Every finding on record at Capitol Rehabilitation and Healthcare Center

Based on facility policy review, clinical record review, review of facility documentation, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for six of 24 residents reviewed (Residents 5, 6, 7, 8, 9, and 10).Findings include:Review of the facility policy, titled Administering Medications with a last revised date of April 2019, revealed 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are to be administered within one hour of their prescribed time, unless otherwise specified.Review of Resident 5's clinical record revealed diagnoses that included hypothyroidism (when your thyroid gland does not make enough thyroid hormone to meet your body's needs) and depression (a serious mood disorder that involves persistent sadness and a loss of interest in daily activities).Review of Resident 5's physician orders revealed the following orders: Zyprexa oral tablet 2.5 milligrams (mg) (Olanzapine), give 0.5 mg by mouth at bedtime for behavioral disturbances, with a start date of January 7, 2026;Mirtazapine Oral Tablet 7.5 mg, give one tablet by mouth at bedtime for depression, with a start date of January 7, 2026.Review of Resident 5's nursing progress notes revealed Resident 5 was admitted to the facility on [DATE], at 5:40 PM from the hospital.Review of Resident 5's medication administration record (MAR) for January 2026 revealed on January 7 and 8, 2026, Resident 5's 9:00 PM doses of Zyprexa oral tablet and Mirtazapine oral tablet were blank, indicating they were not administered to the Resident; and marked 5 on January 9, 2026, which is code for Hold.Further review of Resident 5's nursing progress notes revealed a note on January 9, 2026, corresponding with the aforementioned time that the medications were waiting to be delivered by the pharmacy.Review of Resident 6's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD - a progressive lung disease that causes airflow obstruction and breathing problems, including shortness of breath, chronic cough, and wheezing).Review of Resident 6's physician orders revealed an order for Meropenem Intravenous (IV) Solution Reconstituted 500 mg, use 500 mg intravenously every 6 hours for right AKA (above-the-knee amputation) wound until December 24, 2025, with a start date of December 4, 2025.Review of Resident 6's December 2025 MAR revealed on December 4, 2025, Resident 6's 6:00 PM dose of Meropenem IV salutation 500 mg was documented as 22, which is code for drug/treatment not administered.Review of Resident 6's nursing progress notes revealed a note written on December 4, 2025, corresponding with the aforementioned time that the medication was not available yet from pharmacy.Review of Resident 7's clinical record revealed diagnoses that included bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels) and diabetes (a chronic metabolic disorder that causes high blood sugar levels).Review of Resident 7's physician orders revealed the following orders:Lithium Carbonate Oral Capsule 150 mg, give one capsule by mouth one time a day for Bipolar, with a start date of December 18, 2025;Tizanidine HCL oral tablet 2 mg, give three tablets by mouth at bedtime for muscle spasms, with a start date of December 17, 2025.Review of Resident 7's nursing progress notes revealed Resident 7 was admitted to the facility on [DATE], at 2:40 PM, from the hospital.Review of Resident 7's December 2025 MAR revealed on December 17, 2025, Resident 7's 8:00 PM dose of Tizanidine HCL oral tablet 2 mg, three tablets at bedtime was documented as 22, which is code for drug/treatment not administered.Further review of Resident 7's December 2025 MAR revealed on December 18, 2025, Resident 7's 8:00 AM dose of Lithium Carbonate Oral Capsule 150 mg was marked 5, which is code for Hold.Further review of Resident 7's nursing progress notes revealed a progress note written on December 17, 2025, at 8:54 PM, indicating Resident 7 was a new admit and was waiting from pharmacy to deliver their Tizanidine HCL oral tablet medication.Review of progress note written on December 18, 2025, at 9:31 AM, indicated the medical director was aware that Resident 7's Lithium Carbonate Oral Capsule was not administered.Review of Resident 8's clinical record revealed diagnoses that included hypertension and diabetes.Review of Resident 8's physician orders revealed the following orders:Glipizide oral tablet 10 mg, give one tablet by mouth one time a day for diabetes, with a start date of January 4, 2026, at 9:00 AM;Dapagliflozin Propanediol oral tablet 10 mg, give one tablet by mouth two times a day for diabetes, with a start date of January 4, 2026;Dapagliflozin Propanediol oral tablet 10 mg, give one tablet by mouth one time a day for diabetes, with a start date of January 6, 2026, at 9:00 AM;Metformin HCI oral tablet 850 mg, give one tablet by mouth with meals for diabetes, with a start date of January 4, 2026; andDivalproex sodium oral tablet delayed release 500 mg, give one tablet by mouth two times a day for mood disorder, with a start date of January 3, 2026.Review of Resident 8's clinical record revealed the Resident was admitted to the facility from the hospital on January 3, 2026.Review of Resident 8's January 2026 MAR revealed on January 4, 2026, Resident 8's 9:00 AM dose of Glipizide oral tablet 10 mg, was marked 5, which is code for Hold.On January 4, 2026, Resident 8's 9:00 AM dose of Dapagliflozin Propanediol oral tablet 10 mg was marked 5 and their 5:00 PM dose was marked 22, which is code for Medication/treatment not administered.On January 6, 2026, Resident 8's 9:00 AM dose of Dapagliflozin Propanediol oral tablet 10 mg was marked 22.On January 4, 2026, Resident 8's 8:00 AM and 12:00 PM doses of Metformin HCI oral tablet 850 mg, were marked 5, and their 5:00 PM dose was marked 22.On January 4, 2026, Resident 8's 8:00 AM dose of Divalproax sodium oral tablet delayed release was marked 5.Review of Resident 8's nursing progress notes revealed corresponding documentation with the aforementioned dates and times that the medications were either on order or waiting to be delivered from the pharmacy.Review of Resident 9's clinical record revealed diagnoses that included dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells) and glaucoma (group of eye diseases damaging the optic nerve).Review of Resident 9's physician orders revealed an order for Dorzolamide HCI - Timolol Mal Ophthalmic Solution 2-0.5%, instill 1 drop in both eyes every 12 hours for glaucoma, with a start date of December 30, 2025.Review of Resident 9's nursing progress notes revealed Resident 9 was admitted to the facility on [DATE], from the hospital, at 9:30 PM.Review of Resident 9's December 2025 MAR, revealed on December 31, 2025, Resident 9's 9:00 PM dose of Dorzolamide HCI - Timolol Mal Ophthalmic Solution was documented 22, which is code for Medication/treatment not administered.Further review of Resident 9's nursing progress notes revealed corresponding documentation with the aforementioned date and time that the medication was unavailable and on order from the pharmacy.Review of Resident 10's clinical record revealed diagnoses that included COPD and hypertension.Review of Resident 10's physician orders revealed an order for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (one millionth of a gram - Aerosol Solution), 2 puff inhales orally every 12 hours for COPD rinse mouth after use, with a start date of January 12, 2026.Review of Resident 10's nursing progress notes revealed Resident 10 was admitted to the facility on [DATE], at 3:14 PM from the hospital.Review of Resident 10's January 2026 MAR revealed on January 12, 2026, Resident 10's 8:00 PM dose of Budesonide-Formoterol Fumarate Inhalation Aerosol was marked 5, which is code for Hold.Further review of Resident 10's nursing progress notes revealed corresponding documentation with the aforementioned date and time that the medication was waiting for pharmacy delivery. Interview conducted with the Nursing Home Administrator (NHA) on January 13, 2026, at approximately 10:30 AM, revealed that the facility had their pixis well stocked and they would not admit a resident without having their medications available.Further interview conducted with the NHA on January 14, 2026, at approximately 2:00 PM, revealed that she would not necessarily expect a resident to have their medications available as ordered by the physician all the time, and will inform their medical provider if a medication is not available.28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for three of four residents observed on contact precautions (Residents 1, 2, and 3).Findings include:Review of the facility policy, titled Isolation - Categories of Transmission-Based Precautions with a last revised date of September 2022, revealed 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. A. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room.Review of Resident 1's clinical record revealed diagnoses that included diabetes (a chronic condition where the body has trouble regulating blood sugar) and hypertension (high blood pressure).Review of Resident 2's clinical record revealed diagnoses that included hypertension and anxiety (a persistent feeling of worry that interferes with daily life).Review of Resident 3's clinical record revealed diagnoses that included heart failure (a chronic condition where the heart can't pump enough blood and oxygen to the body) and chronic kidney disease (long-term condition where the kidneys are damaged and lose their ability to filter waste and excess fluid from the blood over time).Observation of Resident 1's room on January 13, 2026, at 2:15 PM, revealed Resident 1's call bell was on. On the entrance door to Resident 1's room there was a sign indicating that Resident 1 was on droplet precautions and that it was required to clean your hands before entering and before leaving Resident 1's room. Further observation at that time revealed Employee 3 (Nurse Aid) leave Resident 2 and Resident 3's room, which had a sign on the door indicating both Resident 2 and 3 were on enhanced barrier precautions and that is was required to clean your hands before entering and leaving the room. Employee 3 was then seen entering Resident 1's room to answer the call bell, and did not clean her hands prior to leaving Resident 2 and 3's room and entering Resident 1's room. Employee 3 assisted Resident 1's roommate, who was not on precautions in the bathroom.Observation of Resident 1's room on January 14, 2026, at 12:01 PM, revealed Resident 1's call bell was on. On the entrance door to Resident 1's room there remained a sign indicating that Resident 1 was on droplet precautions. Further observation at that time revealed Employee 3 entered Resident 1's room without cleaning her hands, put gloves on, removed the trash from Resident 1's room, and entered Resident 2 and 3's room without performing hand hygiene in between and wearing the same gloves. Further observation revealed Employee 3 taking the trash bag from Resident 1's room into Resident 2 and 3's room, getting the trash from Resident 2 and 3's room, removing her gloves, and leaving without performing hand hygiene.Review of Resident 1's clinical record revealed a Health Status Progress Note written on January 2, 2026, at 3:06 PM, with text indicating Resident 1 was to be on contact precautions until RVP (Respiratory Syncytial Virus, a very common respiratory virus causing cold-like symptoms but severe illness in infants, older adults, and immunocompromised individuals, leading to bronchiolitis or pneumonia, and spreading via respiratory droplets) results are received.Review of Resident 2's physician orders revealed an order for Resident 2 to be on enhanced barrier precautions starting on August 12, 2025, for dialysis and a peg tube.Review of Resident 2's care plan revealed a focus area that Resident 2 required enhanced barrier precautions related to dialysis and peg tube, with an initiation date of November 6, 2024; and an intervention to change personal protective equipment and perform hand hygiene prior to caring for another resident, initiated on November 6, 2024.Review of Resident 3's physician orders revealed an order for Resident 3 to be on enhanced barrier precautions starting on August 12, 2025, due to having a foley.Review of Resident 3's care plan revealed a focus area that Resident 3 requires enhanced barrier precautions related to foley, with an initiation date of August 13, 2025.During an interview with the Nursing Home Administrator conducted on January 14, 2026, it was revealed that she would have expected Employee 3 to have performed appropriate hand hygiene before entering and leaving the residents' rooms.