Every finding on record at Chambers Pointe Health Care Center

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for one of 24 residents reviewed (Resident 42).Findings include:The facility's policy regarding the use of psychotropic medication, dated February 12, 2026, included that who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 42 dated March 12, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included dementia, and depression.Physician's orders for Resident 42 dated January 2, 2026, January 16, 2026, and January 28, 2026, February 14, 2026, February 24, 2026, February 26, 2026, and March 12, 2026, included for the resident to receive 0.50 milligrams (mg) of Lorazepam (an antianxiety medication) every eight hours as needed for anxiety/agitation for 14 days. Review of the Medication Administration Record MAR dated January 2026, February 26, 2026, and March 2026, indicated that 0.50 mg of Lorazepam was administered on January 9 at 5:36 p.m., January 14 at 1:34 p.m., January 17 at 6:59 a.m., January 22 at 3:24 p.m., January 28 at 2:35 p.m., January 30 at 8:22 a.m., February 2 at 11:03 a.m., February 15 at 5:24 p.m., February 18 at 11:58 p.m., February 26 at 7:31 a.m., March 1 at 8:27 a.m., March 10 at 6:57 a.m., March 14 at 7:16 a.m., March 18 at 12:34 p.m., March 23 at 12:46 p.m., and March 24 at 2:10 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to the use of the antianxiety medication on these dates and times.Interview with the Nursing Home Administrator on March 25, 2026, at 2:36 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Lorazepam to Resident 42 on the above-mentioned dates and times and there should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food at appetizing temperatures.Findings include:The facility's policy regarding food temperatures, dated February 12, 2026, revealed that cold foods were to be served at a temperature between 33 to 50 degrees Fahrenheit (F) and hot foods were to be served at a temperature between 135 to 155 degrees (F). Interview with Resident 5 on March 23, 2026, at 12:20 p.m. revealed that the hot foods were often served not hot when he received them. The menu for the lunch meal on March 24, 2026, revealed that the meal consisted of a salmon fillet, stir fried rice, green beans, pickled beets with onions, and cheesecake. The temperatures of the food were taken prior to the meal service, and the salmon was 155 degrees (F), stir fried rice was 168 degrees (F), green beans were 165 degrees (F), and the pickled beets were 41 degrees (F).Observations of the lunch meal on the Dogwood unit on March 24, 2026, at 12:07 p.m. revealed that Homeworker 1 placed the hot food items directly from the steam table onto a plate, and the pickled beets and cheesecake from containers on the counter onto a plate for a test tray. She took the temperatures of the foods once plated and the temperature of the salmon was 126 degrees (F), the stir-fried rice was 134 degrees (F), the green beans were 123.9 degrees (F), pickled beets were 63.5 degrees (F), and the cheesecake was 50.3 degrees (F). At 12:13 p.m. the test tray was tasted, and the salmon and green beans were lukewarm and the pickled beets were not cold.Interview with Homeworker 1 on March 24, 26, at 12:07 p.m. confirmed that the temperatures were a little low for the hot foods and the temperature of the beets was a little high. She referred to the recommended temperatures of foods listed on the tray line sheet as a reference.28 Pa. Code 211.6(b) Dietary services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards of food service safety, by failing to properly label and date frozen foods on one of two units (Dogwood unit). Findings include:The facility's policy regarding food storage, dated February 12, 2026, revealed that all products were labeled and dated with the receiving date. All open items were to have an open date and resealed to prevent contamination.Observations in the reach-in freezer on the Dogwood unit on March 23, 2026, at 11:07 a.m. revealed that there were two half gallon containers of ice cream, Butter Pecan and Chocolate, that were open and not labeled with the date they were opened.Interview with Homemaker 2 on March 23, 2026, at that time confirmed that the half gallon containers of ice cream should have been dated when they were opened.Interview with the Nursing Home Administrator March 23, 2026, at 2:46 p.m. confirmed that the open containers of ice cream should have been dated when opened.28 Pa. Code 211.6(f) Dietary services.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to complete air mattress safety assessments for two of 24 residents reviewed (Residents 21, 45) who utilized air mattresses. Findings include:The facility's policy regarding assistive devices and equipment, dated February 12, 2026, revealed the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated February 13, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care. The resident's current care plan, dated December 12, 2025, revealed that the resident had potential or actual impairment to skin integrity, with intervention of alternating air mattress to maintain intact skin. Observation on March 23, 2026, revealed that Resident 21 utilized an air mattress on her bed. Review of her clinical record revealed that there was no documented evidence that an air mattress safety assessment was completed. Interview with Nursing Home Administrator on March 25, 2026, at 10:41 a.m., confirmed that Resident 21 should have had an air mattress safety assessment performed but it was not completed. A quarterly MDS assessment for Resident 45, dated January 27, 2026, revealed that the resident was cognitively impaired, was dependent on staff for daily care, and was receiving hospice services. A care plan, dated February 3, 2026, revealed that the resident had an alternating air mattress provided by hospice. Observation on March 23, 2026, at 12:20 p.m. revealed that Resident 45 was in bed and had an air mattress on her bed. Review of her clinical record revealed that there was no documented evidence that an air mattress safety assessment was completed. Interview with the Nursing Home Administrator on March 25, 2026, at 10:41 a.m. revealed that there was no documented evidence that an air mattress safety assessment was completed for Resident 45.