clinical records, and facility documentation, it was determined the facility failed to implement interventions to prevent the development of diabetic wound. This failure placed Resident R86 at risk for developing a diabetic wound to the right heel, requiring debridement and antibiotic therapy for one of 28 clinical records reviewed (Resident R86). Finding includes: Review of Resident R86's admission Minimum Data Set (MDS- standardized assessment tool used to evaluate resident functional status, cognitive abilities, and health conditions) dated February 26, 2025, revealed the resident was assessed as cognitively impaired with fluctuating inattention, and disorganized thinking. Continued review of the MDS revealed the resident had bilateral lower extremity impairment, and used a wheelchair to ambulate. Resident R86 needed substantial assistant for hygiene (able to do less than half the effort) and needed partial or moderate assistance with bed mobility. Review of Resident R86's MDS assessment included diagnoses of a progressive neurological condition, Diabetes Mellitus (failure of the body to produce insulin), Cerebral Vascular Accident (stroke), Dementia (progressive degenerative disease of the brain), malnutrition, and Parkinson Disease (progressive disease of the central nervous system). Review of Resident R86's nursing note dated March 24, 2025, revealed a discoloration to Resident R86's right heel, was identified and the resident was to use multi-podus boots (device use to float the heels) to bilateral feet to relieve pressure on the heels. Review of the facility's documentation dated March 24, 2025 revealed the discolored area found on the resident's right heel, included witness statements from nursing staff indicating the resident was observed pressing his/her foot against the foot board, also the resident confirmed to the staff he/she had been doing so. Review of Resident R86's March 2025 physician orders revealed a physician's ordered initiated March 25, 2025, to apply multipodus boot to bilateral feet when in bed. Review of Resident R86's current care plan failed to reveal a care plan for the risk of developing diabetic ulcers to the lower extremities due to the resident's diagnosis of diabetes and decreased bed mobility. Review of Resident R86's initial wound note by a wound physician dated March 27, 2025, revealed the right heel etiology was from the resident's diagnosis of diabetes. The measurements of the wound was 5.x 2.5 cm (unable to determine the depth). Further review of same wound note revealed Resident R86 has a chronic wound which may or may not heal and could worsen due to resident's restricted mobility, thinning skin, reoccurring trauma, non-compliance. Continued review of same wound note revealed an overall prognosis determined to be fair and the overall goal for the wound is prevention of wound decline, offloading heels, and to turn the resident per facility protocol. Review of Resident R86's wound physician note dated April 3, 2025, revealed risk factors of diabetes, limited mobility, poor nutritional intake, and dementia and indicated the resident was at risk for developing pressure ulcers due to those risk factors. Interview conducted with Licensed nurse, Employee E5 on April 10, 2025, at 12:00 p.m. revealed the resident developed a pressure injury from his/her feet hitting the footboard and the need for wearing multi-podus boots in bed. Review of Resident R86's surgical note from wound physician dated April 10, 2025, revealed assessment and plans indicated Resident R86 has a wound on the right heel. The wound debrided today was at the right heel wound there was indication of tissue deterioration requiring ongoing administration and may very well need future debridement. No guarantee for wound healing can be made given the patients' risk factors/diagnoses that alter the state of this wound. The patient is also at risk for the development of a pressure injury as a result of the following risk factors of, poor nutritional intake, dementia, diabetes and limited mobility. The same assessment stated the resident has a chronic wound which may not heel and may worsen because of chronic comorbidities, thinning skin, recurring trauma, restricted mobility, noncompliance, maceration of wound edges and peripheral arterial disease resulting in poor tissue perfusion possible further tissue breakdown. Observation conducted on April 10, 2025, at 12:10 p.m. with Licensed Nurse, Employee E4, revealed Resident R86 laying in bed, barefoot with his feet crossed at the ankles. The resident was not wearing multi-podus boots. Resident R86 stated, I don't wear the boots (multi-podus boots). I bang my feet against the footboard because I slide down from the bed and my feet keep hitting the footboard. Nurse, E4 stated, I see (him/her) slide down from the bed and it causes (him/her) to press (his/her) feet against the footboard. It's the reason why (he/she) has the wound. Resident R86 complained it was painful when the nurse removed the dressing. The wound was covered in a medicated dressing that had purulent drainage (thick, opaque, greenish - brown drainage). Interview conducted with the wound doctor on April 10, 2025, at 2:30 p.m. revealed, the wound was debrided today and he placed the resident on antibiotics because the wound is now infected. The physician stated that it may have started as a diabetic wound but now, from the pressure of [his/her] feet without using proper footwear it has become worse. I spoke to the staff I could not stress enough how important proper footwear is and explained bending [his/her] knees propped with a pillow would prevent the resident from sliding and causing the pressure. Review of nursing note dated April 10, 2025 revealed the resident was ordered Keflex 500 milligrams twice a day for 10 days for right heel wound infection. 28 Pa. Code: 201.14(a) Responsibility of licensee 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) Nursing services 28 Pa. Code: 211.12 (d)(2) Nursing services 28 Pa. Code: 211.12 (d)(5) Nursing services

Based on a review of clinical records, review of facility documentation, review of facility policy, review of hospital records and interviews with staff, it was determined that the facility failed to assess resident's pain and timely obtain pain medication for adequate pain management for one of 28 residents reviewed. This failure resulted in actual harm to Resident R381 whose pain to the left foot was not properly relieved and managed and continued to experience uncontrolled pain. (Resident R381). Findings include: Review of the facility's policy for Emergency Medication Supplies (Emergency kit) revised December 2023 stated the pharmacy may provide the facility with Emergency Medication. Emergency medications shall be accessed by authorized facility staff when a medication is medically necessary to be administered before the next scheduled pharmacy delivery and for New Admissions. Review of the facility's pain management policy revised August 2024 stated the policy of this community to ensure any resident admitted to the facility is assessed for pain and/or potential for pain. A pain evaluation will occur on admission and with a significant change in condition. The evaluation will include active pain, including the type, intensity, characteristics, and frequencies, what pharmacological interventions used in the past to address the pain and the efficacy of such interventions, including use of opioids and any history of opioid use .Using the numeric pain rating scale (an 11-point scale where 