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy, document review, and resident and staff interviews, it was determined that the facility failed to provide a resident the right to voice a grievance to the facility and make prompt efforts by the facility to resolve the grievance for one of four residents reviewed (Resident 4).Findings include:Review of the facility policy, titled Grievances/Complaints, Filing with a last revised date of April 2027, revealed, 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, or behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 10. The grievance officer and stall will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.During an interview with Resident 4 on January 13, 2026, at 3:00 PM, she revealed an incident that occurred with Employee 4 (Licensed Practical Nurse) on January 8, 2026, where Employee 4 came into Resident 4's room that morning to pass medications and Resident 4 stated to Employee 4 that she had to use the restroom, but Employee 4 told Resident 4 that she was not able to assist at this time due to passing out medications. During that time, Resident 4's roommate asked Employee 4 to get their bed pan, where Employee 4 proceeded to get a bed pan from the bathroom and rolled Resident 4 over, put the bed pan under her, and walk out of the room. Resident 4 revealed that she was left sitting on the bed pan until she got tired and pulled it out from under her the best she could, with the call bell on, waiting for someone to come back and assist her. Resident 4 revealed that she uses a bed pan during the night, but is independent on using the rest room during the day and is continent with her bowel and bladder. Resident 4 revealed that she told Employee 5 (Admissions Director) and Employee 6 (Social Worker) about the incident the same day and requested to speak to Employee 1 (Nursing Home Administrator [NHA]) about the incident. Resident 4 revealed that Employee 5 told her they would file a grievance for her. During an interview with Employee 5 on January 14, 2026, at 1:42 PM, revealed that she goes into Resident 4's room daily to check in on her, and was made aware by the Resident on January 8, 2026, that the Resident wanted to speak to Employee 1 regarding an issue with another staff member, but did not mention the staff member's name. Resident 4 told Employee 5 that she was put on the bed pan and left there, and expressed that it was her roommate who had requested to use the bed pan. Employee 5 stated that she told Employee 1 that Resident 4 was requesting to speak to them; however, there was no documentation of their conversation with Resident 4 or any documentation of when they notified Employee 1 about the incident.During an interview with Employee 6 on January 14, 2026, at 12:54 PM, it was revealed that Resident 4 told Employee 6 about the incident that occurred with Employee 4, however, could not recall if she was told about it on January 8 or 9, 2026, as she had no documentation of her conversation with Resident 4 of her concern. Employee 6 revealed that Resident 4 reported a concern involving Employee 4 where the Resident expressed to Employee 4 that the Resident had to use the rest room, and her roommate needed the bed pan; however, Employee 4 gave the bed pan to Resident 4 instead of her roommate, and left her there with it underneath on the Resident and proceeded to walk out of the room and not return. Employee 6 revealed that she spoke to Employee 1 about Resident 4's concern, however, has no documentation of it. Employee 6 was unable to remember if she filed a grievance for Resident 4, but revealed that she would normally write a grievance for a resident if she was made aware of a concern involving a staff interaction.Review of the facility's grievance log from November 2025 to the present day failed to reveal a grievance was filed for Resident 4 and the incident that occurred with Employee 4 on January 8, 2026.Review of Resident 4's clinical record failed to reveal any documentation of the incident that occurred with Employee 4 on January 8, 2026.Review of the facility records failed to reveal any documentation regarding the concern reported by Resident 4 that occurred with Employee 4 on January 8, 2026.During an interview with the NHA on January 13, 2026, at approximately 10:30 AM, revealed that she was made aware of a concern Resident 4 had with an employee and was not feeling well but visited the Resident briefly on January 9, 2026, who informed the NHA that the Resident felt safe in the facility and can talk to the NHA about her concern another day. The NHA had no documentation to provide relating to Resident 4's concern at this time.Further interview with the NHA on January 14, 2025, at 9:19 AM, revealed that she spoke to Resident 4 that morning about her concern with Employee 4 and was going to file a grievance, as well as complete education with Employee 4 on customer service.28 Pa Code 201.18(b)(2)(3)Management28 Pa code 201.29(a) Resident rights

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one residents reviewed for self-administration of medications (Resident 103).Findings include: Review of facility policy, titled Self-Administration of Medications, dated February 2021, revealed, in part, If it is deemed safe and appropriate for a resident to self -administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Review of Resident 103's clinical record revealed diagnoses that included hypertension (high blood pressure) and depression. Review of Resident 103's physician orders revealed an order for May keep poured meds at bedside until he is able to take them, dated May 29, 2024. Review of Resident 103's care plan revealed a focus for I chose to self-administer my own medications with an initiated date of April 11, 2024. Interventions included, but were not limited to, Complete a Medication Self-Administration assessment prior to allowing self-administration, quarterly, and with significant change in condition, with an initiated date of April 11, 2024. Review of Resident 103 clinical record revealed that his Self-Administration of Medications Evaluation was last completed on April 11, 2024. During a staff interview with Employee 4 (Regional Director of Clinical Services) on November 14, 2025, at 1:25 PM, Employee 4 confirmed there were no recent Self-Administration of Medications Evaluations completed for Resident 103. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 4 on November 14, 2025, at 1:58 PM, the NHA confirmed that Resident 103 should have had a Self -Administration of Medications Evaluation completed at least quarterly. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(d) Resident care Policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, facility policy reviews, and staff interviews, it was determined that the facility failed to properly label drugs in one of three medication carts observed (North Unit West); failed to store medications properly in one of three medication carts observed (North Unit West); and failed to discard expired medications in one of three medication carts observed (Guild Unit) and one of two medication rooms observed (South Unit).Findings Include: Review of facility policy, titled Administering Medications, dated April 2019, revealed, in part, 13. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of facility policy, titled Medication Labeling and Storage, dated February 2023, revealed, in part, 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation of the North Unit [NAME] Medication Cart with Employee 1 (Licensed Practical Nurse) on November 13, 2025, at 9:00 AM, revealed a Lispro insulin pen for Resident 12 that was not dated with an open date or expiration date. In addition, an unopened Glargine insulin pen for Resident 9 was noted to be in the cart. The pharmacy sticker indicated that the medication was to be refrigerated until opened. Immediate interview with Employee 1 confirmed the findings and discarded Resident 12's Lispro insulin pen. She said that another nurse may have just pulled Resident 9's insulin pen from the medication refrigerator since the other pen was getting low. Observation of the South Unit Medication Room with Employee 2 (Registered Nurse) on November 13, 2025, at 9:37 AM, revealed two unopened bottles of Aspirin 325 mg tablets, both with a manufacturer expiration date of October 2025; and a bottle of Naproxen 220 mg tablets with an open date of February 20, 2025, and a manufacturer expiration date of September 2025. Employee 2 confirmed that the medications were expired and said she would discard them. Observation of the Guild Unit Medication Cart with Employee 2 on November 13, 2025, at 9:51 AM, revealed a bottle of guaifenesin 400 mg caplets with an open date of October 1, 2025, and a manufacturer expiration date of September 2025. Employee 2 confirmed that the guaifenesin tablets were opened after the manufacturer date. She further indicated that the resident that was taking this medication had just recently finished the course of treatment and that she did not think they had anyone else on this medication. She said she would discard the medication. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 4 (Regional Director of Clinical Services) on November 13, 2025, at 2:19 PM, the NHA confirmed that she would expect medications to be stored properly to include being discarded when expired. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, review of select employee files, and a staff interview, it was determined that the facility failed to verify if individuals have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property for four of five employee files reviewed (Employees 5, 6, 7, and 8).Findings include:Review of facility policy, titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed October 9, 2025, read, in part, Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property; a disciplinary action taken against his or her professional license by a state licensing body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of select facility documentation provided revealed Employee 5 (Registered Nurse) had an original hire date of October 9, 2025. Upon request, the facility was not able to provide evidence that a criminal background check was requested prior to hire.Review of select facility documentation provided revealed Employee 6 (Nurse Aide) had an original hire date of August 14, 2025. Upon request, the facility was not able to provide evidence that a nurse aid registry verification was performed prior to hire. Review of select facility documentation provided revealed Employee 7 (Nurse Aide) had an original hire date of September 4, 2025. Upon request, the facility was not able to provide evidence that a nurse aid registry verification was performed prior to hire. Review of select facility documentation provided revealed Employee 8 (Licensed Practical Nurse) had an original hire date of October 16, 2025. Upon request, the facility was not able to provide evidence that a professional license verification was performed prior to hire. Interview with Employee 4 (Regional Director of Clinical Services) and the Nursing Home Administrator (NHA) on November 14, 2025, at 1:02 PM, revealed the employee files reviewed were prepared by the previous Human Resources Director and they did not complete the license verification, nurse aide registry inquiries, or background check prior to hire. The NHA revealed she would expect license verification, nurse aide registry inquiries, and background checks to be completed prior to hire.28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations, facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 30 residents reviewed (Residents 5 and 84).Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-centered, revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of facility policy, titled Isolation- Categories of Transmission-Based Precautions, revised September 2022, failed to reveal any expectation of adding transmission-based precautions to a resident's care plan. Review of Resident 5's clinical record revealed diagnoses that included depression, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 5's clinical record revealed that he began experiencing cognitive issues and behaviors around August 5, 2025, and that an anti-anxiety medication was ordered as well as a psychiatric consult. Further review of Resident 5's care plan failed to reveal a care plan focus for his dementia diagnosis or hisidentified target behaviors. During a staff interview with Employee 4 (Regional Director of Clinical Services) on November 14, 2025, at 1:30 PM, Employee 4 confirmed that the care had not been revised when behaviors started and dementia diagnosis added. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 4 on November 14, 2025, at 1:58 PM, the NHA confirmed that Resident 5's care plan should have been revised when the changes occurred. Review of Resident 84's clinical record revealed diagnoses that included cerebral infarction (the death of brain tissue caused by a lack of blood flow) and hemiplegia (paralysis affecting one side of the body, resulting in weakness, stiffness, and poor motor control on that side). Observation of Resident 84's room door on November 12, 2025, at 9:45 AM, revealed a sign signifying that Resident 84 was on contact precautions. Review of current physician orders for Resident 84 revealed a current order for contact precautions due to ESBL (Extended-Spectrum Beta-Lactamase, which are enzymes produced by bacteria that make them resistant to certain antibiotics). Review of Resident 84's care plan failed to reveal any indication that contact precautions need to be followed when caring for Resident 84. An interview with the NHA on November 14, 2025, at 12:15 PM, revealed that Resident 84 should have contact precautions included on their care plan. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, document review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on one of three nursing units (three shower rooms on the north unit and one resident bathroom on the north unit).Findings include: During an interview with Resident 24 on November 12, 2025, at 11:00 AM, the resident stated that the shower room in the northwest hall needed to be repaired; there were holes in the flooring. During an interview with Resident 120 on November 12, 2025, at 11:30 AM, the resident stated that the shower room on the northeast hall needed to be cleaned. Observation in the Northwest shower room on November 12, 2025, at 11:45 AM, revealed there were holes in the flooring an inch and a half a quarter way around the drain (down to the tile floor) and in two areas in front of the shower: an inch and a half by four inches and two by three inches. Observation in the Northeast front shower room on November 12, 2025, at 11:45 AM, revealed the bottom of the shower curtain contained black substance, the lip to the shower and along the non-skid tape inside the shower contained a black substance, and the shower head was removed from the hose and was on the sink counter (the thread on the shower head was inside the hose). Observation in the Northeast rear shower room on November 12, 2025, at 11:50 AM, revealed there was no caulk in front of the shower, and the inside of the shower floor was chipped. Observation of the above shower rooms with the Nursing Home Administrator (NHA) on November 13, 2025, at 9:00 AM, revealed the shower rooms were as stated above. At that time, the NHA revealed the shower rooms were scheduled to be renovated, the Guild shower room was in the process of being renovated, and one shower room on the South unit had already been renovated. Interview with the NHA on November 14, 2025, at 2:25 PM, revealed that the shower rooms should be clean, and the shower head and curtain should've been replaced. During an interview with Resident 136, on November 12, 2025, at 11:59 AM, she reported that the shower in her bathroom was dirty with water sitting in it. She indicated that it had been like that for weeks and that she had been asking for someone to fix it. She said that the smell upset her stomach. Immediate observation of Resident 136's bathroom at 12:01 PM, revealed the shower stall had no shower head and the waterspout was plugged off. There was brown colored water sitting on the floor of the shower. The shower drain was closed off with a bolt. The vented drain covered was removed and laying on the soap dish of shower wall. There was a strong, offensive odor noted. During a follow-up observation of Resident 136's bathroom on November 13, 2025, at 8:57 AM, the same findings were noted. During an observation with the NHA on November 13, 2025, at 9:37 AM, the NHA indicated that she thought the plumber had been called to address the issue but would follow-up. During a staff interview with the NHA, Director of Nursing (DON), and Employee 4 (Regional Director of Clinical Services on November 13, 2025, at 2:10 PM, the NHA Indicated that she had spoken to the facility's maintenance director regarding the drain in Resident 136's shower. She said that maintenance went and looked at the drain and removed the bolt that was plugging the drain. She indicated that the water drained out with no issues. The NHA said she was not sure why the drain was closed off. She said that the shower had now been cleaned, and the vented drain plate was placed. Review of facility provided Housekeeper 3 cleaning checklist for November 12, 2025, revealed that a housekeeper had completed cleaning of Resident 136's room. 28 Pa. Code 201.18 (b)(1)(3) (e)(2.1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services necessary for care dependent residents for two of five residents reviewed (Residents 1 and 2).Findings Include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) and hypertension (high blood pressure). Review of Resident 1's comprehensive care plan under the focus section for Activities of Daily Living (ADL), revealed an intervention that Resident 1 required total assistance with eating and drinking, initiated on June 25, 2025. Further review of Resident 1's care plan, under the focus section for nutrition, revealed an intervention to provide feeding assistance at meals, initiated on April 18, 2024.Review of Resident 1's clinical record revealed an eating task with a 30 day look back from August 25, 2025, through September 22, 2025 revealed that Resident 1 did not receive the required assistance with eating on the following dates: August 27 for two meals, September 6 for one meal, September 8 for three meals, September 10 for one meal and September 16 and 17 for one meal.Review of Resident 2's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily lift) and atrial fibrillation (irregular heartbeat). Review of Resident 2's comprehensive care plan under the focus section for ADLs, revealed an intervention that Resident 2 required total assistance with eating and drinking, initiated on August 15, 2025. Further review of Resident 2's care plan under the focus section for nutrition revealed that the Resident was at risk for malnutrition related to dementia diagnosis, with an intervention to monitor and record intake at meals, initiated on August 20, 2025. Review of Resident 2's clinical record revealed an eating task with a 30 day look back from August 25, 2025, through September 22, 2025 revealed that Resident 2 did not receive the required assistance with eating on the following dates: August 26 for two meals, August 27 for one meal, September 6 for one meal, September 8 for three meals, September 12 for one meal, September 17 for two meals and September 18 for two meals. During an interview with the Nursing Home Administrator on September 23, 2025, at approximately 3:00 PM, it was revealed they would expect staff to be documenting if a resident received feeding assistance for every meal. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of five residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) and hypertension (high blood pressure). Further review of Resident 1's clinical record revealed that the Resident had a stage 4 pressure ulcer on the sacral region. Review of Resident 1's Treatment Administration Record (TAR) for June 2025, revealed an order to change wound vac (Vacuum-assisted closure - a medical device that uses negative pressure to remove drainage from wounds and promote healing) three times a week, wash with normal saline, pack with black foam drape and set negative pressure to 125 mmHg (millimeters of mercury). Dust surrounding skin with over the counter (OTC) antifungal powder. Use skin prep prior to wound vac placement, every evening shift every Monday, Wednesday, and Friday for wound care, with a start date of April 18, 2025, and discontinue date of June 20, 2025. Further review of Resident 1's June 2025 TAR revealed that on June 2 and 5, it was marked 5, which is code for hold. Review of Resident 1's nursing progress notes revealed a medication administration note written on June 2, 2025, at 9:28 PM, in relation to the order above, that read, in part, wet to dry applied, wound nurse states she was going to do it but she never showed up. When writer attempted to do it, writer couldn't find a wound vac kit. Went to wound nurse's office door were locked. Called the supervisor no answer. Further review of Resident 1's nursing progress notes revealed a medication administration note written on June 3, 2025, at 11:48 AM, that the Resident's wound vac was not on at present time. On June 4, 2025, at 8:45 PM, there was a nursing progress note written Resident 1's wound vac was done PRN (as needed) on June 3, 2025. Review of Resident 1's June 2025 TAR revealed a PRN order to change wound vac three times a week, wash with normal saline, pack with black foam drape and set negative pressure to 125 mmHg. Dust surrounding skin with OTC antifungal powder. Use skin prep prior to wound vac placement as needed, with a start date of April 18, 2025, and a discontinue date of June 20, 2025. Further review of Resident 1's June 2025 TAR revealed that there was no documentation indicating a PRN wound vac change occurred on June 3, 2025. Review of Resident 1's June 2025 TAR revealed a PRN order that if wound vac not functioning, place a wet to dry dressing to site and notify medical director as needed, with a start date of April 18, 2025, and discontinue date of June 15, 2025. Further review of the June 2025 TAR failed to reveal any documentation indicating the Resident received wet to dry dressing during that time. Review of Resident 1's July 2025 TAR revealed an order for State IV left buttock: cleanse wound with vasche, apply triple mix ointment (1% hydrocortisone, zinc oxide, antifungal ointment mixed in equal parts) to skin surrounding wound, apply aquacel ag rope to wound opening, cover with silicone bordered super absorbent dressing twice a day and prn soilage every day and evening shift, with a start date of June 13, 2025. Further review of Resident 1's July 2025 TAR relating to the order above revealed that on July 3, 2025, during day shift, it was left blank, indicating the wound treatment did not occur. During a staff interview on September 23, 2025, at approximately 3:00 PM, the Nursing Home Administrator (NHA) revealed that she felt like Resident 1's wound treatment was completed on the dates listed above and felt it was a documentation error. NHA revealed she would expect staff to be documenting when any treatment or prn treatment was completed. 28 Pa. Code 211.12 Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 10 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included anxiety disorder (excessive fear or apprehension about real or perceived threats) and depression (persistent feelings of sadness, loss of interest in activities, and a range of emotional, physical and cognitive symptoms). Review of Resident 2's clinical record revealed she was ordered Lorazepam 0.5 milligrams (mg) one time daily for anxiety for six months, with a start date of November 4, 2024 and Lorazepam 0.5 mg every 12 hours as needed (PRN). Review of Resident 2's May 2025 medication administration record (MAR) revealed Resident 2's daily Lorazepam order stopped on May 3, 2025 and a new order did not start until May 13, 2025. Review of the controlled drug record for the Resident 2's Lorazepam revealed Employee 1 continued to sign out the medication for six days after the daily order stopped (May 4 - 9, 2025). Further review of Resident 2's May 2025 MAR revealed no doses of the PRN Lorazepam had been documented as administered during May 4 - 9, 2025. An interview on June 17, 2025 at 2:00 PM, with the Director of Nursing (DON), reveled that the issue was brought to her attention around May 10, 2025 and an investigation was conducted. The investigation found that Resident 2 had a routine Lorazepam order that had fallen off the MAR. Employee 1 continued to administer the medication for several days before it was discovered that there was no order for the daily Lorazepam. Employee 1 continued to sign off the Lorazepam on the narcotic count sheet and Resident 2 did have a prn order for the Lorazepam, but Employee 1 did not document the administration under the prn order. The physician was notified and provided a new order for the daily Lorazepam. A QAPI review of the incident was completed and a plan of correction was put into place. An initial audit of all narcotics was done with a follow up audit one month later, no additional issues were found. Education and a medication administration competency was provided for all nursing staff. The DON stated it was the expectation of the facility that medication be administered and documented properly. Due to the facility completing a plan of correction on May 28, 2025, the deficient practice was found to be past non-compliance. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for one of six residents reviewed (Resident 1). Findings include: Review of facility policy, titled Weight Assessment and Intervention, last reviewed March 29, 2025, read, in part, Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Care planning for weight loss or impaired nutrition is a multidisciplinary effort. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy (the loss of muscle mass and strength), dysphagia (difficulty swallowing), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 1's physician orders revealed an order for Weekly weights X 4 weeks - new admission, every day shift every Wednesday for 4 Weeks, Document weight in PCC, with a start date of January 29, 2025, and a noted completed date of February 26, 2025. Review of Resident 1's clinical record revealed he weighed 193.4 pounds on January 29, 2025, and showed he had experienced a significant weight loss in one month to 178.2 pounds (7.8%) on February 26, 2025. Further review of Resident 1's clinical record failed to reveal weights were obtained and documented weekly as per physician order on February 12 and 19, 2025. Review of Resident 1's progress notes revealed Employee 1 (Registered Dietitian) wrote a progress note titled Brief Weight Note, about Resident 1 on February 26, 2025, that detailed, in part, Resident noted with significant weight loss in 30 days - which is unplanned/undesirable. Reweigh requested to confirm and pending. Full nutrition assessment to follow once weight change is confirmed. Discussed food preferences and possible interventions and resident agreeable to having fortified foods twice daily [and] will add fruit with breakfast. Review of Resident 1's physician orders revealed an order for Weight STAT (without delay or immediately), with a start and completed date of March 3, 2025. Review of Resident 1's March 3, 2025, weight measure revealed it was 177.4 pounds, which confirmed his significant weight loss. Review of Resident 1's care plan on April 7, 2025, failed to reveal his weight loss or nutrition interventions in response to his weight loss had been added to his care plan. During an interview with the Director of Nursing on April 8, 2025, at 1:46 PM, she revealed her expectation that weights should be obtained per physician's order, reweighs should be obtained the next day for confirmation, and care plans should be updated to reflect residents' weight loss and interventions. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on record review and staff interview, it was determined that the facility failed to document physician ordered medication administrations in the clinical record for one of seven residents reviewed (Resident 6). Findings include: A review of the clinical record for Resident 6 revealed diagnoses that included Type 2 Diabetes Mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and hypertension (elevated blood pressure). Further review of the clinical record revealed that Resident 6 was admitted to the facility on [DATE], post-hospitalization for sepsis (bacterial blood stream infection). The Resident was admitted with a PICC (peripherally inserted central catheter) to administer intravenous medications. The Medication Administration Record (MAR) for Resident 6 revealed the following intravenous (IV) flushes were not signed off as completed: Sodium Chloride 0.9%, use 10 milliliters (ml) to flush IV for PICC maintenance on December 28, 2024, evening shift Heparin Lock flush IV solution, use 10 units/ml, flush with 5 ml IV every shift for PICC maintenance on December 28, 2024, evening shift; January 8, 11, 12, 25, 26, 30, and 31, 2025, day shift; and January 20, 23, 28, and 30, 2025, night shift. Written statements from the staff revealed the Registered Nurses (RNs) performed these IV flushes due to the Licensed Practical Nurses not being permitted to flush PICC lines, and the RNs failed to sign off on the MAR. During an interview with the Director of Nursing (DON) on March 5, 2025, at 4:50 PM, the DON confirmed that documentation in the clinical record should be completed for care and services provided to residents. 28 Pa. Code 211.12(d)(5)Nursing services

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's comprehensive plan of care for one of five residents reviewed (Resident 1). Findings include: Review of facility policy, titled Perineal Care, last revised February 2018, read, in part, The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. Review of Resident 1's clinical record revealed diagnoses that included benign prostatic hyperplasia (BPH- a condition in which the flow of urine is blocked due to the enlargement of prostate gland), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Review of Resident 1's comprehensive care plan revealed a focus area of I have urinary incontinence, diagnosis BPH, with an intervention for check resident approximately every 2 hours and provide incontinence care as needed. Review of Resident 1's nurse aide task documentation on December 23, 2024, revealed it was documented that Resident 1 was last assisted with toileting on December 23, 2024, at 9:19 AM. Observation of Resident 1 on December 23, 2024, at 11:47 AM, revealed he was sitting in a dining area with other residents, and a yellow puddle consistent with urine appeared underneath his chair. Further observation in the dining area on December 23, 2024, at 12:10 PM, revealed Resident 1 wheeling away from the dining area and Employee 1 (Nurse Aide) wheeled him back over to the table where he was sitting previously, over the urine puddle. During an interview with Employee 2 (Licensed Practical Nurse) on December 23, 2024, at 1:02 PM, the surveyor revealed the concern that Resident 1 was still sitting in the dining area appearing to be incontinent of urine. Observation on December 23, 2024, at 1:09 PM, revealed Employee 3 (Nurse Aide) and Employee 4 (Nurse Aide) were wheeling Resident 1 into a shower room with incontinence care supplies and new pants. During an interview with the Director of Nursing (DON) on December 23, 2024, at 1:19 PM, she confirmed that Resident 1 was incontinent of urine, and she spoke with Employee 1 who stated she told Employee 3 that the Resident needed to be changed when she realized he was incontinent at 12:10 PM. The DON further revealed that Employee 3 stated she got sidetracked with other tasks and lost track of time before she was able to get to him to provide incontinence care. The surveyor revealed the concern with the lack of incontinence care until surveyor inquiry. No further information was provided. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of five residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Observation of Resident 1 on December 23, 2024, at 11:47 AM, revealed he was sitting in a dining area with other residents, and a yellow puddle consistent with urine appeared underneath his chair. Further observation in the dining area on December 23, 2024, at 12:10 PM, revealed Resident 1 wheeling away from the dining area and Employee 1 (Nurse Aide) wheeled him back over to the table where he was sitting previously, over the urine puddle. During an interview with Employee 2 (Licensed Practical Nurse) on December 23, 2024, at 1:02 PM, the surveyor revealed the concern that Resident 1 was still sitting in the dining area appearing to be incontinent of urine. Observation on December 23, 2024, at 1:09 PM, revealed Employee 3 (Nurse Aide) and Employee 4 (Nurse Aide) were wheeling Resident 1 into a shower room with incontinence care supplies and new pants. During an interview with the Director of Nursing on December 23, 2024, at 1:19 PM, she confirmed that Resident 1 was incontinent of urine, and when she spoke to Employee 1, she revealed she told Employee 3 that Resident 1 needed to be changed when she realized he was incontinent at 12:10 PM; but that Employee 3 got side tracked with other tasks and lost track of time before she was able to get to him to provide incontinence care. The surveyor revealed the concern with the lack of incontinence care until surveyor inquiry. No further information was provided. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, observation, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 25 residents reviewed (Residents 65, 102, 106, and 113), and failed to give the opportunity to participate in the development, review, and revision of his/her care plan for four of 25 residents reviewed (Residents 41, 73, 91, and 101). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revised date of March 2022, and last review date of June 17, 2024, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; 4. Each resident ' s comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; and 5. The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences. Review of Resident 65's clinical record revealed diagnoses that included acute embolism (a life-threatening condition that occurs when a blood clot blocks a pulmonary artery) and thrombosis (when blood clots block veins or arteries). Review of Resident 65's physician orders on October 7, 2024, revealed an order for Apixaban (anticoagulant medication) 2.5 mg twice daily, with a start date of September 1, 2024. Review of Resident 65's care plan on October 7, 2024, failed to reveal a care plan with any information regarding Resident 65's anticoagulation therapy. Interview with the Director of Nursing (DON) on October 9, 2024, at 12:33 PM, revealed that Resident 65's care plan should include care information regarding her use of anticoagulant medication. Review of Resident 102's clinical record revealed diagnoses that included protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and acute respiratory failure (a condition where you don't have enough oxygen in the tissues in your body). Review of Resident 102's POLST (Pennsylvania Orders for Life Sustaining Treatment) completed and signed on December 6, 2023, revealed that Resident 102's Representative indicated that Resident 102 should have DNR (do not resuscitate) status. Review of Resident 102's physician orders on October 7, 2024, revealed an order for DNR (Do Not Resuscitate), with a start date of May 1, 2024. Review of Resident 102's care plan on October 7, 2024, revealed a care plan with a focus area of the Resident has the following advanced directives on record with an intervention of, I am Full Code, with a date initiated of August 23, 2023. Interview with the DON on October 9, 2024, at 12:33 PM, revealed that Resident 102's care plan should have been updated to remove full code status when Resident's Representative updated the advanced directive on December 6, 2023. Review of Resident 106's clinical record revealed diagnoses that included presence of cardiac pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and muscle weakness. Review of Resident 106's physician orders revealed an order for Monitor pacer site every day for signs and symptoms of infection until healed, with a start date of August 16, 2024, and discontinued on September 24, 2024. Review of Resident 106's clinical record revealed a nursing progress note on August 14, 2024, that she was admitted to the hospital, and she was scheduled for a pacemaker implant that morning. Observation in Resident 106's room on October 6, 2024, at 11:18 AM, revealed a pacemaker monitor at her bedside. Review of Resident 106's care plan failed to reveal notation of her cardiac pacemaker. During an interview with the DON on October 8, 2024, at 1:38 PM, she revealed Resident 142's pacemaker had now been added to her care plan and that it should have been on her care plan. Review of Resident 113's clinical record revealed diagnoses that included retention of urine (unable to empty bladder) and urinary tract infection (UTI - bacterial infection occurring in the bladder, kidneys, ureters, and urethra). Review of Resident 113's current physician orders failed to reveal an order for a foley catheter. Review of Resident 113's discontinued/completed physician orders revealed an order dated August 27, 2024, to remove the foley catheter. Review of Resident 113's care plan revealed a focus area for an indwelling urinary catheter. During an interview on October 8, 2024 at 1:47 PM, with the DON and Nursing Home Administrator (NHA), the DON revealed the facility failed to revise Resident 113's care plan after the foley catheter was discontinued. The DON stated it was the expectation of the facility that care plan revisions be done timely. Review of Resident 41's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 41's clinical record revealed that the facility had completed quarterly assessments on May 13, 2024, and August 13, 2024. Further review of Resident 41's clinical record revealed that their last documented care plan meeting occurred on February 29, 2024. Review of Resident 73's clinical record revealed diagnoses that included dementia and thyroid cancer. Review of Resident 73's clinical record revealed that the facility had completed a quarterly assessment on August 24, 2024. Further review of Resident 73's clinical record revealed that their last documented care plan meeting occurred on June 21, 2024. Review of Resident 91's clinical record revealed diagnoses that included stroke and pressure ulcer (wound of the skin caused by pressure over a bony prominence that extends to the subcutaneous tissue). During an interview with Resident 91's Representative on October 6, 2024, at 1:21 PM, they indicated that they had not participated in a care plan meeting in six months and that, when they asked about the care plan meetings, they were told the facility was down a Social Worker. Review of Resident 91's clinical record revealed that the facility had completed quarterly assessments on May 4, 2024, and August 24, 2024. Further review of Resident 91's clinical record revealed that their last documented care plan meeting occurred on February 15, 2024. Review of Resident 101's clinical record revealed diagnoses that included dementia and unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact can be lost with reality). Review of Resident 101's clinical record revealed that the facility had completed quarterly assessments on June 7, 2024; September 7 and 19, 2024. Further review of Resident 101's clinical record revealed that their last documented care plan meeting occurred on March 22, 2024. During a staff interview with the DON on October 8, 2024, at 10:11 AM, she indicated that the facility Social Worker was off on a medical leave and that, although they had someone to cover the Social Worker's leave, not all resident care plan meetings occurred. During a final staff interview with the NHA and DON on October 8, 2024, at 1:51 PM, the DON confirmed that the care plan meetings should have been held, and that Residents 41, 73, 91, and 101 or their Representatives should have been invited to participate. 