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident 2) resulting in a fall with a fracture.Findings include:The facility's abuse policy, dated February 20, 2025, revealed that the facility will not tolerate abuse and that facility staff must immediately report all such allegations to the Nursing Home Administrator/Abuse Coordinator.The facility's abuse policy, dated February 20, 2025,revealed that the facility provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Neglect means 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.An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 2, dated April 29, 2025, revealed that the resident was cognitively intact, was understood, was able to understand others, had no impairment of the upper extremities, and required assistance for transfers.A nurse's note for Resident 2, dated July 11, 2025, at 8:00 p.m., revealed that the resident had a witnessed fall. The resident stated that she fell backwards. The staff person in the room indicated the resident was ambulating with a rollator and had assisted the resident from the bathroom to the bed. When the staff person side stepped to arrange the blankets on the bed the resident fell backwards. Resident 2 had complaints of 10 out of 10 pain of the right shoulder and was unable to perform range of motion due to the pain. The resident was transported to the hospital for evaluation of the right upper extremity pain.Information submitted by the facility, dated July 11, 2025, at 7:00 p.m., indicated that on July 11, 2025 at 5:00 p.m. Nurse Aide 1 was ambulating Resident 2 from the bathroom to the bed with a four wheeled walker. The nurse aide turned to pull the bed linen down and the resident lost her balance and fell backwards. Resident 2's right shoulder hurt. A gait belt was not in used during the fall. Resident 2 was sent the emergency room for evaluation and was noted to have a proximal Humerus fracture. The facility's investigation concluded that Nurse Aide 1 verbalized that she knew she should have used a gait belt prior to transfer, but she forgot. Resident 2's care plan prior to the fall and the gait belt policy indicated that a gait belt should have been used for ambulation and transfer, and was not used by the nurse aide. The findings of the investigation substantiated neglect.A nurse's note for Resident 2, dated July 16, 2025, at 1:42 a.m., revealed the resident was adjusting well to readmission to the facility. Resident 2 used a sling to the right shoulder due to a fracture and pain medication was used as needed for increased shoulder pain.A witness statement from Registered Nurse 2, dated July 11, 2025, revealed that she entered the room to see that Resident 2 was lying on her back leaning to the right and did not see a gait belt on the resident. Resident 2 complained of right shoulder pain and was unable to move her right arm.A witness statement from Nurse Aide 1, dated July 11, 2025, revealed that she was providing care for Resident 2 and while walking back to the bed the resident called out that she was falling as I used my right hand to pull the sheets back from the bed. Resident 2 was not wearing a gait belt at this time. The resident fell to the ground.Interview with the Nursing Home Administrator on August 8, 2025, at 11:09 a.m. revealed that she substantiated neglect and terminated the employee for not using a gait belt.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' chairs were clean for one of 19 residents reviewed (Resident 10). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated November 27, 2024, revealed that the resident was usually understood, could understand others, and had diagnoses that included cerebral palsy (a group of non-progressive neurological disorders that affect movement, posture, and balance). Observations of Resident 10's power wheelchair on February 26, 2025, at 3:10 p.m. and on February 27, 2025, at 11:49 a.m. and 1:45 p.m., respectively, revealed that the resident's power wheelchair had a buildup of food and dust debris on the lower frames, as well as an accumulation of dust on the black motor/battery cover. Interview and observations with the Director of Housekeeping on February 27, 2025, at 1:45 p.m. confirmed that Resident 10's power wheelchair had a buildup of food and dust debris on the lower frames, as well as an accumulation of dust on the black motor/battery cover. She indicated that they have a regular cleaning schedule for the regular wheelchairs; however, they do not have one for the resident's power wheelchair. 28 Pa. Code 207.2(a) Administrator's Responsibility. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 19 residents reviewed (Residents 17, 24). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0451K was to be coded if the resident received an anti-convulsant during the seven-day assessment period. Physician's orders for Resident 17, dated January 24, 2025, included orders for the resident to receive 300 mg Gabapentin (anti-convulsant) three times a day. Review of the January MAR revealed that the resident received Gabapentin during the assessment period. However, an admission MDS assessment for Resident 17, dated January 30, 2025, revealed that Sections N0415K was coded to indicate that the resident had not received the anti-convulsant. Interview with the Nursing Home Administrator on February 28, 2025, at 1:59 p.m. confirmed that MDS assessment for Resident 17 was coded inaccurately. The Long-Term Care Facility Resident Assessment Instrument User's Manual, dated October 2024, indicated that Section B-Hearing, Speech, and Vision (B0100-B1200) was to be completed to indicate the resident's ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in aged persons. Section C-Cognitive Patterns (C0100-C1000) of the MDS was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The RAI User's Manual also indicated that if a resident did not answer a question, then the question should be coded as a zero for an incorrect answer. If there were no responses, or the responses were nonsensical, then the BIMS interview was to be stopped after Section C0300 (day of the week), a dash was to be coded in the remaining sections of the individual interview, a (99) was to be entered in Section C0500, and then a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. A quarterly MDS assessment for Resident 24, dated February 6, 2025, revealed that section B0700 was coded (3) indicating that the resident was rarely or never understood, and section B0800 was coded (3) indicating the resident could rarely or never understand others. However, according to Section C0100, attempt to conduct interview, was coded (1) indicating yes, interview the resident. Interview with the Nursing Home Administrator on February 28, 2025, at 1:59 p.m. confirmed that Section C0100 of Resident 24's February 6, 2025, MDS assessment was not accurate and should have been coded zero (0). 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policies and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of 19 residents reviewed (Resident 17). Findings include: The facility's policy regarding pain management, dated February 20, 2025, indicated that the facility would ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences. When pain medications were administered the facility would follow up monitoring the effectiveness. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated January 30, 2025, revealed that the resident was alert and oriented, received pain medication routinely and as needed, received an opioid (a controlled pain medication), and was receiving hospice services. Physician's orders for Resident 17, dated January 30, 2025, included orders for the resident to receive 0.5 milliliters (mL) of morphine sulfate solution (a narcotic pain medication) 20 milligrams/milliliter (mg/mL) every two hours as needed for shortness of breath or pain. Resident 17's Medication Administration Record for February 2025 revealed that 0.5 mL morphine sulfate was administered on February 6 at 1:13 p.m. There was no documented evidence of the effectiveness of pain relief after the administration of the morphine sulfate until 4:17 p.m., at which time the effectiveness was documented as ineffective and 0.5 mL of morphine sulfate was administered at that time. Resident 17's Medication Administration Record for February 2025 revealed that 0.5 mL morphine sulfate was administered on February 7 at 6:55 a.m. There was no documented evidence of the effectiveness of pain relief after the administration of the morphine sulfate until 10:03 a.m., at which time the effectiveness was documented as ineffective and 0.5 mL of morphine sulfate was administered at 10:07 a.m. Interview with the Nursing Home Administrator on February 28, 2025, at 1:59 p.m. confirmed that there was no follow up regarding the effectiveness of the morphine sulfate after administration on February 6 and 7, 2025. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a therapeutic diet was provided as ordered by the physician for one of three residents reviewed (Resident 1). Findings include: The facility's policy regarding thickened liquids, dated April 11, 2024, indicated that the definition for thickened liquids are liquids where the consistency has been altered to facilitate safe, oral intake. They are ordered as part of treatment for a disease or clinical condition, such as dysphagia (a medical term for difficulty swallowing) due to stroke, cancer, multiple sclerosis (a chronic disease of the central nervous system) or other neuromuscular disease. Thickened liquids are provided only when ordered by a physician/practitioner, or when ordered by a dietitian or speech-language pathologist who has been delegated to write diet orders, to the extent allowed by state law. The facility utilizes standard liquid categories. Category 0: Thin; Category 1: Slightly thick (naturally thick); Category 2 Mildly thick (nectar thick); Category 3: Moderately thick (honey thick), and Category 4: Extremely thick (spoon thick). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 19, 2024, revealed that the resident was usually understood, could usually understand, had a diagnosis which included dysphagia, and was on a mechanically altered diet (foods that are easy to swallow because they are blended, chopped, ground, or mashed so that they are easy to chew and swallow). A care plan for the resident, dated May 31, 2024, revealed that the resident has a swallowing problem. Staff were to provide the resident's diet as ordered, and she was to have nectar thick liquids (have slightly more body than thin liquids, but still can pour easily). Physician's orders for Resident 1, dated April 5, 2024, included an order for the resident to receive 237 milliliters (ml) of Ensure Plus (a nutritional supplement) three times a day. Physician's orders for Resident 1, dated May 31, 2024, included an order for the resident to receive a liberal geriatric diet (tailored to a person's preferences and health needs) with chopped meats and nectar/mildly thick consistency for her liquids. A nursing note for Resident 1, dated June 19, 2024, at 12:11 p.m. revealed that the resident went to a luncheon off the unit and was given thin water instead of a thickened drink. The resident's lungs were clear and her temperature. range was within normal limits. The resident had no coughing or signs of respiratory distress. Observations of Resident 1 during the supper meal on August 5, 2024, at 4:59 p.m. revealed that the resident was sitting at a table in the Evergreen Unit main dining room eating her supper. The resident had a hot dog that was cut up in small pieces on a hot dog bun, baked beans, enriched pudding (nutrients that were lost during processing are added back in), a small glass containing a red-colored nectar thick juice, and a container of Ensure Plus with a straw in the container. The resident picked up the container of Ensure Plus and took sips through the straw throughout the meal. Interview with the Nursing Home Administrator on August 5, 2024, at 5:27 p.m. confirmed that the nursing note for Resident 1 on June 19, 2024, indicated that the resident received the incorrect consistency for her liquids. Interview with Dietitian 1 on August 5, 2024, at 6:25 p.m. revealed that there was only one Ensure product that he is aware that would be considered nectar thick at room temperature, and that would be Ensure Max Chocolate. He indicated that Chocolate Ensure Plus would be considered Category 1 at room temperature, which would be considered slightly thick. He indicated that Resident 1 would require Category 2 level for her liquid consistency. Interview with Registered Nurse 2 on August 5, 2024, at 6:40 p.m. confirmed that she did not add any thickener to Resident 1's Ensure Plus prior to giving it to the resident. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility's policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable and at proper temperatures. Findings include: The facility's policy regarding Food Handling Principles dated September 14, 2023, revealed that hot foods are to be served at 135-155 degrees Fahrenheit (F). Observations on March 12, 2024, at 10:52 a.m. revealed that the food was brought to the kitchenette and initial temperatures were taken. The pasta was 152.0 degrees F, the popcorn chicken was 143.0 degrees F, the shrimp was 173.0 degrees F, the mashed potatoes were 160.0 degrees F, the beets and carrots were 164.0 degrees F, the mechanical chicken was 163.0 degrees F, and the ground shrimp was 156.0 degrees F. The food was then placed in the steam table. The steam table pans containing the hot food were left uncovered throughout the lunch meal service. After serving lunch to the last resident in the dining room on March 12, 2024, at 12:26 p.m., temperatures for a test tray were obtained. The mechanical shrimp was 137.0 degrees F and cold to taste, the mechanical chicken was 135.0 degrees F and cold to taste, the carrots and beets were 131.0 degrees F and cold to taste, the mashed potatoes with gravy were 133 degrees F and cold to taste, the shrimp with pasta and garlic butter was 136.0 degrees F and cold to taste. Interview with Dietary Aide 4 on March 12, 2024, at 12:26 p.m. revealed that the lids should have been closed when not plating food. Interview with the Nursing Home Administrator on March 12, 2024, at 2:16 p.m. confirmed that food should be served at an appropriate temperature, and that the food would be cold if lids are left open during service. 