0 indicates no pain and 10 indicates the worst pain imaginable) when evaluating the presence of pain. Further review of the facility's pain policy indicates, when the pharmacological interventions are needed the effect of the medication will be documented, and The physician will be notified of new onset of pain or a significant increase in pain as appropriate. Review of Resident R381's clinical records revealed the resident was admitted to the hospital on October 5, 2024, when emergency services found (him/her) outside screaming in pain, due to a chronic ulcer wound on (his/her) right ankle. Review of the hospital's physical therapy note, dated October 11, 2024, noted the resident complained of pain, with contractures in multiple joints and limited range of motion in (resident) hips and knees with chronic right ankle deformity. Therapy notes stated the resident remained in (his/her) wheelchair 24/7 without transferring for toileting or sleeping and was unable to lay flat on (his/her) back. Review of admission documentation revealed that Resident R381 was admitted to the facility on [DATE]. Resident R381 was admitted to the facility with the diagnoses of an unspecified open wound, left ankle sequela (any complication or condition as a result of a previous disease or injury), chronic leg pain, Peripheral Vascular Disease (poor circulation of the extremities) and Cellulitis (potentially serious bacterial infection that effects the deeper layers of the skin). Review of hospital medication orders revealed that the resident was ordered pain medication Oxycodone IR (immediate release) 5 milligrams by mouth every 6 hours. Review of admission progress note dated October 12, 2024, at 2:17 a.m. Licensed Practical Nurse (LPN) Employee E9 revealed Received resident sitting on the side of the bed complaining of pain. APAP (Acetaminophen) 975 MG (milligrams) was offered to resident and (he/she) refused stating (resident) wants (his/her) oxycodone. This writer then informed resident that its not available this second take tylenol until we're able to obtain it, resident still refused APAP. Review of Resident R381's October 2024 Medication Administration Record (MAR) revealed that the resident was ordered on October 11, 2024, Acetaminophen 325 milligrams two tablets by mouth every 4 hours as needed for headache/pain. The resident was administered the medication on October 11, 2024, at 8:12 a.m. for a pain level of 9 on his/her right knee and left ankle. Continued review of the MAR revealed that this was the only occasion Acetaminophen 325 milligrams was administered to the resident. There was no documented evidence that the resident's pain level was assessed on October 11, 2024, during the evening and night shifts. The next time the resident was medicated for pain was October 12, 2024, that an order was obtained for Oxycodone 5 milligrams one tablet by mouth every 6 hours for severe pain over 7/10 (pain severely scale of 0-10). The resident was administered Oxycodone 5 milligrams on October 12, 2024, at 9:55 a.m. for a pain level of 9. Continued review of nursing notes dated October 12, 2024, at 1:15 p.m. revealed that the resident was requesting as needed Oxycodone. Licensed nurse, Employee E9 explained again that its every 6 hours and it has only been 3 hours. Resident was offered APAP (Acetaminophen) in which he refused. The resident began to demand to see the supervisor and DON saying its every 4 hours. Supervisor explained to resident it's every 6 hours and that it's too soon to administer. Continued review of Resident R381's clinical record revealed, approximately an hour after receiving the first dose of Oxycodone, a note written by physical therapist at 10:59 a.m. stated the resident, Perseverates on LLE (left lower extremity) pain and states (he/her) is in 10/10 pain; nursing is aware and reports patient received pain meds this AM . Pt continues to refuse any further mobility and states, 'The only therapy I want to do is jump out the window and hopefully slit my carotid on the way, when pressed regarding statement pt reports [Resident] is in a lot of pain at this time. Nursing supervisor and charge nurse made aware of patient's statements and behaviors. When the resident expressed to the therapist, (Resident) was in a severe pain there was no evidence the physician was notified. Instead of acknowledging the resident's pain, a late note written by the supervisor, dated October 12, 2024, documented that the therapist reported the resident with suicidal ideation and was immediately placed on a 1:1 supervision, and further stated After that, resident did not report suicidal ideation. Continued review of the clinical record revealed the resident was Placed on 1:1 for suicidal ideation related to pain management. The LPN, Employee E9 witness statement indicated, 'The supervisor and the Director of Nursing asked the resident to stay and 'Wait for pharmacy to deliver (his/her) meds.' During interview with the Director of Nursing (DON) on October 31, 2024, at 2 p.m. the DON was asked why the medication wasn't available. In addition, the delay obtaining an authorization code, and why the emergency medication was not utilized sooner. The DON was also interviewed as to no evidence that the resident's physician was notified regarding the resident's pain. The DON had no response for not calling the physician nor waiting for the authorization number but did reply it was the weekend and staff did not want to bother the physician. The facility failed to ensure that Resident's left foot pain was managed resulting in actual harm to Resident R381 who continued to experience uncontrolled pain. 28 Pa. Code 211.2 (d)(9)(10) Medical director 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on a review of established guidelines for cardiopulmonary resuscitation (CPR), review of facility's policies, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy for one of eleven residents reviewed (Resident 207), creating a situation in which the residents were placed in Immediate Jeopardy related to failure to perform cardiopulmonary resuscitation immediately. (Resident 207) Findings include: Review of guidelines from the American Heart Association (AHA), dated 2020, revealed, the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR), revision date [DATE], stated that CPR will be provided to all residents/patients who experience cardiopulmonary arrest unless one or more of the following is present: A valid Advance Directive or POLST/MOLST/POST/MOST requesting withholding of CPR. A properly executed and witnessed Do Not Resuscitate (DNR) order. Documented verbal wishes by the resident/surrogate decision maker indicating the desire to be DNR but physician order is pending. Dependent lividity, rigor mortis, decapitation, or transection. Review of Inservice sheet dated February 28, 2024, revealed Objective if resident is found pulseless or without respirations, do not leave the resident alone, call out for help if necessary, instruct someone to call 911, and start CPR. Use an AED as soon as possible if one is available. If no AED is available, continue compressions and breaths for 2 Minutes then recheck pulse until EMS arrives. Review of Resident R1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses of type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar). Review of Resident R1's clinical record revealed a February 2, 2024, physician's order for Full Code, indicating Resident R1's intention to have FULL treatment which includes attempt resuscitation, CPR. Review of facility