Every finding on record at Cathedral Village

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possess the appropriate knowledge, competencies, and skill sets related to wheelchair mobility for one of one employees reviewed (Employee E4), involving resident R1. This deficiency was identified as past non-compliance.Findings include: A review of facility policy titled Wheelchair Mobility Policy, last approved December 30, 2025, revealed Foot pedals/footrests must be properly positioned and in place prior to staff assisting with wheelchair propulsion, unless clinically contraindicated and documented in the residents plan of care. Review Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness/paralysis of left side of body following a stroke), muscle weakness (generalized), other abnormalities of gait and mobility (abnormal walking or movement), pneumonia (infection in the lungs) and heart failure (heart is unable to effectively/efficiently pump enough blood). Review of Resident R1's Minimum Data Set (MDS- federally mandated resident assessment and care screening) dated May 25, 2026, revealed the resident has moderate cognitive impairment and impaired range of motion on one side of his body of both upper and lower extremities. Per the MDS, Resident R1 utilizes a walker and wheelchair for mobility and was coded as dependent for walking 10-, 50-, and 150-foot distances. Review of Resident R1's care plan revealed the resident is at risk for falls, with goal of being free of falls and intervention Assist Resident with ambulation and transfers, utilizing therapy recommendations. Review of facility documentation submitted to the State Survey Agency on June 25, 2026, revealed on June 25, 2026, at 8:50 a.m., Resident R1 had a witnessed fall from his/her wheelchair in the dining room while former agency nurse aide, Employee E4, was assisting the resident in his/her wheelchair back to the resident's room following breakfast. Review of facility incident report revealed agency nurse aide, Employee E4, offered to assist Resident R1 back to his/her room. Nurse aide, Employee E4, asked Resident R1 to pick up his/her feet during transport. Resident R1 was unable to hold his/her feet up causing the resident's feet to lower to the floor, stop the wheelchair, and Resident R1 fell forward out of the wheelchair. Review of facility documentation revealed footrests were not in place, due to Resident R1 self-propelling prior to nurse aide, Employee E4, assistance. Nurse aide, Employee E4, failed to apply the footrests before assisting the resident and instead asked Resident R1 to keep his/her legs elevated while she pushed, and instead, resident put his/her feet on the ground, causing the resident to fall forward from the wheelchair. Resident R1 was assessed with abrasions to bilateral knees and was subsequently transferred to the local hospital for evaluation. Review of facility documentation revealed the agency nurse aide, Employee E4, did not have Resident R1's footrests on at time of transport and the facility concludes the allegation of neglect is substantiated. Interview on August 19, 2026, with Physical Therapist, Employee E5, revealed resident R1 was able to self-propel dining room but needed assistance maneuvering inside the dining room. Physical therapist, Employee E5, reported Resident R1's capabilities fluctuated drastically having good and bad days, varying from needing contact guard assist with a cane walking 75 to 100 feet to the next day not being able to walk at all. Interview on August 19, 2026, at approximately 1:00 p.m. with Nursing Home Administrator, Employee E1, confirmed Nurse Aide, Employee E4, should have applied Resident R1's footrests on the wheelchair before transporting the resident. Nursing Home Administrator, Employee E1, revealed the Wheelchair Mobility Policy was not part of Employee E4's competency orientation packet and that the employee may not have known the policy. This was discovered as the result of a root cause analysis. Interview on August 19, 2026, at 1:45 p.m. with Staffing Coordinator, Employee E7, confirmed that the facility Wheelchair Mobility Policy was not previously included in the agency employees' orientation packets. Since the above incident, the agency employee orientation packet has been updated to include the facility Wheelchair Mobility Policy. On June 25, 2026, immediately following the incident, the facility immediately implemented the following corrective actions: Resident had a fall from wheelchair during transport from dining room to his/her room on 6/25/2026 by the nurse aide. Resident's footrests were not in place at the time of the fall. Resident was sent to hospital for care and services and returned 6/25/2026Wheelchair Mobility Policy added to agency employees' orientation packets.The Director of Nursing or designee will conduct an audit of all wheelchairs to ensure that current residents have leg rests. Findings of deviations of missing equipment will be acted upon by the Director of Nursing to ensure footrests are available for every resident who utilized a wheelchair for mobility 6/27/2026.The Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) will provide re-education to all nursing staff on the Wheelchair Mobility Policy to be completed by (6/29/2026). The policy emphasizes that residents are not to be transported by wheelchair without footrests unless clinically justified. All residents who utilize a wheelchair for mobility will have their care plan reviewed and updated if not already completed to ensure any residents who are able to self-propel have individualized care plan interventions updated by 6/29/2026.The Director of Nursing or Designee will complete a random audit on 3 residents weekly x 4 weeks and then monthly x 2 months to ensure identified residents who use footrests have the appropriate footrests in place and feet are positioned safely during transport. Audits will be forwarded to the Quality Assurance Team for review and any recommendations as needed. Date of compliance: 6/29/2026 Interview with Nursing Home Administrator, Employee E1, on August 19, 2026, at 12:51 p.m. confirmed the Assistant Director of Nursing (ADON), Employee E3, conducted the wheelchair audits and also re-educated the Lead Nurse Aide, Employee E12, so that she could educate all the other nurse aides on the wheelchair mobility policy. Interview with Assistant Director of Nursing (ADON), Employee E3, on August 19, 2026, at 1:16 p.m., confirmed audits of wheelchair leg rests were completed for the dates of 7/6/26, 7/13/26, 7/20/26 and 7/27/26. He stated audits were now monthly (and would be done for 8/26/26 and 9/25/26). Interviews on August 19, 2026, with one licensed nurse and two nurse aides Employees E8, E9, and E10, at 2:12 p.m., revealed that they have all been in-serviced regarding the Wheelchair Mobility Policy and that wheelchair leg rests must be in place before providing pushing assistance to residents in wheelchairs. The licensed nurse, Employee E8, added the wheelchair footrests are kept in a bag on the back of the chair in the event someone has to push them for any reason. Further review of resident R1's care plan indicated the intervention for preventing falls If resident is propelled in wheelchair by staff use foot rests, added June 26, 2026 (the day following the incident). Review of Orientation Packets for agency and staff employees confirmed the inclusion of the Wheelchair Mobility Policy. This deficiency was identified as past non-compliance. Corrective actions taken to remedy the deficient practice have been reviewed and implementation was confirmed based upon review of facility documentation, observations, and staff interview. 28 Pa. Code 211.10 (d) Resident care policies. 29 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to provide each resident with adequate supervision and assistance devices to prevent accidents related to transfer assistance for two of four residents reviewed (Resident R1 and R2). This deficiency was identified as past non-compliance. Findings include: Review for Resident R1's quarterly MDS (Minimum Data Set - a mandatory periodic assessment) dated June 17, 2026, indicated that the resident was admitted to the facility on [DATE], with the diagnoses including Heart Failure (heart muscle is too weak or too stiff to pump blood well; the heart cannot pump enough blood and oxygen to the rest of the body, fluid can build up in the lungs and legs); and Arthritis (conditions that cause pain, swelling, and stiffness in an individual's joints). Further review of Resident R1's MDS revealed that the resident was dependent on staff and needed two-person assistance for Chair/ bed-to chair transfer. Review of Care Plan Report for R1 dated June 15, 2026, revealed that the resident requires maximum assistance by two staff to move between surface using Hoyer Lift. Review of Health Status Note of R1, dated June 28, 2026, revealed; R1 reported pain in right foot this morning. Upon assessment, patient's right foot was swollen and painful to touch with patient reporting pain. Resident R1 explained the cause of the pain was sustained during a transfer from the chair to the bed that occurred the day before. New orders received by the physician and implemented for, Tylenol 650 milligrams 1 tablet administered as needed, and ice applied to right foot with relief. Review of Xray result of R1 completed on June 28, 2026, indicated prominent degenerative changes throughout without a fracture. Review of further Xray result of R1, indicated no fracture or significant change from the last right foot X-ray exam. Review of facility documentation submitted to the state survey agency revealed that on June 27, 2026, while R1 was being transferred from chair to bed, R1 slipped from the grasp of the assigned caregiver, Employee E3. Resident R1 reported pain in the right leg, primarily on the dorsal foot. The investigation findings of the facility revealed that the agency Nurse Aide, employee E3, did not transfer R1 according to the care plan. X-ray of foot was completed, and results were unremarkable. Review of written statement dated June 28, 2026, by Nurse Aide, Employee E3, who transferred R1 on June 27, 2026, revealed he/she changed and cleaned up Resident R1 and transferred him/her to the chair upon request. Nurse aide, Employee E3, revealed Resident R1 was transferred manually because he/she misunderstood directions written on his/her paper. Resident R1 told the Nurse Aide, Employee E3, his/her right foot only touched the right floor but didn't offer any complaints. On July 17, 2026, Employee E3 was not available for interview. Interview on July 17, 2026, at 11:55 a.m., with Resident R1 confirmed the above information, but couldn't recall pain levels at that time. Interview on July 17, 2026, at 12:15 p.m. the Assistant Director of Nursing confirmed that nurse aide, Employee E3, was terminated. Assistant Director of Nursing confirmed that nurse aide, Employee E3, failed to safely transfer Resident R1 according to the plan of care. Review for Resident R2's quarterly MDS dated [DATE], indicated that the resident was admitted to the facility on [DATE], with the diagnoses including cerebral infarction (damage to the brain) and muscle weakness. Review of care plan report for R2 dated April 27, 2026, and revised on May 4, 2026, revealed that the resident requires assistance by two staff to move between surface, squat pivot, for Transfer. Review of facility documentation submitted to the state survey agency revealed that on June 28, 2026, Resident R2 sustained two skin tears during transfer from bed to chair by care giver agency nurse aide, Employee E3. In reviewing the plan of care, Resident R2 is transfer status is a two-person pivot and nurse aide, Employee E3, transferred the resident with assist of one. Review of Resident R2's clinical record revealed a nursing note/incident dated June 28, 2026, that revealed the charge nurse was notified Resident R2 hit his/her right leg on the wheelchair while being transferred from the bed to the wheelchair. Resident R2 subsequently sustained two skin tears near to the right shin. Appropriate parties were notified and the areas were cleansed/treated. Interview on July 17, 2026, at 12:02 p.m., with Resident R2 confirmed the above information. Review of written statement dated June 28, 2026, by agency Nurse Aide, Employee E3, who transferred R2 on June 28, 2026, revealed nurse aide, Employee E3, transferred Resident R2 from the bed to the chair, and Resident R2 bumped his/her right leg on the wheelchair, causing a skin tear. Incident was reported to nurse. On July 17, 2026, Employee E3 was not available for interview. Interview on July 17, 2026, at 12:15 p.m. the Assistant Director of Nursing confirmed that nurse aide, Employee E3, was terminated. Assistant Director of Nursing confirmed that nurse aide, Employee E3, failed to safely transfer Resident R2 according to the plan of care. On June 28, 2026, following the above incidents, the facility implemented the following corrective actions: On June 28, 2026, Xray of right foot for R1 was completed, Xray results indicated no fracture or significant change from the last right foot X-ray exam. Therapy screen to evaluate Resident R1 and Resident R2 for proper transfer status. Therapy screens for Resident R1 and R2 identified no changes in transfer status. Nursing staff were reeducated on use of Kardex to review Resident's transfer status. Agency orientation packet had been updated to include instructions on how to access Kardex (quick-reference tool that organizes essential patient information to guide daily nursing care). Resident R1 and R2 referred for emotional support. Nurse aide, Employee E3, terminated from facility. Facility to defer to Nurse aide, Employee E3, to staffing agency for human resources follow up. Facility reviewed process for agency orientation in regard to accessing resident Kardex. Further review of facility documentation revealed corrective by the facility also included the following: Director of Nursing or Designee reviewed current resident Activity of Daily Living (ADL) care plans to ensure transfer status is accurate and is linked to each resident Kardex., and it was completed on July 1, 2026. Director of Nursing or Designee reeducated the nursing staff on utilizing Kardex for transfer status. Facility assessed return demonstration from licensed nurses and nurse aides regarding the ADL care plan and mobility piece of Kardex, and it was completed on July 1, 2026. The Director of Nursing or Designee will complete a random audit on three residents weekly X 4 weeks and then monthly X 2 months to ensure resident transfer status remain updated on the Kardex. Director of Nursing or Designee will complete a random audit on three team members weekly from different shifts to ensure team members can access the Kardex to view resident mobility status. Audits will be forwarded to the Quality Assurance Team for review and any recommendations as needed. Review of facility documentation and clinical records indicated that the above corrective action was completed. The deficient practice was determined to be past non-compliance effective as of July 1, 2026. This deficiency was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical documentation and interviews with staff, it was determined that the facility did not ensure that one resident was free from accidents and hazards related to inappropriate transfers for one of five residents reviewed. This deficiency is cited as past non-compliance. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], and had diagnoses including Alzheimer's disease (progressive degenerative disease of the brain, resulting in loss of reality contact), chronic kidney disease, and depression (major loss of interest inpleasurable activities). Review of facility documentation submitted to the State Survey Agency on February 28, 2026, revealed [Resident R1] was gently guided to the floor matt by one aide during transfer from bed to chair. When reviewing incident and care plan IDT (Inter-Disciplinary Team) noted that care plan reflects transfer utilizing 2 person stand up lift. Resident did not sustain any injury. Resident was immediately assessed, no injuries noted. Vital Signs stable. MD (physician) and responsible party notified. Therapy to re evaluate to ensure the use of stand up lift is the most appropriate mode of transfer.Review of the incident investigation confirmed that Nurse aide, Employee E3 was assisting the resident with morning care on February 28, 2026. A witness statement from Nurse aide, Employee E3, emailed on March 2, 2026, stated [I] was assistanting [Resident R1] to get up for the day he was sitting on the edge of the bed stood him up he couldn't stand so I assisted him down the floor and got staff help to get him up go report from [Employee E4] he was stand and pivot. A record of a verbal statement from Nurse aide, Employee E4, dated March 2, 2026, stated I thought (he/she) was a pivot to the chair.[Nurse aide, Employee E3] did not ask anyone for any assistance in putting the resident in the chair. A written statement from Nurse aide, Employee E4, signed March 2, 2026, stated I gave report at the start of shift to the CNA (Nurse aide) on [Resident R1]. She also had a copy of the assignment and also had access to the Kardex (electronic system which contains documentation on the care needs of a resident). A statement from Licensed nurse, Employee E5, stated Pt (patient) has 2 cuts on (her/his) forehead, above the [right] & [left] eyes, a bump in between the cuts, & a black eye. Mouth was bleeding too, I wiped the blood and noticed that the patient has a small cut insider (her/hids [right] upper mouth.I checked the side of the bed & noticed that there was blood on the [right] corner side of the bed frame. Review of the care plan for Resident R1 revealed an intervention dated July 21, 2025, that stated The resident requires sit to stand lift (a type of mechanical lift that enables safe transfer between surfaces) with 2 staff assistance for transfers. Review of the documentation related to transfers for Resident R1 revealed that from February 24 through February 28, 2026, that out of nine documented assisted transfers, four were appropriately documented as a two person assist, while five were documented as one person assist. For those same nine transfers, four were appropriately documented as total dependence on staff, while three were documented as extensive assistance (resident is involved in the transfer, but staff bear some of the resident's weight during the activity), one was documented as independent (the staff provides no help or supervision), and one was documented as not applicable. During an interview on March 25, 2026, at 11:15 a.m., the Nursing Home Administrator (NHA), Employee E1, revealed that during the investigation, Nurse aide, Employee E3 was found to have not appropriately ensured that the method of transfer for Resident R1 was consistent with the plan of care. The NHA also confirmed that any mechanical lift requires two nursing staff to operate. Documentation was presented on March 25, 2026, by the NHA, alleging that the facility had initiated a plan of correction on March 2, 2026, related transfer safety. The facility alleged a date of compliance of March 5, 2026. The plan of correction stated the following:Resident lowered to the floor matt during transfer; no injuries. Care plan reviewed and found to be 2 person stand up lift for all transfers.Care plans will be reviewed for transfers using stand up lifts to ensure they are linked to Kardex. Completion date: 3/4/26The Director of Nursing or Designee will re educate the nursing staff on utilizing Kardex for transfer status. Return demonstration from licensed nurses and care aides in regards to accessing Kardex. Completed: 3/4/26.The Director of Nursing or Designee will complete a random audit on 3 residents weekly x 4 weeks and then monthly x 2 months who are stand up lift transfers to ensure stand up lift transfer is noted on the assignment sheets. Audits will be forwarded to the Quality Assurance Team for review and any recommendations needed. Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of appropriate verification method for transfer status. Random staff and resident interviews were conducted to verify compliance with the plan of correction. QAPI records reviewed to verify ongoing monitoring. Observations on the units revealed staff to be utilizing the Kardex to verify transfer status. Further observation confirmed residents were being safely transferred in accordance with the plan of care. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance.28 Pa. Code 201.14. (a) Responsibility of licensee28 Pa Code 201.18(b)(1) Management

Based on review of policy, review of clinical records and review of facility provided documentation, it was determined that facility did not ensure to complete a thorough investigation for two of 18 residents reviewed regarding facility reported incidents (Resident R42, R2)Review of facility policy 'Falls management program,' indicates that when a resident sustains a fall, the assessment process will include an investigation using the Fall investigation analysis sheet. This is to help identify the root cause and whether or not the fall was avoidable or unavoidable.Review of Resident R42 clinical record revealed medical diagnosis of Alzheimer's disease, pain in bilateral knees, osteoarthritis, long-term use of insulin.Review of physical therapy discharge recommendations, completed on March 20, 2025, indicate that R42 is to continue to walk and stand with supervision.Review of R42's care plan, dated August 14, 2025, indicates that R42 is at risk for falling related to confusion, history of falls, poor safety awareness, with following interventions, dated November 5, 2025: resident prefers to sit down the floor occasionally. Encourage to sit on the chair or bed if she is in her room, and walker within reach. Remind resident to use it - unable to reeducate due to cognition.Further review of R42's care plan, dated July 17, 2025, indicates the resident requires 1 person assist with rolling walker for ambulation.Review of R42's clinical record, revealed health status note, dated December 16, 2025 at 8:39 pm, stating R42 had a fall in her room at 7:15 in the morning. Fall was witnessed by nurse aide, employee E11.Further review of R42's progress notes revealed that R42 tripped over her own feet, resulting in head hematoma, closed non-displaced fracture of right middle finger, and right knee abrasion.Review of 'interview/statement form for investigative purposes falls,' completed by nurse aide, E11 on December 16, 2025 at 7:15 am, indicates no evidence that R42 was supervised during ambulation with walker; and no indication of preventative measures in place during fall incident.Interview with facility's physical therapist, employee E12 on Wednesday, February 4, 2025 at 12:00 pm, confirmed Resident R42 required supervision during ambulation with walker.Review of Resident R2's clinical record revealed medical diagnosis of Alzheimer's disease, polyosteoarthritis, muscle weakness.Review of physical therapy discharge recommendation notes for R2, completed on September 9, 2025, indicates R2 required supervision or touching assistance during ambulation.Review of R2's care plan, dated July 21, 2025, indicates the resident (R2) has an ADL self-care performance deficit related to Alzheimer's, with intervention to supervise/one person assist with walker for ambulation.Review of facility provided investigation report related to R2's fall, completed on November 6, 2025, indicates that R2 was observed walking into the dining room with her walker and appeared to have tripped over her own feet while placing her walker to the side and lost her balance causing her to fall onto her left side. Staff had witnessed the fall and unable to get to her in time to intercept the fall. The fall resulted in left hip fracture.Interview with facility's director of nursing and administrator on Thursday, February 5, 2025, at 12:30 pm, indicates the statement on investigative report related to R2's fall are inaccurate; further elaborating that R2 was actually on her way out of dining area further stating that an adequate amount of staff were present during incident.However, further review of investigation report revealed no evidence that all fall preventative measures were in place, including supervision.28 Pa Code 211.10(d) resident care policies28 Pa Code 211.12(d)(5) nursing services

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to implement care plan interventions to meet resident needs for one of three residents reviewed (Resident R1). This deficiency was identified as past non-compliance.Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to implement care plan interventions to meet resident needs for one of three residents reviewed (Resident R1). This deficiency was identified as past non-compliance.Findings Include:Review of facility policy Care Planning review 01/07/2026 revealed the facility will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning.Review of Resident R1's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 9, 2025, revealed the resident was assessed as cognitively intact and had diagnoses of cerebral vascular accident (CVA -damage to the brain from interruption of its blood supply), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), and hemiplegia (one sided paralysis).Further review of Resident R1's comprehensive MDS dated [DATE], revealed the resident was dependent on staff for toileting hygiene and shower/bathing, and required partial/moderate assistance with personal hygiene (including combing hair, shaving, applying makeup, washing/drying face and hands).Review of Resident R1's comprehensive care plan dated July 17, 2025, revealed the resident had an activity of daily living self-care performance deficit related to dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), hemiplegia, and limited mobility. Intervention revised October 23, 2025, indicated that two staff members should participate in all care for Resident R1 (referred to as paired care)Review of Resident R1's comprehensive care plan dated November 3, 2025, revealed the resident was resistive to care and would use foul language/make derogatory statements towards staff.Review of facility incident report dated December 27, 2025, revealed on December 27, 2025, nurse aide, Employee E3, made licensed nurse, E4, aware that Resident R1 had a skin tear to the top of the right hand. Resident R1 stated that nurse aide, Employee E3, hurt his/her hand and was going to report the employee.Continued review of facility documentation revealed a written statement dated December 27, 2025, by nurse aide, Employee E3, that indicated while providing care for Resident R1 the resident became agitated. Nurse aide, Employee E3, stated he/she was trying to clean Resident R1's hand when the resident quickly pulled his/her hand away and subsequently sustained a skin tear.Interview on January 21, 2026, at 10:00 a.m. with the Nursing Home Administrator, Employee E1, confirmed that Resident R1 required paired care. Further interview on January 21, 2026, at 10:00 a.m. with the Nursing Home Administrator, Employee E1, confirmed the nurse aide, Employee E3, failed to implement care plan interventions and provide paired care for Resident R1.On December 27, 2025, following the incident, the facility immediately implemented the following corrective action:On 12/27/2025 [Resident R1] was assessed at the time of incident, the skin tear was cleaned and dressed in a bandage.Resident R1's care plan was reviewed and Resident R1 was found to be paired care for all activities of daily livingA full house audit on current residents who are paired care was completed to ensure paired care still neededAssignment sheets were updated to reflect what resident's require paired careCare plans reviewed for paired care accuracyThe Director of Nursing or Designee will re-educate the nursing staff on reading the assignment sheet and ensuring instructions are followed (completed January 5, 2026)The Director of Nursing or Designee will complete a random audit on 3 residents who are paired care weekly x 4 weeks and then monthly x 2 months to ensure paired care is noted on the assignment sheets.Audits will be forwarded to the Quality Assurance Team for review and any recommendations as neededInterviews on January 21, 2026, with nurse aide staff revealed staff were educated on how to identify a resident who is paired care. Review of facility documentation revealed assignments sheets were updated to reflect residents who require paired care. Review of clinical records confirmed care plans were developed and implemented to reflect pair cared status. This deficiency was identified as past non-compliance.