28 Pa. Code 211.6(b) Dietary Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure that dietary staff wore hair coverings that completely covered their hair during food handling and not storing food properly. Findings include: The facility's dietary policy regarding Use of Hair Restraints, dated September 14, 2023, revealed that staff were to wear a hat or hairnet to cover all visible hair. The facility's dietary policy regarding Food Storage, dated September 14, 2023, revealed that food is stored in a manner that prevents damage, spoilage, infestation, and bacterial contamination. Observations in the main kitchen on March 11, 2024, at 10:26 a.m. revealed that the Assistant Dietary Director was wearing a hair restraint and approximately three inches of her bangs were uncovered. Observations in the freezer on March 11 2024, at 10:26 a.m. revealed a tray containing 22 uncovered, unlabeled and undated grey colored, unidentifiable food patties; 24 patties of pureed cranberry that was uncovered, unlabeled and undated; and a full box of [NAME] that was uncovered, undated and unlabeled and open to the air. Observations in the Evergreen kitchenette on March 11, 2024, at 10:41 a.m. revealed that Dietary Aide 5 exited the kitchenette without a hairnet. Observations in the Dogwood kitchenette on March 11, 2024, at 10:45 a.m. revealed that Dietary Aide 6 had three inches of hair on the back of her head that was not covered by her hair restraint. Interview with the Executive Culinary Director on March 11, 2024, at 10:46 a.m. confirmed that staff did not have all hair covered with hair restraints and should have, and that the frozen patties and box of [NAME] were not covered and dated and should have been. 28 Pa. Code 211.6(f) Dietary Services.

Based on observations and review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievances. Findings include: A meeting with a group of residents on March 11, 2024, at 10:37 a.m. revealed that the food was cold, unappetizing and unpalatable. A grievance filed on November 14, 2023, revealed that a resident received cold food on November 11, 2023, and November 12, 2023. A grievance filed on February 7, 2024, revealed that Resident 8 continued to receive cold food. Observations of the lunch meal service on March 12, 2024, at 10:52 a.m. in the Evergreen dining room revealed the following temperatures at the beginning of service: the pasta and butter sauce was 152 degrees Fahrenheit (F), the popcorn chicken was 143.0 degrees F, the shrimp was 173.0 degrees F, the mashed potatoes were 160.0 degrees F, the beets and carrots were 164.0 degrees F, the mechanical chicken was 163.0 degrees F, and the mechanical shrimp was 156.0 degrees F. After the last resident was served lunch in the Evergreen dining room on March 12, 2024, at 12:26 p.m. a test tray was conducted. The pasta with shrimp and butter sauce was 136.0 degrees F and tasted cold, the mashed potatoes with gravy was 133.0 degrees F and tasted cold, the carrots and beets were 131.0 degrees F and tasted cold, the mechanical chicken was 135.0 degrees F and tasted cold, and the mechanical shrimp was 137.0 degrees and tasted cold. Interview with the Nursing Home Administrator on March 12, 2024, at 4:32 p.m. confirmed that cold food has been an ongoing concern and that it was not resolved based on continued grievances and cold test tray. 28 Pa. Code 201.29(i) Resident Rights. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for one of 30 residents reviewed (Resident 36). Findings include: The facility's policy for pharmacy services, dated September 14, 2023, revealed that the licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care and medical care, or quality of life. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated August 11, 2023, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, high cholesterol, thyroid disorder, arthritis, and renal failure. Physician's orders for Resident 36 on admission, dated January 19, 2023, included orders for the resident to receive 7.5 milligrams (mg) of Meloxicam (nonsteroidal anti-inflammatory pain medication) twice a day for pain, 20 milliequivalent (meq) of potassium chloride daily for low potassium levels, 25 mg of Losartan (high blood pressure medication) daily for high blood pressure, 50 micrograms (mcg) of Levothyroxine daily for low thyroid levels, 300 mg of Allopurinol (uric acid lowering medication) daily for gout (high uric acid level causes arthritis), and 20 mg of lasix (diuretic medication) for edema. Review of the pharmacy medication regime review (MRR) for Resident 36, dated September 27, 2023, revealed recommendations to have blood draws for laboratory testing that included a basic metabolic panel for taking an angiotensin receptor blocker (a type of high blood pressure medication) every six months, a lipid panel yearly for taking a statin (cholesterol lowering medication), an uric acid level yearly when taking Allopurinol, and a thyroid stimulating hormone level yearly for taking Levothyroxine (synthetic thyroid medication). The MRR recommendation was never reviewed, responded to, or signed by the physician to agree or disagree. Review of a pharmacy MRR for Resident 36, dated November 6, 2023, revealed recommendations to have blood draws for laboratory testing that included a complete metabolic panel for taking furosemide (Lasix), Meloxicam, potassium medication, and Losartan every six months; a full lipid panel yearly for taking a statin; and an uric acid level yearly when taking Allopurinol. The MRR recommendation was never reviewed, responded to, or signed by the physician to agree or disagree. Interview with the Director of Nursing on March 13, 2024, at 3:41 p.m. confirmed that the pharmacy MRR recommendations for Resident 36 were not addressed by the physician and should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for hospitalization for one of 30 residents reviewed (Resident 38). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated January 30, 2024, indicated that the resident was severely cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included stroke and traumatic brain injury. Resident 38's daughter was listed in the clinical record as the responsible party and first emergency contact. MDS discharge assessments for Resident 38, dated October 13 and 19, 2023, and November 4, 2023, revealed that the resident was admitted to the hospital on those dates. Nursing notes for Resident 38, dated October 13 and 19, 2023, and November 4, 2023, indicated that the resident was transferred to the hospital for further evaluation, treatment and admission. There was no documented evidence in Resident 38's clinical record to indicate that the resident's representative was notified in writing of the purpose for the resident's transfer about the hospitalization s in October and November 2023. Interview with the Nursing Home Adminstrator on March 12, 2024, at 4:19 p.m. confirmed that there was no documentation that the resident's representative was notified in writing of Resident 38's transfers and hospitalization s in October and November 2023, and there should have been. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 30 residents reviewed (Resident 21). Findings include: A facility policy for care planning, dated September 14, 2023, revealed that assessments of residents were ongoing and that care plans were revised as information about the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated January 10, 2024, revealed that the resident was sometimes understood and could usually understand others, was cognitively impaired, and was dependent on staff for daily care needs. A care plan for Resident 21, updated January 10, 2024, revealed that the resident had inadequate oral intake with swallowing difficulty and unintended weight loss. There was nothing in the care plan to indicate that Resident 21 refused dinner trays. A note from speech therapy, dated January 25, 2024, revealed that Resident 21 can have a mechanically soft diet if resident is alert, out of bed, and in the dining room. A note from dietary, dated February 13, 2024, revealed that Resident 21 continues to refuse her dinner tray. Nursing notes for Resident 21 revealed that the resident refused dinner trays on February 14, February 17, February 18, February 22, February 26, and March 8, 2024. Interview with Speech Therapist 1 and Speech Therapist 2 on March 12, 2024, at 1:16 p.m. revealed that they were made aware on March 8, 2024, that Resident 21 continues to refuse dinner trays and is on the case load to evaluate safety to remain in bed while eating. Interview with Nursing Home Administrator on March 12, 2024, at 1:31 p.m. revealed that the care plan needed to be updated to reflect resident's continued refusals of supper trays. 28 Pa. Code 201.24(e)(4) Admission Policy.

Based on observations and staff interviews, it was determined that the facility failed to ensure that controlled medications were stored in a separately-locked, permanently-affixed compartment in one of two medication rooms reviewed (Main), and failed to discard expired medical supplies in one of two medication rooms reviewed (Evergreen). Findings include: Observations in the Main medication room refrigerator on [DATE], at 8:12 am. revealed that there was a narcotic storage box containing an unopened bottle of liquid Ativan (a controlled medication used to treat anxiety) and the box was not permanently affixed inside the refrigerator. An interview with Registered Nurse 1 on [DATE], at 8:14 a.m. confirmed that the narcotic storage box containing the bottle of Ativan should have been permanently affixed inside the Main medication room. Observations in the Evergreen medication room on [DATE], at 8:17 a.m. revealed that there were multiple intravenous catheters (medical supplies used in the vein to provide fluids or medication) that expired in February, September and December of 2023, and three syringes that expired in [DATE] and [DATE]. An interview with Registered Nurse 1 on [DATE], at 8:19 a.m. confirmed that the medical supplies were expired and should not have been in circulation to be used on residents. Interview with the Nursing Home Administrator on [DATE], at 3:24 p.m. confirmed that the facility had no policy that spoke to expired medical supplies or narcotic boxes being permanently affixed in the medication refrigerator. Furthermore, she confirmed that the narcotic storage box containing Ativan was not permanently affixed inside the refrigerator and expired medical supplies were in circulation, and they should not have been. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for two of three residents reviewed (Residents 1, 3), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. Recommendations for the use of devices and equipment were based on the comprehensive assessment and documented in the resident's plan of care. The facility's care plan policy, dated September 14, 2023, indicated that the comprehensive, person-centered care plan included measurable objectives and time frames, and described the services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 23, 2023, revealed that the resident was cognitively impaired, required extensive assistance with transfers, had limited range of motion to his upper extremities, used a wheelchair, had a history of falls, and had diagnoses that included dementia and traumatic brain injury (sudden injury that causes damage to the brain). The resident's care plan, dated September 14, 2023, revealed that he was at risk for falls and used a wheelchair. Investigative documents for Resident 1, dated November 15, 2023, revealed that the resident was on the floor lying in front of his wheelchair with the nurse aide standing beside him. The resident was stabilized, the bleeding was stopped from the laceration, and he was assessed by the registered nurse. A statement from Registered Nurse 1, dated November 15, 2023, revealed that when she came upon the situation to help staff, it was noted that Resident 1's foot rests for his wheelchair were in the bag hanging on the back of the wheelchair. There was no documented evidence that a care plan was developed to address Resident 1's specific and individualized interventions and care needs related to using foot rests on his wheelchair prior to falling from his wheelchair. However, the foot rests were hanging on the back of the chair and readily available at the time of Resident 1's fall. A significant change Minimum Data Set MDS assessment for Resident 3, dated November 2, 2023, revealed that the resident was cognitively impaired, used a wheelchair, had a history of falls, and had diagnoses that included dementia and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Observations of Resident 3 on November 29, 2023, at 12:41 p.m. revealed that the resident was in his wheelchair in the dining room, seated at a table, and had leg rests on. There was no documented evidence that a care plan was developed to address Resident 3's specific and individualized interventions and care needs related to using foot rests on his wheelchair. Interview with the Nursing Home Administrator on November 29, 2023, at 2:51 p.m. confirmed that there were no residents care planned for the use of foot rests. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of policies, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to take precautions to prevent injury to a resident caused by not having foot rests on his wheelchair during transport for one of three residents reviewed (Resident 1), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. Recommendations for the use of devices and equipment were based on the comprehensive assessment and documented in the resident's plan of care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 23, 2023, revealed that the resident was cognitively impaired, required extensive assistance with transfers, had limited range of motion to his upper extremities, used a wheelchair, had a history of falls, and had diagnoses that included dementia and traumatic brain injury (sudden injury that causes damage to the brain). The resident's care plan, dated September 14, 2023, revealed that he was at risk for falls and used a wheelchair. Investigative documents for Resident 1, dated November 15, 2023, revealed that the resident was on the floor lying in front of his wheelchair with the nurse aide standing beside him. The resident was stabilized, the bleeding was stopped from the laceration, and he was assessed by the registered nurse. A statement from Registered Nurse 1, dated November 15, 2023, revealed that Nurse Aide 2 went to the nurse's desk after she was involved in an incident with Resident 1. She stated that she was assisting another resident in the dining room and Resident 1 was in the dining room as well, and he began asking for help to get back to his room. She continued to help the resident she was with, but Resident 1 continued to ask her for help, so she began pushing him back to his room because he would not stop asking her for help. Nurse Aide 2 did not have foot rests on while she was pushing Resident 1 back to his room. Nurse Aide 2 stated that he was leaning forward and then he put his feet down and fell forward. When Registered Nurse 1 came upon the situation to help staff, it was noted that Resident 1's foot rests for his wheelchair were in the bag hanging on the back of the wheelchair. An emergency room report, dated November 15, 2023, revealed that Resident 1 was being pushed in his wheelchair and fell forward landing on his face and sustained a facial laceration measuring 5.0 centimeters (cm). An e-mail sent from the Director of Nursing to staff, dated November 16, 2023, revealed that Resident 1 had a fall, was transported by the nurse aide without foot rests, and received eight staples on his forehead. Interview with Nurse Aide 2 on November 29, 2023, at 3:11 p.m. confirmed that Resident 1 was in the dining room, needed someone to push him back to his room, and he fell on the floor. She stated that she did not add anything to his wheelchair. Interview with Registered Nurse 1 on November 29, 2023, at 3:05 p.m. confirmed that Nurse Aide 2 was pushing Resident 1 in his wheelchair without foot rests, he fell , and received a laceration to the middle of his forehead, and that he should have had foot rests on his wheelchair before Nurse Aide 2 started to push him. Interview with the Nursing Home Administrator on November 29, 2023, at 2:51 p.m. confirmed that Nurse Aide 2 did not use foot rests on Resident 1's wheelchair when he fell , and she should have put them on prior to pushing Resident 1. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of seven residents reviewed (Resident 2), resulting in harm to Resident 2 due to a fall that resulted in fractures. Findings include: The facility's policy regarding abuse and neglect, dated April 13, 2023, indicated that the facility was to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 30, 2023, revealed that the resident was cognitively intact, required the extensive assistance of two staff for transfers, required limited assistance with ambulation (walking), was only able to stabilize and balance herself with staff assistance, and had no recent falls. The resident's care plan, dated March 25, 2023, revealed that she required one staff member and a wheeled walker for transfers. A nursing note, dated May 20, 2023, at 11:09 p.m. revealed that the nurse aide was yelling for help and Resident 2 was found lying on the ground on her stomach, and there was a large amount of blood under her face, which was coming from the resident's nose. The bridge of the resident's nose was swollen with bruising and a laceration, and she was transferred to the hospital. A CT-scan (diagnostic test), dated May 21, 2023, revealed the resident had a fracture of the nasal bone. The facility's investigation dated May 20, 2023, revealed that Resident 2 requested that Nurse Aide 1 walk with her, and Nurse Aide 1 followed the resident with her wheelchair as the resident walked with her rolling walker. When Nurse Aide 1 asked the resident to turn and go back to her room the resident said she was dizzy, and before the resident could be seated, she fell forward. The resident has a history of being dizzy and receives medication three times a day. The investigation determined that Nurse Aide 1 was not using a gait belt at the time of the fall. Nurse Aide 1 stated that she thought the resident did not need a gait belt since it was not care planned. The facility's new employee training checklist, dated January 25, 2023, revealed that Nurse Aide 1 completed training regarding transfer/ambulation with a gait belt. An interview with Nurse Aide 1 on June 5, 2023, at 2:47 p.m. confirmed that she did not use a gait belt while walking and transferring Resident 2 because it was not care planned; however, she did confirm that she received education regarding the use of the gait belt. An interview with the Nursing Home Administrator on June 5, 2023, at 2:25 p.m. confirmed that Nurse Aide 1 did not use a gait belt when transferring and ambulating Resident 2 and she should have, and that neglect was substantiated. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to provide care using adequate assistance devices to prevent accidents for one of seven residents reviewed (Resident 2), resulting in the resident experiencing a fall and fracture. Findings include: The facility's policy regarding gait belt use, dated April 13, 2023, indicated that gait belts were to be used with residents that could not independently ambulate or transfer for the purpose of safety. Each nursing department employee was to be given a gait belt during orientation. All employees would receive education on the proper use of the gait belt during orientation and annually. It would be the responsibility of each employee to ensure they have it available for use at all times when at work. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 30, 2023, revealed that the resident was cognitively intact, required the extensive assistance of two staff for transfers, required limited assistance with ambulation (walking), was only able to stabilize and balance herself with staff assistance, and had no recent falls. The resident's care plan, dated March 25, 2023, revealed that she required one staff member and a wheeled walker for transfers. A nursing note, dated May 20, 2023, at 11:09 p.m. revealed that the nurse aide was yelling for help and Resident 2 was found lying on the ground on her stomach, and there was a large amount of blood under her face, which was coming from the resident's nose. The bridge of the resident's nose was swollen with bruising and a laceration, and she was transferred to the hospital. A CT-scan (diagnostic test), dated May 21, 2023, revealed the resident had a fracture of the nasal bone. The facility's investigation, dated May 20, 2023, revealed that Resident 2 requested that Nurse Aide 1 walk with her, and Nurse Aide 1 followed the resident with her wheelchair as the resident walked with her rolling walker. When Nurse Aide 1 asked the resident to turn and go back to her room the resident said she was dizzy, and before the resident could be seated, she fell forward. The resident has a history of being dizzy and received medication three times a day. The investigation determined that Nurse Aide 1 was not using a gait belt at the time of the fall. Nurse Aide 1 stated that she thought the resident did not need a gait belt since it was not care planned. The facility's new employee training checklist, dated January 25, 2023, revealed that Nurse Aide 1 completed training regarding transfer/ambulation with a gait belt. An interview with Nurse Aide 1 on June 5, 2023, at 2:47 p.m. confirmed that she did not use a gait belt while walking and transferring Resident 2 because it was not care planned. An interview with the Nursing Home Administrator on June 5, 2023, at 2:25 p.m. confirmed that Nurse Aide 2 did not use a gait belt when transferring and ambulating Resident 2 and she should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records, and incident reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that recommended interventions to prevent falls were placed on the resident's care plan and implemented for one of 22 residents reviewed (Resident CR20), resulting in harm to the resident from a fall that resulted in a subdural hemorrhage (bleeding in the brain) and death. The facility also failed to ensure that the use of interventions such as bed rails and placing beds against the wall were assessed for possible safety hazards for two of 22 residents reviewed (Residents R1, R6), failed to ensure that a resident had interventions in place for the prevention of bruises and skin tears for one of 22 residents reviewed (Resident R7), and failed to thoroughly investigate the possible cause of bruises in order to prevent further bruises for one of 22 residents reviewed (Resident R8). Findings include: The facility's policy regarding care plans, dated January 17, 2017, indicated that the care plan was designed to incorporate identified needs/problem areas and to enhance the optimal functioning of the resident, while reducing the risk of decline in functional status. The policy also indicated that the care plan was updated by all staff members on an ongoing basis. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR20, dated May 23, 2017, revealed that the resident was confused, her balance was unsteady, she had a limited range of motion in one of her lower extremities, and she had a history of [REDACTED]. Incident reports for Resident CR20, dated June 20 through July 8, 2017, revealed that the resident fell or was found on the floor on 11 occasions. The resident's care plan addressing her risk for falls, last updated July 14, 2017, included interventions such as, placing fall mats beside the bed; for the resident to wear bilateral hipsters (padded undergarment worn over the hips to prevent injuries); for staff to check the resident every 15 minutes; to take the resident to the toilet before and after meals, at bed time, and as needed; for a body pillow (pillow used for positioning) in bed; to transfer the resident with the assistance of one staff, or two staff if necessary; to educate/remind the resident to use her call bell to request assistance; for the bed to be at wheelchair height; and for the resident to wear gripper socks (socks with non-skid material on the bottom) when in bed. An incident report for Resident CR20, dated July 16, 2017, revealed that the resident was found on the floor at 8:10 p.m. To prevent a recurrence, the report indicated that the resident's care plan was changed to add the intervention that the resident was to be kept with a staff member when awake. There was no documented evidence that this intervention was added to the resident's care plan and/or implemented. physician's orders [REDACTED]. An incident report for Resident CR20, dated July 18, 2017, revealed that the resident was found on the floor outside of the door to her bathroom at 2:42 p.m., and the resident was last seen by a staff member at 2:35 p.m. There was still no documented evidence that the resident was kept with a staff member in order to prevent further falls. An incident report for Resident CR20, dated July 30, 2017, revealed that the resident was found on the floor of the Cluster One nursing unit at 9:30 a.m. The report indicated that the resident was last seen by staff members at 9:25 a.m. and was noted to be seated in her wheelchair. There was no documented evidence that the resident was being kept with a staff member to prevent falls. The facility's investigation documents for Resident CR20's fall on July 30, 2017, included an undated statement from Nurse Aide 1, which indicated that she took the resident to the toilet at approximately 9:00 a.m., placed the resident in the hallway between the Cluster One unit and the dining area, and checked on the resident at approximately 9:25 a.m., and then she (Nurse Aide 1) went to the dining area. She indicated that at approximately 9:30 a.m. a dietary staff member notified her that the resident was on the floor. A written statement from Dietary Staff 2, dated July 30, 2017, indicated that she saw Resident CR20 sitting in her wheelchair on the Cluster One nursing unit at a few minutes before 9:30 a.m. She then went in the back door of the kitchen to do dishes. She indicated that they normally keep the door open to observe the resident. She then walked to the front of the kitchen where the dishwasher was and noticed that the resident was on the floor, and this was approximately ninety seconds after she had previously checked on the resident. Dietary Staff 2 indicated she then notified nursing staff that the resident was on the floor. There was no documented evidence that staff implemented and/or followed the fall prevention intervention of keeping the resident with staff, as noted on the fall report of July 16, 2017. An emergency department report for Resident CR20, dated July 30, 2017, revealed that as the resident was being taken for a diagnostic scan, she started to become more lethargic, and then became unresponsive. The scan indicated that the resident was bleeding in the brain. The resident was placed on comfort measures (no extraordinary