documentation submitted to the State Agency on February 17, 2024, revealed that Resident R1 was found unresponsive when Licensed nurse, Employee E6, walked into the resident's room to obtain a blood sugar. Employee E6 went and checked the code status and looked in the computer under the first name and looked at the incorrect resident whose was coded as Do not Resuscitate. Employee informed the Nursing Supervisor (RNS), Employee E30, that the code status of Resident R1 was DNR. The Acting DON (Director of Nursing), Employee E3, was informed by Employee E30. The Acting DON, Employee E3 reported to the PA (Physician Assistant) Employee E7, that Resident R1 was unresponsive and was a DNR. The PA, Employee E7 reported to the Acting DON that resident R1 was a Full Code. At that time the Acting DON called a code, CPR was initiated and 911 (Emergency Medical Services) was called. The paramedics took over CPR and were able to obtain a pulse and transported the resident to the hospital. Interview with Licensed nurse, Employee E6, on February 28, 2024, at 12:05 p.m. confirmed that she was on duty on February 14, 2024, when she found Resident R1 unresponsive. She also confirmed that she had looked up the wrong resident in the computer using a first name because she could not remember Resident R1's last name at the time. Employee E6 also confirmed that she left the resident's room to use the computer and to get the supervisor (RNS), Employee E30, and that she told him that Resident R1 was a DNR. Employee E6 said that the RNS assessed the resident who was still unresponsive, and that it was later that the PA (Employee E7) said that Resident R1 was a full code, and then they started CPR. The Acting DON called 911 and did the paperwork. Employee E6 could not confirm the timing, stating that everything happened so fast, and that if she knew the resident was a Full Code she would have started CPR immediately. Telephone interview with Nurse aide, Employee E31, on February 28, 2024, at 5:50 p.m. confirmed that she was on duty on February 14, 2024, when Licensed nurse, Employee E6, reported to her that Resident R1 was unresponsive. She stated that she was in Resident R1's room giving care to Resident R1's roommate when Licensed nurse, Employee E6 made this report. Nurse aide, Employee E31 also stated that the Licensed nurse, Employee E6, asked her to provide after care to Resident R1. Employee E31 further stated that the Licensed Nurse, Employee E6 removed Resident R1's Foley (indwelling urinary) catheter, and Employee E31 said she cleaned the resident up and changed her gown to make her presentable to the family if they came to view the resident's body. Employee E31 stated that it was about 15 minutes from the time she was told that Resident R1 was unresponsive and when the code was called, and CPR was started. She said she remembered this because after the incident someone had asked this question and appeared upset when she said 15 minutes, she did not recall who this was. She said that she remained in the room to help with the code until the paramedics arrived. Telephone interview with Employee E30, RNS, on February 28, 2024, at 5:40 p.m. confirmed that he was the supervisor on duty on February 14, 2024, when Resident R1 was found unresponsive by Employee E6, and that Employee E6 had reported to him that the resident was a DNR, and that he called the Acting DON before he went to Resident R1's room to assess her. He said it was a short while later that the Acting DON and PA came to the floor to report that Resident R1 was a Full Code, and that the Acting DON had called a code and they began CPR. Interview on February 28, 2024, at 11:05 a.m. with Employee E3, ADON, who was Acting DON on February 14, 2024, confirmed that she was on duty when Employee E30, RNS called her about Resident R1 being unresponsive and that she was a DNR. She stated that she saw the PA, Employee E7, and told her about Resident R1 being unresponsive and a DNR, and that the PA checked and found that the resident was a Full Code. The ADON stated that she and the PA went to the first floor, and that she stopped in the lobby to have the receptionist call a code. She said that once the team started CPR, she called 911 and started the paperwork for transfer to the hospital. The ADON confirmed that it was about 10:50 a.m. the time she put on the report when she was talking to the PA when they realized that Resident R1 was a Full Code. Interview with the PA, Employee E7, confirmed that she was on duty on February 14, 2024, when Employee E3, ADON reported to her that Resident R1, who was a DNR, was found unresponsive. She stated that she looked it up in the computer because she thought the resident was a Full Code, and when she confirmed that Resident R1 was a full code they went down to the first floor to call a code. When asked what time this was, she said it was shortly after she got there for the day, and that she signed in at the front desk that morning. The Nursing Home Administrator, Employee E1 was able to pull the camera for the first floor which showed the Licensed nurse, Employee E6 and RNS, Employee E30 entering Resident R1's room at 10:41 a.m., and the nurse getting the crash cart at 10:55 a.m., leaving 14 minutes from the time the RNS found the resident unresponsive and when the code was called and CPR was started. A review of the Resident R1's clinical record revealed a nursing note by RNS, Employee E30, dated February 14, 2024, indicating call placed to hospital ER Nurse who indicated that Resident R1 had expired at 11:58 a.m. Interview conducted with the NHA, DON and ADON on February 28, 2024, at 11:25 a.m. confirmed that there was a delay in starting CPR due to Licensed nurse, Employee E6 misidentifying Resident R1's code status and proceeding as a DNR when the resident was a Full Code. Based on the above findings, an Immediate Jeopardy was identified to the Nursing Home Administrator on February 28, 2024 at 1:48 p.m. for failure to perform CPR immediately for a resident who had elected to be Full Code. The Immediate Jeopardy template was provided to the Administrator and Director of Nursing on February 28, 2024, at 1:53 p.m., and an immediate action plan was requested. The facility submitted an action plan on February 28, 2024, at 5:55 p.m. that included the following actions: -DON determined that resident was a full code, CPR was inititiated and 911 was called 10:55 a.m. The paramedics arrived at 11:07 a.m. and continued CPR. Resident had a pulse when she left the building. Resident was transported to the hospital. -Social Services completed a house audit of Code status and ensure medical reflects current status. -ADON/designee audited crash carts to ensure all equipment is available per community policy. -Payroll coordinator to conduct an audit of all licensed staff for current CPR certification. -LPN was suspended pending investigation. ADON/designee educated licensed nurses on CPR policy-to include resident identification and following resident code status wishes. -Payroll coordinator by Nursing Home Administrator was educated on ensuring Licensed nurse have a current CPR certification. -DON/designed will completed [NAME] codes over 2 shifts-[DATE]; ,d+[DATE] and ,d+[DATE]. [DATE], ,d+[DATE]; Ad hoc QAPI (Quality Assurance Program Improvement) completed [DATE] via phone and [DATE] interdisciplinary team ad hoc completed. -DON/designee will monitor code status for all new admissions and for any order changes -ADON/designee will monitor crash cart checks to ensure crash carts are being