Based on review of clinical records, facility documentation, and staff statements, it was determined that the facility failed to provide assistance with activities of daily living related to nutrition, incontinence care, and positioning for five residents reviewed. (Resident R1, R2, R3, R4, and R5). This was identified as past non-compliance. Findings Include: Review of Resident R1's clinical record revealed a quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 2, 2025, indicated diagnoses including progressive neurological conditions, dementia (loss of cognitive functioning), Parkinson's disease (neurovegetative disorder that affects movement), paralytic gait (difficulty initiating movement), and dysphasia (language disorder); and had a BIMS score of six, indicating cognitive impairment. Further review revealed that Resident R1 was dependent with eating, oral hygiene, toileting and personal hygiene. Review of Resident R2's clinical record revealed a quarterly MDS dated [DATE], which indicated that Resident R2 was admitted to the facility with diagnoses including progressive neurological conditions and Alzheimer's disease (degeneration of the brain). Further review revealed that the resident required maximal assistance with toileting hygiene. Review of Resident R3's clinical record revealed a quarterly MDS dated [DATE], which indicated that Resident R3 was admitted to the facility with diagnoses including aphasia (inability to understand or produce speech), dementia, hemiparesis (one sided muscle weakness), and neuralgia (pain along the course of a nerve). The continuing review revealed the resident was dependent with sitting and lying to sitting. Review of Resident R4's clinical record revealed a quarterly MDS dated [DATE], which indicated that Resident R4 was admitted to the facility with diagnoses including aphasia. Further review revealed that Resident R4 was dependent on staff for mobility. Review of Resident R5's clinical record revealed a quarterly MDS dated [DATE], which indicated that the resident was admitted to the facility with diagnoses including neurological conditions, Parkinson's disease, restless leg syndrome (strong urge to move the legs), and spinal stenosis (loss of the normal structure of the spine). Further review revealed that Resident R4 was dependent on staff for mobility. Review of facility documentation originally submitted to the State Survey Agency on July 17, 2025, alleged that on July 17, 2025, Resident R1, R2, and R3, did not receive incontinent care and Resident R4 was noted to have food in mouth after evening meal had completed. Further review revealed that Nurse Assistant, Employee E4, was observed asleep in a resident room by multiple staff which resulted in residents R1, R2, R3, R4, and R5, being unkempt, soiled, and uncomfortable, and placed them at risk for skin breakdown, infection, and decreased dignity. The continued review revealed that Resident R1 was observed lying flat with food in her mouth unsupervised. Resident R2 was observed with a bowel movement that had spread up her back and soiled her shirt. Resident R3 was observed in bed with his head hanging off one side of the mattress and his feet hanging off the opposite end. Residents R4 and R5 were observed to be wet and in need of incontinent care that appeared to have been for an extended period. Review of statement by Nurse Aid, Employee E3, dated July 18, 2025, revealed that at approximately 5:00 p.m. Employee E3 witnessed Nurse Aid, Employee E4 in the back by the computers on long hall with her head down on the desk, it appeared to be she was sleeping. After dinner, another Nurse Aid notified Employee E3 that Employee E4 was observed sleeping. Review of documented interview with Nurse Aid, Employee E4, confirmed, I was tired so yes, I did close my eyes. This deficiency was cited as past non-compliance. Review of facility Action plan/Follow up documentation revealed the following information. 1. Identified residents in neglect allegation had skin assessments completed and were interviewed with statement obtained as able on care and services received. Police, Area Office on Aging, DOH, resident representative, and physician/physician extender were notified of allegations of neglect. The alleged perpetrator was on administrative leave at the time the investigation was initiated 7/25/25.2. Current residents on the 3rd floor were interviewed and received skin assessments by 7/26/2025. An audit was completed of 3rd floor resident progress notes for current residents between 7/17/2025 to 7/25/25 to review for any changes in condition documented and to identify any abuse or neglect allegations. The Director of Nursing and Nursing Home Administrator were provided with re-education on 7/25/2025 by the organizations VP Clinical Excellence on neglect allegation follow up required and actions to be taken.3. Current nursing staff were reeducated by Executive Director or designee on the facility Abuse Neglect or Exploitation Policy by 7/28/2025. If a nursing team member is not scheduled and not able to be reached, education will occur prior to their next scheduled shift.4. The Nursing Home Administrator or designee will conduct a random audit during a specified 48 hour time frame in the audit period of resident progress notes and grievances received to identify any potential abuse or neglect allegations weekly x 4 weeks, then monthly x 2 months. Any identified allegations will be immediately reported to the DOH and other regulated required entities and an investigation initiated. Results of these audits will be forwarded to Quarterly Quality Assurance meeting for review.A review was conducted of clinical records, skin assessments, staff education, and documentation of audits conducted by the facility. It was confirmed that the corrective action plan was immediately initiated on July 25, 2025, and identified as past non-compliance. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Number of residents sampled: n/aNumber of residents cited: n/a the facility did not ensure food was stored, prepared, and served in accordance with professional standards of practice Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.Findings include:Review of facility policy titled, Labeling and Dating Food, dated February 25, 2025, revealed that All received food product must have a Date Received' clearly marked on the package and that distributer dating is not to be followed.A tour of the Food Service Department was conducted on July 14, 2025, at 10:30 a.m. with the Assistant Foodservice Director, Employee E3, and the Food Service Director (FSD), Employee E4.Observations revealed the following food items were defrosted and dated July 14, 2025; multiple food items were observed labeled with the same date- the first date of the survey: eye of round bottom; raw ground beef; to boxes of 40- pounds chicken thighs.In an interview at approximately 10:37 a.m., the FSD, Employee E4, stated, they must've taken off the original dates and labeled with todays. The FSD acknowledged that the items confirmed that the food items mentioned above were labeled on that day specifically due to the survey. The FSD as unable to provide documentation or other evidence verifying that the food items were delivered or prepared on July 14, 2025.Continued interview confirmed that the facility failed to accurately label food items with the correct date of receipt or preparation, which is necessary to ensure proper food rotation, storage, and safety in accordance with regulatory requirements.Further observation failed to reveal a received date on the following foods: two boxes of 40-pound chicken thighs; jumbo wings; brisket; beef chuck 8/2 lbs.; two five-pound beef hot dogs; and veal.28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for two of three residents observed during medication administration observed, resulting in a significant medication error (Residents R32, and R67).Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for two of three residents observed during medication administration observed, resulting in a significant medication error (Residents R32, and R67).Findings include:On July 15, 2025, at 9:35 a.m., observed that Employee E6, a Licensed Nurse, administered to Resident R67, the medicine, Citalopram (Celexa) 20 mg, and Citalopram (Celexa) 10 mg tablets, totaling Citalopram (Celexa) 30 mg.Review of physician order for Resident R67, revealed an order, dated March 27, 2025, to administer Citalopram (Celexa) 20 mg, by mouth every day for Generalized Anxiety Disorder.But, the Licensed Nurse, E6, did not follow the physician order as E6 administered to Resident R67, the medicine, Citalopram (Celexa) 20 mg, and Citalopram (Celexa) 10 mg tablets, totaling Citalopram (Celexa) 30 mg.At the time of the finding, during an interview with E6, confirmed the above findings.On July 15, 2025, at 10:10 a.m., observed that Employee E6, a Licensed Nurse, dispensed and crushed the following medicines and was going to administer to Resident R32; Clopidogrel 75 mg tablet, Senna Plus Stool Softener tablet.Review of physician order for Resident R32, revealed an order, dated October 23, 2024, to administer Clopidogrel 75 mg tablet, do not crush; and Senna Plus Stool Softener tablet, do not crush.But, the Licensed Nurse, E6, did not follow the physician order. At the time of the finding, during an interview with E6, confirmed the above findings.The facility incurred a medication error rate of 11.54%.Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Number of residents sampled: 3Number of residents cited: 2the facility did not ensure a medication error rate of < 5%Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of three residents observed during medication administration (Residents R32, and R67). Findings include: On July 15, 2025, at 9:35 a.m., observed that Employee E6, a Licensed Nurse, administered to Resident R67, the medicine, Citalopram (Celexa) 20 mg, and Citalopram (Celexa) 10 mg tablets, totaling Citalopram (Celexa) 30 mg.Review of physician order for Resident R67, revealed an order, dated March 27, 2025, to administer Citalopram (Celexa) 20 mg, by mouth every day for Generalized Anxiety Disorder. But, the Licensed Nurse, E6, did not follow the physician order as E6 administered to Resident R67, the medicine, Citalopram (Celexa) 20 mg, and Citalopram (Celexa) 10 mg tablets, totaling Citalopram (Celexa) 30 mg.At the time of the finding, during an interview with E6, confirmed the above findings.On July 15, 2025, at 10:10 a.m., observed that Employee E6, a Licensed Nurse, dispensed and crushed the following medicines and was going to administer to Resident R32; Clopidogrel 75 mg tablet, Senna Plus Stool Softener tablet.Review of physician order for Resident R32, revealed an order, dated October 23, 2024, to administer Clopidogrel 75 mg tablet, do not crush; and Senna Plus Stool Softener tablet, do not crush.But, the Licensed Nurse, E6, did not follow the physician order. At the time of the finding, during an interview with E6, confirmed the above findings. The facility incurred a medication error rate of 11.54%. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to conduct a complete and thorough investigation to rule out an allegation of neglect for one of four residents reviewed (Resident R4). Findings Include: Review of facility policy Abuse Neglect or Exploitation reviewed July 2, 2025, revealed neglect is the failure of the facility, or its employees, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress to the resident despite knowledge that the care and services were required.Further review of facility policy revealed events involving evidence of abuse and neglect should be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 hours or within the timeframe that has been identified.Review of Resident R4's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 4, 2025, revealed the resident was admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS - assesses for cognitive impairments) score of 14 (cognitively intact).Review of Resident R4's MDS dated [DATE], revealed the resident had diagnoses of arthritis (inflammation of the joints), polyosteoarthritis (arthritis that affects multiple joints simultaneously), and muscle weakness.Further review of Resident R4's MDS dated [DATE], revealed the resident used a walker and wheelchair for mobility devices and required supervision/touching assistance for walking 10-150 feet and toilet transfers (the ability to get on and off the toilet/commode).Review of Resident R4's comprehensive care plan dated April 18, 2025, revealed the resident had impaired functional status related to transfers, walking, and toileting.Review of Resident R4's comprehensive care plan dated April 18, 2025, revealed the resident was at risk for falling related to pain with movement and osteoarthritis.Review of Resident R4's clinical record revealed a nursing note dated April 14, 2025, at 1:14 a.m. by licensed nurse (LPN), Employee E5, that indicated during routine rounds the nurse aide informed LPN, Employee E5, that Resident R4 was found lying on the bathroom floor at approximately 11:40 p.m. Per documentation, Resident R4 stated he/she attempted to call for help to use the bathroom, but when no one responded, she decided to ambulate independently and subsequently ended up on the floor.Interview on July 17, 2025, at 2:15 p.m. with Director of Nursing, Employee E2, revealed no incident report or investigation was available related to Resident R4's allegation of neglect that no staff responded to the resident's need for assistance with the bathroom and subsequent fall.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on staff interviews, review of clinical records, facility documentation, and facility policy, it was determined the facility failed to ensure one of four residents reviewed was free of neglect, (Resident R1). This failure resulted in actual harm to Resident R1 who was not provided care by two nurse aides while experiencing a combative episode. Resident R1 grabbed onto nurse aide, who moved resident's arm, resulting in a fracture of the right humerus (arm). Finding includes: Review of the facility policy titled Abuse, Neglect or Exploitation, last dated October 2023, states, That each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. Review of Resident R1's quarterly Minimum Data Set, (MDS-assessment of resident needs) dated May 17, 2025, revealed the resident was assessed as severely cognitively impaired, diagnosed with Traumatic Brain Injury, Quadriplegic, (experiencing limited or complete loss of movement and sensation in their arms and hands), Multiple Sclerosis (disease progression effecting the brain and the spinal cord), and Dementia (decline in mental ability, interfering with activities of daily living). Further review of MDS assessment revealed the resident was incontinent of bowel and bladder, dependent on staff for toilet hygiene and transfers and required substantial/maximal assistance for bed mobility and personal hygiene. The resident was assessed as requiring maximum assistance with upper body dressing and total dependence with lower body dressing, Continued review of the MDS revealed that the resident had one side impairment of the upper extremities and impairment of both side to the lower extremities. The resident required substantial to maximum assistance with toileting. The resident displayed physical and verbal behaviors four to six days, but less than daily. Review of Resident R1's physician orders of October 19, 2024, revealed an order for nursing staff to document Resident R1's behaviors, including, combativeness, resistive to care, verbal and/or physical aggression, sexually inappropriateness, and wandering. Review of Resident R1's care plan dated February 19, 2025, revealed the resident required two staff assistance with bed mobility and deemed total dependance for toileting. Review of Resident R1's nursing notes dated, March 29, 2025, revealed the resident was agitated, yelling. Additional review revealed the resident removed shirt and attempted to take off pants, while ripping up incontinence brief. Review of Resident R1's nursing notes dated, May 1, 2025, revealed the resident attempted to go outside unsupervised. When Resident R1 was redirected the resident cursed and yell including, I'm going to kill all of you. Review of Resident R1's physician note, dated May 11, 2025, indicated Resident R1 yells and refuses care at times. Review of the facility documentation submitted to the State Survey Agency on June 6, 2025 revealed, on June 4, 2025 while nurse aide, Employee E3 was providing care the resident was combative, the resident grabbed the CNA's (nurse aide) leg, when the CNA lifted the resident's arm to remove (her/his) hand from (his/her) leg he heard a pop sound. The resident then yelled out in pain. CNA notified RN (Registered Nurse) Supervisor, who assessed and notified the MD (physician) who ordered for resident to be sent to ED (Emergency Department) for evaluation. Review of incident investigation note dated June 4, 2025 at 10:10 p.m. revealed Resident sustained injury to right upper extremity during incontinence care and was transferred to [hospital] for further evaluation. Per CNA (nurse aide) resident was displaying combative behavior while [he/she] was being changed. Review of nursing notes dated June 5, 2025 at 9:06 a.m. revealed Resident unexpectedly admitted to the hospital 6/4/25. Continued review of nursing notes revealed a note dated June 8, 2025 at 3:59 p.m. Readmit to unit. DX (diagnosis) R (right) arm FX (fracture) Received resident AAOX1-2 (oriented to people, time, or place) in bed with soft cast removed and thrown on the floor. Review of Resident R1's hospital discharge documentation revealed, the resident was admitted to the hospital on [DATE] and discharged on June 6, 2025 with a diagnosis of closed fracture of distal end of right humerus (arm). Review of a brief description of the incident/accident from a written statement obtained from Nurse Aide (NA), Employee E3 who provided to Resident R1 care on June 4, 2025 revealed, while receiving incontinence care [Resident R1] became combative grabbed onto my thigh with both hands. While using my right hand, I attempted to move [Resident R1's] arm by the top of (her/his) wrist. [Resident R1] continued to press [his/her] arm towards me, for only a brief moment . before arm produced a loud pop and (she/he) no longer produced any force. Continued review of the written statement revealed [Resident R1] became less agitated up to during and even after dinner. However, [Resident R1] became less agitated before I decided to change (her/him). While being changed (she/he) initially seem to be as combative is (she/he) is most days, however once I turned (her/him) to face towards me. (She/He) began screaming and grabbed onto my right thigh with both hands .[Resident R1] began to hurt my thigh as (she/he) grabbed me, and was not responsive to me asking (her/him) to let me go. I placed my right hand onto the top of (her/his) right wrist and began moving (her/him) arm away form my thigh towards (her/him) torso. [Resident R1] continued to reach for my body for a brief amount of time . before (her/his) arm produced a loud pop and (she/he) was and (she/he) was no longer producing force. I immediately alerted nursing staff and supervisor. Review of facility abuse investigation documentation revealed, the facility concluded the allegation of neglect was substantiated due to resident's need for two staff members during incontinence care for safety but only one nurse aide performed the care. Nurse aide, Employee E3 was terminated from employment on June 9, 2025. Interview with the Nursing Home Administrator and Director of Nursing on June 16, 2025 at approximately 11:00 a.m. confirmed Resident R1's combative behaviors, and failed to have the required two staff members present during care on June 4, 2025. The facility failed to ensure that two staff members provided care to Resident R1, who displayed combative behaviors during care. This failure resulted in actual harm to Resident R1 who was assisted by one staff member during care, resident became combative, grab the nurse aide's leg who proceeded to move the resident's arm and Resident R1 sustained a fracture of the right humerus. 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)(5) Nursing Services.