28 Pa. Code 211.10(c)Resident care policies 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice when administering medications for five of 22 residents reviewed on the East Wing (Residents 11, 21, 43, and 55), and that physician orders are discontinued for one of 25 residents reviewed (Resident 99). Findings Include: Review of Resident 11's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and age-related osteoporosis (occurs when bones become weaker and more fragile due to the aging process). A review of Resident 11's clinical record revealed she was ordered Levothyroxine 75 mcg (micrograms) daily at 6:00 AM. A review of Resident 11's medication administration record failed to reveal that the medication was initialed by Employee 10 as administered on October 6, 2024, at 6:00 AM. Review of Resident 21's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and insomnia (difficulty sleeping). A review of Resident 21's clinical record revealed she is ordered Levothyroxine for hypothyroidism 88 mcg every other day at 6:00 AM that was due on October 6, 2024. A review of Resident 21's medication administration record failed to reveal that the medication was initialed by Employee 10 as administered on October 6, 2024, at 6:00 AM. Review of Resident 43's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and insomnia (difficulty sleeping). A review of Resident 43's clinical record revealed she is ordered Levothyroxine for hypothyroidism 50 mcg daily at 6:00 AM. A review of Resident 43's medication administration record administration section failed to reveal that the medication was initialed by Employee 10 as administered on October 6, 2024, at 6:00 AM. Review of Resident 55's clinical record revealed diagnoses that included hypothyroidism (thyroid doesn't produce enough thyroid hormone) and hypertension (elevated blood pressure). A review of Resident 55's clinical record revealed she is ordered Levothyroxine for hypothyroidism 62.5 mcg daily at 6:00 AM. A review of Resident 55's medication administration record administration section failed to reveal that the medication was initialed by Employee 10 as administered on October 6, 2024, at 6:00 AM. During an interview with the Director of Nursing (DON) on October 7, 2024, at approximately 10:00 AM, she informed this surveyor that all medications should be signed off by staff immediately after administering the medication. The DON also stated that she interviewed Employee 10, who said she did administer the medication and the levothyroxine doses were not present in the Resident's medication compartments. The DON notified the physician regarding the situation. A review of Resident 99's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine). A review of Resident 99's physician orders dated October 2024 revealed an order to provide the Resident with an extra 240 cc (equals 8 ounces) of fluids every shift x (times) 5 days effective June 10, 2024, and on October 7, 2024, the order was still active. During an interview with the DON on October 7, 2024, at approximately 10:00 AM, she informed the surveyor that the physician never added a stop date to the order, so the order remained in effect. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to administer the correct dosage of medication for one of 25 residents reviewed (Resident 41); and failed to ensure that physician's orders were implemented for three of 22 residents on the East Wing (Residents 69, 87, 89). Findings include: A review of the facility policy, titled Administering Medications, last revised April 2019, revealed that the individual administering the medications records in the resident's medical record; the date and the time the medication was administered; the dosage; the signature and title of the person administering the medication. The individual administering medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. Review of Resident 41's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 41's current physician orders revealed an order for oxycodone (a controlled opioid pain medication) oral tablet 5 mg give 0.5 tablet by mouth every six hours as needed for severe pain, dated February 19, 2024. Review of Resident 41's progress notes revealed a note dated May 6, 2024, that indicated a nurse had identified that Resident 41's medication card for their ordered oxycodone contained tablets that were 5 mg (milligrams) and that it was noted on the controlled substance log that only one of the six documented medication administrations had indicated that half a tablet was wasted; therefore, Resident 41 received the wrong medication dose on five occasions (March 5, 9, 14, and 21, 2024; and May 6, 2024). The note also indicated that Resident 41 had no negative outcomes and that their Representative and physician was made aware of the error. Review of facility provided medication error report revealed that Employees 11, 12, and 13 confirmed that they gave the wrong dose of oxycodone to Resident 41. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 9, 2024, at 12:11 PM, the DON indicated education was provided to all licensed nurses regarding the 10 rights to medication administration, and she confirmed that she would expect nurses to administer the correct doses of medication as ordered. During the survey screening process on October 6, 2024, at approximately 11:45 AM, Resident 87 ambulated to the hall to inform this surveyor that she was not administered her 6:00 AM medications by the night shift nurse on that morning. During the conversation, Employee 9 (Licensed Practical Nurse) was present and stated that Resident 87 also informed her that the medications were not administered when she started her medication pass on day shift, and that she notified the Supervisor, who was going to notify the physician. Employee 9 also stated that she requested an order for the analgesic so that she wouldn't have to wait several hours until the next dose was due. Resident 87 said that she needs her Tylenol because she has pain in the morning when she first gets out of bed. A review of Resident 87's BIMS (brief interview of mental status) reveals a score of 15, indicating she is cognitively intact. Review of the clinical record revealed the medication administration record (MAR) was not signed off for Buspar (anxiolytic- to decrease anxiety/depression) and Tylenol (analgesic for pain). During interview with Employee 9 on October 6, 2024, the employee stated that other residents stated they did not receive their early morning medications and that the Supervisor was made aware of the reports. The DON interviewed the three residents that were capable of interviews, based on a BIMS score. Resident 87 informed the DON that she had not received her 6:00 AM medications that included the buspar and Tylenol; Resident 69 informed the DON that she didn't receive her 6:00 AM Lasix (diuretic to decrease edema) for a diagnoses of congestive heart failure (excessive body/lung fluid caused by a weakened heart); and Resident 89 informed the DON that she didn't receive her 6:00 AM medications that included Tylenol for pain and phenobarbital for seizures (uncontrolled jerking, loss of consciousness, blank stares and other symptoms caused by abnormal electrical activity in the brain). A review of the clinical records for Resident 69 and Resident 89 revealed their 6:00 AM medications were not signed off to indicate administration. The phenobarbital narcotic count revealed the 6:00 AM dose was present and not administered as ordered by Employee 10. The DON was made aware of the complaints of medication omissions on October 6, 2024, by the night shift supervisor, and began an investigation that included interviewing staff and residents and contacting the individual assigned to the medication pass from 5:00 AM until 6:00 AM on October 6, 2024. The facility interview with Employee 10 revealed that Employee 10 stated she gave the medications but didn't sign them off because she thought she could do that at home remotely. The Tylenol is a stock medication so administration could not be confirmed, four doses of levothyroxine (to treat hypothyroidism when thyroid doesn't produce enough thyroid hormone) could not be confirmed as administered, the levothyroxine doses were not present, indicating the medication was removed to administer but the Medication Administration Record (MAR) was not signed off as administered. During an interview with the DON on October 7, 2024, at approximately 11:00 AM, the DON confirmed that medications should be administered as prescribed and initialed by the individual after administration. The DON also informed this surveyor that staff are never given remote access. 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)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 77). Findings include: Review of facility policy, titled End stage renal disease, Care of a Resident with, last revised September 2010, read, in part, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Education and training of staff includes, specifically: The nature and clinical management of ESRD; The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: How information will be exchanged between the facilities. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of Resident 77's clinical record revealed diagnoses that included ESRD (failure of kidney function to remove toxins from blood), hypertension (elevated/high blood pressure), and dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body, a process that is needed when the kidneys are not functioning properly). Review of Resident 77's physician orders revealed an order for Dialysis: Monday-Wednesday-Friday. Arrival time is at 1000 am to 1015 am every day shift every Mon, Wed, Fri, with a start date of April 3, 2024. Review of Resident 77's dialysis communication sheets revealed there were missing communication sheets February 7-March 11, 2024; April 8, 2024; May 6 and 29, 2024; July 15 and 26, 2024; August 5, 16, and 26, 2024; and September 20, 23, and 25, 2024. Further review of Resident 77's dialysis communication sheets provided failed to reveal post-dialysis weights recorded on August 12, 2024, and September 6, 2024. Interview with the Director of Nursing (DON) on October 8, 2024, at 1:28 PM, revealed if information such as post-dialysis weights were not recorded on the communication sheets, she would reach out to dialysis for the missing information. Follow-up interview with the DON on October 8, 2024, at 1:28 PM, revealed they are unable to locate the missing communication sheets or missing documentation from the reviewed communication sheets. The surveyor revealed the concern with the missing dialysis communications and information. The DON further revealed the facility has identified issues with dialysis communication and they are working on fixing that process. 28 Pa code 211.5(f) Medical records 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 25 residents reviewed (Residents 11, 17, 91, and 101). Findings include: Review of Resident 11's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and age-related osteoporosis (occurs when bones become weaker and more fragile due to the aging process). Further review of Resident 11's clinical record revealed that Resident 11 had a fall on February 18, 2024, without injury. A review of Resident 11's Quarterly MDS (minimum data set-periodic assessment) dated April 16, 2024, was marked for a fall with major injury. Further review of the clinical record failed to reveal any documentation of a fall with major injury. The clinical record for Resident 11 revealed that on April 4, 2024, the Resident complained of pain in her left upper arm and shoulder. The physician was notified and assessed the Resident, noting that her left arm hung lower than the right arm. X-rays were ordered and revealed that the bones with osteopenia (body doesn't make new bone as quickly as it reabsorbs the old bone), there was an age-indeterminate comminuted left humeral fracture (a break in the upper arm bone that occurs in at least two places), and a distal fragment is medially displaced over the axillary region. During an interview with Employee 6 (RNAC-Registered Nurse Assessment Coordinator) she confirmed that Resident 11's April 16, 2024, MDS was marked in error. Employee 6 said that the RNAC marked that MDS as a fall with major injury due to the report of the x-ray assuming the fracture occurred with the February 18, 2024, fall. The fall investigation report for February 18, 2024, failed to reveal any injury or complaints of pain. Employee 6 informed the surveyor that the April 16, 2024, MDS will be corrected and resubmitted. During an interview with the Director of Nursing (DON) on October 8, 2024, the DON confirmed that there was no fall with major injury and that the MDS for Resident 11 was marked in error. Review of Resident 17's clinical record revealed diagnoses that included end stage renal disease (kidneys no longer function) and dependence on renal dialysis (treatment needed to clean waste from the body due to kidney failure). Review of Resident 17's physician orders revealed an order for dialysis treatments three times a week. During an interview with Resident 17 on October 6, 2024 at 12:40 PM, it was revealed that Resident 17 had been admitted to the facility about one month ago. Resident 17 also revealed he had started dialysis treatments several months ago due to kidney failure. Review of Resident 17's admission MDS assessment dated [DATE], revealed Resident 17 was coded as not receiving dialysis on admission. Further review of Resident 17's clinical record revealed a hospital discharge summary dated September 7, 2024. Review of the hospital discharge summary revealed Resident 17 had been receiving dialysis services at the time of admission. During an interview on October 7, 2024, at 1:29 PM, Employee 6 revealed Resident 17's admission MDS was coded incorrectly. During an interview on October 8, 2024 at 1:49 PM, with the DON and Nursing Home Administrator (NHA), the DON stated that it was the expectation of the facility that MDS assessments be accurate. Review of Resident 91's clinical record revealed diagnoses that included stroke (damage to the brain from interruption of its blood supply) and Stage 4 pressure ulcer (wound of the skin caused by pressure over a bony prominence that extends to the muscle, tendons, ligaments, and bone). Further review of Resident 91's clinical record revealed that they acquired their stage 4 pressure ulcer at the facility in January 2023. Review of Resident 91's Quarterly MDS with the assessment reference date of May 4, 2024, revealed in Section M. Skin Conditions that their pressure ulcer was coded as being present upon admission to the facility. Review of Resident 91's Quarterly MDS with the assessment reference date of August 4, 2024, revealed in Section M. Skin Conditions that their pressure ulcer was coded as being present upon admission to the facility. Email communication received from Employee 7 (Regional Director of Clinical Services) on October 9, 2024, indicated that Resident 91's MDS's were coded inaccurately. Email communication received from the DON on October 9, 2024, at 1:01 PM, indicated that she would expect a resident's MDS assessments to be coded accurately. Review of Resident 101's clinical record revealed diagnoses that included dementia and unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact can be lost with reality). Review of Resident 101's Quarterly MDS with the assessment reference date of June 7, 2024, indicated in Section N. Medications that the Resident had received an antipsychotic medication on a routine basis and that their physician had not documented that a gradual dosage reduction was clinically contraindicated. Review of Resident 101's clinical record revealed a psychiatric consult visit note dated April 19, 2024, that indicated that a gradual dose reduction of their antipsychotic medication was clinically contraindicated. Review of Resident 101's Quarterly MDS with the assessment reference date of September 19, 2024, indicated in Section N. Medications that the Resident had received an antipsychotic medication on a routine basis and that their physician had not documented that a gradual dosage reduction was clinically contraindicated. Review of Resident 101's clinical record revealed a psychiatric consult visit note September 16, 2024, that indicated that a gradual dose reduction of their antipsychotic medication was clinically contraindicated. During a staff interview with Employee 3 (Registered Nurse Assessment Coordinator) on October 9, 2024, at 8:59 AM, she confirmed that the gradual dose reduction clinically contraindicated dates should have been included in Resident 101's MDS assessments and that modifications would be completed. During a staff interview with the Nursing Home Administrator and DON on October 9, 2024, at 12:12 PM, the DON confirmed that she would expect a resident's MDS assessments to be completed accurately. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, evidenced by an acute fracture of the left humeral neck (upper arm), for one of five residents reviewed (Resident 3). Findings Include: Review of facility policy titled Lifting Machine, Using a Mechanical, undated, revealed At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift Types of lifts that may be available in the facility are: .Sit-to-stand lifts. Review of Resident 3's clinical record revealed diagnoses that included Multiple Sclerosis (a potentially disabling disease of the brain and spinal cord), ataxia (impaired balance or coordination; can be due to damage to brain, nerves, or muscles), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 3's quarterly MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated August 3, 2022, revealed a BIMS (brief interview for mental status) score of 15; meaning Resident 3 is cognitively intact. Review of Resident 3's physician orders revealed an order dated May 11, 2022, to transfer with standing lift. Review of Resident 3's Kardex, dated March 25, 2022, revealed that Resident transferred via standing lift. Review of Resident 3's nursing progress note dated October 18, 2022, revealed that, at 10:00 PM, the nurse was called to Resident 3's room and Resident 3 was observed sitting on the floor in front of her recliner chair, resting her back against the recliner chair, with her legs stretched out in front of her. The progress note further states that the nurse aide was present with the stand-up lift in the room, and stated that Resident 3's feet criss-crossed while on platform of lift causing her to not be able to bear weight and slide. The nurse aide stated she assisted the Resident to the floor. Review of facility's investigation revealed a witness statement from Employee 1 (Registered Nurse), dated October 18, 2022, stating that a nurse aide came to Employee 1 for help with a lift. Upon entering Resident 3's room, Employee 1 noted Resident 3 lying on her back with her head resting on the footrest of Resident 3's recliner chair. Per Employee 1's statement, the nurse aide stated I lowered her to the floor. She didn't fall and she didn't hit her head. Employee 1's statement also said that the nurse aide told her she asked another nurse aide for assistance with the lift and the Resident, but didn't get any response. Review of Employee 2's (Nurse Aide) witness statement, dated October 18, 2022, revealed Employee 2 was assisting Resident 3 to bed using the stand lift and her feet began to cross/overlap. Employee 2 stated when she noticed that Resident 3 was unable to stand, she lowered Resident 3 to the floor. Employee 2's statement said that after assisting Resident 3 to the floor, she removed the lift belt and went and got the nurse for assistance. Review of Employee 3's (Nurse Aide) witness statement, dated October 19, 2022, revealed that at approximately 8:30 PM, Employee 2 asked Employee 3 how Resident 3 transfers. Employee 3 stated to use the stand lift. Employee 3 stated that Employee 2 said she was going to do her around 9:00 PM. Per Employee 3's witness statement, Employee 2 did not ask Employee 3 for help. Review of Resident 3's witness statement, dated October 19, 2022, at 10:00 AM, revealed that Resident 3 was in the recliner chair and the nurse aide was using the stand lift. Resident 3 stated I told her she needed 2 people when using lift. She moved me from the chair and as I was near the bed I started to slip. I went to the floor Resident 3 stated the nurse aide then went and got other staff for assistance, and Resident 3 was put back to bed using a hoyer lift. Review of Resident 3's nursing progress note dated October 19, 2022, at 11:04 AM, revealed that Resident 3 was complaining of 9/10 pain in her left shoulder with the slightest movement. Left shoulder was noted to be swollen. Physician was made aware and an X-ray was ordered. Review of Resident 3's X-ray results, dated October 19, 2022, revealed Resident 3 had an acute fracture of the left humeral neck. Resident 3 was transferred to the hospital at 8:26 PM and returned to the facility on [DATE], at 2:20 AM, with a left arm sling in place. During an interview with Resident 3 on November 3, 2022, at 1:22 PM, Resident 3 stated that an aide was using a lift to transfer Resident 3. Resident 3 stated she told the aide that the stand lift needs two people but the aide thought Resident 3 was confused and told Resident 3 that she could do it herself. Resident 3 stated that she then fell during the transfer with the lift. During an interview with the Director of Nursing (DON) on November 2, 2022, at 10:35 AM, she stated that Employee 2 did not follow the facility's lift policy, requiring two persons to assist with operating a lift, while transfering Resident 3 with the stand lift. She stated that Employee 2 was immediately educated on the facility's lift policy requiring two people and then, ultimately, Employee 2 was made a do not return to the facility. On November 3, 2022, at 12:10 PM, the DON stated that a plan of correction was put into place as a result of the facility's investigation, which determined that Employee 2 failed to follow the facility's lift policy for a two person assist for all transfers requiring a lift. The facility's education and audits were reviewed during the survey. On October 18, 2022, Employee 2 was educated that all lifts need two assists when operating/transfering residents. On October 19, 2022, education was started for all employees, stating that all transfers using any lift requires two assist. On October 19, 2022, lift competencies were started for all employees. On October 19, 2022, an audit was started on all residents in the facility to ensure their transfer status, with assist level, was clearly stated in all physician orders and their task Kardex. On October 22, 2022, daily observation audits of staff using lifts were started to ensure compliance. Prior to the abbreviated survey, the facility failed to provide the appropriate transfer for Resident 3, resulting in harm to the Resident, as evidenced by a left humeral fracture. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. Review of facility documentation revealed that on October 23, 2022, the facility had completed education for staff, competencies, housewide audit for all residents and initiated continued audits to ensure compliance. During the abbreviated survey, audits, staff education, and residents care Kardex were reviewed. Resident record review and observations revealed no concerns with transfer status for the sampled residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

APPEAL FILED Based on facility policy review, clinical record review, facility incident reports, and staff interviews it was determined that the facility failed to ensure that residents were free of neglect which resulted in actual harm, by sustaining a left leg fracture during a transfer for one of three residents reviewed (Resident 2). Findings Include: Review of the facility's current abuse and neglect policy stated that residents have the right to be free from neglect. The policy stated that all staff of the Jewish Home of Greater Harrisburg are expected to meet the residents needs with a high standard of care in an environment that both cares for and about the resident. The essential focus is on creating an environment of respect, dignity, and protection from harm. Review of the clinical record for Resident 2 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) (periodic assessment tool) dated (MONTH) 27, 2019, revealed that Resident 2 transfers with extensive assistance using a two-person physical assist. Review of Resident 2's care plan revealed an intervention dated (MONTH) 13, 2019, to transfer with a two-person assist. Review of the progress notes revealed a note dated (MONTH) 10, 2019, at 11:58 AM and the note stated, Resident found to have a swollen left foot/ankle area. Left foot is approximately 2X the size of the right foot/ankle. Positive pedal pulse, foot is warm, non-discolored. No c/o pain in foot/ankle area voiced. Dr. (Doctor) aware. Mobile X-ray unit called for a stat X-ray of left foot. Resident is in bed, no weight bearing at this time. The facility's investigation discovered that on (MONTH) 9, 2019, at approximately 3:30 PM Nurse Aide (NA) 1 was transferring Resident 2 by herself. NA 2 walked by Resident 2's room and saw NA 1 transferring the resident into the wheelchair using a bear hug technique. NA 2 entered the room and noticed Resident 2's left leg was tangled in the wheel of the chair. NA 2 untangled resident's leg and assisted NA 1 in finishing the transfer. NA 2 stated that she went to the nursing office to report it, but no one was there. She did not report the incident until the next morning on (MONTH) 10, 2019. At that time, Resident 2 was assessed by the nurse and noted to have swelling to his left foot. A progress note dated (MONTH) 10, 2019, at 12:08 PM stated that Resident 2's X-ray results of left foot/ankle revealed an acute non-displaced oblique [MEDICAL CONDITION] fibula ([MEDICAL CONDITION] leg). Review of the Kardex (Care Guide used by Nurse Aides), in place at the time of the transfer on (MONTH) 9, 2019, revealed under transfers that Resident 2, transfers 2 assist. The active fall care plan on (MONTH) 9, 2019, also stated, transfers 2 assist. During an interview with the Director of Nursing on (MONTH) 17, 2019, at 10:30 AM she confirmed that the care card and care plan reflected that Resident 2 was a two-person assist. During an interview with the Nursing Home Administrator on (MONTH) 17, 2019, at 1:30 PM she confirmed that NA 1 should have used two-person assist. The facility failed to ensure that Resident 2 was free of neglect which resulted in actual harm by sustaining a left leg fracture during transfer. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 2/19/19, 1/12/18. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 2/19/19, 1/31/19, 7/19/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/19/19, 7/19/18. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 1/31/19, 10/4/18, 8/15/18, 7/19/18, 1/12/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/19/19, 1/31/19, 10/4/18, 8/15/18, 7/19/18, 1/12/18.

APPEAL FILED Based on review of incident/accident investigation information and clinical records, as well as staff interviews, it was determined that the facility failed to maintain essential resident care equipment in a safe manner for 55 residents that required the use of mechanical lifts, (Residents 1 through 55), which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and struck his head. The resident was sent to the hospital and diagnosed with [REDACTED]. Findings included: Review of the manufacturer service manual for the Viking M lift, dated (MONTH) 27, 2012, revealed, The lift must be thoroughly inspected when the Service Light at the control unit CBL illuminates (a display on the equipment that indicates serving is required), or at least once per year. Viking with other control unit shall be thoroughly inspected at least once per year. Inspection and service must be carried out by (distributor\manufacturer) authorized personnel. Review of the manufacturer instruction guide for the Uno 102 lift, dated (MONTH) 22, 2013, revealed, A periodic inspection of the lift should be carried out at least once per year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (distributor\manufacturer) and using original (manufacturer) spare parts. Review of the manufacturer instruction guide for the Sabina II sit-to-stand lift, dated (MONTH) 12, 2012, revealed, Sabina should be periodically inspected at least once a year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original (manufacturer) spare parts. Review of an incident/accident investigation information form provided by the facility dated (MONTH) 2, 2019, revealed that on (MONTH) 2, 2019, at approximately 8:38 PM Resident 2 was being returned to bed, when the Viking M lift, which was being used broke, and the resident fell to the floor and struck the back of his head on the floor, resulting in a laceration to the left posterior (back) of the head with bleeding present. Resident 2 was assessed and transported to the hospital where Resident 2 was diagnosed with [REDACTED]. An interview with the Facilities Director on (MONTH) 14, 2019, at 3:42 PM revealed, they (the lifts in the facility) have not been serviced by the manufacturer and that the facility staff had not been trained by the lift manufacturer to service the lifts. During an interview with the Nursing Home Administrator (NHA) on (MONTH) 14, 2019, at 4:50 PM the NHA revealed that the facility did not have a contract with an authorized service company to inspect and service the lifts in the facility annually, as specified in the Instruction Guides and Service Manuals for the three types of lifts being utilized in the facility. When asked for her expectation regarding the contracts she replied, we should have had them. The facility failed to ensure that the mechanical lifts were maintained, inspected and serviced by authorized service providers which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and striking his head, resulting in a brain bleed. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/31/19, 1/12/18. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 1/31/19, 7/19/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/19/18. 28 Pa. Code 207.2(a) Administrator's responsibility.

APPEAL FILED Based on observations, interviews, and review of an incident/accident report it was determined that the facility failed to ensure the residents' environment was free of accident hazards for 55 residents who required the use of mechanical lifts, which resulted in actual harm to Resident 2 when the lift (mechanical device used to transfer residents) broke and the resident fell to the floor and struck his head, requiring transport to the hospital with a diagnosed brain bleed. Findings include: Review of the manufacturer service manual for the Viking M lift, dated (MONTH) 27, 2012, revealed, The lift must be thoroughly inspected when the Service Light at the control unit CBL illuminates (a display on the equipment that indicates serving is required), or at least once per year. Vikings with other control units shall be thoroughly inspected at least once per year. Inspection and service must be carried out by authorized personnel. Review of the manufacturer instruction guide for the Uno 102 lift, dated (MONTH) 22, 2013, revealed, A periodic inspection of the lift should be carried out at least once per year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original spare parts. Review of the manufacturer instruction guide for the Sabina II sit to stand lift, dated (MONTH) 12, 2012, revealed, Sabina should be periodically inspected at least once a year. Periodic inspection, repair and maintenance should be performed only in accordance with the (manufacturer) Service Manual, and by personnel authorized by (manufacturer) and using original (manufacturer) spare parts. Observation of the lifts in the facility revealed they had 5 Viking M lifts-the oldest being a 2007, 5 Sabina or Sabina II lifts-the oldest being a 2002, and 5 Uno 102 lifts-the oldest being a 2001. Review of an incident/accident investigation information form provided by the facility dated (MONTH) 2, 2019, revealed that on (MONTH) 2, 2019, at approximately 8:38 PM Resident 2 was being returned to bed, when the Viking M lift, which was being used broke, and the resident fell to the floor and struck the back of his head on the floor, resulting in a laceration to the left posterior (back) of the head with bleeding present. Resident 2 was assessed and transported to the hospital where Resident 2 was diagnosed with [REDACTED]. The facility investigation revealed that a metal pin which connects the lift arm (the part of the lift that articulates up and down to provide lift to the resident) to the slingbar (a metal bar with hooks on each end used to attach the sling, which the resident is sitting in) had broken, causing the slingbar, the sling and the resident to fall to the floor. An interview with the Facilities Director on (MONTH) 14, 2019, at 3:42 PM revealed, they (the lifts in the facility) have not been serviced by the manufacturer and that the facility staff had not been trained by the lift manufacturer to service the lifts. The facility was unable to provide a policy related to the lifts, that included the required annual inspection and maintenance provided by the manufacturer's authorized service provider. The facility failed to ensure the resident's environment was free of accident hazards for 55 residents that required the use of mechanical lifts, which resulted in actual harm to Resident 2 when the lift broke and the resident fell to the floor and struck his head. The resident was sent to the hospital and diagnosed with [REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 1/31/19. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/31/19, 1/12/18. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 1/31/19, 7/19/18. 28 Pa. Code 201.18(d) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/19/18. 28 Pa. Code 201.29(d) Resident rights. Previously cited 7/19/18. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 7/19/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/31/19, 10/4/18, 8/15/18, 7/19/18, 1/12/18.

Based on review of clinical records, Title 49. Professional and Vocational Standards, and staff interviews, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted initial and/or follow up resident assessments in relation to vitals signs for one of three residents reviewed (Resident 3) which resulted in no blood pressure being taken for 12 hours after the initial low blood pressure assessment, nursing progress notes revealed the resident was transferred to the hospital, [MEDICAL CONDITION] (infection in blood), was placed on life support (mechanical ventilation), and subsequently died . Findings include: Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing Chapter 21, Subchapter A, Section 21.11 states The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse Collects complete and ongoing data to determine nursing care needs. Review of the clinical record for Resident 3 revealed that the resident was admitted to the facility on (MONTH) 1, (YEAR), and transferred to the hospital on (MONTH) 28, (YEAR). Resident 3's [DIAGNOSES REDACTED]. Further review of Resident 3's clinical record progress notes for (MONTH) 27, (YEAR), revealed a note by Registered Nurse (RN) 3, at 8:05 p.m. which reported that the resident's [MEDICATION NAME] (medication used to treat high blood pressure) was held because her blood pressure was lower than the parameters ordered by her physician. The hold parameters are, to hold the medication for systolic blood pressure (the upper number) below 90, or for a heart rate below 60 beats per minute, her blood pressure was assessed at ,[DATE] (normal is ,[DATE]) with a heart rate of 76. An additional progress note by Licensed Practical Nurse (LPN) 1, dated (MONTH) 27, (YEAR), at 11:40 p.m. revealed Resident 3 was administered two tablets of [MEDICATION NAME] (pain medication) 325 milligrams, as needed for moderate pain (pain rated as ,[DATE] on a ,[DATE] scale) because of abdominal pain. Review of the Medication Administration Record [REDACTED]. There was no documentation that the staff reassessed Resident 3's blood pressure at this time. A progress note dated (MONTH) 28, (YEAR), by RN 2 at 1:00 a.m. revealed resident complained of pain across upper abdomen, emesis one time of a clear mucous, and her abdomen was assessed as obese and hard. There was no documentation that the staff reassessed Resident 3's blood pressure at this time. A progress note dated (MONTH) 28, (YEAR), by LPN 1 at 1:08 a.m. revealed that Resident 3's pain was now a 3 out of 10. There was no documentation that the staff reassessed Resident 3's blood pressure at this time. A progress note dated (MONTH) 28, (YEAR), by RN 2 at 1:45 a.m. revealed,the resident is still awake, still complaining of abdominal pain, but not as guarded upon palpation (the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness). There was no documentation that the staff reassessed Resident 3's blood pressure at this time. There was no documentation that the staff notified the physician, or family, at this time. A progress note dated (MONTH) 28, (YEAR), entered by Registered Nurse (RN) 2 at 2:36 a.m. revealed resident continues to holler out if no one is sitting at her bedside, states pain is still present, very anxious, audible wheezing heard, instructed team leader to give [MEDICATION NAME] (a breathing treatment). There was no documentation that the staff reassessed Resident 3's blood pressure at this time. A progress note dated (MONTH) 28, (YEAR), entered by RN 2, at 4:31 a.m. revealed resident having periods of calmness and not hollering, ambulated to bathroom with walker and 1 assist, wanted to sit out of bed, transferred with assist without difficulty or doubling over in pain. There was no documentation that the staff reassessed Resident 3's blood pressure at this time. A progress note dated (MONTH) 28, (YEAR), entered by RN 1, at 9:14 a.m. revealed, per report from night shift supervisor, resident has been complaining of significant abdominal pain overnight and again this morning. Resident stated that she wanted to go to the hospital this morning for evaluation of the pain. RN back to assess the resident. When the RN attempted to palpate the abdomen, resident was guarding area. When the RN able to palpate, resident did complain of pain with all palpations. RN attempted to get vital signs, electronic machine (automatic blood pressure cuff) had blood pressure at ,[DATE], and when RN attempted to obtain a manual blood pressure neither RN or team leader were able to auscultate (the action of listening to sounds of organs, typically with a stethoscope, as part of medical diagnosis). Heart rate was elevated at 101 beats per minute (high). At this time the on-call physician was notified and ordered for Resident 3 to be sent out to the hospital for evaluation of this abdominal pain. 911 was called at 8:55 a.m. and Resident 3 left the facility at 9:15 a.m. This notification of the physician is more than 12 hours after the initial low blood pressure assessment, and more than 9 hours after the resident first started complaining of abdominal pain. During an interview with the Nursing Home Administrator on (MONTH) 6, (YEAR), at approximately 2:30 p.m. it was revealed her expectation is that a staff member would have notified the on-call doctor, if a resident was in pain that long. The facility failed to assure that a Registered Nurse (RN) conducted initial and/or follow up resident assessments in relation to vitals signs for one of three residents reviewed (Resident 3) which resulted in no blood pressure being taken for 12 hours after the initial low blood pressure assessment, nursing progress notes revealed the resident was transferred to the hospital, [MEDICAL CONDITION] (infection in blood), was placed on life support (mechanical ventilation), and subsequently died . 42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards. Previously cited [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE]. 28 Pa. Code 201.18(b)(3) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.29(d) Resident rights. Previously cited [DATE]. 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE], [DATE]. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE]

Based on facility records, policies, and staff interview, it was determined that the facility failed to notify the resident's responsible representative and the attending physician of a change in condition, for one of three residents reviewed (Resident 3) which resulted in the resident having abdominal pain for nine hours, nursing progress notes revealed the resident was transferred to the hospital, [MEDICAL CONDITION] (infection in blood), was placed on life support (mechanical ventilation), and subsequently died . Findings include: Review of the facility policy titled, Call Policy Guidelines For Nursing Supervisors in Nursing Facilities, (the information provided by the facility when a request for information on notifying Physicians after hours was made) revealed the Post-Acute Clinical Practices listed below, provide on call support 24 hours a day, seven days a week. The goal: to provide rapid responses to urgent needs after work hours and on weekends to ensure patient safety and increase efficiency of response times. Further review of the policy guidelines revealed that an acute change of condition call should be presented in SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) format with all data needed readily available. Review of the clinical record for Resident 3 revealed that the resident was admitted to the facility on (MONTH) 1, (YEAR), and transferred to the hospital on (MONTH) 28, (YEAR). Resident 3's [DIAGNOSES REDACTED]. Further review of Resident 3's clinical record progress notes for (MONTH) 27, (YEAR), revealed a note by Registered Nurse (RN) 3, at 8:05 p.m. which reported that the resident's [MEDICATION NAME] (medication used to treat high blood pressure) was held because her blood pressure was lower than the parameters ordered by her physician. The hold parameters are, to hold the medication for systolic blood pressure (the upper number) below 90, or for a heart rate below 60 beats per minute, her blood pressure was assessed at ,[DATE] (normal is ,[DATE]) with a heart rate of 76. An additional progress note, from (MONTH) 27, (YEAR), by Licensed Practical Nurse (LPN) at 11:40 p.m. revealed Resident 3 was administered two tablets of [MEDICATION NAME] (pain medication) 325 milligrams, as needed for moderate pain (pain rated as ,[DATE] on a ,[DATE] scale) because of abdominal pain. Review of the Medication Administration Record [REDACTED]. There was no documentation that the staff reassessed Resident 3's blood pressure at this time. A progress note dated (MONTH) 28, (YEAR), by RN 2 at 1:00 a.m. revealed resident complained of pain across upper abdomen, emesis (involuntary forceful expulsion of stomach contents out of the mouth) one time of a clear mucous, and her abdomen was assessed as obese and hard. There was no documentation that the staff notified the physician, or family, at this time. A progress note dated (MONTH) 28, (YEAR), by LPN 1 at 1:08 a.m. revealed that Resident 3's pain was now a 3 out of 10. A progress note dated (MONTH) 28, (YEAR), by RN 2 entered at 1:45 a.m. revealed,the resident is still awake, still complaining of abdominal pain, but not as guarded upon palpation (the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness). There was no documentation of vital signs being taken at this time. There was no documentation that the staff notified the physician, or family, at this time. A progress note dated (MONTH) 28, (YEAR), entered by Registered Nurse (RN) 2 at 2:36 a.m. revealed resident continues to holler out if no one is sitting at her bedside, states pain is still present, very anxious, audible wheezing heard, instructed team leader to give [MEDICATION NAME] (a breathing treatment). There was no documentation that the staff notified the physician, or family, at this time. A progress note dated (MONTH) 28, (YEAR), entered by RN 2, at 4:31 a.m. revealed resident having periods of calmness and not hollering, ambulated to bathroom with walker and 1 assist, wanted to sit out of bed, transferred with assist without difficulty or doubling over in pain. A progress note dated (MONTH) 28, (YEAR), entered by RN 1, at 9:14 a.m. revealed, per report from night shift supervisor, resident has been complaining of significant abdominal pain overnight and again this morning. Resident stated that she wanted to go to the hospital this morning for evaluation of the pain. RN back to assess the resident. When the RN attempted to palpate the abdomen, resident was guarding area. When the RN able to palpate, resident did complain of pain with all palpations. RN attempted to get vital signs, electronic machine (automatic blood pressure cuff) had blood pressure at ,[DATE], and when RN attempted to obtain a manual blood pressure neither RN or team leader were able to auscultate (the action of listening to sounds of organs, typically with a stethoscope, as part of medical diagnosis). Heart rate was elevated at 101 beats per minute (high). At this time the on-call physician was notified and ordered for Resident 3 to be sent out to the hospital for evaluation of this abdominal pain. 911 was called at 8:55 a.m. and Resident 3 left the facility at 9:15 a.m. This notification of the physician is more than 12 hours after the initial low blood pressure assessment, and more than 9 hours after the resident first started complaining of abdominal pain. During an interview with the Nursing Home Administrator on (MONTH) 6, (YEAR), at approximately 2:30 p.m. it was revealed her expectation is that a staff member would have notified the on-call doctor, if a resident was in pain that long. The staff failed to notify the on-call physician of Resident 3's complaints of abdominal pain, or an abnormal blood pressure in a timely manner, which resulted in the resident having abdominal pain for nine hours, nursing progress notes revealed the resident was transferred to the hospital, [MEDICAL CONDITION] (infection in blood), was placed on life support (mechanical ventilation), and subsequently died . 42 CFR 483.10(g)(14)(i)-(iv)(15) Notify of Changes (injury/decline/room, Etc.) Previously cited [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE]. 28 Pa. Code 201.18(b)(3) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.29(d) Resident rights. Previously cited [DATE]. 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE], [DATE]. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE].

Based on review of select facility reports, clinical record review and staff interviews, it was determined that the facility failed to prevent resident neglect which resulted in a fall with injury to one of 3 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], from the hospital with [DIAGNOSES REDACTED]. Review of Resident 1's comprehensive MDS assessment (Minimum Data Set-a periodic review of resident needs completed on admission, annually or if there are significant changes in condition), dated May 27, 2016, revealed in Section G, Functional Status (ability for resident to perform tasks) G0110 - Activities of Daily Living (ability for resident to perform tasks on a daily basis) regarding transfer status (the ability to move from bed to chair) Resident 1 required limited assistance to perform the task with the physical assist of one staff person. In regards to the activity of toileting, Resident 1 required extensive assistance to perform the activity with the assistance of two staff members. Review of Resident 1's care plan (instructions on how a resident will be taken care of with interventions, goals and outcomes) for the, Potential for Falls, dated May 20, 2016, revealed interventions for bed and chair alarms (devices used to alert staff when a resident attempts to get up from the bed or a chair), indicating that the staff are to check the placement and the function of the alarms each shift. During an interview on June 29, 2016, at 1:15 PM with SD 1 (a Staff Development Registered Nurse), it was confirmed that the facility's expectation is that if a resident had a bed/chair alarm they should not be left unattended in the bathrooms and that when new employees are trained, they are instructed to not leave residents who require the use of a bed/chair alarm alone or unattended while in the bathrooms. Review of a, Post Fall/Found on Floor Investigation, form (a form completed by the staff after a resident has a fall or is found on the floor) dated June 26, 2016, at 1:45 PM revealed that a nurse was responding to the bathroom alarm when Resident 1's husband called stating that the resident was on the floor. The resident was found on the floor lying on her left side with her feet towards the toilet and her head in the doorway, unresponsive. Further review of the clinical record for Resident 1 revealed a progress note (a form used to document care for the resident) that was written after the incident on June 16, 2016 at 1:45 PM by RN 1(Registered Nurse 1). The progress note was dated June 26, 2016, at 9:31 PM and indicated Resident 1 was not responding (not reacting to her surroundings or the people around her- unconscious) but had a pulse and a blood pressure. A small amount of blood was noted on the floor by her left forehead. A cervical collar (also known as a neck brace, a medical device used to support a person's neck) was noted to be on. Resident 1's vital signs (indicators of body function) were heart rate 38 (normal is 72 for men and 80 for women), blood pressure 78/39 (normal is 120/80), and the percent of oxygen in the blood was 68% (normal is greater than 92 %), on room air. After approximately 2 minutes the resident began to respond. Her vital signs at this time were, heart rate 81, blood pressure 98/63 and the percent of oxygen in her blood was 89%, with supplemental oxygen. Resident 1 denied any neck pain or numbness or tingling. The progress note stated that the resident was, hollering to get off the floor. An order to send the resident to the ER (emergency room ) was obtained on June 26, 2016, at 2:00 PM and the resident was transported to the hospital for treatment and evaluation. During the ride to the hospital, the resident, Coded (no heart beat and no breathing) and was pronounced dead in the Emergency Department. Further review of the, Post Fall/Found on Floor Investigation form revealed that NA 1 (Nurse Aide 1) stated that she was unsure if she knew the resident had bed/chair alarms. She said that she believed she knew not to leave the resident alone in the bathroom. She admitted to asking Resident 1 to ring for assistance and then left the floor without telling anyone that Resident 1 was in the bathroom. During an interview with the Nursing Home Administrator and the Director of Nursing on June 29, 2016, at 12:30PM it was revealed that their expectation is that since Resident 1 used bed/chair alarms, Resident 1 should not have been left unattended in the bathroom. The facility failed to provide necessary supervision for a resident who required supervision during toileting, resulting in a fall that required transfer to the hospital. 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/11/16, 2/4/16, 2/12/15. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/12/15. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 2/12/15. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 2/4/16, 2/12/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/11/16, 2/4/16, 2/12/15. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 2/12/15.