monitored. -ADON/designee will complete Mock codes three times a week for 4 weeks to determine competency and any need for further education. -The results of the audits will be forwarded to the faciltiy QAPI committee for further review and recommendations. -[DATE] Licensed staff per our policy were re-educated to perform CPR on residents who have elected such services by performed until EMS arrives and assumes responsibility for the resident. Licensed staff were educated on where to find advanced directives and CPR status. -Ad hoc review of CPR policy. The Immediate Jeopardy was lifted on February 29, 2024, at 4:11 p.m. when it was confirmed that the facility provided nursing staff with education regarding providing CPR in accordance with residents' advanced directives, and the facility's policy, and completed [NAME] Code drills to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations of the operations of the Food and Nutrition Department, reviews of policies and procedures, interviews with staff and reviews of chemical manufacturer's specifications, it was determined that the facility failed to ensure that the dish machine dispensed the proper level of sanitizing solution to sanitizing food service equipment. The facility failed to ensure that there was proper water pressure to maintain water in the three compartment sink, to sanitizing the food service equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays). This failure resulted in an Immediate Jeopardy situation for one of one kitchens serving 128 residents. (Kitchen) Findings include: A review of the facility policy titled dish machine use and three compartment sink use dated April 1, 2013, for the Food and Nutrition Services Department indicated that dietary employees were responsible for following standards of practice to ensure that all food service equipment, utensils and dishes are washed and sanitized. The policy indicated that prior to use of the dish machine and three compartment sink (manual washing and sanitizing) the employees were to verify the temperature of the water and chemical concentration. The policy said that the employees were to follow the specifics provided by the dish machine manufacturer and chemical supplier specifications for proper use of the chemicals(hypochlorite and quaternary solution). The dietary employees were to monitor the temperature gauge and chemical concentration of the sanitizers frequently and if requirements were not met they were to immediately discontinue use of the dish machine and three step process to manually wash , rinse and sanitize dishware. Observations of the operation of the dish machine with the Director of Dietary Services, Employee E4, on January 29, 2024 at 9:16 a.m. revealed that the chemical that was dispensing into the dish machine was not registering when tested with the litmus test directed by the chemical manufacturer. The Director of Dietary Services, Employee E4 reported that the chemical being used during the operation of the low temperature dish machine was [NAME] Sani Quat (a quaternary ammonia product). Observations of the dish machine manufacturer's operation procedures that were permanently affixed to the dish machine revealed that the proper chemical to use when operation this machine was chlorine or hypochorite at 50 ppm (parts per million). The instructions also indicated that the optimal temperature of the water for wash and final rinse was a minimum of 120 degrees Fahrenheit to 140 degrees Fahrenheit. Observations were confirmed with the Director of Dietary services, Employee E4, and the Nursing Home Administrator, Employee E1 January 29, 2024 at 10:00 a.m. Observations of the three compartment sink revealed that there was no sanitizing system in place to clean and sanitize the dietary equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays). The Director of Dietary services, Employee E4 reported that the three compartment sink had not been used since January 3, 2024. The piping underneath the sink was leaking water onto the floor and the plumbing and water pressure was not fully operating at the faucet. The Director of Dietary, Employee E4 also reported that with out the proper water pressure and ability to maintain water in the sink, the chemical for sanitizing the food service equipment (pots, pans, dishes, utensils, bowls, cups, dome lids, meal trays) was ineffective. The chemical sanitizer was not dispensing or manually added to the three compartment sinks. The process used to manually wash, rinse and sanitize dishware was standard of practice procedure for ensuring food safety. Observations were confirmed with the Director of Dietary Services, Employee E4 and the administrator, Employee E1, on January 29, 2024, at 10:30 a.m. Interview with the Director of Dietary Service, Employee E4, on January 29, 2024 at 11:00 a.m. revealed that the food and nutrition department was not keeping a log of temperatures or chemical concentration testing during the operation of the dish machine or the manual use of the three compartment sink. Based on these findings, and jeopardy related to the unsafe and unprofessional practices of the dietary staff inside the main kitchen of the Food and Nutrition Services Department. The nursing home administrator was notified of the immediate jeopardy situation on January 29, 2024 at 4:16 p.m., at which time an immediate action plan was requested from the administrator, by the survey team. The immediate jeopardy template was provided to the nursing home administrator on January 29, 2024 at 4:16 p.m. On January 29, 2024 at 7:13 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: 1. The facility initiated paper products for the lunch meal on Janaury 29, 2024. 2. [Chemical manufacture company] was notified that there were issues with the sanitation for the dish machine and the three compartment sink. State Chemical Solutions technician evaluated for correct sanitation process around 1530 on Janaury 29, 2024. 3. The current director of dietary services was no longer employed with [NAME] Mawr Extended Care Center. 4. The facility immediately cleaned and sanitized the dish ware, pots and pans to prevent food borne illness. 5. [Nurse consultant] completed a seventy two hour progress note to review and identify any signs of food borne illness. One resident was identified with loose stools. The resident was assessed [the nursing supervisor]. The registered nurse indicated that the resident denied any complaints. 6. Certified Dietary Manager completed education with current dietary staff in the building on proper use of the sanitizer for the dish machine and three compartment sink, this includes how to test sanitizer solution. A cleaning and sanitizing competency and education was planned for each dietary employee. 7. On January 30, 2024 Registered Dietitian was responsible for education of the dietary staff on all shifts to ensure that all dietary staff understands about the required sanitation process for the dish machine and three compartment sink. 8. All off duty staff were to receive education about the required sanitation process for the dish machine and three compartment sink upon return to work. 9. Dish machine will be checked for proper sanitation prior to doing the dishes, after each meal and documented on the sanitation log. At some point during washing of the dishes another sanitation check will occur and be documented. If the sanitation check does not fall within parameters, stop washing and notify the supervisor immediately. The supervisor will notify the administrator; who would be responsible to notify State Chemical, the manufacturer. 