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of policy titled, Sanitizing of Equipment revised May 2, 2022, revealed that employees must check the sanitizer for proper concentrating and record solution PPM on log. Review of policy titled, Labeling and Dating of Food revised April 3, 2023, revealed that All received food product must have a Date Received' clearly marked on the Package. Do not rely on the distributer or produce stickers for dating purposes. On large items, place the received date sticker beside the distributer sticker for easy viewing. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date Use a date gun that lists the day, month and year that the item was received. Review of facility policy titles, Leftover Foods undated, revealed that Leftover foods shall be stored in appropriate refrigeration units for no more than 72 hours. Potentially hazardous foods shall be stored for no more than 24 hours. An initial tour of the main kitchen was conducted on February 4, 2025, at 10:00 a.m. with the Assistant Food Service Director, Employee E4, and revealed the following: Observations at 10:12 p.m. revealed kitchen staff, Employee E8, was manually washing dishware by utilizing the three-compartment sink. A test of the sanitizer concentration was conducted at 1:14 p.m. with the state surveyor and assistant food services director, Employee E4, utilizing the Quaternary Ammonium Compound test strip (QAC QR) which indicate da reading of 100 parts per million (ppm). Follow-up interview with Employee E4 confirmed the above-mentioned finding and that the concentration is inappropriate and should have correctly registered at 200 ppm. Review of the facility documentation titled, Pot Sink Temperature Sanitizing Concentration Log, for the months of February and January, 2025 revealed faulty test strips were taped to the Log. Observations of the attached test strips revealed inaccurate reading- all strips appeared white in color. Facility documentation provided by the facility failed to reveal evidence that proper concentration solution was maintained when utilizing the three-compartment sink. Interview with the AFSD, Employee E4 confirmed this finding. Observations of the main refrigerator revealed two 10-pound briskets were unlabeled and undated. Further observations revealed that burgers, lamb, pork boneless loin, and four 10-pound beef roasts were labeled with only the received date by the distributer. Further review revealed potentially hazardous food, including Buffalo Chicken breast dated January 30, 2025; two turkey breast dated January 30, 2025; cooked salami dated January 7, 2025, and 2 smoked ham dated January 30, 2025, remained refrigerated for more than 72 hours. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: A tour of the Food Service Department was conducted on February 4, 2025, at 10:00 a.m. with the Assistant Food Service Director, Employee E4, and revealed the following concerns: Observation revealed a lot of debris around the compactor including used latex gloves, paper and plastic waste, and piles of leaves. Further observation revealed large puddles of oily liquid discharge from the trash compactor. An interview with the Assistant Food Service Director, Employee E4 on February 4, 2025, at approximately 10:30 a.m. confirmed the above findings. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 24 residents reviewed (R38). Findings include: Review of Resident R38's clinical record revealed the resident was initially admitted to the facility on [DATE]; diagnosed with Chronic Obstructive Pulmonary Disease (COPD- a common lung disease causing restricted airflow and breathing problems, in people with COPD, the lungs can get damaged or clogged with phlegm); and Dependence on Supplemental Oxygen. Review of clinical record indicated that Resident R38 was ordered on October 30, 2024, Oxygen at 2 Liters/Min, via Nasal Cannula, every Shift Continuously. On February 4, 2025, at 11:38 a.m., observed that Resident R38 was administered with Oxygen at 4 Liters/Min, via Nasal Canula., and not 2 Liters/Min, as ordered by the physician; and the same was confirmed with the Director of Nursing. 28 Pa Code 211.12(d)(5) Nursing services

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related appropriate cleaning techniques for medical equipment, on three of the six Medication Administration Reviews. Findings include: Review of Facility policy last approved on January 16, 2025, on Infection Control, indicated that the staff will follow established infection control procedures such as hand washing, antiseptic technique, gloves, and isolation precautions for administration of medications, as applicable. It also indicated that all reusable equipment will be decontaminated and/or sterilized between residents at the point-of-care. On February 5, 2025, 9:26 a.m., during medication administration, to Resident R9, Employee E6, a Licensed Nurse, used the sphygmomanometer (an instrument for measuring blood pressure), without disinfecting it, which was used for checking blood pressure of other residents. At the time of the finding, Employee E6 confirmed the same. On February 5, 2025, 9:57 a.m., during medication administration, to Resident R180, Employee E7, a Registered Nurse, used the sphygmomanometer without disinfecting it, which was used for checking blood pressure of other residents. On February 5, 2025, 10:07 a.m., during medication administration, to Resident R50, Employee E7, used the sphygmomanometer without disinfecting it, which was used for checking blood pressure of other residents. At the time of the finding, E7 confirmed the same. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of six residents observed during medication administration (Resident R51). Findings include: On February 5, 2025, 11:01 a.m., observed that Employee E5, a Licensed Nurse, administered to Resident R51, the medicine, Memantine 5 milligrams (mg) tab, one tablet, by mouth, after crushing it; when asked the Licensed Nurse to double check the medicine, the nurse stated it was Memantine 5 mg tab, one tablet. Review of physician order for Resident R51, revealed an order, dated October 10, 2024, to administer Memantine HCL,ER 7 mg Capsule, give one capsule by mouth daily for Dementia. The Licensed Nurse, E5 did not follow the physician order to administer 7 mg of Memantine HCL, ER (enteric coated). Review of literature revealed that enteric-coated medicines (ER) should not be administered crushed. On February 5, 2025, 11:01 a.m., observed that Employee E5, a Licensed Nurse, administered to Resident R51, the medicine, Ferrous Sulfate 325 mg RED Type one tab, by mouth, after crushing it; when asked the Licensed Nurse to double check the medicine, the nurse stated it was Ferrous Sulfate 325 mg RED Type one tab. Review of physician order for Resident R51, revealed an order, dated February 5, 2025, to administer Ferrous Sulfate 325 mg RED Type, Take one Tablet by mouth once Daily for Anemia. Review of literature revealed that Ferrous Sulfate Tablet should not be administered crushed. At the time of the finding, during an interview with the Director of Nursing, confirmed the above findings. The facility incurred a medication error rate of 7.14%. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from verbal abuse, which resulted in emotional distress for one of 24 residents reviewed. (Resident R38) Findings include: Review of facility policy, Abuse Neglect or Exploitation' dated October 24, 2022, revealed Each resident is provided with a safe environment where they are not subject to mental, physical, verbal and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation and misappropriation of property. Continued review revealed; verbal abuse includes but is not limited to any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Review of Resident R38's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated October 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses of Type 2 Diabetes Mellitus, Presence of Cardiac Pacemaker (a small, implantable medical device that helps regulate the heart's rhythm. It works by delivering electrical impulses to the heart muscle, ensuring that the heart beats at a consistent and healthy rate), and Dependence on Supplemental Oxygen. Review of facility documentation submitted to the Department of Health on November 21, 2024, revealed that on November 21, 2024, Resident R38 stated that a Nurse Aide, Employee E10, was attempting to throw a piece of paper in the trash-can, when the piece of paper hit Resident R38. The resident stated to the Nurse Aide that the paper hit him, and the Nurse Aide began to yell at the resident and stated, : f k you [Resident R38]. The Nurse supervisor intervened. The Nurse Aide, Employee E10 was immediately placed on administrative leave. Review of facility investigation documentation on the incident revealed that on November 22, 2024, the Administrator, and Director of Nursing spoke with the Nurse Aide E10 via phone, and the Nurse Aide stated: I had a conversation with a Licensed Nurse, and asked why I was working with a certain resident, because my assignment got switched. I was upset with my assignment. I tried to throw a piece of paper in [Resident R38]'s waste basket, but it did not make it. The piece of paper hit [Resident R38], and [Resident R38] called me an idiot. I basically cursed him out, I said the F word at him. I was burned out from working so much and lost my temper, I wanted to apologize to him for it. Review of facility investigation documentation related to the incident revealed that the Nursing Home Administrator obtained statements from all staff involved, interviewed residents, completed skin check on Resident R38, reviewed the video footage of the incident. The facility substantiated the allegation of verbal abuse of Employee E10 to Resident R38. The Employee E10 was placed on administrative leave and termination. Facility provided emotional support to Resident R38, and made the psych consult. Review of Employee E10's personnel file revealed that he was hired by the facility on November 25, 2023, as a Nurse Aide. Continued review revealed that Employee E10, received certification training on the prevention of elder abuse on January 11, 2024. Interview on February 6, 2025, at 1:35 p.m., with the Nursing Home Administrator (NHA) confirmed the findings. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on observation, interviews with residents, interviews with staff, review of facility documentation and clinical records, the facility failed to ensure each resident's dignity was maintained regarding cell phone use of staff, for one out of 24 residents reviewed. (R50). Findings include: Clinical record review revealed that Resident R50 was admitted in the facility on January 14, 2025, with diagnoses that included Permanent Atrial Fibrillation (a condition where the upper chambers of the heart (atria) beat irregularly and rapidly, and this rhythm persists for more than 12 months despite treatment attempts), and Type 2 Diabetes (chronic condition where the body does not use insulin effectively or does not produce enough insulin. Insulin is a hormone that helps glucose (sugar) from food enter cells for energy). Review of clinical records of Resident R50 revealed that the resident complained to a Licensed Nurse, Employee E9, on January 30, 2025, at 5:06 a.m., that Resident R50 could not sleep well, as Resident R50 felt that the Licensed Nurse E9's cell phone was very loud, causing unprofessional noise, and that Employee E9 did express her apology to the resident . In an interview on February 04, 2025, at 01:52 p.m., the Nursing Home Administrator and Director of Nursing stated that staff were not allowed to use cellphones in resident's room . 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on the review of facility documentation, review of clinical records, and interviews with resident and staff, it was determined the facility failed to monitor the temperature of a hot liquid before being served to a resident. This failure resulted in actual harm to Resident R1 who spilled hot water and sustained a second degree burn on the forearm for one of two resident records reviewed (Resident R1). Findings include: Review of Resident R1's admissions, Minimum Data Set (MDS- assessment of resident needs) dated August 12, 2024, revealed a BIMS (brief interview for mental status) score of 14 which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident had physical impairments to both sides of her upper body, used a walker for ambulating, was occasionally incontinent of bowel and bladder, had a history of falls, and was dependent on staff (helper does all the effort to complete the task) for her activities of daily living including eating.) The same MDS had diagnoses for the resident that included dementia (cognitive loss) arthritis (joint pain), and osteoporosis (brittle weak bones). Review of nursing note, dated September 8, 2024, stated Resident R1 spilled hot water on her right forearm and knee. Her forearm was noted to have a wrinkled layer of skin that was intact measuring 8 x 7.5 cm and a redden area on her knee measuring 12 x 12 cm. Review of the wound consultant notes dated September 12, 2024, revealed that Resident R1 was assessed with a second degree burn to her right forearm measuring 9 x 6.5 x 0.1 cm with 100% of epithelial tissue (first stage in wound healing) and scant drainage. Review of facility documentation revealed the Nursing Home Administrator (NHA) and the Director of Nursing (DON) conducted a telephone interview with Nursing Assistant (NA), Employee E3, who served Resident R1 hot water for the resident's tea. The NA, Employee E3, stated she went to the dining room to get juice for the resident and a dietary aide was there to assist her. The NA, Employee E3 said the dietary aide was no longer in the dining room when the NA, Employee E3 went back for the hot water. The NA, Employee E3 indicated she then took a standard mug and filled it with hot water from the coffee dispensers located in the dietary area of the dining room and then served it to Resident R1. Approximately 30 minutes later the NA, Employee E3 was informed that Resident R1 burned herself taking the lid off the mug. The documentation further revealed the NA, Employee E3 was, Unaware of how hot the water was coming out of the dispenser. Interview conducted with Resident R1 on September 19, 2024, at approximately 1:00 p.m. the resident confirmed that the nursing assistant handed her a mug of hot water and left the room. The resident stated, I had a very hard time taking the white lid off the mug because my hands don't work so well. It slipped out of my hands and hot water spilled on my arm and all over my chair where I was sitting. Observation conducted during the interview revealed a gauze bandage wrapped around Resident R1's right wrist and forearm. The Assistant Director of Nursing removed the bandages to reveal the burn. Instead of seeing the resident's normal dark skin color, the skin appeared raw and red with outer white edges, approximately 8 x 4 cm in length. The resident said. It (the burn) still hurts but it is getting much better. Interview with the Nutrition Coordinator, Employee E6 during lunch observation on September 19, 2024, at approximately 1:30 p.m. indicated the dietary department is responsible for servicing hot beverages. It was observed that the hot liquids were taken from the coffee/water dispenser and served in carafe where they are cooled down to a safe temperature prior to being served to the residents. Dietary logs for the month of September 2024 revealed coffee and hot water temperatures were obtained and within the specified temperature standards listed on the log forms which was between 145-155 degrees. Interview with the Food Service Director, Employee E5 on September 19, 2024, at 1:30 p.m. revealed that the facility was currently working on developing a policy on the temperature of hot beverages at the time of service. Interview with NA, Employee E3 was attempted on September 19, 2024, via phone but no returned called was received. The facility failed to ensure safe hot water temperatures prior to being served to Resident R1. This failure resulted in actual harm to Resident R1 who spilled the hot water and sustained a second degree burn on her right forearm. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(c)(d) Dietary Services