measure to be taken) and subsequently passed away at the hospital. Review of Resident CR20's death certificate, dated August 3, 2017, revealed that the causes of death were intracranial (inside the skull) bleed, mechanical fall, chronic anticoagulation (routine administration of blood thinning medication), and dementia. Interview with the Nursing Home Administrator on August 30, 2017, at 1:15 p.m. confirmed that the intervention of keeping the resident with staff while awake that was noted on the fall investigation on July 16, 2017, was not placed on the resident's care plan and implemented, and it should have been. She stated that the resident should have been with a staff member at the time of the fall on July 30, 2017. A comprehensive admission MDS assessment for Resident R1, dated July 28, 2017, revealed that the resident was usually understood, could understand, required the limited assistance of one person for bed mobility and ambulation, and had [DIAGNOSES REDACTED]. The resident's care plan, dated July 25, 2017, indicated that the resident was at risk for falls and had an alteration in decision making/memory. Observations on August 30, 2017, at 11:20 a.m. revealed that Residents R1's bed was equipped with bilateral rails (small side rails on both sides of the bed) and one side of the bed was positioned against the wall. The resident's clinical record contained no documented evidence that the use of rails on the resident's bed and placing the bed against the wall was assessed to ensure that they did not create potential safety hazards for the resident. These two interventions were also not included in the resident's care plan. A quarterly MDS assessment for Resident R6, dated June 1, 2017, revealed that the resident was sometimes understood, could sometimes understand, required extensive assistance of one person for bed mobility and ambulation, and had [DIAGNOSES REDACTED]. A restraint assessment for Resident R6, dated June 14, 2017, indicated that the resident had her bed against the wall, which could be considered a physical restraint. The assessment indicated that the resident had decreased safety awareness due to dementia or judgement problems. Observations on August 28, 2017, at 6:00 p.m. and August 29, 2017, at 10:10 a.m. revealed that Resident R6's bed was equipped with small bilateral rails and one side of the bed was positioned against the wall. The resident's clinical record contained no documented evidence that the use of the rails and placing the resident's bed against the wall were assessed to ensure that they did not create potential safety hazards for the resident. These two interventions were also not included on the resident's care plan. Interviews with the Nursing Home Administrator on August 30, 2017, at 12:05 p.m. and 3:50 p.m. confirmed that there was no documented evidence that safety assessments were completed for Residents R1's and R6's use of side rails and placing the residents' beds against the wall. She also confirmed that Residents R1's and R6's care plans did not include these interventions and should have. A current [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident R7, dated July 10, 2017, indicated that the resident was severely cognitively impaired, required extensive assistance with activities of daily living, and had impaired range of motion in both legs. Review of incident investigations conducted by the facility revealed that on December 10, 2016, staff discovered a 2.0 x 1.8 centimeter (cm) bruise on Resident R7's right lower leg; 8.5 x 3.5 cm and 4.0 x 3.5 cm bruises on the resident's left breast on January 18, 2017; a 2.5 x 2.3 cm bruise to the right lower leg on February 11, 2017; and a 16.0 x 9.0 cm bruise to left leg on April 6, 2017. On April 7, 2017, staff noted that the resident bumped her right shin on a window sill and suffered a 8.5 cm skin tear, and on April 25, 2017, a 1.0 cm scratch was discovered on the left upper elbow. On May 2, 2017, staff noted that the resident was bleeding from a 0.5 x 0.5 cm skin tear on the right lower leg, and on July 13, 2017, the resident had a 5.0 x 6.0 cm bruise on her left lower forearm. On July 21, 2017, staff noted a 6.0 x 12.0 cm bruise that extended from the resident's knuckle of the right index finder and up the back of her hand. On August 13, 2017, staff noted a 1.2 x 2.0 cm skin tear that was bleeding and a bruise on her right leg, and on August 22, 2017, a 3.0 x 5.0 cm bruise was noted on the back of the resident's left arm. The above incident investigations, along with Resident R7's current care plan revealed no documented evidence that interventions to prevent bruises and skin tears were developed or implemented for the resident. Interview with the Nursing Home Administrator on August 30, 2017, at 2:20 p.m. confirmed that there was no documented evidence that interventions to prevent bruises and skin tears were developed and implemented for Resident R7. The facility's policy regarding abuse prevention and management, dated January 17, 2017, indicated that incidents would be immediately investigated, and the investigation would include asking for written statements describing the incident from all involved individuals, and the supervisor interviewing the resident, if the resident was able, would record the findings. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R8, dated April 18, 2017, revealed that the resident was alert and oriented and required the extensive assistance of one staff member for bed mobility and transfers. An adverse event document for Resident R8, dated May 14, 2017, indicated that a bruise was noted to the resident's right shin, and the resident stated that she did not know how she got the bruise. An incident report, dated June 4, 2017, indicated that a bruise was noted to the resident's right hand, and the resident stated that she was not sure how she got the bruise. The report also indicated that the investigation was to be conducted by the supervisor for the past 24 hours and documented in order to try to determine the cause of the bruise. However, both the adverse event report and the incident report revealed no documented evidence that written statements were obtained from staff members for the 24 hours preceding the injuries. An interview with the Nursing Home Administrator on August 30, 2017, at 12:55 p.m. confirmed that thorough investigations of the possible cause(s) of Resident R8's bruises were not completed. She confirmed that there was no documented evidence that written statements were obtained from staff members for the previous 24 hours, and that these statements should have been obtained. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 7/21/16. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/30/15. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 7/21/16, 10/24/15. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 7/21/16.