10. The three compartment sink will be checked for sanitation prior to each use and three times a day after each meal and documented on the sanitation log. At some point during washing of the dishes another sanitation check will occur and be documented. If sanitation check does not fall within parameters, stop washing and notify the supervisor immediately. The supervisor will notify the administrator: who would be responsible to notify State Chemical, the manufacturer. The administrator /assigned designee will observe dish machine sanitation and three compartment sink sanitation three times a day for two weeks and daily thereafter. 11. Results will be presented to QAPI for review and revision as needed. Interviews were conducted with dietary staff on January 30, 2024, from 9:00 a.m. until 3:00 p.m. to verify the implementation of the plan of action. Dietary staff interviewed were able to confirm that they were trained and demonstrate that training was effective related to proper chemical sanitizer, proper chemical sanitizer concentration to use and proper temperature of the water to effectively use the chemicals in the dish machine and manually in the three compartment sink. Observations were done with dietary staff on January 30, 2024, following the breakfast and noon meals to verify the method of chemical sanitizer testing, water temperature and concentration of chemical solution being used to sanitize with in the low temperature dish machine and the three compartment sink. Following verification of the immediate action plan, the Immediate Jeopardy was lifted on January 30, 2024 at 4:09 p.m. 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 Pa. Code 204.19 Plumbing, heating ventilation and air conditioning and electrical 28 Pa. Code 211.10(d) Resident care policies

Based on the review of clinical records, facility reported incident, facility policies, interviews with staff and facility documentation, it was determined that the facility failed to provide appropriate supervision for one of five residents reviewed, which resulted in Resident R1 eloping from the facility and remaining out of the facility for 12 hours. This failure placed Resident R1 at risk for harm. This deficiency was identified as Immediate Jeopardy past non-compliance. (Resident R1) Findings include: Review of facility policy Elopement/Unauthorized Absence Policy dated March 18, 2022, revealed that The facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner Definition- Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Review of facility policy Resident Leave of Absence Policy dated October 24, 2022, revealed, The resident's provider will determine if the resident may have a leave of absence and if it is with or without supervision and an order will be entered in the medical record. Residents deemed to be at risk for safety issues related to independent leaves of absences will have interventions incorporated into their plan of care to reduce safety risks. Initiating the Leave of Absence: 1. Upon admission, resident/responsible party will sign Leave of Absence/72 hr. rule notice 2. The Resident/Responsible Party will be requested to sign-out of the facility (which indicates the resident's/Responsible Party's acceptance of responsibility for self/resident while participating in an (LOA- leave of absence) and reminded to sign back in and alert staff upon return 3. Prior to leaving the facility the charge nurse will request address and phone number of the location where the resident will be, if known, and estimated date and time of return. Review of Resident R1's clinical record revealed that the resident was admitted to the facility with diagnoses of complete traumatic amputation (the removal of a limb by trauma, medical illness, or surgery.) at level between left hip and knee and abnormalities of gait and mobility. Review of Resident R1's Minimum Data Set (MDS-assessment of resident care needs) dated October 17, 2022, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 12 which indicated that the resident's cognitive status was moderately impaired. Review of physician order for Resident R1 dated October 10, 2022, revealed that the resident had an order for LOA with supervision and an order for LOA with activity staff. Review of psychiatric assessment for Resident R1 dated November 16, 2022, revealed that the resident had a MoCA (A screening test to detect cognitive impairment, a score of 26 or above indicated no cognitive impairment, 18-25 points: Mild cognitive impairment, 10-17 points: Moderate cognitive impairment, Fewer than 10 points: Severe cognitive impairment.) score of 21/30 with deficits in visuospatial and executive functioning, abstract and delayed recall. Resident was diagnosed with adjusted disorder with mixed anxiety and mood as cognitively disabled. Review of facility investigation dated January 6, 2023, at 2.00 a.m. revealed that the staff reported Resident R1 was not in the room. The facility including parking lot was searched by staff. Resident R1 was not able to be located on facility grounds. The police, administration and physician were notified, and report given. Resident R1's friend on another unit called Resident R1, Resident R1 stated he left the facility at 2.00 p.m. (on January 5, 2022). Review of statement by Employee E5, Recreational Aide, dated January 6, 2023, revealed that she was sitting at the lobby because the receptionist asked her to cover the reception. Resident R1 was sitting at the lobby and did not pay attention to him. When two family members asked to open the door, she did but did not notice Resident R1 leaving the facility. Review of a Disciplinary Action Form for Employee E5, Recreational Aide dated January 10, 2023, revealed that, on January 5, 2023, the employee was asked to cover the reception for the receptionist for her break. Employee E5 was given remote control of the front desk. Resident R1 who was not allowed to leave the facility, approached the sliding door, Employee E5 opened the sliding door for him, and Resident R1 left the facility unsupervised. Interview with Employee E5, Recreational Aide on January 25, 2023, at 12:19 p.m. stated she was covering front desk. Resident R1 was sitting at the front desk near the sliding door. At some point when she opened the front sliding door, he got the opportunity, and he went through the front door. Employee E5 stated she saw him leaving but she thought he was just going out for smoke, but she did not check the smoking list. Employee E5 also stated she did not check the LOA list at the front desk or report Resident R1 leaving to any staff. Review of statement by Employee E6, Nursing Assistant, who worked 7 am-3 pm shift on January 5, 2023, revealed that she collected Resident R1's breakfast and lunch tray but did not see Resident R1 for the entire shift. Review of a statement by Employee E7, Nursing Assistant, who worked 3 pm-11 pm shift on January 5, 2023, revealed that she was late. She was busy and did not see Resident R1, she thought Resident R1 was with his friend on 2nd floor. Employee E7 placed the dinner tray in his room but did not collect the tray. After 11 p.m. she started her second shift and realized that she did not see him at all and informed the supervisor. Review of a statement by Employee E8, Nursing Assistant, who worked 11 pm-7 am shift on January 5, 2023, revealed that she came in on January 5, 2023, and checked on resident's, she did not see Resident R1 and assumed he was probably in the building