Based on the review of facility documentation, review of personnel records and interviews with staff, it was determined that the facility failed to ensure six of six employees possessed the appropriate skills and competencies to provide nursing and related care and services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Further, review of Employee E21's personnel file revealed that the Employee E21 was an unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration as a nurse. This failure placed 63 residents who received care and services from Employee E21 at the facility, at risk of injury and/ or harm and resulted in an Immediate Jeopardy situation. (Employees E16, 17, 18, 19, 20 and 21). Findings Include: Review of the Professional Nursing Law The Act of [DATE] P.L 317, No 69, revealed that Section 3. Registered Nurse, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Use of Title and Abbreviation R.N., C.N.S. or C.R.N.A.; Credentials; Fraud.--(a) Any person who holds a license to practice professional nursing in this Commonwealth, or who is maintained on inactive status in accordance with section 11 of this act, shall have the right to use the titles nurse and registered nurse and the abbreviation R.N. No other person shall engage in the practice of professional nursing or use the titles nurse or registered nurse or the abbreviation R.N. to indicate that the person using the same is a registered nurse, except that the title nurse also may be used by a person licensed under the provisions of the act of [DATE] (1955 P.L.1211, No.376), known as the Practical Nurse Law. No person shall sell or fraudulently obtain or fraudulently furnish any nursing diploma, license, record, or registration or aid or abet therein. (b) An individual who holds a license to practice professional nursing in this Commonwealth who meets the requirements under sections 6.2 and 8.5 of this act to be a clinical nurse specialist shall have the right to use the title clinical nurse specialist and the abbreviation C.N.S. No other person shall have that right. Review of job description for Registered Nurse (RN) revised on [DATE], revealed that Education and Experience Requirements: Current state professional nursing license, one to two years' experience, geriatric/long term care experience preferred, maintain or able to obtain current CPR certification. Job accountabilities. 1. Plan, directs and provides resident care according to physician orders and the interdisciplinary plan of care. 2. Communicates changes in resident's condition in a timely fashion to include but not limited to physicians, other disciplines, the following shift, and family members. 3. Administer medications, treatments in compliance with federal, state and local laws and with the community policies and procedures. 6. Performs venipuncture to obtain blood. Further review of job description for Registered Nurse revealed that skills and competencies are required for the job accountabilities including; Administering medications and treatments, performs venipuncture to obtain blood specimens according to community practice, use of standard precautions to prevent spread of communicable disease, enforces and trains proper infection control practices to team members, exhibits knowledge of and effectively executes disaster plans and communicates changes in residents' condition in a timely fashion to include but not limited to the RN, physician other disciplines the following shift and family members. Review of a blank facility competency evaluation form indicated that the facility developed a competency evaluation program with performance indicators to ensure that the nurses including RNs and LPNs have the competency to perform necessary job accountabilities which indicated if a job function are met or not met. Review of facility documentation dated February 2, 2024, revealed that A concern was brought to this NHA (Administrator) on February 2, 2024, at approximately 10:13 am regarding a licensure investigation for an employee of Cathedral Village. Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents. Further review of the documentation revealed that upon hire Employee E21, Registered Nurse, presented a registered nursing license with the name (First name Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. The individual (RN) remained on administrative leave while facility conducted investigation and did not submit any further documentation. Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included a name with three parts, last name included two parts). License was verified under a similar name (but only had two parts to the name, last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a name that has three parts. Employee 21's name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy in the name. A request for competency evaluation for Employee E21 was requested from the Nursing Home Administrator on [DATE] at 2:17 p.m. Facility did not provide evidence of competency evaluation for Employee E21. Review of Employee E21's personnel file revealed that the employee was offered the job as an RN with a hire date of [DATE]. Further review of the personal file revealed that the employee worked in the facility as an RN until February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN. Continued review of Employee E21's personnel file did not include any verifiable nursing or any related education. Personnel files did not include any competency evaluation form. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 administered medications to residents including anxiolytics, antihypertensive, antipsychotics, Parkinson's medications, antidepressants, anticonvulsants, anticoagulant, antibiotics, diuretics, beta blockers (slows heart rate, treat chest pain), anti-diabetic medication, steroids, antiviral medications, which require monitoring of side effects. Review of clinical record also revealed that Employee E21 administered resident complex resident assessment which needed specialized skills and competencies including wound care, neurological assessments, administered insulin, admission assessments, skin assessments change of condition assessments and PICC line assessments. There was no documentation available to review to determine that facility ensured Employee E21 was competent in performing these services. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift. A review of the facility record revealed that the facility had one resident with PICC line/Midline catheter who received treatment and care from the staff such as dressing change, medication and fluid administration, site assessment and monitoring. Interview with the Director of Nursing (DON) on [DATE], at 11:00 a.m. stated nursing staff provided care for residents with PICC lines and midline. A review of the facility record revealed that the facility had residents with pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin.) and other wounds who received care and services from staff such as dressing change and wound assessment. A request for the evidence of PICC line/midline/ IV care and wound care staff competencies or annual evaluations of additional 5 selected licensed and registered nurses, Employee E16, 17, 18, 19, 20 were made to the Nursing Home Administrator and Director of nursing on April Facility was not able to provide evidence of PICC line/midline/ IV care and wound care staff competencies or annual evaluations of 5 selected licensed and registered nurses. During an interview on [DATE], at 11:30 a.m. the Nursing Home Administrator confirmed that the nursing staff competencies or annual evaluations related to PICC line/midline/ IV care and wound care was not completed for the nursing staff in the past year. The Nursing Home Administrator also confirmed that the facility did not have a process of competency evaluation. The Nursing Home Administrator stated facility has a competency evaluation program developed to evaluate the competencies of the nurse but the facility did not implement the program for the nurses. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 4:00 p.m. for the facility's failure to ensure that Employee E21, (unlicensed staff who provided care and services as a Registered Nurse without verifiable educational background as a nurse) possessed appropriate skill sets and competencies to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident This failure placed 63 residents who received care and services from Employee E21 at the facility at risk of injury and or harm and resulted in an immediate jeopardy situation. The facility submitted a written plan of action on [DATE], at 9:00 p.m. and implemented the plan of action which included: Employee A was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses will be informed on [DATE]. Legal counsel notified that state's Attorney General is involved. An electronic health record audit was completed on [DATE] by the Nursing Home Administrator or designee to review residents who may have received care or treatment from Employee E21. Current residents identified from this audit will be interviewed by a Licensed Nurse and Social Worker. This inquiry will include a statement from the individual related to medication administration, evaluations and assessments, wound care, and general care and nursing services provided was completed [DATE]. A physical head to toe skin evaluation of the residents in the assignments of Employee E21 was completed on [DATE]- [DATE]. An audit was conducted by the Human Resource Department to ensure that licensed staff have a skills competency completed and present in their employee file within the last year on [DATE]. Any licensed staff identified not to have had skills competency completed will have the competency completed prior to their next scheduled shift; all staff completed by [DATE]. An audit was completed by human resource department on current licensed nurses employed by PSL (Presbyterian Senior Living) at the community to ensure compliance with licensure verification on [DATE], no variances identified. The human resource department team members at the community were re-educated on new hire/pre- employment processes for licensed staff by the [NAME] President of Employee Relations or designee on [DATE]. The Human Resource department team members at the community were re-educated by the [NAME] President of Employee Relations or designee on- the requirement to ensure that all licensed staff have a current skill competency checklist completed at new hire during the orientation period and then annually in their employee file to ensure that all licensed staff possess competencies, education, and license as applicable to provide nursing care, all staff completed by. [DATE]. On [DATE], at 11:40 a.m. the action plan was reviewed, personell records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed. The Immediate Jeopardy was lifted on [DATE], at 11:40 a.m. Refer to F839 28 Pa. Code 201.14 (a)(b) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(e)(1)(2) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on the review of facility documentation, review of personal records and interviews with staff, it was determined that the facility failed to ensure that a professional staff possessed required nursing license in accordance with applicable state law. Review of one of six personnel files revealed that Employee E21, who was an unlicensed staff, and provided care as a Registered Nurse, to 63 residents. Employee E21 did not have a verifiable educational background and registration, as a Registered Nurse. This failure resulted in an Immediate Jeopardy situation to 63 residents who received care and services from Employee E21. (Employee E21). Findings Include: Review of the Professional Nursing Law The Act of [DATE] P.L 317, No 69, revealed that Section 3. Registered Nurse, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Use of Title and Abbreviation R.N., C.N.S. or C.R.N.A.; Credentials; Fraud.--(a) Any person who holds a license to practice professional nursing in this Commonwealth, or who is maintained on inactive status in accordance with section 11 of this act, shall have the right to use the titles nurse and registered nurse and the abbreviation R.N. No other person shall engage in the practice of professional nursing or use the titles nurse or registered nurse or the abbreviation R.N. to indicate that the person using the same is a registered nurse, except that the title nurse also may be used by a person licensed under the provisions of the act of [DATE] (1955 P.L.1211, No.376), known as the Practical Nurse Law. No person shall sell or fraudulently obtain or fraudulently furnish any nursing diploma, license, record, or registration or aid or abet therein. (b) An individual who holds a license to practice professional nursing in this Commonwealth who meets the requirements under sections 6.2 and 8.5 of this act to be a clinical nurse specialist shall have the right to use the title clinical nurse specialist and the abbreviation C.N.S. No other person shall have that right. Review of job description for Registered Nurse revised on [DATE], revealed that Education and Experience Requirements: Current state professional nursing license, one to two years' experience, geriatric/long term care experience preferred, maintain or able to obtain current CPR certification. Job accountabilities. 1. Plan, directs and provides resident care according to physician orders and the interdisciplinary plan of care. 2. Communicates changes in resident's condition in a timely fashion to include but not limited to physicians, other disciplines, the following shift, and family members. 3. Administer medications, treatments in compliance with federal, state and local laws and with the community policies and procedures. 6. Performs venipuncture to obtain blood Review of facility information dated February 2, 2024, revealed that A concern was brought to this NHA(Nursing Home Administrator) on February 2, 2024, at approximately 10:13 a.m. regarding a licensure investigation .Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents. Further review of the documentation revealed that upon hire on [DATE], Employee E21, presented a Registered Nurse's license with the name (First name and Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included first name and last name which had two parts). The Registered nurse license was verified under a similar name (but only the last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a last name that had two parts. Employee 21's last name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy with Employee E21's last name. Interview with previous facility Nursing Home Administrator (Administrator at the time of the alleged incident), on [DATE], at 2:00 p.m. stated Employee E21 provided a fraudulent RN license by obtaining identity of another person with similar name. Facility did not follow up on the discrepancy between the name provided and the name on the license. Facility also did not ask the employee to provide the copy of the license issues by the state to the individual who possessed the license. Facility only verified and kept copy of the license which was available online to the public. She confirmed that the Employee E21 obtained identity of another individual who possessed a RN license with similar name and worked in the facility for 4 months and provided care to the residents including medication administration and licensed/registered nurse's assignments. Review of Employee E21's personal file revealed that the employee was offered the job as an RN with a hire date of [DATE]. Further review of the personal filed file revealed that the employee worked in the facility as an RN till February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN. Continued review of Employee E21's personal file did not include any verifiable nursing or any related education. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 administered medications to residents including anxiolytics, antihypertensive, antipsychotics, Parkinson's medications, antidepressants, anticonvulsants, anticoagulant, antibiotics, diuretics, beta blockers (slows heart rate, treat chest pain), anti-diabetic medication, steroids, antiviral medications, which require monitoring of side effects. Review of clinical record also revealed that Employee E21 administered resident complex resident assessment which needed specialized skills and competencies including wound care, neurological assessments, administered insulin, admission assessments, skin assessments change of condition assessments and PICC line assessments. There was no documentation available to review to determine that facility ensured Employee E 21 was competent in performing these services. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 4:00 p.m. for the facility's failure to ensure that professional staff possessed requited licenses or registration in accordance with applicable state law. This failure resulted in Employee E21, unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration, as a nurse and placed 63 residents at the facility at risk of injury and or harm and resulted in an Immediate jeopardy situation. The facility submitted a written plan of action on [DATE], at 9:00 p.m. and implemented the plan of action which included: Employee 21 was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses who be informed [DATE]. Legal counsel notified that state's Attorney General is involved. An audit was completed by human resource department on current licensed nurses employed by PSL at the community to ensure compliance with licensure verification as applicable according to the job description and state laws on [DATE]. All licensed staff after the initial audit have also been audited by the Human Resource department prior to employment. The policy for employee onboarding process was updated and revised on [DATE] to ensure licensed staff are appropriately licensed and educated as applicable according to the job description and state laws. The Human Resource department team members at the community were re-educated by the [NAME] President of Employee Relations or designee on the updated policy on [DATE]. All licensed staff after the initial audit which was completed on [DATE] have also been audited by the Human Resource department prior to employment. Audits started [DATE] no concerns identified and will continue to be completed biweekly according to new employee orientation schedule. Audits will continue to be going forward. On [DATE], at 11:40 a.m. the action plan was reviewed, personal records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed. The Immediate Jeopardy was lifted on [DATE], at 11:40 a.m. 28 Pa. Code 201.14 (a)(b) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(e)(1)(2) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm to Resident R1 who fell out of bed during continence care and sustained a left fourth posterior rib fracture, a left fifth anterolateral rib fracture and a left parieto-occipital scalp hematoma for one of five residents reviewed. (Resident R1) Findings include: Review of facility policy, Abuse Neglect or Exploitation' dated October 24, 2022, revealed Each resident is provided with a safe environment where they are not subject to mental, physical, verbal and sexual abuse. Residents shall also be protected from mistreatment, neglect, exploitation and misappropriation of property. Continued review revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress to the resident despite knowledge that the care and services were required (the care giver knew better but still acted in a manner that could potentially or did result in harm). Review of facility policy, Providing Care to a Resident in Bed dated July 11, 2019, revealed that the objective of the policy was to ensure that residents are turned safely on their side while being provided care while in bed. The policy states, Go to the side of the bed you are turning the resident toward. Always turn resident toward you. Continued review revealed, Gently roll the resident onto their side as one unit, toward you. Your body will block resident and help prevent them from rolling out of bed. Only turn away from you if there is a second staff member to assist who will be on the side of the bed you are turning the resident toward. Review of Resident R1's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 10, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Parkinson's Disease (a progressive disorder of the nervous system that affects movement), and anxiety disorder (intense, excessive, persistent worry or fear). Continued review of the MDS assessment revealed that the resident had severe cognitive impairement. Further review revealed that the resident was always incontinent of bowel and bladder and that she required extensive assistance from staff for bed mobility and personal hygiene. Review of Resident R1's care plan, dated October 25, 2022, revealed that the resident had a self care deficit related to aging, impaired mobility and dementia. Interventions included for staff to provide extensive assist of one staff person for ADLs (Activities of Daily Living) and for staff to provide extensive assist of two staff persons with toileting, transfers and bed mobility. Interventions also included for staff to provide continence care, that the resident wore a brief and to use barrier cream after each incontinent episode. Review of facility documentation submitted to the Department of Health on April 16, 2023, revealed that on April 15, 2023, Resident R1 sustained a fall out of bed while she was receiving incontinence care from Employee E5, nurse aide. The resident had a hematoma (collection of blood) and abrasion on her head and was subsequently transferred to the hospital for evaluation. Hospital records indicated that Resident R1 sustained multiple rib fractures from her fall. Review of facility investigation documentation related to the incident revealed a written statement from Employee E5, nurse aide, dated April 15, 2023, which stated, Washing up resident turn resident on right side to change diaper turn to reach for a diaper and witness resident roll out of bed head first landing on her back made sure resident was safe asked resident is she okay she said her back was hurting called for charge nurse. Continued review revealed that an interview was conducted on April 17, 2023, by the Director of Nursing (DON) and Employee E5, nurse aide, which stated that when Employee E5, nurse aide, went into Resident R1's room to provide continence care, that Employee E5, nurse aide, raised the bed to her waist height and then turned the resident, who was on her back in the center of the mattress, toward the resident's right side, away from her, facing the window. The interview continued that Employee E5, nurse aide, then proceeded to provide incontinence care and when she turned away from the resident to get the [incontinence] product and prepare it to put on the resident . [Employee E5] witnessed the resident roll out of bed, but was unable to prevent the fall. Review of hospital records revealed that CT scans (diagnostic imaging) were performed on Resident R1 and revealed that the resident sustained a left fourth posterior (toward the back) rib fracture, a left fifth anterolateral (toward the front) rib fracture and a left parieto-occipital scalp hematoma (collection of blood on the head). Review of Employee E5's personnel file revealed that she was hired by the facility on May 2, 2014, as a nurse aide. Continued review revealed that Employee E5, nurse aide, received training on the prevention of elder abuse on January 14, 2023. Further review revealed that Employee E5, nurse aide, received training on facility policy, Providing Care to a Resident in Bed in September 2020. Interview on April 26, 2023, at 9:20 a.m. the Nursing Home Administrator (NHA) confirmed that Resident R1 fell while receiving care from Employee E5, nurse aide, and sustained multiple rib fractures. The NHA confirmed that Employee E5, nurse aide, did not turn the resident appropriately in bed which resulted in her fall. The NHA confirmed that the facility substantiated the allegation of neglect against Employee E5, nurse aide, and subsequently terminated her from employment. 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on observation of facility video footage, review of clinical records, facility policies and procedures, facility documentation and interviews with staff and others, it was determined that the facility neglected to monitor and assess a resident for a change in condition, when the resident became unresponsive following a fall and subsequently died for one of 13 residents reviewed (Resident CL1). This failure placed the residents at high risk of harm from neglect and placed the facility in an Immediate Jeopardy Situation. Findings include: Review of facility policy, Abuse Neglect or Exploitation, dated last approved [DATE], revealed that . each resident is provided with a safe environment . and . residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. Continued review of the policy revealed that the facility defined neglect as . failure to provide goods and services required for the sustained health and wellbeing of the resident Neglect is further defined as failure to provide goods and services necessary to avoid physical harm Neglect usually occurs on an individual basis when a resident receives a lack of care in one or more areas . Review of facility policy, Neurological Evaluation (assessment of nerve function), dated last approved [DATE], revealed that . 1. Any resident with the potential for head trauma injury or having an acute change in level of consciousness will receive 72 hours of neurological evaluation, following notification of the physician. In addition, the policy indicated that the neurological assessments were to be completed as follows: a. Every 15 minutes for the first hour, b. Every hour for the next three hours, c. Every two hours for the next four hours, d. Every four hours for the next sixteen hours and e. Every eight hours for the next forty-eight hours. Review of facility policy, Do Not Resuscitate (in the event that the heart stops beating or breathing stops there are no medical intervention started), dated last approved [DATE], revealed, All residents will be resuscitated (emergency medical treatment to maintain a heart rate and/or breathing- CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating)) without observable signs of life unless they have a Do Not Resuscitate (DNR) order. and 4. CPR will be initiated on all residents without observable signs of life unless a DNR order has been obtained. Review of facility policy, Change in Medical Condition, dated last approved [DATE], revealed that the facility, .shall provide notice of changes in medical condition related to but not limited to . incidents and other care issues in a timely manner . Continued review of the policy revealed no specific timelines had been developed for physician notification regarding changes in residents' medical condition. The policy indicated that . Timeliness may be defined based on the severity of situation, time of day and responsible party/designated person/facility expectations. Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Continued review of Resident CL1's clinical record revealed that the resident had a prior fall in (MONTH) (YEAR). Additionally, Resident CL1's clinical record noted that the resident had a history of [REDACTED]. Further review of Resident CL1's clinical record revealed no documentation and no physician orders related to the resident's code status (specific instructions for what measures the resident wants in the event of a medical emergency - i.e. CPR). Physician's orders for Resident CL1 dated (MONTH) 9, (YEAR), and continuing to present, revealed an order for [REDACTED]. Further review of Resident CL1's clinical record revealed that from approximately 9:45 p.m. on (MONTH) 9, (YEAR), through 1:55 a.m. on (MONTH) 12, (YEAR), a period of three days, Resident CL1 sustained four falls. On (MONTH) 12, (YEAR), at approximately 11:30 p.m. Resident CL1 was found lying on the floor near his bed. Facility documentation related to the fall revealed that the fall was unwitnessed and that the resident sustained [REDACTED]. x 1cm.), right shoulder (1cm. x 1cm.) and knee area as a result of the fall. It was also noted that the cover to the resident's night light had shattered as a result of the fall. Continued review of facility documentation related to Resident CL1's fall revealed that following the fall Employees E9 and E15 both Nurse Aides and E14 a Licensed Practical Nurse transferred the resident into a wheelchair and brought the resident out to the nurse's station for staff to monitor him. Additional review of Resident CL1's clinical record revealed that facility staff had contacted the residents' physician regarding the fall and initiated neurological checks (assessment of nerve function) as per the facility policy. Review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that Employee E14 had completed a Neurological Flow Sheet (assessment of neurological/brain function) on Resident CL1 at 11:30 p.m., following the resident's fall and continued through until (MONTH) 13, (YEAR), at 7:20 a.m. Continued review of the clinical record for Resident CL1 revealed that the resident had been found unresponsive (unarousable) at approximately 7:15 a.m. Resident CL1 was subsequently pronounced dead at 7:17 a.m., however, the neurological evaluation form completed by Employee E14 indicated that she had taken the resident's vital signs and completed a neurological evaluation at 7:20 a.m. Review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that during an interview, Employee E14 had admitted to Employee E2, Assistant Director of Nursing, that she had not completed the 7:20 a.m. neurological evaluation and that she had falsified the documentation. In further interview, Employee E2 indicated that the remaining neurological evaluations had been completed as documented. Observation of the facility's camera footage revealed that following the resident's transfer to the lobby at 11:44 p.m., until 7:00 a.m., a period of over seven hours, Employee E14 had not completed any of the seven scheduled neurological examinations. Review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that facility staff had contacted the physician regarding the resident's fall at 12:30 a.m. Continued review of facility documentation indicated that the physician had directed staff to continue monitoring the resident' s neurological checks. Interview with Employee E12, the on-call physician, on (MONTH) 24, (YEAR), at 12:25 p.m. he confirmed that the physician's answering service had received a call from the facility at approximately 12:,[DATE]:15 a.m. on (MONTH) 13, (YEAR). Further interview with Employee E12 revealed that the physician had not returned the call to the facility until 2:30 a.m., approximately three hours later, at which point he spoke with the resident's nurse. Continued review of facility documentation related to Resident CL1's fall indicated that the resident had remained in the lounge area for the remainder of the night. At approximately 7:15 a.m. Employee E20, staffing coordinator, had arrived on the first floor and observed Employees E16, E7 Registered Nurses, E14, Licensed Nurse and E8, E18, E19, Nurse's Aides lifting Resident CL1 from a reclining chair into a wheelchair. Employee E20 further indicated that she overheard staff say that the resident had died . Review of the clinical record revealed no documentation that staff had initiated any resuscitative efforts for the resident. Observation of facility camera footage of the first-floor lobby and elevator areas for (MONTH) 12, (YEAR), at 11:10 p.m. to (MONTH) 13, (YEAR), at 7:35 a.m. confirmed that staff had not attempted any resuscitative measures upon finding the resident unresponsive. Observation of Resident CL1's room on (MONTH) 17, (YEAR), at 11:00 a.m. with a representative of the Philadelphia Police Department revealed the presence of a recessed night light on the wall adjacent to the resident's bed. The night light was noted as shattered with multiple missing pieces noted. Continued observation of the resident's room revealed the presence of a large indention in the wall, adjacent to the night light, measuring approximately 12 inches long by four inches wide. Further review of the facility's camera footage revealed that following the resident's transfer to the lobby at 11:44 p.m. until 7:00 a.m. a period of over seven hours, Employee E14, had not completed any of the seven scheduled neurological examinations. In addition, Employee E14 neglected to re-attach the resident's scheduled tube feeding following his transfer to the lobby causing the resident to miss six hours of nutritional support. Continued review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that during an interview Employee E14 had admitted to Employee E2, Assistant Director of Nursing, that she had not completed the 7:20 a.m. neurological evaluation and that she had falsified the documentation. Further review of Resident CL1's clinical record revealed no documentation that upon finding the resident unresponsive any of the staff present (Employees E16 and E7-Registered Nurses and E14 Licensed Practical Nurse) had attempted to call [DATE] to secure emergency medical treatment for [REDACTED]. Interview with Employee E7, on (MONTH) 20, (YEAR), at approximately 3:40 p.m. revealed that he had been present on the floor at the time Resident CL1 had been found unresponsive. Employee E7 indicated that he went over to the resident to lend assistance. Employee E7 stated that he had asked the resident's nurse, Employee E16, what's the code status? Employee E7 indicated that Employee E16 never answered him and had proceeded to move the resident back to his room. In further interview the employee confirmed that staff had never started CPR on Resident CL1. Continued review of the clinical record revealed that the resident was pronounced dead at approximately 7:17 a.m. and that the resident's body was subsequently transferred to the medical examiner's office for an evaluation. Interview with a representative of the Philadelphia Police Department on (MONTH) 17, (YEAR), at 11:00 a.m. revealed that the coroner had listed the resident's cause of death as [MEDICATION NAME] force trauma. Review of the facility staffing schedule for the night shift on (MONTH) 12, (YEAR), revealed that Employee E15, Nurse Aide, had been assigned to provide care to Resident CL1. Review of facility camera footage revealed that the employee had not toileted (provide assistance to use the bathroom) Resident CL1 throughout the night nor had the employee checked in with the resident to see if there was anything the resident needed/wanted during the course of the night. Interview with Employee E8, Nurse Aide, on (MONTH) 21, (YEAR), at 4:40 p.m. revealed that she had assisted staff in returning Resident CL1 to bed in the morning of (MONTH) 13, (YEAR). Employee E8 stated that the resident's brief was heavily saturated with urine and feces at the time. The employee further indicated that Employee E15 had never completed rounds (process of checking on the well-being of the residents assigned to you) on Resident CL1 and had never checked on the resident. Interview with Employee E9, Nurse Aide, on (MONTH) 23, (YEAR), at approximately 10:00 a.m. confirmed that the employee had worked the night shift on (MONTH) 12, (YEAR), and had provided care to Resident CL1 during the night. Employee E9 revealed that he had observed the resident's, knee was red and noted that there was glass on it. Employee E9 stated that he told the resident's nurse, Employee E14, who instructed him to wash it off. In a further interview Employee E9 indicated no additional first aid had been obtained for the resident following the discovery of glass on his knee. Based on the above findings Immediate Jeopardy to the health and safety of residents was identified to the Nursing Home Administrator at 2:30 p.m. on (MONTH) 19, (YEAR), and an immediate action place was requested. The facility's immediate action plan included: 1. All staff (facility and agency) will be re-educated immediately regarding abuse, neglect and exploitation with emphasis on the definition, examples and reporting requirements. Staff competency in these areas was determined by successful completion of a written post test 2. All current staff on site will be educated immediately and as each shift change occurs all oncoming staff will be re-educated. Competency will be determined through post testing using scenarios and requiring staff to identify abuse, neglect and exploitation. 3. Fall Management Program Policy will be revised immediately. 4. All residents will be reassessed for fall risk. 5. All current facility staff will be re-educated regarding the policy modifications immediately. As each shift change occurs all oncoming staff will be re-educated. 6. All new admissions will be assessed for fall risk within four hours of admission. 7. Employee E14 agency licensed nurse has been determined not to be allowed back to facility to work. Following verification of the implementation of the immediate action plan and review of the staff re-education documentation and completed resident fall risk assessments, the Immediate Jeopardy was lifted at 11:10 a.m. on (MONTH) 23, (YEAR). The facility neglected to complete neurological evaluations as required for one resident following an unwitnessed fall, neglected to toilet the resident throughout the night and neglected to administer the tube feeding as ordered. The facility also failed to respond to an acute change in the resident's medical condition following the fall resulting in actual harm and death to one resident and placed other residents at risk for potential harm creating an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE] 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited [DATE] 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on observation of facility video footage, review of clinical records, facility policies and procedures, facility documentation and interviews with staff and others, it was determined that the facility failed to provide adequate supervision and implement interventions to meet a resident's needs, to properly respond to an acute change in the resident's medical condition from a fall for one of 13 residents reviewed which resulted in actual harm of [MEDICATION NAME] force trauma followed by death to that resident (Resident CL1). This failure placed all residents, who might sustain an accident, at a potential for high risk for harm from injury, and resulted in an Immediate Jeopardy situation. Findings include: Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Continued review of Resident CL1's clinical record revealed that the resident had a prior fall in (MONTH) (YEAR). Additionally, Resident CL1's clinical record noted that the resident had a history of [REDACTED]. A review of a Resident Risk Evaluation, completed on (MONTH) 9, (YEAR), indicated that the resident was identified as being a high risk for falls. A review of the clinical documentation revealed a nursing progress note, dated (MONTH) 10, (YEAR), at 12:20 a.m. that indicated the resident was found on the floor by a nursing assistant and was assessed to have no injuries. A review of a nursing progress, dated (MONTH) 10, (YEAR), at 8:15 a.m. indicated the resident attempted to stand and fell to the ground before staff could get to him. A nursing progress note, date (MONTH) 11, (YEAR), in the morning at 6:53 am, revealed that the resident was observed on the floor next to his bed. He was assessed to have obtained an abrasion on his right knee. The facility placed the resident on every 30-minute checks. Further review of the nursing progress notes, dated (MONTH) 12, (YEAR), at 3:00 p.m. indicated the resident was observed sitting on the floor next to his bed sometime during the shift. On (MONTH) 12, (YEAR), at approximately 11:30 p.m. Resident CL1 was found lying on the floor near his bed. Facility documentation related to the fall revealed that the fall was unwitnessed and that the resident sustained [REDACTED]. x 1cm.), right shoulder (1cm. x 1cm.) and knee area as a result of the fall. It was also noted that the cover to the resident's night light had shattered as a result of the fall. Continued review of facility documentation related to Resident CL1's fall revealed that following the fall Employees E9 and E15 both Nurse Aides and E14 a Licensed Practical Nurse transferred the resident into a wheelchair and brought the resident out to the nurse's station for staff to monitor him. Additional review of Resident CL1's clinical record revealed that facility staff had contacted the residents' physician regarding the fall and initiated neurological checks (assessment of nerve function) as per the facility policy. Continued review of facility documentation related to Resident CL1's fall indicated that the resident had remained in the lounge area for the remainder of the night. At approximately 7:00- 7:15 a.m. Employee E8, Nurse Aide, had noted that the resident was unresponsive, with no observable signs of life. Employees E8, E18 and E19, all Nurse Aides, E7 and E16 both Registered Nurses and E14 a Licensed Practical Nurse then transported the resident back to his room where he was returned to bed. Further review of the clinical record revealed no documentation that staff had initiated any resuscitative efforts for the resident. Review of facility camera footage of the first-floor lobby and elevator areas for (MONTH) 12, (YEAR), at 11:10 p.m. to (MONTH) 13, (YEAR), at 7:35 a.m. confirmed that staff had not attempted any resuscitative measures upon finding the resident unresponsive. Further review of Resident CL1's clinical record revealed no documentation that upon finding the resident unresponsive any of the staff present (Employees E16 and E7-Registered Nurses and E14 Licensed Practical Nurse) had attempted to call 9-1-1 to secure emergency medical treatment for [REDACTED]. Continued review of the clinical record revealed that the resident was pronounced dead at approximately 7:17 a.m. and that the resident's body was subsequently transferred to the medical examiner's office for an evaluation. Interview with a representative of the Philadelphia Police Department on (MONTH) 17, (YEAR), at 11:00 a.m. revealed that the coroner had listed the resident's cause of death as [MEDICATION NAME] force trauma. Further review of the facility's camera footage revealed that following the resident's transfer to the lobby at 11:44 p.m. until 7:00 a.m., a period of over seven hours, Employee E14 had not completed any of the seven scheduled neurological examinations. Review of the facility staffing schedule for the night shift on (MONTH) 12, (YEAR), revealed that Employee E15, Nurse Aide, had been assigned to provide care to Resident CL1. Review of facility camera footage revealed that the employee had not toileted (provide assistance to use the bathroom) Resident CL1 throughout the night nor had the employee checked in with the resident to see if there was anything the resident needed/wanted during the course of the night. Interview with Employee E8, Nurse Aide, on (MONTH) 21, (YEAR), at 4:40 p.m. revealed that she had assisted staff in returning Resident CL1 to bed in the morning of (MONTH) 13, (YEAR). Employee E8 indicated that Employee E15 had never completed rounds (process of checking on the well-being of the residents assigned to you) on Resident CL1 and had never checked on the resident. Interview with Employee E9, Nurse Aide, on (MONTH) 23, (YEAR), at approximately 10:00 a.m. confirmed that the employee had worked the night shift on (MONTH) 12, (YEAR), and had provided care to Resident CL1 during the night. Employee E9 revealed that he had observed the resident's knee was red and noted that there was glass on it. Employee E9 stated that he told the resident's nurse, Employee E14, who instructed him to wash it off. In a further interview Employee E9 indicated no additional first aid had been obtained for the resident following the discovery of glass on his knee. Based on the above findings Immediate Jeopardy to the health and safety of residents was identified to the Nursing Home Administrator at 2:30 p.m. on (MONTH) 19, (YEAR), and an immediate action place was requested. The facility's immediate action plan included: 1. All staff (facility and agency) will be re-educated immediately regarding abuse, neglect and exploitation with emphasis on the definition, examples and reporting requirements. Staff competency in these areas was determined by successful completion of a written post test 2. All current staff on site will be educated immediately and as each shift change occurs all oncoming staff will be re-educated. Competency will be determined through post testing using scenarios and requiring staff to identify abuse, neglect and exploitation. 3. Fall Management Program Policy will be revised immediately. 4. All residents will be reassessed for fall risk. 5. All current facility staff will be re-educated regarding the policy modifications immediately. As each shift change occurs all oncoming staff will be re-educated. 6. All new admissions will be assessed for fall risk within four hours of admission. 7. Employee E14 agency licensed nurse has been determined not to be allowed back to facility to work. Following verification of the implementation of the immediate action plan and review of the staff re-education documentation and completed resident fall risk assessments, the Immediate Jeopardy was lifted at 11:10 a.m. on (MONTH) 23, (YEAR). The facility failed to provide adequate supervision and implement interventions to prevent accidents for one resident (Resident CL1) resulting in actual harm of [MEDICATION NAME] force trauma following a fall and placed the other residents at risk for potential harm creating an Immediate Jeopardy situation. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 01/03/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/12/18, 01/03/17, 03/01/16 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 04/12/18, 01/03/17, 03/01/16 28 Pa. Code 201.18(b)(3) Management Previously cited 04/12/18, 03/01/16 28 Pa. Code 201.18(e)(1) Management Previously cited 04/12/18 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited 04/12/18 28 Pa. Code 211.10(c) Resident care policies Previously cited 04/12/18 28 Pa Code 211.10(d) Resident care policies Previously cited 04/12/18, 01/03/17 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited 04/12/18, 01/03/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 04/12/18, 08/22/17, 01/03/17, 03/01/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 04/12/18, 08/22/17, 01/03/17

Based on observations of facility video footage, review of clinical records and staff interviews, it was determined that the facility failed to assess and monitor a resident for a change in condition, when a resident became unresponsive following a fall and subsequently died , for one of 13 residents reviewed (Resident CL1). This failure placed the residents at a high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, Neurological Evaluation (assessment of nerve function), dated last approved [DATE], revealed that . 1. Any resident with the potential for head trauma injury or having an acute change in level of consciousness will receive 72 hours of neurological evaluation, following notification of the physician. In addition, the policy indicated that the neurological assessments were to be completed as follows: a. Every 15 minutes for the first hour, b. Every hour for the next three hours, c. Every two hours for the next four hours, d. Every four hours for the next sixteen hours and e. Every eight hours for the next forty-eight hours. Review of facility policy, Do Not Resuscitate (in the event that the heart stops beating or breathing stops there are no medical intervention started), dated last approved [DATE], revealed, All residents will be resuscitated (emergency medical treatment to maintain a heart rate and/or breathing- CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating)) without observable signs of life unless they have a Do Not Resuscitate (DNR) order. and 4. CPR will be initiated on all residents without observable signs of life unless a DNR order has been obtained. Review of facility policy, Change in Medical Condition, dated last approved [DATE], revealed that the facility, .shall provide notice of changes in medical condition related to but not limited to . incidents and other care issues in a timely manner . Continued review of the policy revealed no specific timelines had been developed for physician notification regarding changes in residents' medical condition. The policy indicated that . Timeliness may be defined based on the severity of situation, time of day and responsible party/designated person/facility expectations. Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Continued review of Resident CL1's clinical record revealed that the resident had a prior fall in (MONTH) (YEAR). Additionally, Resident CL1's clinical record noted that the resident had a history of [REDACTED]. A review of a Resident Risk Evaluation, completed on (MONTH) 9, (YEAR), indicated that the resident was identified as being a high risk for falls. physician's orders [REDACTED]. On (MONTH) 12, (YEAR), at approximately 11:30 p.m. Resident CL1 was found lying on the floor near his bed. Facility documentation related to the fall revealed that the fall was unwitnessed and that the resident sustained [REDACTED]. x 1cm.), right shoulder (1cm. x 1cm.) and knee area as a result of the fall. It was also noted that the cover to the resident's night light had shattered as a result of the fall. Continued review of facility documentation related to Resident CL1's fall revealed that following the fall Employees E9 and E15 both Nurse Aides and E14 a Licensed Practical Nurse transferred the resident into a wheelchair and brought the resident out to the nurse's station for staff to monitor him. There was no documentation that the night shift supervisor, Employee E6, was notified of the fall before the resident was put in the wheelchair and taken to the lobby at approximately 11:44 p.m. During an interview with Employee E6, night shift supervisor on (MONTH) 20, (YEAR), at 4:15 p.m. she stated that she had not been contacted regarding the residents fall by Employee E14, charge nurse, to assess him until he was up in the wheelchair. Additional review of Resident CL1's clinical record revealed that facility staff had contacted the residents' physician regarding the fall and initiated neurological checks (assessment of nerve function) as per the facility policy. There was no documentation that Employee E14, licensed charge nurse, performed an assessment of the resident immediately after the fall. There was no evidence of a progress note written by the charge nurse. Review of facility camera footage did not indicate that the nurse had assessed the resident at any time during the night or take any vital signs or complete any neuro checks. The facility did have a Neurological Flow Sheet completed by the charge nurse with all of the vital signs filled out through the night as required. There was an entry of vital signs completed at 7:20 a.m. after the resident was found unresponsive and deceased . Continued review of facility documentation related to Resident CL1's fall indicated that the resident had remained in the lobby area for the remainder of the night. At approximately 7:,[DATE]:15 a.m. Employee E8, Nurse Aide, had noted that the resident was unresponsive, with no observable signs of life. Employees E8, E18 and E19, all Nurse Aides, E7 and E16 both Registered Nurses and E14 a Licensed Practical Nurse then transported the resident back to his room where he was returned to bed. Further review of the clinical record revealed no documentation that staff had initiated any resuscitative efforts for the resident. Review of facility camera footage of the first-floor lobby and elevator