with his friend upstairs. Review of a statement by Employee E9, Licensed Nurse, who worked 11 pm-7 am shift on January 5, 2023, revealed that Resident R1 was not in his room on January 5, 2023, at 11 a.m., Resident was always upstairs with his friends playing video games until in the morning. She assumed he was upstairs as usual. Later at 2 a.m. she called upstairs to check his friend's room. Interview with Employee E10, Licensed Nurse, who was assigned to Resident R1, stated she did not see Resident R1 and assumed he was in the building. Interview with Employee E11, Nursing assistant, on January 25, 2023, revealed that she made rounds when she came in to work on January 5, 2023. She did not see Resident R1. She thought that he was upstairs but did not check or check with staff of second floor to confirm that the resident was upstairs. Interview with the Nursing Home Administrator, on January 25, 2023, at 11:48 p.m., stated Resident R1 usually ambulated in the facility and visited resident upstairs. He was found by the psychiatric practitioners as cognitively impaired and a physician order for LOA with supervision was ordered for the resident. On January 5, 2023, Resident R1 came to the lobby and sat near the front sliding door. Employee E5 was covering the front door for receptionist, she saw the resident sitting at the lobby. Employee E5 opened the front door for family members of another resident to leave. Resident R1 followed the family member. Employee E5 sitting approximately 15 feet from the from the front door who was able to clearly see who was leaving and entering the facility. Administrator stated Employee E5 did not react when resident left behind the family members. Continued interview with Nursing Home Administrator stated, Nursing Assistant, Employee E10, and Licensed Nurse, Employee E11 did not complete the safety rounds as required and did not enquire the whereabouts of resident when he was not available in his room for their entire shift. Nursing assistant, Employee E8 and Licensed Nurse, Employee E9 did not complete the safety rounds immediately after the shift and did not enquire the whereabouts of resident when he was not available in his room. Nursing Home Administrator confirmed that the resident was not allowed leave the facility without supervision due to the safety concern. Review of clinical record and facility documentation revealed that the facility process failed to stop a resident who was only allowed to leave the facility with supervision from leaving the facility unsupervised. Facility failed to recognize that Resident R1 was only allowed to leave the facility supervised and that the resident was absence for 12 hours after he left the facility unsupervised. The facility's failure to provide to provide appropriate supervision put Resident R1 and other residents of the facility at risk for harm. Review of facility documentation Assessment Scoring Report, dated January 6, 2023, revealed that, as of January 25, 2023, 13 residents were at risk for elopement. The NHA and DON were notified of the Immediate Jeopardy on January 25, 2023, at 12:53 p.m. An Immediate Plan of Correction was requested. The Immediate Plan of Correction was provided by the facility, on January 25, 2023, at 4.00 p.m. and was accepted. On January 6, 2022, the facility initiated a plan of correction to address the failure to provide an environment free of accident hazards and failed to provide appropriate supervision which put the Resident R1 and other residents of the facility at risk for harm. Facility plans of correction included the following: 1. On 1/6/2023 7:50 a.m. the DON contacted Resident R1 via his cell phone number and he stated he was safe at a friend's house, and he will not be returning to the facility. DON reviewed the AMA (Against Medical Advice) policy and educated on risks, and he voiced understanding and stated he will not be returning to the facility. The physician was notified and agreed with AMA- Completed -1/6/2023 2. To identify other residents with the potential to be affected, On 1/6/2023 0300 Facility head count completed and all residents accounted for elopement assessments were reviewed on residents and care plans updated if needed. Completed -1/6/2023 3. The Elopement book was reviewed and updated as needed on 1/6/2023. Elopement drills conducted on each shift 7-3, 3-11, 11-7 on 1/6/2023 and 1/7/2023 4. To prevent this from reoccurring, DON/designee has educated Licensed staff on completion of midnight census, to check residents at minimum of once a shift for those that are independent and mobile- Completed on 1/6/2023 Nursing assistants to check residents that are independent and mobile that have not touched their meal tray and locate the residents. If unable to locate resident to notify the charge nurse. A receptionist cheat sheet will be created and provided to the staff for review when covering the front desk. Covering receptionist will initial cheat sheet. Completed on 1/6/ 2023 5. Ongoing monitoring for compliance, NHA/designee will interview 5 A&Ox3 residents 3 times a week for 4 weeks for understanding of requesting discharge planning, 2 times a week for 4 weeks, and weekly for 4 weeks - Started on 1/9/2023 and on-going 6. Nursing Supervisor will complete every 4-hour house census checks for 3 days and then every 8 hours for 14 days to ensure house census is correct. Started 1/6/2023 and on-going 7. Nursing Supervisor will complete a midnight census and place a copy in the Administrator and Business office Manager's mailboxes daily. Started 1/6/2023 and on-going. 8. DON/designee will interview 5 residents, 3 times a week to ensure the A &OX3 independent residents are being checked by staff for 4 weeks, 2 times a week for weeks, and randomly thereafter. Started 1/9/ /2023 and ongoing. 9. Elopement Drills were conducted to educate staff on all 3 shifts. Completed 1/6 and 1/7/2023 10. Elopement education was completed as part of the Elopement Drills. Completed 1/6 and 7t 2023 including potential signs of future elopement. Licensed nurses were educated to check their mobile and independent residents at least one per shift, as well as CNAs to check residents who are independent and mobile that have not touched their meal trays and report it immediately to their Charge Nurses / Supervisor Completed on 1/6/2023. 11. RN Night Supervisors were educated on the appropriate completion, the midnight census - Completed 1/6/2023. 12. Receptionist was educated on her break policy. Completed on 1/6/202 13. Activity employee was educated on secured door policy. Completed on 1/6/2023 14. Results were presented at QAPI for review and revision on 1/6/2023 Review of facility documentation revealed that the corrective plan was immediately developed and initiated on January 6, 2022. Education was completed and Audits were initiated to ensure that the environment was free of accident hazards and to provide appropriate supervision with 100% compliance. Review of facility plan of correction revealed that facility completed a list of residents who were at risk of elopement. Facility completed elopement drill for the facility staff. Audits were reviewed to ensure resident census and to account each resident in the facility. LOA list verified and appropriate LOA forms and instructions updated at the reception. Review of disciplinary action form revealed that all involved staff was counseled for failing to follow facility elopement protocol, documentation protocol and failure to report resident not available on the unit. Interviews were conducted with Licensed Nursing staff, Registered Nurses and Nursing Assistants regarding education related to elopement protocol and resident safety checks according to the facility protocol. Staff also stated that they received sufficient trainings from the facility. Nurses verbally demonstrated knowledge of elopement prevention and facility safety check protocol. The action plan was accepted January 25, 2023, at 4:02 p.m. and identified as past non-compliance. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies

Based on a review of clinical records, interviews with staff, review of facility documentation, and review of hospital records, it was determined that the facility failed to ensure the assistance of two staff members during personal care, which resulted in actual harm to Resident R66 who sustained a laceration to the forehead and a fracture of the left distal femur and failed to ensure that appropriate assistive devices during wheelchair transport which resulted in actual harm to Resident R42, sustaining a left acetabular fracture, for two of 32 residents reviewed (Resident R66 and Resident R42). Findings include: Review of Resident R66's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of essential hypertension (high blood pressure) other abnormalities of gait and mobility; chronic [CONDITION(S)] (irregular and often rapid heart rate that causes poor blood flow); muscle weakness; and coronary artery bypass graft without [CONDITION(S)] pectoris (disease of the arteries). Review of Resident R66's plan of care, dated June 3, 2021, revealed that the resident was at risk for falls related to impaired balance, and weakness and required two person assist at all times. Review of the resident's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs), dated August 3, 2021, revealed that Resident R66 had a BIMS (Brief Interview for Mental Status) score of 99, indicating severe cognitive impairment. Further review of the MDS assessment revealed that Resident R66 required extensive assistance of two staff members with all ADL's (activities of daily living including personal care, bed mobility and transfers) and no ambulatory capabilities. Review of Resident R66's nursing note by Licensed nurse, Employee E6, dated September 2, 2021 revealed A cna (nursing assistant) reported at 3:00 p.m. that resident was laying on the floor next to her bed while cna was giving care to the resident, and she turned over to her left side and fell on the floor and the cna was unable to reach the resident in time. Two nurses immediately ran into the room and found Resident R66 laying on the floor on her right side with a small amount of blood noted on the floor. Resident R66 was assessed and on right side of forehead a laceration was noted (4cm X 0.5 cm. X 0.2 cm). Immediate pressure and dressing was applied to area. Bleeding stopped. Skin tear noted on right great toe (2cm. X 2cm.) Neuo check within normal limits and positive range of motion to all four extremities noted. Further review of nursing notes dated September 3, 2022 revealed that the faciity received notification from the lab of the resident critical hemoglobin level of 6.4 g/dL [normal range is 12 grams per deciliter (d/dL) or higher].The physican was notified and ordered for the resident to transferred to the hospital via 911 (Emergency Medical Services). Review of the hospital history and physical dated September 4, 2022 at 12:38 a.m. stated patient rolled out of bed, she sustained a laceration to her forehead Further, it was revealed that the resident was assessed with left upper weakness, and bilateral lower extremities with [CONDITION(S)] (swelling). Continue review of the history and physical confirmed that an x-ray of the left knee revealed a fracture of the distal shaft of the femur just above a left knee prosthesis. There was overlying soft tissue swelling. Further review of Resident R66's clinical record revealed that the resident was readmitted to the facility on [DATE] with a left leg immobilizer. Interview on March 30, 2022 at approximately 1:00 p.m. with licensed nurses, Employee E4, and Employee E6, revealed, I think there were two staff members present at the time of the fall. The cna (nursing assistant) assigned to the resident is here today. Interview on March 30, 2022 at approximately 1:20 p.m. with nursing assistant, Employee E12, revealed, Originally myself and another cna entered the room to provide care for the resident. Resident was turned to her left and I was cleaning her up. he other staff member stated that she had to use the bathroom and I asked her to bring back a sheet when she returned from the bathroom because the resident's sheet was wet. I reached back to my right to grab resident's diaper and gown and she fell off of the bed. Further during interview with nursing assistant, Employee E12, it was confirmed that at the time of the fall, only one staff member was present. The facility failed to ensure that two staff members were present while providing personal care to Resident R66, which resulted in actual harm to Resident R66 sustaining a fall from bed, a laceration to the forehead and a fracture to the left femur. Review of Resident R42's clinical record revealed the diagnosis of muscle weakness, history of falling and dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Review of Resident R42's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs), dated October 6, 2021, indicated that the resident required the assistance of one person when moving on the unit, and that the resident used a wheelchair for mobility. Review of Resident R42's plan of care dated July 14, 2021, identified the resident at risk for falls due to dementia, history of falls and impaired balance/gait. The interventions included for the resident was to be assisted with mobility as needed. Review of an interdisciplinary note dated October 19, 2021, revealed that while being transported by nurse aide, Employee E14, the resident placed his foot on the floor, fell forward, lost consciousness. Continued review of the October 19, 2021 fall incident indicated that Resident R42 sustained a large hematoma (a pocket of blood inside the body caused by bleeding) and skin tear to the right side of the resident's forehead. A small amount of bleeding from site was also documented as being present. Resident R42 was transferred to the emergency room for treatment and returned to the facility from the emergency room approximately 11 hours later. Further of nursing documentation dated October 20, 2021, at 10:17 p.m. revealed that the resident returned from the emergency department with the diagnoses of hematoma and non- displaced left acetabular (the socket part of the hip joint) fracture. Review of the facility investigation regarding the fall incident sustained by Resident R42 on October 19, 2021, revealed a statement from nurse aide, Employee E14 indicating that he was transporting the resident to the nursing station. Employee E14 explained in his statement that during the transport, he saw Resident R42 leaning forward, and he eventually fell forward and onto the floor before he could intervene. Employee E14 reported that afterwards, he notified the charge nurse. Continued review of the investigation revealed that Resident R42 did not have leg rest attached to his wheelchair during the transport by Employee E14. During interview with the Director of Nursing on March 31, 2022, at approximately 11:50 a.m. regarding fall incident sustained by Resident R42, the Director of Nursing reported that the resident was in need of leg rest while being transported by staff. The facility failed to ensure that Resident R42 was provided with leg rest during transport via wheelchair which resulted in actual harm to Resident R42 sustaining a fall from the wheelchair, a hematoma and non- displaced left acetabular fracture. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)Nursing services 28 Pa. Code 211.12(d)(3)Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on interviews with staff, the review of clinical records, and review of facility documentation, it was determined that the facility failed to ensure that residents were free from neglect for two of 32 residents reviewed (Resident R66 and Resident 42), which resulted in actual harm to Resident R66 who sustained a laceration to the forehead and a fracture of the left distal femur and Resident R42, who sustained a left acetabular fracture. Findings include: Review of the facility's policy, Pennsylvania Resident Abuse with a revision date of July 2019 stated that facility's procedures to prevent and identify abuse will include an analysis of the physical environment that may make abuse and/or neglect more likely to occur, having sufficient number of staff members to meet the needs of the residents, in addition to assuring that the staff assigned have knowledge of the individual residents' care needs. The policy also stated that if a staff member is accused or suspected of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property, the facility will immediately remove staff member from resident care areas and request a written statement from the accused staff member. The accused staff member will remain under direct supervision until the statement is complete and/or law enforcement arrives if applicable. The accused staff member will then be removed from the facility and the schedule pending the outcome of the investigation. Review of Resident R66's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R66's plan of care, dated June 3, 2021, revealed that the resident was at risk for falls related to impaired balance, and weakness and required two person assist at all times. Review of the resident's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs), dated August 3, 2021, revealed that Resident R66 had a BIMS (Brief Interview for Mental Status) score of 99, indicating severe cognitive impairment. Further review of the MDS assessment revealed that Resident R66 required extensive assistance of two staff members with all ADL's (activities of daily living including personal care, bed mobility and transfers) and no ambulatory capabilities. Review of Resident R66's nursing note by Licensed nurse, Employee E6, dated September 2, 2021, revealed A cna (nursing assistant) reported at 3:00 p.m. that resident was laying on the floor next to her bed while cna was giving care to the resident, and she turned over to her left side and fell on the floor and the cna was unable to reach the resident in time. Two nurses immediately ran into the room and found Resident R66 laying on the floor on her right side with a small amount of blood noted on the floor. Resident R66 was assessed and on right side of forehead a laceration was noted (4cm X 0.5 cm. X 0.2 cm). Immediate pressure and dressing was applied to area. Bleeding stopped. Skin tear noted on right great toe (2cm. X 2cm.) Neuo check within normal limits and positive range of motion to all four extremities noted. Review of the hospital history and physical dated September 4, 2022, at 12:38 a.m. stated patient rolled out of bed, she sustained a laceration to her forehead The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the history and physical confirmed that an x-ray of the left knee revealed a fracture of the distal shaft of the femur just above a left knee prosthesis. Interview on March 30, 2022, at approximately 1:20 p.m. with nursing assistant, Employee E12, who was assigned to the care of Resident R66 at the time of the fall incident revealed that Originally myself and another cna entered the room to provide care for the resident. Resident was turned to her left and I was cleaning her up. The other staff member stated that she had to use the bathroom and I asked her to bring back a sheet when she returned from the bathroom because the resident's sheet was wet. I reached back to my right to grab resident's diaper and gown and she fell off of the bed. Further, during interview with nursing assistant, Employee E12, it was confirmed that at the time of the fall, she was aware that the resident was a two person assist and she confirmed that only one staff member was present when the resident fell . The facility failed to ensure that two staff members provided personal care as indicated in the resident's plan of care which resulted in actual harm to Resident R66 rolling out of bed, and sustaining a laceration to the forehead and a fracture to the left distal femur. Review of Resident R42's clinical record revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R42's plan of care dated July 14, 2021, identified the resident at risk for falls due to dementia, history of falls and impaired balance/gait. The interventions included for the resident was to be assisted with mobility as needed. Review of Resident R42's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs), dated October 6, 2021, indicated that the resident required the assistance of one person when moving on the unit, and that the resident used a wheelchair for mobility. Review of an interdisciplinary note dated October 19, 2021, revealed that while being transported by nurse aide, Employee E14, the resident placed his foot on the floor, fell forward, lost consciousness. Continued review of the October 19, 2021 fall incident indicated that Resident R42 sustained a large hematoma (a pocket of blood inside the body caused by bleeding) and skin tear to the right side of the resident's forehead. A small amount of bleeding from site was also documented as being present. Resident R42 was transferred to the emergency room for treatment and returned to the facility from the emergency room approximately 11 hours later. Further review of nursing documentation dated October 20, 2021, at 10:17 p.m. revealed that the resident returned from the emergency department with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility investigation regarding the fall incident sustained by Resident R42 on October 19, 2021, revealed a statement from nurse aide, Employee E14 indicating that he was transporting the resident to the nursing station. Employee E14 explained in his statement that during the transport, he saw Resident R42 leaning forward, and he eventually fell forward and onto the floor before he could intervene. Employee E14 reported that afterwards, he notified the charge nurse. Continued review of the investigation revealed that Resident R42 did not have leg rest attached to his wheelchair during the transport by Employee E14. During interview with the Director of Nursing on March 31, 2022, at approximately 11:50 a.m. regarding fall incident sustained by Resident R42, the Director of Nursing reported that the resident was in need of leg rest while being transported by staff. The facility failed to ensure that Resident R42 was provided with leg rest during transport via wheelchair which resulted in actual harm to Resident R42 sustaining a hematoma and non- displaced left acetabular fracture. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)Nursing services 28 Pa. Code 211.12(d)(3)Nursing services 28 Pa. Code 211.12(d)(5) Nursing services