areas for (MONTH) 12, (YEAR), at 11:10 p.m. to (MONTH) 13, (YEAR), at 7:35 a.m. confirmed that staff had not attempted any resuscitative measures upon finding the resident unresponsive. Further review of the facility's camera footage revealed that following the resident's transfer to the lobby at 11:44 p.m. until 7:00 a.m. a period of over seven hours, Employee E14, had not completed any of the seven scheduled neurological examinations. In addition, Employee E14 had never re-attached the resident's scheduled tube feeding following his transfer to the lobby causing the resident to miss six hours of nutritional support. Continued review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that during an interview Employee E14 had admitted to Employee E2, Assistant Director of Nursing, that she had not completed the 7:20 a.m. neurological evaluation and that she had falsified the documentation. Further review of Resident CL1's clinical record revealed no documentation that upon finding the resident unresponsive any of the staff present (Employees E16 and E7-Registered Nurses and E14 Licensed Practical Nurse) had attempted to call [DATE] to secure emergency medical treatment for [REDACTED]. Interview with Employee E7, on (MONTH) 20, (YEAR), at approximately 3:40 p.m. revealed that he had been present on the floor at the time Resident CL1 had been found unresponsive. Employee E7 indicated that he went over to the resident to lend assistance. Employee E7 stated that he had asked the resident's nurse, Employee E16, what's the code status? Employee E7 indicated that Employee E16 never answered him and had proceeded to move the resident back to his room. In further interview the employee confirmed that staff had never started CPR on Resident CL1. Continued review of the clinical record revealed that the resident was pronounced dead at approximately 7:17 a.m. and that the resident's body was subsequently transferred to the medical examiner's office for an evaluation. Interview with a representative of the Philadelphia Police Department on (MONTH) 17, (YEAR), at 11:00 a.m. revealed that the coroner had listed the resident's cause of death as [MEDICATION NAME] force trauma. Review of the facility staffing schedule for the night shift on (MONTH) 12, (YEAR), revealed that Employee E15, Nurse Aide, had been assigned to provide care to Resident CL1. Review of facility camera footage revealed that the employee had not toileted (provide assistance to use the bathroom) Resident CL1 throughout the night nor had the employee checked in with the resident to see if there was anything the resident needed/wanted during the course of the night. Interview with Employee E8, Nurse Aide, on (MONTH) 21, (YEAR), at 4:40 p.m. revealed that she had assisted staff in returning Resident CL1 to bed in the morning of (MONTH) 13, (YEAR). Employee E8 stated that the resident's brief was heavily saturated with urine and feces at the time. The employee further indicated that Employee E15 had never completed rounds (process of checking on the well-being of the residents assigned to you) on Resident CL1 and had never checked on the resident. Interview with Employee E9, Nurse Aide, on (MONTH) 23, (YEAR), at approximately 10:00 a.m. confirmed that the employee had worked the night shift on (MONTH) 12, (YEAR), and had provided care to Resident CL1 during the night. Employee E9 revealed that he had observed the resident's knee was red and noted that there was glass on it. Employee E9 stated that he told the resident's nurse, Employee E14, who instructed him to wash it off. In a further interview Employee E9 indicated no additional first aid had been obtained for the resident following the discovery of glass on his knee. Based on the above findings Immediate Jeopardy to the health and safety of residents was identified to the Nursing Home Administrator at 2:30 p.m. on (MONTH) 19, (YEAR), and an immediate action place was requested. The facility's immediate action plan included: 1. All staff (facility and agency) will be re-educated immediately regarding abuse, neglect and exploitation with emphasis on the definition, examples and reporting requirements. Staff competency in these areas was determined by successful completion of a written post test 2. All current staff on site will be educated immediately and as each shift change occurs all oncoming staff will be re-educated. Competency will be determined through post testing using scenarios and requiring staff to identify abuse, neglect and exploitation. 3. Fall Management Program Policy will be revised immediately. 4. All residents will be reassessed for fall risk. 5. All current facility staff will be re-educated regarding the policy modifications immediately. As each shift change occurs all oncoming staff will be re-educated. 6. All new admissions will be assessed for fall risk within four hours of admission. 7. Employee E14 agency licensed nurse has been determined not to be allowed back to facility to work. Following verification of the implementation of the immediate action plan and review of the staff re-education documentation and completed resident fall risk assessments, the Immediate Jeopardy was lifted at 11:10 a.m. on (MONTH) 23, (YEAR). The facility failed to provide basic care to meet the resident's needs and failed to properly respond to an acute change in a resident's medical condition following a fall resulting in actual harm to one resident and placed other residents at risk for potential harm creating an Immediate Jeopardy situation. Quality of Care CFR(s): 483.25 - Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE] 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited [DATE] 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on a review of the Facility Assessment, the facility failed to assess the knowledge, skills, abilities, behaviors and other characteristics needed to ensure that the staff were able to perform work roles to meet the residents' needs. This failure resulted in actual harm to one resident when the facility staff failed to maintain the well being of a resident who sustained an acute change in their medical condition resulting from a fall which resulted in actual harm of [MEDICATION NAME] force trauma followed by death to that resident (Resident CL1). Findings include: Review of the Facility Assessment tool, dated (MONTH) 18, (YEAR), revealed the facility would determine what resources were necessary to provide competent care for the residents, including staff and staff training/education and competencies. The Facility Assessment further specified the assessment tool aids the facility would use to make decisions about the direct care staff needs, as well as their capabilities, to provide services to maintain, or attain the resident's highest practicable physical, mental and psychosocial well-being. Further review of the facility assessment revealed no information was provided related to the ethnic, cultural or religious factors of the facility's residents. Additionally, there was no data included pertaining to the types of staff education, training or competencies required to provide the appropriate level of care to their resident population. No information was provided regarding required in-service training, abuse and neglect training and training on resident's rights and facility responsibilities. The facility assessment did not contain any information regarding staff competencies on resident assessments, including neurological checks and examinations and no description and or information for the facility's health information technology resources as required. Based on the findings of an abbreviated survey in response to a complaint completed on (MONTH) 23, (YEAR), which identified multiple areas of regulatory non-compliance, including an Immediate Jeopardy situation and harm level deficiencies, it was determined the Nursing Home Administrator and the Director of Nursing failed to conduct, document and maintain a facility-wide assessment which includes both their resident population and the resources necessary to meet the needs of their residents. Refer to F600, F610, F684 and F689 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/12/18, 01/03/17, 03/01/16 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(3) Management Previously cited 04/12/18, 03/01/16 28 Pa. Code 201.18(e)(1) Management Previously cited 04/12/18 28 Pa. Code 201.18(e)(2) Management 28 Pa. Code 211.12(c) Nursing services Previously cited 04/12/18, 01/03/17

Based on review of the clinical record, facility policy and procedure, facility documentation and interviews with staff, it was determined that the facility failed to conduct complete and thorough fall investigations for one of 13 residents reviewed which resulted in actual harm for a resident that sustained [MEDICATION NAME] force trauma following a fall and subsequently died (Resident CL1). Findings include: Review of facility policy, Abuse Neglect or Exploitation, date last approved [DATE], revealed that . each resident is provided with a safe environment . and . residents shall also be protected from mistreatment, neglect, exploitation, and misappropriation of property. Continued review of the policy revealed that the facility defined neglect as . failure to provide goods and services required for the sustained health and wellbeing of the resident Neglect is further defined as failure to provide goods and services necessary to avoid physical harm Neglect usually occurs on an individual basis when a resident receives a lack of care in one or more areas . Review of facility policy, Falls Management Program, dated last approved (MONTH) 18, (YEAR), revealed .4. Any occurrence of falls along with interventions will be documented in the nursing notes. 6. When a resident sustains a fall, the assessment process will include an investigation using the Fall Investigation analysis sheet. This is to help identify the root cause (process for determine causative factors surrounding an incident) and whether or not the fall was avoidable or unavoidable. The investigation and appropriate interventions will be initiated at the time of the fall. Additional review will be done by Nursing management following the next morning stand-up (Daily administrative meetings) meeting. The results of the investigation and recommendations will be documented in the clinical record.and .11. Other follow-up to a resident fall will be conducted depending on the nature of the injury sustained and in keeping with accepted standards of practice. Review of facility policy, Neurological Evaluation (assessment of nerve function), dated last approved [DATE], revealed that . 1. Any resident with the potential for head trauma injury or having an acute change in level of consciousness will receive 72 hours of neurological evaluation, following notification of the physician. In addition, the policy indicated that the neurological assessments were to be completed as follows: a. Every 15 minutes for the first hour, b. Every hour for the next three hours, c. Every two hours for the next four hours, d. Every four hours for the next sixteen hours and e. Every eight hours for the next forty-eight hours. Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Continued review of Resident CL1's clinical record revealed that the resident had a prior fall in (MONTH) (YEAR). Additionally, Resident CL1's clinical record noted that the resident had a history of [REDACTED]. Further review of Resident CL1's clinical record revealed that from approximately 9:45 p.m. on (MONTH) 9, (YEAR), through 1:55 a.m. on (MONTH) 12, (YEAR), a period of three days, Resident CL1 sustained four falls. On (MONTH) 12, (YEAR), at approximately 11:30 p.m. the resident sustained [REDACTED]. Review of the facility, Fall Investigation analysis sheet related to Resident CL1's fall on (MONTH) 9, (YEAR), revealed the sheet was incomplete and contained no documentation of resident vital signs (pulse, respiratory rate and blood pressure reading) following the fall and no documentation of the resident's medical [DIAGNOSES REDACTED]. Additionally, the Neurological Flow Sheet (assessment of vital signs and brain function) which had been initiated at the time of the resident's fall on (MONTH) 9, (YEAR), revealed no values entered for the scheduled neurological checks (assessment of nerve function) at 1:30 p.m., 5:30 a.m. and 1:30 p.m. Further review of the facility's documentation related Resident CL1's fall on (MONTH) 9, (YEAR), revealed that the resident had stated that he was . trying to get to the bathroom at the time of the fall. Continued review of Resident CL1's clinical record revealed no documentation that the staff had identified the resident's need to be toileted as a causative factor in his fall and/or developed a toileting schedule to reduce the risk of further falls to the resident. Review of facility documentation related to Resident CL1's fall on (MONTH) 10, (YEAR), at 8:15 a.m., revealed no documentation of the resident's vital signs as per the facility Fall Investigation analysis sheet. Additionally, there was no documentation of staff analysis of the resident's medical [DIAGNOSES REDACTED]. Review of facility documentation related to Resident CL1's fall on (MONTH) 11, (YEAR), at 6:30 a.m. revealed that the resident had sustained an unwitnessed fall in his room. Continued review of facility Fall Investigation analysis sheet related to the resident's fall revealed that documentation of the neurological evaluations was missing for the 7:15 a.m., 7:30 a.m., 8:30 a.m., 9:30 a.m., 10:30 a.m., 2:30 p.m., 4:30 p.m., 6:30 p.m. and 8:30 p.m. scheduled evaluations. In addition, there was no documentation that witness statements had been obtained from staff on duty at the time of the fall, to rule out resident neglect. Review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at approximately 2:00 a.m., revealed that the resident had sustained an unwitnessed fall. Continued review of facility documentation related to the fall revealed that neurological evaluations scheduled for 3:55 a.m., 4:55 a.m., 5:55 a.m., 7:55 a.m. and 9:55 a.m. had not been completed as scheduled. Additionally, there was no documentation that the four hour and eight hour neurological checks had been completed as required. Review of the facility's Fall Investigation analysis sheet related to Resident CL1's fall on (MONTH) 12, (YEAR), revealed no documentation of staff analysis of the resident's medical [DIAGNOSES REDACTED]. Review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that the resident had sustained an unwitnessed fall in his room. Review of Resident CL1's clinical record revealed no documentation from Employee E14, Licensed Practical Nurse, assigned to provide care to the resident that night, regarding the details of the resident's fall, description of the resident's injuries and/or documentation of any necessary care/treatments provided to the resident as a result of the fall. Review of the Fall Investigation analysis sheet revealed that Employee E6, Registered Nurse and Night Shift Supervisor, had indicated that at the time of the fall, the resident's bed had been in the lowest position and that the resident was wearing socks at the time of the fall. Interview with Employee E6 on (MONTH) 20, (YEAR), at 4:15 a.m. revealed that the resident had already been picked up from the floor and moved into a wheelchair at the time of the assessment. Interview with Employee E9, Nurse Aide, on (MONTH) 23, (YEAR), at 10:00 a.m. confirmed that the employee had been present in the room at the time Resident CL1 had been transferred from the floor into the wheelchair. Further interview with Employee E9 revealed that the resident's bed had been in the high position. The employee stated that the staff had to move the resident carefully because there was glass on the floor and the resident did not have socks on his feet. Continued review of facility documentation related to Resident CL1's fall on (MONTH) 12, (YEAR), at 11:30 p.m. revealed that Employee E14 had completed a Neurological Flow Sheet (assessment of neurological/brain function) on Resident CL1 at 11:30 p.m. following the resident's fall and continued through until (MONTH) 13, (YEAR), at 7:20 a.m Continued review of the clinical record for Resident CL1 revealed that the resident had been found unresponsive (unarousable) at approximately 7:,[DATE]:15 a.m. Resident CL1 was subsequently pronounced dead at 7:17 a.m., however, the neurological evaluation form completed by Employee E14 indicated that she had taken the resident's vital signs and completed a neurological evaluation at 7:20 a.m. The facility failed to ensure that fall investigations for one resident were complete and accurate, that neurological evaluations were completed as required and that conflicting data noted in the fall investigations was further analyzed and inconsistencies resolved so that appropriate interventions could be developed and implemented to protect the resident from any further injury from falls. Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4) - Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE] 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE]