Every finding on record at Chestnut Hill Lodge Health and Rehab CTR

Based on review of clinical records, Insulin Glargine's manufacturer's guidelines, and interview with staff, it was determined the facility failed to monitor the blood sugar of resident on Insulin Glargine which resulted in harm to one resident that was transferred to the hospital with Hypoglycemia for one of ten residents on insulin reviewed (Resident R1). This was identified as Past Non-Compliance.Findings Include: Review of the Insulin Glargine's (Lantus) manufacture's guideline revealed under section titled Dosage and Administration: individualized dosage based and metabolic needs, blood glucose monitoring, glycemic control type of diabetes and prior insulin use. Further review of the guidelines revealed, Full Prescribing Information, 2.2 GENERAL DOSING INSTRUCTION, individualize and adjust the dosage of insulin glargine based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal, 4 CONTRAINDICATION Insulin glargine is contraindicated during episodes of hypoglycemia. 5.3 Hypoglycemia: Hypoglycemia is the most common adverse reaction associated with insulins including insulin glargine products. Review of Resident R1's hospital discharge record revealed Resident R1 was admitted to the hospital on [DATE], and was discharged home on March 20, 2026, with diagnoses of but not limited to Type 2 Diabetes, Sepsis (life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection), and CKD (Chronic Kidney Disease - long-term condition where kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood). Further review of Resident R1's hospital discharge record revealed that POC (point of care) glucose testing (rapid blood sugar analysis performed directly at patient's bedside using a portable glucometer providing immediate results for quick management decisions) dated March 20, 2026, at 5:58 a.m. reading of 60mg/dl (milligram/deciliter), and glucose reading at 6:20 a.m. was at 90mg/dl and at 12:58 p.m. was 109 mg/dl. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including but not limited to Type 2 Diabetes Mellitus (chronic condition characterized by high blood sugar (Hyperglycemia) caused by insulin resistance and relative insulin deficiency). Review of Resident R1's physician's orders revealed the following orders: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for regulating blood glucose levels-ordered on April 8, 2026. Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for regulating blood glucose levels with a start date of April 8, 2026 at 9:00 PM. Further review of Resident R1 physician's orders failed to reveal orders for blood sugar monitoring of the resident. Review of Resident R1's MAR (Medication Administration Record) revealed administrative instructions for Insulin Glargine Subcutaneous Solution100 UNIT/ML (Insulin Glargine); Inject 10 unit subcutaneously at bedtime for regulating blood glucose levels with a start date of April 8, 2026 at 9:00 PM. Review of Resident R1's care plans revealed a care plan for Diabetes: I (Resident R1) have diabetes type (2). I am on a CHO (carbohydrate control) diet. GOALS: I want to have my blood sugars within my doctor's acceptable range through the next review period. Date Initiated: April 9, 2026, and INTERVENSIONS: Administer my diabetes medications as ordered. Monitor for side effects and effectiveness. Date Initiated: April 9, 2026. Review of Resident R1's progress note dated April 11, 2026, revealed Around 12:45 PM, CNA (certified nurse's aide) reported that the resident has a pull [sicl] of spit in the corner of her mouth on left side. At this time, the resident's daughter was in attendance. Floor staff and I immediately did vitals and checks BS (blood sugar) which was 54. The nursing supervisor was called; Glucagon was administered and 911 called. EMS arrived and took over. MD was called, order given to send out. Further review of Resident R1's clinical record revealed a progress note dated April 11, 2026, indicating Resident R1 was admitted to local hospital for Hypoglycemia, Sepsis, and wound evaluation. Interview with Director of Nursing Employee E2 conducted on April 30, 2026, at 10:29 AM confirmed Resident R1 was on Insulin Glargine subcutaneously. Further interview with Employee E2 revealed there was no physician's order for accu-checks (blood sugar testing) for Resident R1. Further, interview with Employee E2 revealed the blood sugar monitoring should have been in place since admission. Additionally, Employee E2 confirmed there was no baseline blood sugar documented for Resident R1 at the time admission to the Nursing Facility. Interview with facility physician, Employee E3, conducted on April 30, 2026, at 12:34 PM confirmed Resident R1 was on Lantus. Additionally, Employee E3 revealed residents who receive Lantus should have blood sugar monitoring/fingerstick regularly usually before breakfast, before lunch, before dinner and at bedtime. Further interview with Employee E3 revealed there should have been an order for fingerstick monitoring for Resident R1. Additionally, Employee E3 revealed the lack of blood sugar monitoring on Resident R1 was an oversight on the facility's part. Review of Resident R1's clinical records failed to reveal documented evidence Resident R1's blood sugar level was being monitored. Review of facility's plan of corrections revealed the facility conducted a facility wide audit of residents receiving insulin and blood sugar monitoring. Further, a facility-wide education on blood glucose monitoring for residents on insulin, was conducted with 100% of licensed nurses in-serviced. Plan of correction was completed on April 20, 2026. 28 Pa. Code 211.5 Clinical records28 Pa. Code 211.12 Nursing services28 Pa. Code 211.10 Resident care policies

Based on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure timely notification to the physician of fall incident sustained by Resident R1. This failure resulted in actual harm to Resident R1 who experienced a delay of treatment after a fall in the shower room with injuries, requiring transfer to the hospital and diagnoses of subdural hematoma, left zygomatic fracture, and acute right 3rd - 4th rib fractures for one of four residents reviewed. This deficiency is being cited as past non- compliance. (Resident R1) Findings include: Review of facility policy titled, 'Change of Condition' revised June 28, 2023, revealed, if the nurse aide (CNA) identifies a change in resident's condition, they will immediately notify the nurse of the situation, and the resident, attending physician and resident representative, if applicable, will be notified promptly of a significant change in condition, accident/incident, change in treatment, and/or transfer/discharge. Review of facility policy titled, 'Falls Prevention and Management' revised January 12, 2023, revealed the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining casual factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. Continued review of same policy revealed, in the event a resident has fallen and/or is found on the ground, a complete head to toe assessment must be performed. Resident is not to be moved until assessed for injury by an RN (Registered nurse) unless life-threatening situation exists. Remain with the resident while calling for assistance, if at all possible. If the resident is unconscious, has difficulty breathing or a severe injury is suspected, immediately call 9-1-1 (Emergency Medical Services) for transfer. Review of Resident R1's clinical record revealed medical history of traumatic hemorrhage of cerebrum (subsequent encounter), altered mental status, Cerebral Infarction (stroke) due to embolism (obstruction of an artery, typically by a clot of blood) of left cerebellar artery, age-related Osteoporosis (decreased bone density), muscle wasting and Encephalopathy (general term for brain disease, damage, or dysfunction, resulting in altered mental state, confusion, personality changes, and potential coma), mobility and gait abnormalities, Dementia (progressive degenerative disease of the brain), restlessness and agitation, Paranoid Personality Disorder, and muscle weakness. Review of Resident R1's physician orders revealed an order, initiated December 20, 2025, for 1:1 (one resident to one staff) monitoring secondary to falls, every shift. Review of Resident R1's Minimum Data Set (MDS- assessment of resident's care needs) completed on December 25, 2025, revealed Resident R1 required partial/moderate assistance for tub/shower transfer: helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Continued review of resident's MDS revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 3 which indicated the resident was severely cognitively impaired. Review of Resident R1's care plan initiated November 13, 2024 revealed care plan developed for fall related to episodes of confusion which include interventions of 1:1 nursing supervision at all times, visual cues will be added to resident's room to encourage the use of the call bell, anticipate and meet resident's needs, ensure call light is within reach and keep frequent used items within reach, Review of Resident R1's nursing notes dated February 7, 2026, (9:42 p.m.) revealed the resident was noted with left side facial swelling and bruising and nosebleed from the left nostril. Pressure was applied to left nostril to stop the bleeding. The resident was not complaining of pain when (her/his) face was touched. An order was obtained to send the resident to the emergency room. 9-1-1 (Emergency Medical Services) was called and Resident R1 was transported to the hospital for evaluation. Continued review of Resident R1's nursing notes dated February 7, 2026, (9:18 p.m.) revealed Resident observed lying on the couch as EMT's (Emergency Medical Technician) arrived to pick resident up. Observed resident with swelling and bruising over the left mandibular (lower jaw). Area feels tender with no complaints or signs of pain observed or verbalized by resident. Resident unable to tell this writer what happened to (her/his) face Unable to assess the rest of (her/his) body as resident was leaving to go to the hospital. Resident was able to stand up with minimal assist onto the stretcher, guardian notified by shift supervisor. Left for [local hospital]. Review of facility documentation submitted to the State Survey Agency on February 7, 2026, revealed Resident R1 was observed with swelling and bruising on the left side of (her/his) face by nursing supervisor. The physician was called and gave order to send the resident to the hospital for further evaluation. The resident was sent to the hospital via 911 (Emergency Medical Services). Resident R1 has imaging done in the ER (emergency room) which revealed a subdural hematoma (collection of blood in the brain), left zygomatic fracture (a break in the cheekbone). Review of facility provided investigation report related to fall incident sustained by Resident R1 during evening shift on February 7, 2026, revealed Resident R1 sustained a subdural hematoma (collection of blood in the brain), left zygomatic fracture (a break in the cheekbone), and acute right 3rd - 4th rib fractures. Review of statement completed by Nurse aide, Employee E1, who was assigned to Resident R1 for continuous 1:1 supervision on February 7, 2026 evening shift, revealed I didn't see (her/him) fall, I saw the swollen and the bruise on the left side of the face, after dinner. I did not look at face. Review of additional statement completed by Nurse aide, Employee E1 dated February 9, 2026, revealed at 4:15 p.m. on February 7, 2026, I took (her/him) in the shower room, shower (her/him). After taken (her/him) from the shower chair (she/him) slip and fall on (her/his) left side and I was on (her/his) right side. I did not see any injury. I took (her/him) in the dining room and (she/him) went to sleep on the couch or chair. Review of investigation statement completed by Nurse aide, Employee E3, on February 7, 2026, revealed at approximately 6:00 pm, Resident R1 was noted with nosebleed in dining area of memory care unit; Employee E3 brought the resident to the nurses' station, informed the licensed nurse and nurse aide of Resident R1's nosebleed. Interview with Licensed nurse, Employee E2, who had oversight of memory care unit during evening shift on February 7, 2026, revealed that she was not aware of Resident R1's facial swelling, bruising and/or bleeding until 7:30 p.m. when Nursing Supervisor, Employee E4 notified her. Further review of investigation report revealed, Nursing Supervisor, Employee E4 arrived on the memory care unit, February 7, 2026, for her 7 p.m. shift. While doing rounds approximately 7:15 p.m., she noticed Resident R1 sitting in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. Further review of Nursing Supervisor, Employee E4's statement revealed the nurse aide assigned to the Resident R1's 1:1 monitoring, (Employee E1), alleged she did not know what happened to the resident. When Employee E4 asked the agency charge nurse, Employee E2, about the injuries, the nurse responded angrily and told Employee E4 to ask Employee E1, indicating she had 30 residents to oversee. Continued review of Employee E4's statement revealed, Employee E4 questioned why the nurse had not noticed the injuries after giving the resident medication earlier. The discussion escalated into an argument about responsibility for assessing residents and reporting possible abuse or injuries. Nursing supervisor, Employee E4 then removed the agency nurse from the building and contacted local police and the Director of Nursing regarding Resident R1's injuries. Continued review of Nursing Supervisor, Employee's E4 statement the Nursing supervisor, Employee E4 re-assessed the resident, whose nose continued to bleed, and contacted the Nurse Practitioner (NP). The NP instructed Employee E2 to call 911 (Emergency Medical Services) and send the resident to the hospital for evaluation. Review of interview statement from the Nursing Home Administrator (NHA), Employee E7 on February 9, 2026, at 1:35 pm, revealed the NHA asked Nurse aide, Employee E1 to explain what happened while she was providing one to one (1:1) care to Resident R1. Nurse aide, Employee E1 initially said there was no incident. NHA informed Nurse aide, Employee E1 that Resident R1 had reported, through an interpreter, that she fell because the floor was slippery. NHA also stated that Nursing aide, Employee E3 noticed Resident R1's nose bleeding around 6:00 PM and took Resident R1 for evaluation. Nursing Home Administrator reminded Nurse aide, Employee E1 that her responsibility during the Sunday 3 PM shift was to closely watch Resident R1 on a 1:1 basis to prevent a fall. Further review of written statement of an interview conducted between the NHA and Nurse aide, Employee E1 revealed that Nursing Home Administrator confronted Nurse aide, Employee E1 because he believed something had happened to Resident R1 during Nurse aide, Employee E1's 1:1 supervision of Resident R1. During the NHA's follow up interview with Nurse aide, Employee E1 it was revealed during the interview that Nurse aide, Employee E1 admitted that Resident R1 slipped and fell while getting up from a shower chair. Employee E1 stated that Resident R1 did not appear to be in pain, so she helped dry the resident and took (her/him) to the dining room for dinner. Nurse aide, Employee E1 explained she did not report the incident because she was afraid, she would get into trouble. Interview conducted on March 10, 2026, at 2:00 p.m. with the Director of Nursing, Employee E8 and Nursing Home Administrator Employee E7 confirmed nurse aide, Employee E1 failed to notify licensed nursing staff of Resident R1's fall and injuries sustained by the resident. This deficiency was identified as actual harm past non-compliance for Resident R1 experiencing a delay in treatment after sustaining a fall in the shower room with injuries, requiring transfer to the hospital and diagnoses of subdural hematoma, left zygomatic fracture, and acute right 3rd - 4th rib fractures. The facility presented documentation indicating that the facility initiated a plan of correction to address the failure of the facility to provide timely notification after a fall sustained by resident. The facility alleged a date of compliance of February 9, 2026. The plan of correction stated the following: -On 2/27/2026 on 2/7/26 at approximately 7pm Resident R1 was noted to have swelling and bruising on the left side of (his/her) face by nursing supervisor, The supervisor asked the aide (Employee E1) what happened but aide indicated she didn't know. The DON was made aware and investigation was immediately started. Resident R1 was sent to the ER (Emergency Room) for Evaluation.-At approximately 10:30 pm the DON received a call from the hospital stating Resident R1 had a fracture of the mandible and 2 fractured right ribs and chronic subdural hemorrhage.The 1-1 aide assigned to Resident R1 at the time was suspended pending investigation. The police were contacted and came to the facility. 2/7/2026 In-servicing was started on abuse and reporting of incidents and accidents 2/9/2026- Head to toe skin and body checks were completed and all the resident residing on the Unit that Resident R1 resides. Interviews were also conducted with residents that could be interviewed to rule out abuse. 2/9/2026- Employee E1 was called in again to be interviewed regarding this resident since she was the 1-1 and nothing was noted prior to her taking over the 1-1 assignment. After lengthy discussion Employee E1 admitted that Resident R1 fell in the shower room, she stated she was afraid to report the fall.Employee E1 was educated on reporting of any incident and accidents.Employee E1 was terminated for failure to report and incident/accident.In-servicing- continued in the building to all staff on reporting falls and abuse and reporting abuse. Competencies were also given to staff after the education was done abuse.An audit of the last 2 weeks of nurse's notes and shift reports was conducted to ensure any accidents/incidents were reported per policy.The DON/ Designee will audit nurses' notes and shift reports to ensure any accidents and incidents were reported with the appropriate follow up action completed. Audits will be conducted weekly x 4 weeks and then monthly x2. Results of these audits will be submitted to QAPI to determine if further action is needed. Facility educated staff on types of abuse and reporting abused upon learning or hearing of abuse towards a resident and that every employee is expected to report it as soon as possible. Facility education record and subsequent audits were verified for completion. Skin checks documentation was reviewed and completed. Facility provided evidence of audits of nurses' notes for accidents/incidents and abuse audit of non-interviewable residents. Staff were interviewed to verify education. QAPI (Quality Assurance Improvement Plan) records reviewed to verify ongoing monitoring. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c)(d)(1)(3)(5) nursing services

Based on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure that Resident R1 was free of neglect. This failure resulted in actual harm to Resident R1 who sustained a fall in the shower room with resulting physical injuries; delay in timely assessment and medical treatment for one of four residents reviewed. This deficiency was cited as past non compliance,(Resident R1)Findings include: Review of facility policy 'Falls Prevention and Management,' revised January 12, 2023, indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining casual factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. Continued review of the policy revealed that in the event a resident has fallen and/or is found on the ground, a complete head to toe assessment must be performed. Resident is not to be moved until assessed for injury by an RN (Registered nurse) unless life-threatening situation exists. Remain with the resident while calling for assistance, if at all possible. If the resident is unconscious, has difficulty breathing or a severe injury is suspected, immediately call 9-1-1 (Emergency Medical Services) for transfer. Review of Resident R1's clinical record revealed medical history of traumatic hemorrhage of cerebrum (subsequent encounter), altered mental status, cerebral infarction due to embolism (obstruction of an artery, Typically by a clot of blood) of left cerebellar artery, age-related osteoporosis (decreased bone density), muscle wasting and encephalopathy (general term for brain disease, damage, or dysfunction, resulting in altered mental state, confusion, personality changes, and potential coma), mobility and gait abnormalities, dementia (progressive degenerative disease of the brain), restlessness and agitation, paranoid personality disorder, and muscle weakness. Review of physician orders revealed an order obtained December 20, 2025, for 1:1 (one to one staff) monitoring secondary to falls, every shift. Review of Resident R1's Minimum Data Set (MDS- assessment of resident's care needs) completed on December 25, 2025, revealed Resident R1 required partial/moderate assistance for tub/shower transfer: helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Continued review of resident's MDS revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 3 which indicated that the resident was cognitively impaired. Review of Resident R1's care plan initiated November 13, 2024, revealed a care plan developed for fall related to episodes of confusion which include interventions of 1:1 nursing supervision at all times. Review of facility documentation submitted to the State Survey Agency on February 7, 2026, revealed that Resident R1 was observed with swelling and bruising on the left side of (her/his) face by nursing supervisor. The physician was called and gave order to send the resident to the hospital for further evaluation. The resident was sent to the hospital via 911 (Emergency Medical Services). Resident R1 has imaging done in the ER (emergency room) which revealed a subdural hematoma (collection of blood in the brain), left zygomatic fracture (a break in the cheekbone). Review of investigation report revealed that Nursing supervisor, Employee E4 arrived to memory care unit on February 7, 2026, for her 7 PM shift. While doing rounds around 7:15 PM, she noticed Resident R1 sitting in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. Continued review of the Nursing supervisor, Employee E4's statement revealed that the nurse aide assigned to the resident's 1:1 monitoring, (Employee E1), said she did not know what happened to the resident. When Employee E4 asked the agency charge nurse, Employee E2, about the injuries, the nurse responded angrily and told her to ask Employee E1, stating she had 30 residents to manage. Nursing supervisor, Employee E4 questioned why the nurse had not noticed the injuries after giving the resident medication earlier. The discussion escalated into an argument about responsibility for assessing residents and reporting possible abuse or injuries. Nursing supervisor, Employee E4 then removed the agency nurse from the building and contacted the local police and the Director of Nursing. Continued review of Nursing Supervisor, Employee E4's statement noted that after the agency charge nurse, Employee E2 left the facility, the Nursing supervisor, Employee E4 re-assessed the resident, whose nose continued to bleed, and contacted the Nurse Practitioner (NP). The NP instructed Employee E2 to call 911 (Emergency Medical Services) and send the resident to the hospital for evaluation. Review of the written statement by Nurse aide, Employee E1, who was assigned to Resident R1 for continuous 1:1 supervision on February 7, 2026, during the evening shift. I didn't see (her/him) fall, I saw the swollen and the bruise on the left side of the face, after dinner. I did not look at face. Review of interview statement from the Nursing Home Administrator (NHA), Employee E7 on February 9, 2026, at 1:35 pm, revealed the NHA asked Nurse aide, Employee E1 to explain what happened while she was providing one to one (1:1) care to Resident R1. Nurse aide, Employee E1 initially said there was no incident. NHA informed Nurse aide, Employee E1 that Resident R1 had reported, through an interpreter, that she fell because the floor was slippery. NHA also stated that Nursing aide, Employee E3 noticed Resident R1's nose bleeding around 6:00 PM and took Resident R1 for evaluation. Nursing Home Administrator reminded Nurse aide, Employee E1 that her responsibility during the Sunday 3 pm shift was to closely watch Resident R1 on a 1:1 to prevent a fall. Further review of written statement of the interview conducted between the NHA and Nurse aide, Employee E1 revealed that Nursing Home Administrator confronted Nurse aide, Employee E1 on February 9, 2026 because he believed something had happened to Resident R1 during Nurse aide, Employee E1's 1:1 supervision. Nurse aide, Employee E1, admitted during interview that Resident R1 slipped and fell while getting up from a shower chair. Employee E1 stated that Resident R1 did not appear to be in pain, so she helped dry the resident and took (her/him) to the dining room for dinner. Nurse aide, Employee E1 explained she did not report the incident because she was afraid, she would get into trouble. Further review of the documentation submitted to the State Survey Agency of the investigation of possible neglect sustained by Resident R1, revealed that the facility substantiated the allegation of neglect due to nurse aide, Employee E1 failure to report the fall incident to the nurse. Nurse aide, Employee E1 was terminated for failure to report an accident/incident involving Resident R1. Interview conducted on March 10, 2026, at 2:00 p.m. with the Director of Nursing, Employee E8 and Nursing Home Administrator Employee E7 confirmed that nurse aide, Employee E1 failed to notify licensed nursing staff of Resident R1 fall incident and injuries sustained by the resident. The facility presented documentation indicating that the facility initiated a plan of correction to address the failure of ensuring timely notification to the physician of a fall incident sustained by Resident R1, which resulted in actual harm to Resident R1 who experienced a delay of treatment after the fall incidents with injuries. The facility alleged a date of compliance of February 9, 2026. The plan of correction stated the following: -On 2/27/2026 on 2/7/26 at approximately 7pm Resident R1 was noted to have swelling and bruising on the left side of her face by nursing supervisor, The supervisor asked the aide (Employee E1) what happened the aide state she didn't know. The DON was made aware and investigation was immediately started. Resident ER1 was sent to the ER for Evaluation.-At approximately 10:30 p.m. the DOB received a call from the hospital stating the Resident R1 had a fracture of the mandible and 2 fractured right ribs and chronic subdural hemorrhage.-The 1-1 aide assigned to this resident at the time was suspended pending investigation. The police were called and came to the facility. 2/7/2026 In-servicing was started on abuse and reporting of incidents and accidents 2/9/2026- Head to toe skin and body checks were completed and all the resident residing on the Unit that Resident R1 resides on. Interviews were also conducted with residents that could be interviewed to rule out abuse. 2/9/2026- Employee E1 was called in again to be interviewed regarding this resident since she was the 1-1 and nothing was noted prior to her taking over the 1-1 assignment. After lengthy discussion Employee E1 admitted that Resident R1 fell in the shower room, she stated she was afraid to report the fall.Employee E1 was educated on reporting of any incident and accidents.Employee E1 was terminated for failure to report and incident/accident.In-servicing- continued in the building to all staff on reporting falls and abuse and reporting abuse. Competencies were also given to staff after the education was done abuse.An audit of the last 2 weeks of nurse's notes and shift reports was conducted to ensure any accidents/incidents were reported per policy.The DON/ Designee will audit nurses' notes and shift reports to ensure any accidents and incidents were reported with the appropriate follow up action completed. Audits will be conducted weekly x 4 weeks and then monthly x2. Results of these audits will be submitted to QAPI to determine if further action is needed. Facility education record and subsequent audits were verified for completion. Skin checks documentation was reviewed and completed. Facility provided evidence of audits of nurses' notes for accidents/incidents and abuse audit of non-interviewable residents. Staff were interviewed to verify education. QAPI (Quality Assurance Improvement Plan) records reviewed to verify ongoing monitoring. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required licensure and certifications for three of three employees reviewed. (Employee E13, Employee E14, Employee E15)Findings include:Review of Facility contract with nursing staffing agency, titled Schedule A Statement of work ( SOW) #1 dated [DATE], under section 1. Services d. It is understood and agreed by Facility [nursing staffing agency] only refers candidates for consideration and that the hiring decisions and determinations of suitability, employment eligibility verification and conditions of employment are ultimately the responsibility of Facility. Review of Employee E13's personnel file revealed that Employee E13 was agency employee, hire date of [DATE], working as a Supervisor Registered Nurse. Review of facility investigation revealed on [DATE], it was reported to facility leadership that Employee E13's nursing license was suspended on [DATE]. Interview with Employee E2, Director of Nursing confirmed that upon checking the license verification system on [DATE], it was confirmed that Employee E13's registered nursing license was suspended on [DATE]. Further interview with Employee E2, Director of Nursing, confirmed that Employee E13 worked 19 shifts between [DATE] and [DATE] in the role of Supervisor Registered Nurse. Interview with Employee E2, Director of Nursing on [DATE] at 10:25am revealed that nurses and staff accepted to work in facility nursing staffing agency have all required documentation (license, background checks, etc) loaded into a portal for facility to review and if a nurse unknown to the facility then Director of Nursing will usually confirm license verification via the State Licensing online system. Interview with Employee E1, Nursing Home Administrator on [DATE] at 10:30am revealed that prior to referenced incident, employee licenses and certifications were audited annually as a part of the mock survey process. After referenced incident, facility started new policy for HR Director to maintain a file with a 3 month look ahead with license/ certification expiration dates. However, it did not include agency staff. There was no documented evidence that facility independently verified Employee E13's registered nursing license. Review of Employee E14's personnel file revealed that the employee was full-time employee, hire date of [DATE], working as a nursing Aide. Review of facility investigation revealed that Employee E14, nurse aide certification expired on [DATE]. Interview with Employee E1, Nursing Home Administrator on [DATE] at 10:30am confirmed that Employee E14 remained fulltime in facility between [DATE] and [DATE]. Review of Employee E15's personnel file revealed that the employee was full-time employee, hire date of February 7, 2024, working as a Nurse aide. Review of facility investigation revealed that Employee E15, nursing assistant certification expired on [DATE]. Interview with Employee E15, Nursing Home Administrator on [DATE] at 10:30am confirmed that Employee E15 remained fulltime in facility between [DATE] and [DATE]. 28 Pa. Code 201.19(7) Personnel records

Based on review of clinical records, facility schedules, staff interviews, and observations, it was determined that the facility failed to ensure residents were provided bathing and showering services in accordance with their assessed needs and physician orders for six of eight residents reviewed. (Residents R33, R43, R174, R164, R185, R180)Findings include: Review of facility policy titled ADL Care Bathing (shower, tub, bed, perineal) last reviewed March of 2025, revealed that the facility requires residents be offered bathing or showering at least weekly, based on resident preference and care plan orders. The policy further requires that refusals, missed care, or barriers to providing ADL services be documented and reported to licensed nursing staff. The facility failed to follow its own policy by not offering scheduled showers, inaccurately reporting resident refusals, and failing to document missed care or resident preferences. Review of facility shower schedules and ADL (activities of daily living) documentation for the CD Nursing Unit revealed multiple residents were scheduled to receive showers during the 7:00 a.m. to 3:00 p.m. shift on December 29, 2025, including Residents R172, R43, R174, R164, R185, R69, and R180. Documentation did not reflect that showers were completed as scheduled, nor did it contain documented refusals or clinical justifications for missed care. Observation of the CD Nursing Unit shower room at approximately 11:45 a.m. on December 29, 2025, revealed the shower room was completely dry and being used for storage of floor lifts. There was no evidence that the shower room had been used for resident bathing on that date. During an interview conducted with the Licensed nurse Unit Manager E9, on December 29, 2025, at approximately 11:50 a.m., the surveyor was provided with the shower schedule indicating residents were assigned to receive showers that morning on the 7:00 a.m. to 3:00 p.m. shift. Interview with Nurse aide, Employee E10 on December 29, 2025 at approximately 12:05 p.m. revealed she was preparing to provide Resident R174 with a bed bath at the time of interview and the other residents declined a shower today. Interview with Nursing Aide, Employee E11 at 12:10 p.m. revealed all residents refused showers, and that one resident could not be showered due to having a PICC (central venous) line.Resident interviews contradicted staff statements as follows:Interview with Resident R33 on December 29, 2025, at approximately 11:00 a.m. revealed the resident had not received a shower since admission to the facility three weeks prior.Interview with Resident R43 revealed the resident wanted a shower, had not refused, and stated she was never asked or offered a shower.Interview with Resident R174 revealed the resident wanted to be bathed; during the interview, a CNA was preparing to provide a bed bath.Interview with Resident R164 revealed the resident wanted a shower and stated she had never received one since admission.Interview with Resident R185 revealed the resident wished to receive a shower.Interview with Resident R180 revealed the resident wanted a shower and stated she was never asked or offered one. The resident reported washing herself with wipes due to not being provided shower assistance. 28 Pa. Code 201.20 (a)(5)(6)(b) Staff development 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on review of facility provided documentation, review of clinical records and interview with staff, it was determined facility did not ensure to complete medication regimen reviews according to professional standards of practice for two of five residents reviewed (Residents R3, and R8) Findings include: Review of facility policy 'Medication Regimen Review,' reviewed in May 2025, indicates that the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical. Review of facility provided 'Consultant Pharmacist's Medication Regimen Review,' for recommendations created between August 1, 2025, and August 6, 2025, revealed that dose reduction was recommended for Resident R3 related to Abilify prescription. Further review of 'Consultant Pharmacist's Medication Regimen Review,' revealed no evidence of physician rationale for Resident R3. Review of Consultant Pharmacist's Medication Review Regimen, for recommendations created between July 1, 2025, and July 16, 2025, revealed recommendation for Resident R8, stating Federal Guidelines necessitate review and possible attempts at psychoactive dose reduction. Please review this resident's Lexapro order considering if the resident is a candidate for decrease in dose. Possible responses to circle: 1. After review and assessment the benefit to the resident outweighs any observed risk. No reduction at this time. 2. The resident's condition warrants the following dosage reduction (see order below). 3. The resident's current condition warrants further increase or change in therapy (see order below). Further review of this Consultant Pharmacist's Medication Review Regimen revealed Physician/ Prescriber disagreed with recommendation, however provided no rationale. Review of Consultant Pharmacist's Medication Review Regimen, for recommendations created between August 1, 2025, and August 6, 2025, revealed recommendation for Resident R8, stating Federal Guidelines necessitate review and possible attempts at psychoactive dose reduction. Please review this resident's Risperdal order considering if the resident is a candidate for decrease in dose. Possible responses to circle: 1. After review and assessment the benefit to the resident outweighs any observed risk. No reduction at this time. 2. The resident's condition warrants the following dosage reduction (see order below). 3. The resident's current condition warrants further increase or change in therapy (see order below). Further review of this Consultant Pharmacist's Medication Review Regimen revealed Physician/ Prescriber disagreed with recommendation, however provided no rationale. Interview with Employee E7, Medical Director confirmed findings. 28 Pa Code 211.9(k) Pharmacy services 28 Pa Code 211.12(d)(3) nursing services

Based on review of clinical records, review of facility policy and interview with staff and residents, it was determined that facility failed to develop and implement a comprehensive resident centered care plan for three of 33 residents reviewed. (Residents R69, and R175) Findings include: Review of the facility policy titled Care Planning Process and Care Conference, last reviewed May 2025, revealed the facility is required to develop and implement a comprehensive, resident-centered interdisciplinary care plan based on each resident's assessed needs, diagnoses, and functional limitations. The policy requires the care plan to be initiated upon admission and updated following completion of the comprehensive assessment, with revisions made for any change in the resident's condition. The policy further requires the facility to identify and care plan for each resident's diagnoses and impairments, including visual deficits or blindness, and to develop individualized, measurable goals with specific interventions. Each identified care plan problem must include assigned responsible disciplines, target dates, and interventions designed to promote resident safety, independence, and quality of life. An interdisciplinary team must develop the comprehensive care plan within 21 days of admission, and all staff are required to provide care in accordance with the care plan. Failure to assess, develop, implement, or revise care plans to address identified diagnoses, such as visual impairment or blindness, is inconsistent with facility policy and the requirements. Review of Resident R175's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis including orthopedic conditions, malnutrition, diabetes (failure of the body to produce insulin), and respiratory failure. Resident R175's functional abilities were assessed as independent with supervision and the use of a wheelchair and a walker. The resident's brief interview of mental status (BIMs) was 14 indicating intact cognition and the resident is noted to have severely impaired vision with no corrected lenses. Interview with resident on December 29, 2025, approximately 11:00 AM revealed resident has concerns of not being cared for (her/his) blindness stating that there's no interventions for (her/his) blindness. The resident stated that (she/he) was independent but cannot see and had difficulty and needed some assistance. The nurses leave the medications on the overside bed tray and (she/he) can't see them. Review of Resident R175's care plan did not include a specific problem, goal, or individualized interventions addressing legal blindness. Interview with the Unit Manager Nurse, Employee E9 on January 4, 2026, confirmed the resident is legally blind and confirmed the care plan does not specifically address the resident's visual impairment or include interventions to improve safety and comfort related to blindness. Review of Resident R69's clinical record revealed medical diagnosis of cerebral infarction (stroke), hemiplegia (paralysis) affecting right nondominant side, need for assistance with personal care. Observations of Resident R69 on December 29, 2025, at 10:30 am, revealed resident laying on his right side with right arm underneath him. Interview with facility's Rehabilitation Director, Employee R4, on Friday, January 2, 2026 at 11:30 am, revealed that Resident R69 was to have pillow prop up in bed under right upper extremity. Review of occupational therapy notes, dated December 3, 2025, indicated that Clinician provided education regarding wearing R (right) sling when in therapy or out of bed for increased comfort. Review of R69's care plan revealed no evidence of interventions related to pillow and sling provision for resident's comfort. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12 (c) (d)(1)(3)(5) Nursing services

Based on observation, review of facility policy and procedures and interviews with residents and staff, it was determined that the facility failed to maintain an effective infection control program related to water cup distribution for three of 33 residents observed. (Resident R8, Resident R121 and Resident R18)Findings include: Review of Water Pitcher Pass/ cleaning review date April 2025, revealed that Styrofoam cups will be replaced nightly on 11-7 shift. Cups should be labeled with date of placement. Continued review revealed Nursing staff will fill water pitchers/Styrofoam cups with ice and fresh water placing them at bedside. Interview with Resident R8 on December 29, 2025, at 10:30am, revealed resident doesn't feel like she gets offered enough water and they always use the same cup and fill it at the bathroom sink. Observation of Resident R8's Styrofoam water cup on bedside table on December 29, 2025, at 10:30am, revealed that cup was labeled with a date of December 18, 2025, 11p-7a. Interview with Resident R121 on December 29, 2025, at 10:30am, revealed that cups get filled in the bathroom sink when requesting water and cups do not get replaced often. Observation of Resident R121's Styrofoam water cup on bedside table on December 29, 2025, at 10:35am, revealed that cup was labeled with a date of December 26, 2025, 11p-7a. Interview with Employee E12, Nursing Assistant on December 29, 2025, at 10:45am, confirmed findings and stated, I don't know what happened, I am agency, but I think cups are supposed to be changed every night shift. Interview with Resident R18 on December 29, 2025, at 10:55am, revealed concerns related to water cups filled in bathroom sink of shared resident bathroom and that resident was disgusted by this. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to accurately document resident council concerns as grievances, failed to record follow-up actions and resolutions in resident council minutes, and did not ensure that residents were informed of outcomes, affecting the resident council's ability to function as a formal grievance forum for 7 of 19 residents in resident council attendance. (Resident 33, R44, R70, R85, R152 and R167) Findings include:Review of facility policy titled Clinical Manual - Social Services Manual (last reviewed April 2025) revealed that resident council meetings must be held at least monthly and serve as the formal, legally mandated forum for residents to voice concerns regarding care, treatment, and living environment. The policy requires that all concerns raised during resident council meetings-whether individual or collective-be treated as grievances, followed in accordance with the facility's grievance policy, and communicated back to residents. The policy requires that resident council minutes accurately document concerns raised, actions taken, and follow-up, serving as the official written record of grievances and their resolution. Addressing concerns verbally without documentation does not meet policy requirements.Review of resident council meeting minutes for the previous three months dated September 24, 2025; October 28, 2025; and November 28, 2025, revealed that concerns were consistently documented as no concerns across multiple departments, with minimal notation of issues and no documentation of grievance follow-up or resolution.September 24, 2025: Minutes documented attendance and departmental reports indicating no concerns. Maintenance noted a toilet seat issue on E Wing was fixed or would be fixed. No grievances or documented follow-up actions were recorded.October 28, 2025: Minutes documented attendance and one housekeeping concern marked as resolved. All other departments documented no concerns. No documentation of grievance tracking, corrective actions, or communication back to residents was recorded.November 28, 2025: Minutes documented attendance with all departments indicating no concerns. No grievances or follow-up actions were recorded.Interview with seven residents (R33, R44, R70, R85, R152, R164, and R167) during the resident council meeting held on December 30, 2025, at 10:30 a.m. revealed that residents voiced multiple ongoing concerns related to food services, staffing, physical therapy, supplies, and environmental issues. Residents stated that these concerns are raised repeatedly during monthly resident council meetings and are not resolved or communicated back to residents.Interview with the Activities Director Employee E3 on December 30, 2025, at 1:40 p.m. revealed that she attends all resident council meetings and confirmed that residents voice concerns during meetings. She stated that she does not include these concerns in the resident council minutes if she addresses them verbally during the meeting or if she completes a separate grievance form and forwards it to Social Services. She confirmed that grievances raised during resident council meetings are not consistently documented in the meeting minutes.Review of the resident and family grievance log revealed grievances that were not reflected in resident council minutes:September 2025: Grievances related to nursing care, customer service, missing items, and food services were documented in the grievance log but not in the September 24, 2025 resident council minutes.October 2025: Grievances related to housekeeping, customer service, nursing care, missing items, and medication issues were documented in the grievance log but not in the October 28, 2025 resident council minutes.Interview with Resident R33 on December 30, 2025 at 10:55 a.m. confirmed that resident council minutes were inaccurate. The resident stated she takes personal notes at every meeting and that complaints and concerns are consistently raised but are not reflected in the official resident council minutes. Review of attendance records confirmed Resident R33 attended the resident council meetings.28 Pa. Code 201.18 (e)(3) Management28 Pa. Code 201.29 (a) Resident Rights

Based on observation, clinical record review, and staff interview, the facility failed to ensure a comprehensive assessment was completed upon admission for one of eight residents reviewed. (Resident R 175)Findings include: Review of Resident R175's admission Minimum Data Set (MDS- assessment of resident care needs) dated December 17, 2025, revealed that the resident entered the facility on December 11, 2025, with diagnosis including orthopedic conditions, malnutrition, diabetes (failure of the body to produce insulin), and respiratory failure. Resident R175's functional abilities were assessed as independent with supervision and the use of a wheelchair and a walker. The resident's brief interview of mental status (BIMs) was 14 indicating intact cognition and the resident is noted to have severely impaired vision with no corrected lenses. Interview with resident on December 29, 2025, approximately 11:00 AM revealed resident has concerns of not being cared for (her/his) blindness stating that there's no interventions for (her/his) blindness. The resident stated that (she/he) was independent but cannot see and had difficulty and needed some assistance. The nurses leave the medications on the overside bed tray and (she/he) can't see them. Review of Resident R 175's clinical record primary diagnosis did not include any visual deficit or legal blindness. Interview with Registered Nurse Assessment Coordinator, Employee E5 confirm that Resident R175 was legally blind and confirmed that it was not coded on the diagnosis list of the MDS. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy, as well as interview with staff and residents, it was determined that facility did not ensure to honor residents' preferences related to fresh air breaks and activities for two of 33 residents reviewed (Resident R58 and Resident R16). Findings inclide: Review of facility policy 'Activity Programs,' reviewed on April 2025, indicates that activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.Further review of policy indicates that activities offered are based on the comprehensive resident-centered assessment and the interest and preferences of each resident. Interview with Resident R58 on Monday, December 29, 2025, at 11:45 am, revealed that the only residents who are accommodated with fresh air breaks are the ones who smoke. Further interview with R58 revealed that she is non-smoker, and when she attempts to bring up fresh air break times during resident council meetings, the staff who hold meeting do not address her preference. Interview with facility's activities director, employee E3, on Tuesday, December 30, 2025 at 3:00 pm, revealed that facility currently does not offer fresh air breaks to non-smoking residents' due to weather conditions. Review of Resident R16's clinical record revealed resident admitted to facility on February 27, 2020 with diagnosis of TBI (Traumatic Brain Injury), Major Depressive Disorder and Schizophrenia. Review of Resident R16's BIMS (Brief Interview for Mental Status) assessment dated [DATE], resident scored 11, indicating resident is moderately impaired. Interview with Resident R16 on December 29, 2025 at 12:00pm, We just don't get fresh air unless you are smoking. I feel locked up when I can't go outside, it's terrible. I want to go outside sometimes and they just don't let us. Further interview revealed that resident has expressed this on multiple occasions and no one listens. 28 Pa Code 211.18(b)(1) Management

Based on clinical record review, staff interviews, and incident/accident documentation, the facility failed to demonstrate that it conducted a thorough, timely, and documented investigation into an allegation of misappropriation of resident property, for one of 33 residents reviewed. (Resident R70) Findings include: Review of the facility's policy titled Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices last reviewed October 2025 revealed the facility requires that all incidents and adverse occurrences be fully, timely, and thoroughly investigated until a clear conclusion is reached. An investigation is considered incomplete if required information, documentation, analysis, or approvals are missing.Key points related to incomplete investigations include:Immediate initiation is mandatory: All incidents involving injury, abuse, neglect, mistreatment, or unknown origin must be reported immediately to the DON and Administrator, and an investigation must begin without delay.Comprehensive data collection is required: Incomplete investigations may result from missing incident reports, unsigned or unreviewed witness statements, lack of resident assessments, missing timelines, or failure to identify all parties involved. The policy requires collection of factual witness statements, environmental observations, resident assessments, and supporting documentation.Required review and oversight: Incident reports and investigations must be reviewed by supervisory staff (Unit Manager, DON, ADON, NHA). Failure to obtain required reviews, signatures, or approvals (including regional or executive approval for reportable events) renders the investigation incomplete.Analysis and conclusions must be documented: An investigation is not complete unless it includes documented conclusions addressing:How the incident occurredWhy it occurred (if determinable)Whether it was preventableRoot cause analysis, when possibleFollow-up actions are required: Immediate corrective actions, care plan revisions, and prevention measures must be documented. Missing or unimplemented corrective actions indicate an incomplete investigation.Additional investigation when needed: If facts are insufficient, abuse is suspected, or reasonable cause cannot be established, the policy requires continued investigation, additional statements, and escalation to the DON, Administrator, and appropriate agencies.Final review and closure: Investigations must be finalized, signed, logged, and trended. Incomplete investigations may occur if documentation is not returned for final review, not forwarded for required signatures, or not included in tracking and QAPI review.Review of documentation reported to the State Survey Agency relate to Resident R70 misappropriation of resident property, revealed that the resident contacted social services on December 8, 2025 and notified the Social Service Director that on November 24, 2025, someone came into a room claiming to be a social worker and took her debit card an ID and had her sign some forms. Resident R33 reported that she received a notification on November 26, 2025 from her bank stating that they suspected fraudulent activity. Resident claims $400 was spent out of her account. In conclusion, the bank has reimbursed the money to her account and issued her new card, an investigation was started, the police and Protective Services were contacted.Continued review of reported incident revealed Resident R70 could not identify the person that came into a room only that it was a female and wore a business suit. The Nursing Home Administrator (NHA), Employee E1 instructed staff who do not dress in scrubs to visit this resident while rounding on December 9, 2025 and December 10, 2025. The resident did not recognize any of the employees.Review of the facility's investigation included a police report, the statement of Resident R33 to Social Services, and the Social Services initial assessment of Resident R70, which indicated the resident scored 15 on the BIMS (brief interview of mental status), reflecting intact cognition.The facility concluded that the NHA, Employee E1 was unable to substantiate that the purchase on the resident's card resulted from someone taking it while at the facility, noting that the resident could not provide a description of the alleged individual or identify anyone involved.The investigation did not include interview with other potential witnesses.Interview with NHA, Employee E1, on January 5, 2025, at approximately 9:00 a.m., acknowledged that the resident reported money missing and initially alleged that an individual presenting as a facility employee entered her room and took her funds. Employee E1 stated that the resident's account changed multiple times, including claims that the withdrawals occurred outside the facility, possibly related to a motel stay prior to admission, and later speculation that the individual may not have been a facility employee.NHA, Employee E1 further stated that the facility did not have further involvement because law enforcement and the bank would not release additional information without a subpoena. He believed the incident did not occur within the facility. Based on the resident's changing descriptions, he informally showed the resident several staff members who might match her description but stated the resident was unable to identify anyone. He acknowledged that the resident could not consistently describe the alleged individual and that no staff member matched the description provided. Employee E1 confirmed that while he spoke generally with staff and followed up with the resident, there was no clear documentation of a comprehensive internal investigation, including:A documented timeline of events,Review of staff schedules and sign-in logs,Interviews with other residents on the unit,Identification of potential witnesses,Documentation of investigative findings and conclusions. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, review of a facility document, interviews with residents and staff and review of clinical records, revealed that the facility failed to meet the standard of care for diabetes management and hypoglycemia monitoring in a timely manner for one of 11 residents reviewed. (Resident R164) Findings include: Review of facility policy titled Hypoglycemia Diabetic Management last reviewed May 2025 revealed the facility requires staff to quickly and safely respond to residents exhibiting signs or symptoms of hypoglycemia, to manage diabetes to prevent hypoglycemia, to monitor blood glucose per physician orders, and to ensure timely assessment, intervention, physician notification, and documentation of hypoglycemic episodes. Review of facilities policy titled Care Planning Process and Care Conference last revised March 19 2025 revealed the facility's policy requires the development and implementation of a comprehensive, resident-centered interdisciplinary plan of care for each resident, based on completed assessments and in compliance with federal and state regulations. A baseline care plan must be initiated upon admission and completed within 48 hours, addressing the residents' primary diagnosis, identified risks, and individual needs. The care plan serves as a working document that guides staff in delivering care consistently with professional standards. The interdisciplinary team (IDT)-including nursing, physician (as applicable), dietitian, social services, rehabilitation, nursing assistants, and the resident and/or resident representatives are responsible for care plan development, review, and revision. Care plans must include specific, measurable goals, interventions, responsible disciplines, and target dates, and must be updated with any change in condition. According to the American Diabetes Association (ADA) and the Centers for Disease Control and Prevention (CDC), hypoglycemia is generally defined as blood glucose level below 70 Mg dl. When blood sugar drops too low, individuals may experience symptoms as shakiness, sweating irritability, confusion, dizziness or lightheadedness, rapid heartbeat and blurred vision. If untreated hypoglycemia may progress to severe symptoms, including loss of consciousness, seizure, or coma which can be life-threatening. Initial treatment typically involves the immediate intake of fast acting carbohydrates, such as glucose tablets, juice or non diet sodas, followed by reassessment of blood glucose levels. In severe hypoglycemia, the ADA defines the condition as a medical emergency, particularly when the blood glucose levels fall below 54 MG Slash DL in these situations assistance from another person is required which may include administration of glucagon or activation of emergency medical services. While mild hypoglycemia may be managed by the individual with fast acting carbohydrates severe hypoglycemia requires urgent medical interventions both the ADA and the CDC stressed the importance of timely monitoring, reassessment, and individual lies care planning after hypoglycemic episodes to prevent reoccurrence and avoid serious harm. Review of the American Diabetes Association (ADA) standards of care 2025, section 14: Diabetes Care in Long-Term Care Settings, Diabetes care 2025;48(Suppl 1): S1-S3 state that episodes of hypoglycemia require prompt evaluation and individualized intervention and that the recurrent or severe hypoglycemia should trigger reassessment of the diabetes management plan to prevent further events. The ADA emphasizes that blood glucose monitoring, individualized treatment adjustments, dietary review, and ongoing risk assessments are integral parts of safe diabetes care. Review of The Centers for Disease Control and Prevention CDC Hypoglycemic Guidance-Immediate treatment and post episode monitoring to prevent recurrence. https://wwwcdc.gov/diabetes/treatment/treatment-low-blood-sugar-hypoglycemia.html recommends immediate treatment of hypoglycemia blood glucose less than 70MG per DL and frequent post episode monitoring and care plan review to identify contributing factors and reduce reoccurrence. Review of Resident R164's hospital discharge orders dated December 3, 2025, revealed that Resident R164's medication list with instructions to continue the following medications: one touch delica plus Lancet 33GAGE miscellaneous for type two diabetes mellitus with chronic kidney disease on chronic dialysis, unspecified whether long-term insulin use. With instructions one Lancet 4 times a day for diabetes management, which was not transferred to resident physician orders, indicating the hospital discharge recommendations for Accu-checks were not implemented upon admission. Review of Resident R164's admission Minimum Data Set (MDS -a federal mandated assessment tool for all residents) dated December 9, 2025, revealed that Resident R164 entered the facility on December 3, 2025 with diagnosis including Hypertension ( is a condition where blood pressure is consistently elevated above normal levels), renal failure ( a condition in which the kidneys lose the ability to filter waste and excess fluids from the blood effectively , diabetes mellitus ( is a chronic condition where the body either becomes resistant to insulin or doesn't produce enough insulin leading tear elevated blood sugar levels), seizure disorder(also known as epilepsy is a neurological condition characterized by recurrent unprovoked seizures), and anxiety(is a mental health condition characterized by excessive worry fear or nervousness often interfering with say the activities). The residents' medications include an antidepressant, anticoagulant, antibiotic, diuretic, and the anti-convulsant. Resident R164 receives dialysis. Further review of resident R 164 MDS revealed residents cognition assessed with a brief interview of mental status (BIMs) score of 14 indicating that the resident cognition is intact. Review of resident R164's care plan revealed this resident is at risk for complications from hemodialysis related to end stage renal disease-initiated December 4, 2025, with interventions to adjust medication schedule necessary on dialysis days, maintain enhanced barrier precautions, monitor permcath for signs of bleeding swelling or infection every shift in is needed monitor vital signs as ordered. Continued review of resident's care plan revealed a focus of nutrition, the resident at is at risk for alteration in nutrition hydration related to facility adjustment diabetes and stage renal disease and depression date December 4, 2025 with interventions of diet is ordered, encourage food and fluid, monitor for signs or symptoms of hyper or hypoglycemia, monitor PO (by mouth) intake, supplements as ordered. The goal was for Resident R164 will have no signs and symptoms of hyper or hypoglycemia through the next review date- December 4, 2025. Resident R 164 does not care planed for diabetes management, or hypoglycemia. Review of the Registered Dietitian's nutrition assessment dated [DATE], revealed that the resident was ordered a renal carbohydrate-controlled diet and had a good appetite, consuming approximately 75% of meals. However, there was no evidence of diabetic snack orders or coordinated dietary interventions related to blood glucose management, and no reassessment of nutritional needs following hypoglycemic episodes. R Review of Resident R164's nursing notes revealed that the resident experienced multiple documented hypoglycemic episodes: -December 17, 2025, the resident experienced a hypoglycemic with a documented blood sugar of 48 mg/dl episode requiring glucagon administration. -December 19, 2025, the resident's blood glucose was documented at 34 mg/dL following dialysis. -December 29, 2025, the resident experienced another hypoglycemic episode with a documented blood glucose of 44 mg/dL, which was associated with a fall. Continued review of resident's clinical records revealed there was no evidence of timely physician reassessment, modification of the diabetes management plan, or consistent escalation of monitoring until December 30, 2025, when hypoglycemia protocols, endocrinology consultation, and routine snack orders were initiated. Review of the resident's December 2025 Medication Administration Record (MAR) revealed inconsistent and incomplete documentation of blood glucose monitoring. Continue review of December 2025 MAR revealed that blood sugar checks were in place for specified periods. Nursing staff documented that blood sugars were checked without recording actual glucose values, and multiple required blood glucose readings were not recorded. An interview with Resident R1 conducted on December 29, 2025, revealed that the resident identified herself as a diabetic and reported that she was not receiving any snacks. The resident stated that her blood sugar levels continued to drop and that, despite these episodes, she was still not being provided snacks to help manage her blood glucose. A second interview with the resident conducted December 30, 2025, at 11:00 a.m. revealed continued concerns regarding lack of diabetes management. The resident stated that no one was taking care of her blood sugar monitoring and reported that she had passed out the night before due to low blood sugar. The resident further stated that she was still not receiving snacks at that time. Interview conducted on January 2, 2026, at 10:35 a.m., the resident stated that she had still not been offered any snacks. She reported experiencing multiple episodes of loss of consciousness and stated that she had fallen three times, recalling only waking up with staff around her. The resident stated she did not believe she was injured but described feeling scared and uncertain following the incidents. The resident further reported that she had not seen a physician and had not had any discussion regarding her diabetes or blood sugar management. Interview conducted on January 2, 2026, with the Medical Director, Employee E7, acknowledged that the resident experienced three documented hypoglycemic episodes and stated that while an isolated episode may not require increased monitoring, recurrent hypoglycemia warrants further evaluation and escalation of care. Employee R7 confirmed that consultation with endocrinology following repeated events was medically appropriate. Employee E7 further stated that dialysis patients are at increased risk for glucose variability and require careful coordination of monitoring, nutrition, and dialysis schedules. Phone interviews with the attending physician, Employee E8 on January 2, 2025, revealed acknowledgment of the resident's hypoglycemic episodes and confirmation that increased monitoring was ordered following recurrent events. The physician explained that hypoglycemia in dialysis patients is often related to nutritional intake and dialysis timing rather than medication use and emphasized the importance of dietary interventions and meal coordination. The physician acknowledged documentation gaps and indicated that additional documentation would be completed. Interviews with Licensed nurse manager, Employee E9 revealed delays in initiating blood glucose monitoring, and missed meals related to dialysis scheduling. The nurse manager acknowledged inconsistencies in pre- and post-dialysis documentation, gaps in communication, and failure to consistently ensure that diabetic residents received meals or snacks when leaving the facility for dialysis. These failures contributed to recurrent hypoglycemic episodes and delayed interventions. Continued interview revealed that typically when a resident enters the facility with a diagnosis of diabetes the physician orders include a batch order including accu checks (blood sugar monitoring). 28 Pa Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.10 (b)(c) Care Policies 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were updated in a timely manner for one of 10 records reviewed related to resident's behaviors (Resident R1). Findings include: Review of clinical documentation revealed that Resident R1 was admitted to the facility on [DATE], and had diagnoses including, bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy), major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, post-traumatic stress disorder (a mental condition that's caused by an extremely stressful or terrifying event) and schizoaffective disorder (mental condition that combines schizophrenia and mood disorder). Reviewed of social worker note for Resident R1 revealed that on January 24, 2025, at 8:40 a.m. fire alarm went off shortly after and resident was in the vicinity. Further review revealed a clinical nurses note, dated January 27, 2025, at 9:34 p.m. revealed that resident pulled the fire alarm. Further review revealed a note, dated February 11, 2025, 7:21 a.m. revealed that resident pulled fire alarm on another wing, police and fire came and talked to resident and supervisor. Further record reviews for Resident's R1 care plan were not update with the behavior of pulling the fire alarm. Interview with Director of Nursing, Employee E2, on February 19, 2025, at 10:30 a.m. confirmed that she just revised the care plan related to the resident's behaviors. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations of the food and nutrition services department, interviews with staff, reviews of policies and procedures and the pest control operator's reports, it was determined that the main kitchen was not maintained and operated to ensure an effective pest control program. Findings include: Review of the policy titled kitchen cleaning dated December, 2024 revealed that it was the responsibility of the dietary staff to ensure that the main kitchen was clean and sanitary by adhering to a comprehensive cleaning schedule throughout the food and nutrition department. Observations of the main kitchen in the presence of the director of dietary, Employee E5, at 9:30 a.m., on December 2, 2024 revealed the following: The plumbing in the dish room area was not draining properly. Soiled water and food waste was over flowing onto the floor in the this section of the main kitchen. A dietary staff member was using a hand held plunger to try to unclog the sink that was adjacent to the dish machine. The flooring throughout the dish room area contained a covering of a white substance resembling lime deposits. The dish machine, work tables and racks that were connected to the dish machine contained a white powdery film that resembled hard water and calcium deposit residue. The ceiling tiles in the dish room area contained water damage. The ceiling tiles were brown stained and warped. The ceiling light fixture screens above the dish machine, contained a collection of dead insects. The wall area and ceiling tiles contained dried food debris. The grouting was missing between the floor tiles in the dish room. The missing grouting provided food for common household pests to breed and live. The disrepair in the flooring was porous and not easily cleanable. There was an accummulation of dirt, food debris and moisture in the gaps on the flooring. The entire perimeter of the flooring and cove molding in the dishroom contained a build-up of dirt and discarded food particles. The ceiling tiles and light screen covering above the hot food preparation area that was adjacent to the hood situated directly above the hot food equipment and cooking, contained a heavy accumulation of grease, dust and food splattering. An industrial sized piece of food service equipment located in the hot food preparation area, called a braise or tilt skillet was not functioning for several months. It contained a build of grease, food debris and dust. The perimeter of the flooring in the dry food storage area contained an accumulation of streaking and smudging along the perimeter of the flooring and walls with patches of mice droppings. The ceiling light screens located in the dry food storage area were brown stained with water damage. The ceiling light screens also contained a large number of dead roaches. The working mechanisms underneath the three compartment sink were not holding water regularly and a catch pan was placed below the piping to capture the leaking water. The pest control operator's reports were reviewed for September, October and November, 2024 and revealed that the main kitchen of the food and nutrition department was targeted for common household pests (roaches and mice). The pest control operator was used various treatments and traps to combat the invaders. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 PA. Code 205.13(b) Floors

Based on observation, staff and resident interviews, and review of clinical records, it was determined the facility failed to provide the necessary services to maintain adequate grooming and hygiene for one of 33 sampled residents (Resident R315). Findings include: Review of Resident R315's Admissions Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 20. 2024, revealed the resident was alert and oriented, able to make needs know, and diagnosed with fractures and malnutrition, with impairments to both sides of her upper and lower body. The same MDS indicated the resident was dependent on staff for all activities of daily needs and when asked it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. Interview with Resident R315 on December 4, 2024, at 11:00 a.m. stated that she was never offered a shower since she's been at the facility. I only get bed bath and I would really like a shower. Interview with Resident R351's Nursing Aide, Employee E3 on December 4, 2024, at 11:20 a.m. confirmed the staff only gives her bed baths because it might be too much for the resident. Review of Resident 351's physician orders revealed the resident's shower/bath days were every Tuesday and Friday and care planned for needing one staff member to assist with bathing/showering. Further review of the resident's clinical records did not reveal restrictions for showering. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, review of facility policy, review of clinical records, and interview with resident and staff, it was determined that the facility failed to develop and implement comprehensive, person-centered care plans to address resident care needs related to a diagnosis of anemia and psychotropic medications for one of 33 resident records reviewed (Resident R314). Findings include: Resident R314 was admitted to the facility on [DATE], diagnosed with anemia (not enough healthy red blood cells resulting in a reduced ability of the blood to carry oxygen to the body). Review of Resident R314's physician note, dated November 20, 2024, referenced the resident's critical hematology report dated November 15, 2024. The same note stated to monitor Resident R314's hematocrit (present of red blood cells in the blood) and hemoglobin (Hgb transports oxygen and carbon dioxide) relating to the resident's diagnosis of anemia and stated to consider Transfer for (blood) transfusion if Hg drops <7.0, and to monitor for signs and symptoms of fatigue, impact on therapy, monitor for oxygen use, check pulse ox as needed prior to and during therapy. Further review of Resident R314's clinical record revealed the facility failed to develop a care plan for the resident's diagnosis of anemia. 8 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(3) Nursing services. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations and interviews with residents, it was determined that the facility failed to maintain or enhance the dignity and respect for two of 33 residents reviewed (Resident R38 and R124). Findings include: During an interview with Resident R38 and R124 on December 4, 2024, at 3:40 p.m. the residents stated that when laundry labels their clothes with their names, they put it in places where it is visible when you are wearing them. Resident R38 stated they put my name on a collar of a shirt, in the front where you can see it when you are wearing it. Resident R124 revealed the jacket she was wearing had a 2-inch belt and on the back of the belt in large letters was the resident's name. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (j )Resident rights

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that a comprehensive assessment was completed accurately related to language and communication for one of 33 records reviewed (R417). Findings include: Review of clinical documentation revealed that Resident R417 was admitted to the facility on [DATE], with diagnoses of traumatic subdural hemorrhage (brain bleed caused by injury, which can damage the brain and result in lack of normal functioning), cerebral infarction (death of an area of brain tissue), and dementia (a degenerative neurological condition which results in impaired memory and judgement). Progress notes for the resident revealed that she was on comfort care, a protocol intended to keep a resident comfortable during end of life, but which is not hospice care. Continued review of the documentation revealed that a Brief Interview for Mental Status (BIMS) assessment was completed for the resident on November 14, 2024. The resident scored a ten out of a possible 15, which indicated moderate impairment of cognitive function. This assessment also included a section titled Health literacy/Social isolation/Transportation/ Ethnicity/Race, in which it was stated that the resident's preferred language was Vietnamese. Review of Resident R417's Admission Assessment MDS, dated [DATE], revealed that in section V, Care Area Assessment, that the area Communication was triggered for review and care planning. Review of the accompanying Care Area Assessment worksheet for Communication revealed that under the triggered area Expressive communication, Speaks different language was not selected. No care plan for communication was found in the clinical record. Review of physician notes dated December 4, 2024, at 11:25 a.m. stated, Pt is confused per interpreter service. A Clinical Nurses Note, dated December 1, 2024, at 10:35 p.m., stated, Resident is unable to make needs known. Observations conducted on December 2, 2024, at 11:30 a.m. revealed that the resident was unable to speak with the surveyor in English and was responding in short words in another language, which the surveyor did not speak. Interview with Employee E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that Resident R417 communicated primarily in Vietnamese, and that it should have been reflected in the Care Area Assessment that the resident spoke a different language. 28 Pa Code 211.12 (d)(1) Nursing services

Based on observation, clinical record review and interview with staff and residents and review of facility policy, it was determined that the facility did not develop a person-centered baseline care plan within 48 hours of a resident's admission related to language and communication for two residents, for a surgically wired jaw for one resident, and mental healthcare needs for one resident of 33 residents reviewed (Resident R158, R315, R417, R420). Findings include: Review of facility policy, Care Planning Process and Care Conference, revised July 3, 2023, revealed: Staff shall interact with the residents in a way that accomodates the physical or sensory limitations of the residents, promotes communication and maintains dignity. The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. When encountering LEP individuals, staff members will conduct the initial language assessment and notify the staff person in charge of the language access program. The coordinator of the facility's language access program. The coordinator of the the facility's language access program is the Director of Social Services, or his/her designee as determined by the NHA. It is understood that providing meaningful access to services provided by the facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral Interpretation Services therefore include interpretation from The LEP resident's primary language back to English. Care plans should reflect the LEP services utilized and specific activity programs that are provided to the resident based on their preferences. Activity programs are designed to meet the interests of and support the physical, mental and psycho-social well beingof each resident as well as, encouraging both independence and community iinteraction. An interdisciplinary baseline care plan will be initiated upon admission by the admitting nurse and completed within 48 hours. A copy of the baseline care plan will be reviewed with and provided to the resident/patient and/or resident representative, upon admission (within 48 hours). Facility will maintain evidence that the baseline care plan was provided (ex: nursing enters an admission progress note indicating resident admitted , assessments completed, introduced to surroundings and a copy of the baseline care plan was reviewed with resident and left at the bedside. RP called to notify of resident's arrival and baseline care plan was reviewed with RP). Include such initial needs/problems such as ADL's, falls, skin tears, risk for skin breakdown, nutritional status, behaviors, pacemaker, anticoagulants, psychotropic medication use, etc. Include a care plan related to the resident's primary diagnosis. Resident R158 was admitted to the facility on [DATE] with the following diagnoses: encephalopathy (brain disease that alters brain function or structure); severe protein calorie malnutrition (critical condition where a personis severelydeficient in both protein and calories, leading to significant muscle wasting, loss body fat, and impaired immune function. Diabetes Mellitis type II (condition in which body has trouble controlling blood sugar and using it for energy.) and cerebral infarction due to embolism an ischemic stroke). Review of Resident R158's MDS (Federally mandated resident assessment and care screening) dated November 13, 2024, revealed that English is the primary language of Resident R158. Review of Resident R158s baseline care plan revealed no evidence of language barrier or communication challenges related to English as a second language and Vietnamese as the primary language. Resident R158's care plan did not reflect the LEP services utilized and specific activity programs that are provided to Resident R158 based on her preferences. Interview on December 3, 2024 at 10:42 a.m. with Employee E3, unit manager, revealed that Resident 158 understands some English and speaks Vietnamese. We have consistent staffing here and the resident has a good rapport with her nurse aide. For almost all of our residents (on the memory care unit). we anticipate their needs. We have used the interpreter hotline at times, but not often. Usually we can anticipate her needs. Employee E13, Resident R158's nurse aide was unavailable for interview. Resident R158 was unable to participate in an interview with surveyor. Interview with Employee E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that Residenst R417 and R158 communicated primarily in Vietnamese, and that it should have been reflected in the Care Area Assessment that the resident spoke a different language. Review of Resident R315's Admissions Minimum Data Set, dated dated dated [DATE]. 2024, revealed the resident was alert and oriented, able to make needs know, diagnosed with multiple fractures, and impaired to both sides of her upper and lower body. Nursing note dated November 14, 2024, stated Resident R315 was a pedestrian in a motor vehicle accident and sustain multiple fractures and lacerations to her internal organs. The resident's jaw was wired closed and was ordered a clear liquid diet instructing to be fed with a syringe and a staff member present at all times with meals. Review of Resident 315's care plan revealed the resident was at risk of aspiration and instructed to monitor for signs and symptoms of aspiration. Further review of the care plan failed to develop a plan of care to include removing the wires from the jaw in an emergency. Interview with the Director of Nursing indicated pliers were available at the resident's bedside in case the wires needed to be removed but confirmed the intervention was not included in the resident's plan of care. Review of clinical documentation revealed that Resident R417 was admitted to the facility on [DATE], with diagnoses of traumatic subdural hemorrhage (brain bleed caused by injury, which can damage the brain and result in lack of normal functioning), cerebral infarction (death of an area of brain tissue), and dementia (a degenerative neurological condition which results in impaired memory and judgement). Progress notes for the resident revealed that she was on comfort care, (a protocol intended to keep a resident comfortable during end of life, but which is not hospice care). Review of Resident R417's MDS completed November 14, 2024, indicated a Brief Interview for Mental Status (BIMS) assessment with a score of ten -moderate impairment of cognitive function. This assessment also included a section titled Health literacy/Social isolation/Transportation/ Ethnicity/Race in which it was stated that the resident's preferred language was Vietnamese. Review of resident R417's Admission Assessment MDS, dated [DATE], revealed that in section V, Care Area Assessment, that the area Communication was triggered for review and care planning. No care plan for communication was found in the clinical record. Review of physician notes dated December 4, 2024, at 11:25 a.m. stated, Pt (patient) is confused per interpreter service. A Clinical Nurses Note, dated December 1, 2024, at 10:35 p.m., stated, Resident is unable to make needs known. Observations conducted on December 2, 2024, at 11:30 a.m. revealed that the resident was unable to speak with the surveyor in English and was responding in short words in another language, which the surveyor did not speak. Interview with Employee E1, the Nursing Home Administrator, and E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that Resident R417 communicated primarily in Vietnamese, and that a baseline care plan for communication should have been developed and was not. Review of documentation for Resident R420 revealed that he was admitted to the facility with diagnoses,of suicidal ideations, and bipolar disorder (a mental health condition consisting of extreme highs and lows in mood and affect, which can impact decision making and behaviors). Review of the care plan for the resident revealed that no care plan was developed related to his specific mental health needs related to suicidal ideation and bipolar disorder. Observation of Resident R420 on December 3, 2024, at 1:03 p.m. revealed that the resident had a flat affect and appeared withdrawn. Interview with Employee E1, the Nursing Home Administrator, and Employee E2, the Director of Nursing, on December 5, 2024, at 2:30 p.m. confirmed that a baseline care plan for the specific mental health needs should have been developed and was not. 28 Pa. Code 211.5(f)(viii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of clinical record, review of facility documentation, review of facility policies and procedures, review of the PA Nurse Aide handbook and interviews with resident and staff, it was determined that the facility failed to ensure that a resident was assessed for smoking safety and that safety devices were in place to prevent accidents during the provision of care for two of 37 residents reviewed. (Resident R331 and Resident R13). This failure resulted in actual harm to Resident R13, who fell out of bed, required emergency transfer to the hospital and sustained a fracture of the right femur. Findings include: A review of the facility policy Smoking/Nicotine Devices revised: October, 2022, indicated The facility will maintain a safe resident smoking/nicotine environment. The facility does not permit smoking inside the facility unless a designated smoking area is identified within the facility. Smoking will be permitted in an outside designated area. Residents will be assessed by the nursing staff/designee and determined as to be independent or supervised by a staff member. A review of the PA Nurse Aide Candidate handbook written (or oral) examination & skills evaluation dated January 2022, stated under Skills 11- Gives Modified Bed Bath (face and one arm, hand and underarm) step 19 Signaling device is within reach and bed is in low position. Review of Resident R13's clinical record revealed that the resident was admitted to the facility with diagnoses of osteoarthritis (a type of arthritis that occurs when protective tissue at the ends of bones wears down); chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow to the lungs); chronic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should); muscle weakness; major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life); osteoporosis (a condition in which bones become weak and brittle); and chronic respiratory failure with hypoxia (a condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels). Review of Resident R13's Minimum Data Set (MDS-a standardized, comprehensive assessment of an adult's functional, medical, psychological and cognitive status) dated January 27, 2023, revealed a BIMS (Brief Interview for Mental Status) of three, indicating that the resident had severe cognitive impairment. Further review of MDS assessment revealed Resident R13 required extensive assistance of one person for bed mobility and extensive assistance of two people for transfers. Review of Resident R13's care plan, dated February 8, 2023 revealed, Resident R13 prefers 1/4 side rails as enablers. The goal established was for Resident R13 to demonstrate safe use of side rails as enablers to maintain mobility and function as a focus area. Interventions include physical therapy and occupational therapy evaluation as needed. Continued review of Resident R13's care plan revealed Resident R13 was at risk for falls related to deconditioning and weakness as a focus area. Resident R13 will have risk for falls mitigated while maintaining the highest level of functional independence through review date. Interventions included to consult therapy services (Physical and Occupational) as needed, be sure that the call bell and personal items are in reach before leaving the room, orient resident to room and unit routine and as needed, low bed in lowest position at all times, except during care, check position every shift and as needed, fall mats to both sides of the bed at all times when resident is in bed, check for placement every shift and as needed. Review of Occupational Therapy notes revealed that Resident R13 received services from January to February 9, 2023. Resident R13 was discharged from services with the following discharge recommendations: assistance with ADL's, air mattress and assistive device for safe functional mobility. Interview on April 12, 2023, at 11:00 a.m. with Resident R13 revealed, I fell out of bed twice during care. I fell out in February and in March. The last time, I broke my hip. Review of Resident R13's nursing progress note, dated March 24, 2023, revealed, Resident was found on the floor in her room near her bed. She was lying on her right side. Resident was assessed for pain and injury. Upper extremities range of motion completed without difficulty. Resident complained of pain to the right leg. Received order to send to emergency room for evaluation and treatment. Continued review revealed, Spoke with hospital nurse who stated that resident was being admitted with a diagnosis of distal femur (thigh) fracture. Review of fall investigation dated March 24, 2023 at 12:20 p.m. revealed Employee E25, licensed nurse, stated I heard someone yell, 'she fell '. I ran to Room E118 and found [Resident R13] lying on the floor on her right side near her bed, Resident stated she fell out of the bed. Immediate action was taken. Resident was assessed for pain and injury with no visible injuries. Upper extremities range of motion completed without difficulty. Resident complained of pain to the right leg during range of motion. Physician was called and an order was given to send Resident to emergency room for evaluation and treatment. Continued review of the facility investigation noted that the resident was on a low air pressure relieving mattress with perimeter overlay at the time of the fall incident. Further review revealed an incident witness statement from Employee E24, nurse aide, I went to change Resident R13. As I turned her over, I pulled her to me so she wouldn't be on the edge of the bed. As I went to get her some water for her care, I heard someone scream and witnessed Resident R13 on the floor. I went to get my charge nurse to help with the incident. Interview on April 17, 2023 at 2:30 p.m. with Employee E24, nurse aide, revealed, Resident R13 is my usual assignment. Resident R13 said she felt like she was on the edge of the bed. I repositioned her by pulling her toward me and put her on her side. I raised the bed and told the resident I would be right back after getting the basin of water for AM care. I heard her scream, 'I am on the floor' so I ran to her. I observed her on the floor and I ran to get my charge nurse. Interview on April 17, 2023 at 3:00 p.m. with Employee E25, licensed nurse revealed, Resident R13 was observed on the floor. I assessed her and she was in pain. We left her on the floor with a pillow under her head. The physician was called and Resident was sent out 911 (Emergency Medical Services). She was admitted to the hospital with a fracture to the right distal femur. Employee E25 stated during interview that the resident's bed should not have been left at a high position. Resident 13's bed was left at a high position, without side rails and fall mats in place as it was indicated in the resident's care plan. This failure resulted in actual harm to Resident R13 who fell from bed while nurse aide, Employee E24 went to get water to complete morning care and sustained a fracture of the right femur. Review of Resident R331's clinical record revealed that the resident was newly admitted to the facility on [DATE]. Continued review of the resident's clincial record revealed that the resident was a current cigarette smoker, 1/2 pack daily. Interview conducted wtih Resident R331 on April 12, 2023, at 1:41 p.m. revealed that the resident confirmed that he was a smoker. Review of Resident R331's entire clinical record revealed no documented evidence that a smoking assessment was completed upon admission to the facility to determined if the resident was able to independently smoke or if the resident required supervision to smoke. Interview conducted on April 17, 2023, at 1:41 p.m. with Licensed staff, Employee E5, confirmed that Resident R331 had no smoking assessment completed. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 201.18 (b) (2) Management 28 Pa. Code 201.18 (e) (1) Management 28 Pa. Code 201.29 (c) Residents Rights 28 Pa. Code 211.12 (d) (1) Nursing Services 28 Pa. Code 211.12 (d) (5) Nursing Services

Based on observation, review of clinical record, review of facility documentation, review of facility policies and procedures, review of the PA Nurse Aide handbook and interviews with resident and staff, it was determined that the facility failed to ensure that residents were free from neglect during provision of care for one of 37 residents reviewed. (Resident R13). This failure resulted in actual harm to Resident R13 who fell out of bed, was emergently transfered to the hospital and sustained a fracture of the right femur. Findings include: Review of facility policy, Abuse Prevention, dated October 2017, revealed: The facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, and friends. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, mistreatment and/or misappropriation of property. The facility defines neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. A review of the PA Nurse Aide Candidate handbook written (or oral) examination & skills evaluation dated January 2022, stated under Skills 11- Gives Modified Bed Bath (face and one arm, hand and underarm) step 19 Signaling device is within reach and bed is in low position. Review of Resident R13's clinical record revealed that the resident was admitted to the facility with diagnoses of osteoarthritis (a type of arthritis that occurs when protective tissue at the ends of bones wears down); chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow to the lungs); chronic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should); muscle weakness; major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life); osteoporosis (a condition in which bones become weak and brittle); and chronic respiratory failure with hypoxia (a condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels). Review of Resident R13's Minimum Data Set (MDS-a standardized, comprehensive assessment of an adult's functional, medical, psychological and cognitive status) dated January 27, 2023, revealed a BIMS (Brief Interview for Mental Status) of three, indicating that the resident had severe cognitive impairment. Further review of MDS assessment revealed Resident R13 required extensive assistance of one person for bed mobility and extensive assistance of two people for transfers. Review of Resident R13's care plan, dated February 8, 2023 revealed, Resident R13 prefers 1/4 side rails as enablers. The goal established was for Resident R13 to demonstrate safe use of side rails as enablers to maintain mobility and function as a focus area. Interventions included physical therapy and occupational therapy evaluation as needed. Continued review of Resident R13's care plan revealed Resident R13 was at risk for falls related to deconditioning and weakness as a focus area. Resident R13 will have risk for falls mitigated while maintaining the highest level of functional independence through review date. Interventions included to consult therapy services (Physical and Occupational) as needed, be sure that the call bell and personal items are in reach before leaving the room, orient resident to room and unit routine and as needed, low bed in lowest position at all times, except during care, check position every shift and as needed, fall mats to both sides of the bed at all times when resident is in bed and check for placement every shift and as needed. Review of Occupational Therapy notes revealed that Resident R13 received services from January to February 9, 2023. Resident R13 was discharged from services with the following discharge recommendations: assistance with ADL's, air mattress and assistive device for safe functional mobility. Interview on April 12, 2023, at 11:00 a.m. with Resident R13 revealed, I fell out of bed twice during care. I fell out in February and in March. The last time, I broke my hip. Review of Resident R13's nursing progress note, dated March 24, 2023, revealed, Resident was found on the floor in her room near her bed. She was lying on her right side. Resident was assessed for pain and injury. Upper extremities range of motion completed without difficulty. Resident complained of pain to the right leg. Received order to send to emergency room for evaluation and treatment. Continued review revealed, Spoke with hospital nurse who stated that resident was being admitted with a diagnosis of distal femur (thigh) fracture. Review of fall investigation dated March 24, 2023 at 12:20 p.m. revealed Employee E25, licensed nurse, stated I heard someone yell, 'she fell .' I ran to Room E118 and found Resident R13 lying on the floor on her right side near her bed, Resident stated she fell out of the bed. Immediate action was taken. Resident was assessed for pain and injury with no visible injuries. Upper extremities range of motion completed without difficulty. Resident complained of pain to the right leg during range of motion. Physician was called and an order was given to send Resident to emergency room for evaluation and treatment. Further review revealed an incident witness statement from Employee E24, nurse aide, I went to change Resident R13. As I turned her over, I pulled her to me so she wouldn't be on the edge of the bed. As I went to get her some water for her care, I heard someone scream and witnessed Resident R13 on the floor. I went to get my charge nurse to help with the incident. A second witness statement was provided by Employee E28, nurse aide, I was giving care in Room E114. I heard the resident in Room . yell stating, 'I am on the floor.' Interview on April 17, 2023 at 2:30 p.m. with Employee E24, nurse aide, revealed, Resident R13 is my usual assignment. Resident R13 said she felt like she was on the edge of the bed. I repositioned her by pulling her toward me and put her on her side. I raised the bed and told the resident I would be right back after getting the basin of water for AM care. I heard her scream, 'I am on the floor' so I ran to her. I observed her on the floor and I ran to get my charge nurse. Interview on April 17, 2023 at 3:00 p.m. with Employee E25, licensed nurse revealed, Resident R13 was observed on the floor. I assessed her and she was in pain. We left her on the floor with a pillow under her head. The physician was called and Resident was sent out 911 (Emergency Medical Services). She was admitted to the hospital with a fracture to the right distal femur. Employee E25 stated during interview that the resident's bed should not have been left at a high position. The facility failed to ensure a resident was free from neglect during the provision of care by leaving the resident's bed at a high position and failing to ensure that all supplies needed for morning care were available before rendering care. This failure resulted in actual harm to Resident R13 who fell from bed while nurse aide, Employee E24 went to get water to complete morning care and sustained a fracture of the right femur. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 201.18 (b) (2) Management 28 Pa. Code 201.18 (e) (1) Management 28 Pa. Code 201.29 (c) Residents Rights 28 Pa. Code 211.12 (d) (1) Nursing Services 28 Pa. Code 211.12 (d) (5) Nursing Services

Based on review of facility policy, observations, clinical record reviews, facility documentation, and interviews, it was determined the facility failed to ensure pressure ulcer treatments were provided per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of October 28, 2020, 5 of the 14 residents with pressure ulcers were facility acquired, and 11 residents had Stage IV pressure ulcers with increased risk for serious complications; resulting in an immediate jeopardy situation for the residents. Findings include: A review of the facility's policy titled, Wound Management Guidelines, last revised February 2020, states: residents will receive the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled, Non-Sterile Dressing Change created 8/16, states that staff should document the wound dressing change after the care is provided. Review of Resident 6's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This can happen in your arteries or veins. PVD typically causes pain and fatigue, often in your legs, and especially during exercise.) and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Observation of Resident 6's left heel dressing change on October 28, 2020, at 11:52 AM revealed that the dressing being removed from Resident 6's left heel was dated 10/25 3 PM indicating that it had been applied on October 25, 2020, at 3:00 PM. Review of Resident 6's physician orders, dated October 26, 2020, at 11:53 AM, revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 6's Treatment Administration Record dated October 28, 2020, at 12: 20 PM indicated that Resident 6's dressing was marked as completed on October 26 2020 by LPN 5 (Licensed Practical Nurse). Further review of the Treatment Administration Record revealed Resident 6's dressing was not completed on October 27, 2020. Interview with LPN 1 on October 28, 2020, at 11:52 AM revealed that the dressing removed from Resident 6's heel was dated October 25, 2020, at 3:00 PM and that meant that the dressing had not been changed from October 25, 2020, at 3:00 PM until LPN 1 changed it at 11:52 AM on October 28, 2020. A review of Resident 13's clinical record for May 15, 2020, revealed a clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the May 2020 Treatment Administration Record revealed that the same staff nurse initialed the Treatment Administration Record to indicate that the treatments were administered on May 12, May 13, and May 14, 2020. Resident 13's wound care physician visited May 11, 2020, to provide wound care on the right lateral heel, and at the completion of wound care, the dressing was dated May 11, 2020. On May 15, 2020, the wound care physician revealed that the wound dressing on the right lateral heel of Resident 13 was dated May 11, 2020, the same dressing he had applied four days earlier. An assessment of the wound revealed that the wound had deterioration that included, tunneling to the bone. The wound required debridement (the removal of damaged tissue from a wound), and the physician changed the wound care orders to a frequency of twice per day. The wound assessment by the wound care physician on May 11, 2020, was documented as follows: Measurement 3.2 cm x 2.5 cm x 0.2 cm (length, width, and diameter in centimeters- a metric form of measurement, 2.5 cm equals 1 inch) Exudate (drainage): Light serous (blood-tinged wound drainage) Surface area: 7.50 cm2 (centimeters squared) The wound assessment, by the wound care physician on May 15, 2020, was documented as follows: Measurement: 3.2 cm x 4.5 cm x 0.2 cm Exudate: light serous Peri-wound Radius (area around the wound): Odor (unpleasant smell), Maceration (softening and breaking down of skin as a result of prolonged exposure to moisture) Surface area: 14.40 cm2 Comments by the wound physician on May 15, 2020, stated that, the wound had become malodorous with increased drainage. There is tunneling laterally which tunnels down to the bone. Slough (separation of dead tissue from living tissue, yellow, tan gray, green or brown) removed gently from the wound bed including slough that was overlying along with a small amount of periosteum. Dressing 5/11/2020. Patient had mild pain with bone palpation. Resident denies fevers, chills, chest pain/shortness of breath. Temperature maximum 98 degrees Fahrenheit, Respiratory rate maximum 20 breaths per minute. If patient becomes febrile, I recommend obtaining a CBC (complete blood count) with differential (relative percentages of each type of white blood cell). The facility investigation revealed that LPN 6 assigned to do the daily wound care admitted that the wound care was not provided to Resident 13 on May 12, May 13, or May 14, 2020, and that she had initialed the Treatment Administration Record to indicate the treatment was performed. Review of Resident 14's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 14's sacral (triangular bone at the end of the spine) dressing on October 28, 2020, at 12:40 PM revealed that the dressing was not labeled with time, date, or initials of individual applying the dressing. Interview with RN 1 (Registered Nurse) at the time of observation revealed that she was unable to locate any time, date, or initials on the dressing. Review of Resident 14's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 15's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Observation of Resident 15's sacral dressing on October 28, 2020, at 12:50 PM revealed that the dressing was not labeled with time, date, or initials of individual applying the dressing. Interview with RN 1 at the time of observation revealed that she was unable to locate any time, date, or initials on the dressing. Review of Resident 15's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 16's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 16's bilateral foot dressings on October 28, 2020, at 12:34 PM revealed that the dressing was not labeled with time, date, or initials of individual applying the dressing. Interview with RN 1 at the time of observation revealed that she was unable to locate any time, date, or initials on the dressing. Review of Resident 16's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record for Resident 17 on October 29, 2020, revealed clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 17 also has a wound of the left lateral 4th toe which is ordered daily treatments. A review of the Treatment Administration Record dated October 2020, revealed that effective September 2, 2020, resident 17's treatment stated the following; cleanse the left lateral fourth toe with normal saline solution, pat dry, apply calcium alginate, cover with gauze and secure with Kling wrap. Place lamb wool woven between toes daily and prn (as needed) every day, shift for wound care. A review of the wound physician assessment dated [DATE], states the resident has a shear wound of the left lateral fourth toe. The dressing treatment plan is documented to apply calcium alginate once daily, for 30 days. This same wound is listed as a Stage IV pressure wound that had previously been resolved on October 19, 2020. A screening of all residents requiring wound care, was initiated on October 28, 2020, at 1:45 PM. Observation of Resident 17's dressing on the left lateral fourth toe was dated October 26, 2020. The Treatment Administration Record was initialed as though treatment was provided on October 27, 2020. During an interview with Resident 17 on October 28, 2020, at 1:40 PM, she stated that no wound care was provided the day before (October 27, 2020). A print out of Resident 17's Treatment Administration Record on October 29, 2020, at 11:14 AM, was initialed to indicate that the nurse had already provided wound care for Resident 17, when in fact the wound care was provided on October 29, 2020, at 3:00 PM and the dressing that was removed, was dated October 28, 2020. During an interview with the Director of Nursing and Nursing Home Administrator on October 29, 2020, they agreed the dressing should have been changed as ordered by the physician, and that staff are only to initial the Treatment Administration Record after the treatment is completed. On October 28, 2020, at 7:50PM the facility was told that an Immediate Jeopardy situation had been identified. The NHA and DON was informed that the facility would need to provide an action plan to ensure wound treatments are completed per Physician orders, and documented accurately in the medical record. The facility provided a draft of the plan of action at 8:40 PM. An updated draft of the action plan was presented at 9:00 PM, and a third updated draft was presented at 10:21 PM. The facility was notified at 10:47 PM that the action plan was accepted. The plan of action included: -A full facility skin sweep of all residents was completed on October 28, 2020, on 7-3 and 3-11 shifts using the weekly skin assessment form to check skin integrity and to determine any dressings not completed pre physician order. Findings were as followed: 1 resident was found in need of a dressing change; 1 resident reported he removed the dressing, and it was replaced; and 1 resident was found with a non-pressure superficial area, treatment was ordered, obtained and a consult requested due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Residents 14, 15, and 16 dressings have been completed and dated on October 28, 2020, on 7-3 shift. Residents 6, and 17 had dressings completed on October 28, 2020, on 7-3 shift. -All licensed Nursing staff and Nursing Assistants were educated on wound care including dressing change, and documentation on the treatment administration record indicating completion, and following physician orders. Education was provided on 7-3 and 3-11 shift, and 11-7 shift education was completed prior to the start of the shift on October 28, 2020. Inservice training provided October 28, 2020 for 7-3 and 3-11 shifts included the following talking points: What happened- dressing not done, dressing not dated, and documentation of dressing. All treatments are to be completed per Physician orders. Upon completion, date and time the treatment, with initials. Sign treatment out in point click care only after completed. Check dressing, and replace as needed. Policy to be distributed. Aides must report any skin concerns verbally and in pint click care. Aides must report dislodged/missing/soiled dressings. -A daily audit of all pressure wound care including dressing change, and documentation on the treatment administration record indicating completion will be done by the DON/Designee starting October 29, 2020. This will occur daily for 1 week, than weekly for four weeks. Further audits will be determined by the Quality Assurance and Performance Improvement committee based on results of the audit. The action plan was accepted on October 28, 2020, at 10:47 PM, at which time the facility was notified that the action plan had been accepted. On October 29, 2020, at 8:00 AM surveyor entered the facility to determine if the action plan was implemented. Observation of a dressing on Resident 15's leg at 11:15 AM, was noted to be labeled 10/29/20 and RN 4' s' initials. Interview with RN 1 on October 29, 2020, at 11:20 AM revealed that she had been educated prior to the beginning of her shift that day, regarding changes to the dressing change procedure. The interview with RN 1 revealed that even though she was educated that day she was unable to articulate to the surveyor what elements were required to be labeled on Resident 6's dressing. On October 29, 2020, at 11:45AM the NHA was notified that the Immediate Jeopardy would not be lifted, due to the fact that Resident 15's leg dressing did not contain the time the dressing was changed. Also, staff was unable to articulate what elements needed to be documented on a dressing. RN 1 referenced the facility Non-Sterile Dressing Change policy, which did not contain all of the documentation elements to be placed on a dressing, and not the education she was provided prior to the beginning of the shift. Surveyor was provided a revised copy of the facility policy Non-Sterile Dressing Change, created August 1026; revised October 2020; 6) Place initials and date with time on piece of tape or on the dressing. On October 30, 2020, at 8:00 AM surveyors entered the facility to determine if the action plan was implemented. Review of skin sheets revealed the facility completed a full house skin sweep. Interviews were conducted with 2 Registered Nurses, 5 Licensed Practical nurses, and 1 Nursing assistant, all were able to verbalize their roll in monitoring and providing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the DON on October 30, 2020, at 9:45AM it was revealed that the consulting wound Physician was in the facility on October 29th and 30th, conducted wound rounds to check dressings with the DON; no concerns were found. Education and audits were reviewed. On October 30, 2020, at 11:00 AM the Immediate Jeopardy was lifted. The facility failed to adequately treat and/or accurately document 6 resident's pressure ulcer treatments resulting in Resident 13's pressure ulcer worsening, and placing the other residents in increased risk for serious complications, resulting in an immediate jeopardy situation. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/15/19, 10/6/2019 28 Pa. Code 201.18(e)(1) Management Previously cited 10/6/2019 28 Pa Code 211.12(d)(5) Nursing services Previously cited 02/15/19, 10/6/2019

Based on observation, medical record review, facility documentation review, facility policy review and staff interview, it was determined that the facility failed to provide the appropriate supervision to prevent accidents which resulted in actual harm to Resident R12 who fell from the wheelchair, who sustained a fractured left femur as a result of the fall. Additionally, the facility failed to ensure adequate supervision of residents in lounge areas for five of 16 residents reviewed. (Residents R7, R8, R9, R10 and R12) Findings include: Review of a facility job description for Nursing Assistants (NAs) revealed that NAs provide quality nursing care to residents and report pertinent information to the immediate supervisor. The job description continues, NAs will provide quality nursing care to residents in an environment which promotes their rights, dignity, freedom of choice, and their individuality as illustrated by the following: 1. Provide individualized attention which encourages each resident's ability to maintain or attain the highest practical physical, mental and psychosocial well being. 2. Knowledgeable of the individualized care plan for residents and provide support to the resident according to the care plan. 3. Attend to the individual needs of residents which may include assistance with . transferring, ambulation, range of motion, communicating or other needs in keeping with the individuals' care requirements and scope of practice. Maintain the comfort, privacy and dignity of each resident in the delivery of service to them. Interact with residents in a manner that displays warmth and promotes a caring environment. 5. Fully understand all aspects of residents' rights, including the right to be free of restrains and free of abuse. Responsible for promptly reporting to the charge nurse or administrative staff incidents or evidence of resident abuse or violation of residents' rights. Review of an undated facility policy for the use of Communications Devices from section 3.4 of the employee handbook revealed that all personal communications devices including but not limited to beepers, pagers, Blackberry's, Smart phones, i-Phones, and cell phones are not allowed in patient care areas unless authorized for Chestnut [NAME] Healthcare business. Review of clinical record for Resident R12 revealed diagnoses, including but not limited to, [MEDICAL CONDITION] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, [MEDICAL CONDITION] or convulsions, associated with abnormal electrical activity in the brain), [MEDICAL CONDITION], abnormal posture, abnormalities of gait and mobility, generalized muscle weakness, [MEDICAL CONDITION] (a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small [MEDICAL CONDITION]) with behavioral disturbance, stiffness of the left hand and elbow, [MEDICAL CONDITION] and intellectual disabilities. Review Resident R12's care plan dated initiated on (MONTH) 1, (YEAR) revealed (Resident R12) is at risk for falls or fall related injury because of history of falls, cognitive and sensory factors: [DIAGNOSES REDACTED]. The care plan goal included for the resident not to have a fall related to injury with interventions that included but not limited to Anticipate and meet the resident's needs. Review of the facility documentation, witnessed fall, revealed that the resident fell from the wheelchair in the B wing lounge and landed on his left side. The resident was assisted back to into the wheelchair by two staff members and brought to the room. The resident was assessed by the RNP (Registered Nurse Practitioner) who ordered a STAT (immediate) Left hip/pelvic area x-ray. Review of the x-ray report dated (MONTH) 27, 2019 confirmed that Resident R12 sustained a displaced proximal left femoral (thigh bone) fracture. Review of physician orders [REDACTED]. Review of the facility investigation into Resident R12's fall on (MONTH) 26, 2019 revealed that .reviewed video footage of the lounge and observed (Resident R12) sustained a fall at 8:20 p.m. and 2 nurse aides did not follow the policy and procedure and picked him off the floor and did not tell the nurse that he had fallen. Resident showed s/sx (signs and symptoms) of pain, an x-ray was obtained and revealed a L (left) hip fx (fracture). Interview with the Nursing Home Administrator (NHA) on (MONTH) 6, 2019, at 5:30 p.m. revealed that Employee E12, Nursing Assistant (NA)) was tasked with observing the resident in the dining room and she was observed on surveillance footage to be using her mobile phone with her head down when Resident R12 stood up and fell to the floor on (MONTH) 26, 2019, at 8:20 p.m. Further review of facility documentation dated (MONTH) 29, 2019, at 4:00 p.m. revealed a statement from Employee E12, NA, where the employee stated I was on my phone I looked up and one of the residents was on the ground. Review of a written statement from Employee E13 revealed that (Resident R12) fell in the lounge room. I didn't inform that he fell to the nurse 3-11 pm shift. Another cna (nursing assistant) and I picked him up. Inform the nurse he slid out his chair, His (Resident R12) cna put him to bed. Interview with the NHA on (MONTH) 6, 2019, at 5:30 p.m. revealed that Employee E12, NA, was not permitted to be using her mobile phone on (MONTH) 26, 2019, at 8:20 p.m. when Resident R12 was being supervised by Employee E12 and the resident fell on the floor and fractured his left hip. The facility failed to ensure that Resident R12 was provided with proper supervision to prevent accidents which resulted in actual harm to Resident R12 who fell from the wheelchair and sustained a fractured left hip as a result of the fall. Observation in the A-nursing unit on (MONTH) 6, 2019, at 11:42 a.m. revealed Residents R7, R8, R9 and R10 in the A-unit lounge. There was no facility staff present in the dining room with these residents. At the time of this observation, Employee E7, Licensed Practical Nurse (LPN), was noted at the A-unit nursing station browsing images on her cell phone. Review of Resident R7's care plan revised (MONTH) 27, 2019 revealed that the resident was at risk for falls or fall related injury due to gait/balance problems. Review of Resident R8's care plan revised (MONTH) 12, (YEAR) with a target date of (MONTH) 31, 2019 revealed that the resident was at risk for falls related to history of Cardio Vascular Accident (stroke). Review of Resident R9's care plan revised (MONTH) 22, 2019 revealed that the resident was at risk for falls or fall related injury due to gait/ balance problems, and was unaware of safety needs. Review of Resident R10's care plan revised (MONTH) 20, (YEAR) revealed that the resident was at risk for falls or fall related injury due to a history of previous fall, cognitive and sensory factors. Repeat observation at the A-unit nursing station on (MONTH) 6, 2019, at 12:34 p.m. revealed Employee E7, LPN, browsing a social media application on her cell phone at the nursing station and behind her, in the A-unit lounge, were Residents R7, R8, R9 and R10 sitting in the lounge with no supervision from any facility staff. Interview with the Nursing Home Administrator (NHA) on (MONTH) 6, 2019, at 5:30 p.m. revealed that staff were in-serviced on correct mobile phone use and the expectations of lounge duty on (MONTH) 27, 2019, following Resident R12's fall. The NHA stated that it was her expectation for staff to be physically present when residents are in lounges and that they should not use their mobile phones when on lounge duty. The facility failed to ensure the ongoing supervision of residents in lounge areas. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/15/19 28 Pa. Code 201.18(e)(1) Management Previously cited 28 Pa. Code 201.29(j) Resident rights Previously cited 02/15/19 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services Previously cited 02/15/19

Based on a review of personnel records, review of facility policy and interviews with staff, it was determined that the facility employed an individual that had a finding entered into the Pennsylvania Nurse Aide Registry and the facility failed to obtain a criminal background check for one of two employees reviewed (Employee E5) putting the health and safety of the residents in an Immediate Jeopardy situation. Findings include: Facility policy titled, Abuse Prevention, with a revision date of May 1, 2016, stated that the facility will, Screen all potential employees for a history of abuse, neglect, or mistreating during the hiring process. Screening will consist of, but not limited to: inquiries into state licensing authorities, inquiries into the state nurse aide registry, reference checks from previous and/or current employers and criminal background checks. The policy stated further, Any time an allegation is made involving abuse, neglect, mistreatment of [REDACTED]. The administrator, or in his or her absence the Director of Nursing, the Assistant Director of Nursing, or charge nurse, in that order, must relieve the employee of his/her duties without pay until the investigation is complete, if the allegation is substantiated the employee will be terminated immediately. Review of Employee E5's, Nursing Assistant, personnel record revealed that the employee was hired by the facility on June 8, 2015. Contained in the employee's personnel file was a copy of a report from the Pennsylvania Nurse Aide Registry, printed on July 13, 2016, which revealed that, This nurse aide has substantiated findings on file with the Pennsylvania Nurse Aide Registry. Because there are substantiated findings on file this nurse aide cannot work in a long-term facility in Pennsylvania. On April 7, 2017, at 1:00 p.m. a review of the employee's Pennsylvania Nurse Aide Registry revealed a notation that stated, This nurse aide has substantiated findings on file with the Pennsylvania Nurse Aide Registry. Because there are substantiated findings on file this nurse aide cannot work in a long-term facility in Pennsylvania. Further review of the employee's personnel file revealed no evidence that a criminal background check had been initiated prior to the employee's hire date. The Assistant Director of Nursing confirmed this in an interview on April 7, 2017, at 1:00 p.m. and stated that a criminal background check had not been done prior to the employee being hired. In addition, the personnel record contained two allegations of verbal/emotional abuse that had been reported to the facility and two written warnings that were issued to Employee E5. On November 28, 2016, a resident reported that Employee E5, was yelling and screaming at her when she asked for help to get out of bed, and that Employee E5 said, you can do it yourself. On February 6, 2017, a supervisor observed Employee E5 walking through the dining room and Employee E5 stated to a resident, Ew, someone went to the bathroom on themselves, (Resident R1) did you go to the bathroom on yourself? There was no evidence available for review at the time of the survey that either of the allegations of abuse were investigated or reported as required. An interview on April 18, 2017, at 4:00 p. m. with the NHA, failed to reveal any evidence that the facility had acted upon the notation in the Pennsylvania Nurse Aide Registry, that the facility had printed on July 13, 2016, that indicated that Employee E5 had substantiated findings against her and cannot work in a long-term facility in Pennsylvania. Further, the NHA had no explanation as to why the facility had not acted upon the notice and allowed Employee E5 to continue to work and care for residents until April 18, 2017. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on April 18, 2017, at 4:00 p.m. related to the above findings identified on April 7, 2017, when it was revealed that the facility failed to complete a background check upon hire of Employee E5 and maintained the employee with findings of a notation on the employee's Pennsylvania Nurse Aide Registry stating the employee could not work in long term care in Pennsylvania. A corrective action plan was requested from the NHA on April 18, 2017, at 4:00 p.m. The corrective action plan included the following interventions: 1. Employee E5, Nursing Aide, has been removed immediately from the schedule on April 18, 2017, at approximately 4:00 p.m. 2. No employee will be on the schedule that does not have a current background check 3. A complete audit will be done with all personnel records to determine that all personnel have cleared background checks 4. In the future, no new employees will be allowed to work until a background check and also the registry and licensure is verified. 5. Results of the background check audits will be presented and discussed at the monthly QA (Quality Assurance) meeting 6. We have a total of 84 NA's and 53 licensed nurses in our employment and all will be checked starting with this 3-11 shift, 11-7 and 7-3 tomorrow and then finishing up with rest of staff 7. Moving forward the Human Resource Director will be responsible for performing background checks and Pennsylvania Nurse Aide Registry and licensure checks for all new hires as well as making sure all staff are current. The Administrator will be responsible for training the Human Resource Director on the above mentioned and performing monthly audits to ensure our records are in compliance The corrective action plan was accepted on April 18, 2017 at 6:00 p.m. The Immediate Jeopardy was removed on April 19, 2017, at 1:05 p.m. after it was verified that the corrective action plan had been implemented. The facility allowed a nurse aide with substantiated allegations of physical and emotional abuse to work and care for residents and failed to follow the Abuse Prevention policy, failed to accurately screen an employee prior to hiring and failed to report as required allegations of resident abuse putting the health and safety of the resident in an Immediate Jeopardy situation. 28 Pa. Code 51.3(g)(6) Notification 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 02/08/16, 01/06/17 28 Pa. Code 201.14(c) Responsibility of licensee Previously cited 01/06/17 28 Pa. Code 201.14(e) Responsibility of licensee 28 Pa. Code 201.18(a) Management Previously cited 01/06/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/08/16, 01/06/17 28 Pa. Code 201.19 Personnel policies and procedures 28 Pa. Code 211.12(c) Nursing services

Based on a review of the clinical record, hospital records, review of facility policy and interviews with staff, it was determined that the facility failed to provide adequate monitoring and supervision of a resident with a history of falls which caused actual harm, when the resident fell and sustained a fracture, for one of two residents reviewed (Resident CL1). Findings include: A review of Resident CL1 clinical record revealed a quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated March 3, 2017, which indicated that Resident CL1 had a BIMS (Brief Interview for Mental Status-screening tool for determination of cognitive impairment) score of 10 (a score of 8-12 indicates moderately impaired cognition), had total dependence on two staff members for bathing, required extensive assistance with two person physical assistance with transfers, and required extensive assistance with one person physical assistance for bed mobility and dressing and was frequently incontinent of bowel and bladder. A Nursing Comprehensive Admission and Quarterly Evaluation dated July 7, 2016, stated that the resident had a fall risk score of 11 and noted that a score above 10 indicated that the resident was at high risk for falling. A plan of care was developed to address the risk of falling on October 18, 2016, that included interventions such as locking brakes on the bed before rising, call for assistance before rising, appropriate non-skid footwear, assist with toileting and transfers, to remind the resident of safety precautions and to provide the resident with environmental adaptation. A nursing note on February 12, 2017, at 2:21 p.m. stated that the resident was found face down on the floor in her room. The resident stated she was trying to take off her shoe, she complained of pain in the left eye and the resident had a hematoma (an abnormal collection of blood outside of a blood vessel) that was purple in color above the left eye. The physician and the family were notified and ice was applied to the hematoma. An X-ray of the skull was completed which indicated there was no fracture. There was no evidence available for review at the time of the survey that indicated the facility had developed any new preventative measures at that time. A Nursing Comprehensive Admission and Quarterly Evaluation dated February 20, 2017, stated that the resident had a fall risk score of 11 and noted that a score above 10 indicated that the resident was at high risk for falling. A review of the nursing progress notes dated March 17, 2017, at 4:24 p.m. revealed that resident CL1 was heard screaming for help. The resident had fallen out of the wheelchair, and the resident said she was trying to tie her shoe and was found on the floor in her room. The resident was transferred to the hospital due to pain and limited movement in the right leg and was admitted to the hospital with [REDACTED]. The facility failed to provide adequate monitoring and supervision of a resident who had a history of [REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 01/06/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 02/08/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 02/08/16, 01/06/17

Based on a review of the clinical record, hospital records, review of facility policy and interviews with staff, it was determined that the facility failed to obtain and/or clarify physician's orders [REDACTED]. Findings include: The facility policy titled, Hip/Splint/Abductor/Immobilizer Precautions, with a revision date of May 1, 2016, stated that the purpose of the policy was the prevention of adduction (moving inward) and internal rotation (movement towards the center of the body) of the affected limb and/or bone to ensure the area is in proper alignment. It stated further, assure precautions are documented on the interdisciplinary plan of care, place abductor pillow between legs while sitting or lying in the bed unless ordered otherwise turn the resident on their back or unaffected side only. A review of Resident CL1's clinical record revealed a quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated March 3, 2017, which indicated that Resident CL1 had a BIMS (Brief Interview for Mental Status-screening tool for determination of cognitive impairment) score of 10 (a score of 8-12 indicates moderately impaired cognition), had total dependence on two staff members for bathing, required extensive assistance with two person physical assistance with transfers, and required extensive assistance with one person physical assistance for bed mobility and dressing and was frequently incontinent of bowel and bladder. A review of the nursing progress notes dated March 17, 2017, at 4:24 p.m. revealed that resident CL1 was heard screaming for help. The resident had fallen out of the wheelchair, and the resident said she was trying to tie her shoe and was found on the floor in her room. The resident was transferred to the hospital due to pain and limited movement in her right leg. The resident was admitted to the hospital with [REDACTED]. The hospital discharge documentation dated March 20, 2017, revealed that the orthopedic specialist (a physician who specializes in the skeletal system) had determined that the leg should not be corrected surgically and that the resident was to be treated at the facility, supportively with physical therapy and pain management. A nursing note on March 20, 2017, at 2:50 p.m. stated that the resident was readmitted to the facility, that the orthopedic recommendations included a right knee immobilizer (a knee brace that limits knee movement, used after an injury to limit knee range of motion and to keep the knee in the correct position for healing) which was in place and was to be removed only for bathing, that the heel should be kept off of the bed by placing pillows under the calf and that the resident may transfer to a chair with maximum assist. Review of Resident CL1's clinical record revealed physician's readmission orders [REDACTED]. A plan of care was developed to address the use of splint/braces (knee immobilizer) on March 20, 2017, and included the interventions of teaching the resident the correct application of braces/splints, to assist with the application of splint/braces according to the scheduled wearing time and monitor the skin under the devices for irritation or breakdown. There were no interventions included to address the use of a wedge cushion or the use of pillows or to indicate what specific precautions should be taken by the staff. On March 27, 2017, at 11:21 a.m. documentation by the Occupational Therapist stated that at approximately 10:00 a.m. the resident was, observed in bed, wedge cushion was improperly positioned for right lower extremity and leg was in internal rotation. It further stated, When immobilizer was opened to adjust and visualize leg femur/bone noted to be protruding from leg and blood on immobilizer. A review of occupational therapy progress notes for March 27, 2017, revealed that the resident was observed in her room in bed and stated, The patient's right knee immobilizer was intact, however the wedge which had been used to prevent patient's right knee immobilizer from internally rotating was positioned laterally (along the side) and appeared to increase patient's internal rotation. After removing the patient's wedge cushion, the straps of the right knee immobilizer were opened for a skin check and pressure relief. It was immediately noted that the patient had what appeared to be a small hole and bone showing on the right lateral aspect of right lower extremity. Additionally, it stated, the knee immobilizer was stained in blood. On April 7, 2017, at approximately 1:30 p.m. Employee E6, Occupational Therapist, stated in an interview that, the wedge had been positioned correctly but on the wrong side of the leg and was pushing the leg in the wrong direction and that, some of the blood on the immobilizer was dry and some was damp. Nursing notes dated March 27, 2017, at 3:38 p.m. stated, Charge nurse removed the immobilizer to check skin, observed that resident was bleeding on the right knee fracture area and bone stuck out. Noted dried blood on the immobilizer and on the floor at the left side of the bed. It stated additionally that the resident had been medicated for severe pain on the affected area and that the resident left the facility at 12:45 p.m. Review of facility documentation regarding their investigation into the event noted that the puncture wound to the right knee measured one centimeter by one centimeter (approximately 1/2 inch by 1/2 inch). The nursing notes also indicated that the resident was transferred to the hospital for further evaluation. There was no evidence available for review at the time of the survey that clarification had been obtained from the physician regarding the right knee immobilizer and the use of the wedge for maintaining alignment, including when and how the wedge was to be used, and if it was to be used when in bed. This was confirmed by the Assistant Director of Nursing in an interview on April 7, 2017, at approximately 3:00 p.m. The facility failed to clarify the physician's orders [REDACTED]. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited 02/08/16, 01/06/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 02/08/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 02/08/16, 01/06/17

Based on observations, clinical record review, interviews with residents and staff, review of facility policy and procedure and facility documentation, it was determined that the facility failed to protect the residents in a manner and in an environment that promotes the maintenance or the enhancement of each resident's quality of life with regard to bed bugs for two of 4 nursing units observed (the B Wing Nursing Unit and the C/D Wing Nursing Unit), which directly impacted Residents R56, R57, R58, R59, R106 and R112, and resulting in actual harm to Resident R56 and resulting in an Immediate Jeopardy situation. Findings include: The initial tour of the B Wing Nursing Unit on February 3, 2016 at 6:40 a.m., revealed a sign on Resident Room B17 which read, DO NOT ENTER UNDER CONSTRUCTION. Further observation of the door revealed that gray duct tape was taped around all the edges of the door including the door sweep and the door handle. At the time of the observation, an interview with Employee E3, a Licensed Nurse, revealed that Resident Room B17 was closed because of the reported activity of bed bugs (a small flat, parasitic insects that feed solely on the blood of people and animals while they sleep. The insects are reddish-brown in color, wingless and range from 1 mm (millimeter) to 7 mm and can live several months without a blood meal). Employee E3 indicated that the Sign had been posted on the door for 2 weeks. An interview with Employee E4, the Director of Maintenance, on February 3, 2016 at 9:05 a.m., revealed that on January 14, 2016, multiple Nurse Aides (NAs) from the third shift, brought to the attention of the Director of Nursing (DON) that they had observed bed bugs in Resident Room B17. During the same interview with Employee E4 and the Nursing Home Administrator (NHA), it was revealed that on January 14, 2016, an inspection by Employee E4 of Resident Room B17 revealed that bed bugs were present. Resident Room B17 was occupied by two residents at the time of the inspection (Residents R106 and R112.) The above was confirmed in a copy of the written statement provided by the NHA on February 3, 2016 at 9:05 a.m., to the surveyors. Review of the Pest Summary of Service for the dates of January 15 and January 19, 2016, revealed that treatments were completed throughout the interior of the facility, for identified rodent feeding insects, crawling insects and mice. An interview with the NHA on February 4, 2016 at 9:15 a.m., confirmed that the identified issue related to bed bugs in Resident Room B17 was identified and confirmed but was not specifically treated during the Pest Company's onsite visits on January 15 and January 19, 2016. Review of the Pest Control Inspection and Service Report, dated January 20, 2016, revealed that Resident Room B17 was identified to have a quantity of 500 bed bugs, which were observed throughout the bedding, mattresses, bedframes, walls, curtains, dresser drawers, internal closets, bathroom walls, lighting paneling, window sills and clothing. Further review of the Pest Control Inspection and Service Report, dated January 20, 2016, revealed that Resident Rooms, B15 and B19, which are directly adjacent to Resident Room B17, were identified and confirmed to have bed bugs along the bed frames and baseboards throughout both rooms. Resident Rooms B15 and B19 were both occupied with two residents in each room (Residents R56, R57, R58 and R59). Observations during the entire survey, revealed that Resident Room B17 remained sealed off with duct tape and a sign indicating, DO NOT ENTER UNDER CONSTRUCTION. An interview with the NHA on each day of the survey and at various times, confirmed that the bed bug issue was not resolved in Resident Room B17. An observation of Resident Room B15 on February 4, 2016 at 9:05 a.m., revealed two residents lying in their beds. At the time of the observation, Resident R57 stated that the roommate, Resident R56, was bitten by bed bugs during the night. Resident R57 further indicated being scared of being bitten by the bed bugs. During this observation, Resident R56 indicated being very itchy and again indicated this to Employee E3 during a skin observation on February 4, 2016 at 9:15 a.m. At the time of the room observation, an interview was completed with Employee E3 who confirmed that Residents R56 and R57 were completely alert and oriented and able to make decisions for themselves. An observation of Resident R56's skin on February 4, 2016 at 9:15 a.m., with Employee E3 revealed that Resident R56 had bed bug bites to the back of his/her right shoulder and had a raised reddened area on the back of his/her left shoulder. At the time of the observation, Employee E3 confirmed that the areas of concern were a result of Resident R56 being bitten by bed bugs. An interview with the DON and the NHA on February 4, 2016 at 10:00 a.m., confirmed that Resident R56 was bitten by bed bugs. An observation of Resident R56's bed on February 4, 2016 at 11:15 a.m., with the Pest Control Technician revealed 4 brown stains on Resident R56's pillowcase. The technician indicated that the 4 brown stains were likely to be fecal stains from the bed bugs. This observation was conducted in the presence of the DON. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on February 4, 2016 at 11:45 a.m., related to Resident R56 being bitten by bed bugs and three additional residents, Residents R57, R58 and R59, who were identified as being at immediate risk of being bitten by bed bugs. An immediate plan was requested. Observations of the residents in Resident Rooms B15 and B19, Residents R56, R57, R58 and R59, on February 4, 2016 from 9:05 a.m. to 12:50 p.m., revealed that the residents remained in their rooms after the facility confirmed that Resident R56 had been bitten by a bed bug. A review of Resident R56's clinical record on February 4, 2016 at 1:45 p.m., revealed a physician's progress note dated February 4, 2016, which indicated that Resident R56 was evaluated by the physician and that the physician indicated: Itchy rash to back of neck small papules with surrounding [DIAGNOSES REDACTED] (redness) bed bug treatment in process for other residents seems consistent clean room to bed bug protocol prn [MEDICATION NAME] (an [MEDICATION NAME] medication used to prevent itching and allergies [REDACTED]. An interview with Employee E3 confirmed that the physician saw and wrote the progress note at approximately 12:30 p.m. on February 4, 2016, for Resident R56. An interview with the Pest Control Technician on February 4, 2016 at 2:00 p.m., revealed that the bed bugs in the adjacent room, Resident Room B17, were still active and would be able to crawl through the electrical outlets from room to room or they would crawl through any kind of small opening. The Immediate Jeopardy was removed on February 4, 2016 at 3:53 p.m., after the facility submitted an acceptable corrective action plan. Review of the corrective action plan indicated that the facility was going to have chemical treatment applications to the identified affected areas and would monitor the identified residents' skin. The pest company was observed onsite implementing the corrective action plan and treating the resident rooms that were identified with bed bugs. An interview with the DON confirmed that the skin assessments had been completed on all of the residents on the B Wing Nursing Unit where the bed bugs had originally been observed. An observation on February 5, 2016 at 9:13 a.m., revealed that the same Pest Control Technician from the previous day observation, was in Resident Room D6, which was the room of Resident R112 on the D Wing Nursing Unit. The Pest Control Technician was observed spraying Resident R112's bed mattress. During the observation, an interview was completed with Employee E10, Assistant Director of Maintenance, and the Pest Control Technician which revealed that during the overnight shift, the Nursing Supervisor reported to the DON that a bed bug was observed on Resident R112's pillow while the resident was sleeping. An interview with the NHA on February 5, 2016 at 9:27 a.m., confirmed that a bed bug was found on Resident R112's pillow and that a treatment was in place for the identified bed bug. During the same interview, the NHA confirmed that Resident R112 had originally resided in Resident Room B17, the original room that was identified with 500 bed bugs. The NHA at the same time confirmed that the bed bug problem had been identified on a second nursing unit (the C/D Nursing Wing Unit). During an interview with the NHA on February 5, 2016 at 11:26 a.m., it was revealed that the Human Resource Director for the facility, had quit on January 29, 2016, after being bitten by a bed bug while in the facility during working hours. The NHA revealed that the Human Resource Director brought the bed bug to him/her. During an interview with Employee E12, the Nurse Educator, on February 5, 2016 at 2:45 p.m., in the presence of Employees E3, E7 and E11, all Licensed Nurses, she stated, I jump up and down before entering my home to make sure all bed bugs have been removed. Review of the facility Policy and Procedure, entitled, Maintenance - Pest Control, dated May 1, 2011, indicated that the goal of the policy was, To assure that the facility's buildings and grounds are maintained free of pests and to promote a safe and healthful workplace. An interview with the NHA, on February 5, 2016 at 3:25 p.m., confirmed that the facility was not maintaining the goal of the facility policy and procedure related to Maintenance - Pest Control. The facility failed to protect the residents in a manner and in an environment that promotes the maintenance or the enhancement of each resident's quality of life with regard to bed bugs which had begun on January 14, 2016, and had not been completely removed from the facility, with residents still being bitten by the bugs. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 02/27/14, 01/02/15, 01/22/15, 07/17/15, 09/15/15 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/15/14, 01/02/15, 01/22/15, 07/17/15 28 Pa. Code 201.18(b)(3) Management. Previously cited 01/22/15, 09/15/15 28 Pa. Code 201.18(d)(1) Management. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 02/27/14, 01/02/15, 09/15/15

Based on review of clinical records, review of facility policies and procedures, facility documentation and interviews with staff, it was determined that the facility failed to effectively prevent pressure ulcer development for two of 24 residents reviewed (Residents R113 and R37) resulting in harm to one resident (Resident R113). Findings include: Review of the facility policy, Wound Prevention and Treatment, dated as revised October 26, 2011, revealed that skin assessments are to be completed on all residents upon admission, daily for three days and weekly thereafter. Additionally, the policy indicated that the Braden Scale Assessment (Braden Scale Assessment-a tool used to determine risk factors for pressure ulcer (an area of skin that breaks down when pressure is applied or something keeps rubbing against it) development) was to be completed at the time of admission, weekly for four weeks, monthly for three months, then quarterly and with any significant change in the residents condition. The policy further stipulated that a preventative plan of care should be developed and implemented for all residents identified as at risk for the development of pressure ulcers. The plan of care should contain preventative and treatment interventions that have been individualized to the meet the resident's specific needs. Additionally, the care plan should be reviewed and revised as needed. Review of the clinical record for Resident R113 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated December 28, 2015, revealed that the CAA (Care Area Assessment-indicates which care areas were triggered for more in-depth assessment) Summary identified that Resident R113 had triggered as at risk for developing a pressure sore. There was no evidence that a care plan was developed at this time. Additionally, the clinical record indicated that at the time of admission, Resident R113 had been noted with wounds present to the sacrum (lower back), left ear, above the right eye and to the crown of the head. A review of Resident R113's Braden Score assessments revealed that these assessments were completed on December 19, 2015, December 26, 2015 and January 3, 2016, for a total of three assessments. Further review of the clinical record revealed no documentation that a fourth weekly Braden Score assessment had been completed as per facility policy. The nurses' notes further indicated that on January 3, 2016, Resident R113 had been noted with new reddened areas on the resident's left hand (all knuckles, with no dimensions documented), left buttock measuring 6.0 cm (centimeter) by 3.5 cm, right elbow measuring 2.5 cm by 2.5 cm and right hip measuring 13.0 cm by 7.0 cm. The resident was also noted with a new skin tear present on the right shoulder which measured 2.5 cm by 8.0 cm. Observation of wound care which was provided to Resident R113 on February 4, 2016 at 11:15 a.m., with Employee E8, the Wound Care Nurse, revealed the presence of active wounds on the following locations: left ear, left shoulder, right upper scapula (shoulder blade), right lower scapula, sacrum, right hip and right trochanter (upper portion of femur). Review of Resident R113's comprehensive care plan dated as effective January 7, 2016, revealed that the resident had been admitted to the facility with an actual skin breakdown located on the resident's sacrum. Additionally, the care plan identified Resident R113 to be at increased risk for further skin breakdown. The care plan had not been revised to include any of the new additional areas of skin breakdown as noted in the nursing notes on January 3, 2016, and as observed during the wound treatment. No specific interventions had been developed in the care plan to promote the healing of these new areas of skin breakdown or to reduce the risk of further skin breakdown to Resident R113. An interview with the Director of Nursing on February 8, 2016 at approximately 9:25 a.m., confirmed that the facility's current process for wound prevention and treatment does not match the interventions listed in the facility's formal policy, Wound Prevention and Treatment, revised October 26, 2011. Review of the facility document, Wound Rounds, revealed weekly assessments were completed on Resident R113 as dated December 7, 2015 through February 1, 2016. Further review of the Wound Rounds report revealed no documentation of the location, measurements, progress or treatment modality currently utilized to the resident's left shoulder, right upper scapula and right lower scapula wounds. In addition, the treatment modality listed on the Wound Rounds report for Resident R113's wounds located on the sacrum, left ear, and right trochanter was to: Apply Calcium Alginate (soft highly absorbent dressing) and cover with [MEDICATION NAME] (non-breathable adhesive dressing) every three days and as needed. A review of Resident R113's physician's orders dated February 2016, revealed no current physician's orders for the wound treatments listed in the Wound Rounds report. A Skin Check Form dated December 19, 2015, indicated that upon admission to the facility, Resident R113 had been identified with an open area which measured 12.5 cm by 13.5 cm on the resident's sacrum. Further review of the Skin Check Form, indicated that the open sacral area had been cleansed with normal saline (salt solution), [MEDICATION NAME] (protective skin cream) applied then covered with a dry dressing. The weekly Wound Round report dated December 21, 2015, revealed that Resident R113 had been seen on weekly wound rounds but there was no documentation that the resident's sacral wound was examined, measured or that a treatment protocol was developed by the Wound Care Practitioner. Further review of the weekly Wound Rounds reports indicated that Resident R113's sacral wound was not assessed by the Wound Care Practitioner until December 28, 2015, nine days after the resident's admission into the facility. An interview with the Wound Care Practioner, a Certified Registered Nurse Practitioner, Employee E16, on February 8, 2016 at approximately 9:00 a m., confirmed that the employee had not documented, measured and/or tracked the progress of all of Resident R113's wounds, just the big ones. Further interview with Employee E16 confirmed that the employee had not updated the treatment modalities listed for Resident R113's wounds on the weekly wound report. Employee E16 further indicated that the employee was unaware that the facility's administration utilized the statistical information maintained on the weekly Wound Rounds document to monitor and track the progress of their wound care program. The facility failed to assess, monitor and provide interventions for all of Resident R113's wounds resulting in actual harm to the resident. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on February 8, 2015 at approximately 8:00 a.m., confirmed that the statistical data contained in the weekly Wound Rounds was utilized during the facility's Quality Assurance meetings to assess the overall progress of the facility's wound prevention program. Further interview with the NHA and the DON confirmed that they were unaware that the documentation in the weekly Wound Rounds reports was incomplete and inaccurate. Review of the clinical record for Resident R37 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual MDS dated [DATE], indicated that the resident had care needs identified under the area of pressure ulcers. A comprehensive plan of care dated March 2, 2015, and continuing as current, identified the resident to be at risk for skin breakdown. The nursing notes dated January 25, 2016, indicated that the resident had developed a wound on the sacrum (lower back) and posterior (back portion) of the thigh. The wound was noted as reddened with serosanguineous (blood tinged) drainage. The nursing documentation further indicated that the wound was to be cleansed daily with normal saline and 0.1% [MEDICATION NAME] (non-steroidal anti-[MEDICAL CONDITION]) ointment applied to the wound every shift. Review of the weekly Wound Rounds reports dated January 25, 2016 through February 1, 2016, revealed no documentation of the assessment, measurement, or prescribed treatment for [REDACTED]. The facility failed to ensure that the skin assessment processes developed in their established policy, Wound Prevention and Treatment, was implemented by the staff and failed to ensure that the residents identified with actual alterations in their skin integrity were routinely monitored and assessed in a consistent manner. The facility also failed to ensure that statistical information obtained during the weekly wound rounds was complete and accurate. Additionally, the facility failed to ensure complete and accurate wound data was provided to the facility's Quality Assurance committee. The inconsistencies noted in the facility's wound care program prevented the facility from ensuring that an effective and accurate system for the monitoring and tracking of residents with actual pressure ulcers along with those residents identified at an increased risk for pressure ulcers were developed and maintained. This resulted in actual harm to one of two residents reviewed (Resident R113). 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 02/27/14, 01/02/15, 01/22/15, 07/17/15, 09/15/15 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/15/14, 01/02/15, 01/22/15, 07/17/15 28 Pa. Code 201.18(d)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 07/17/15 28 Pa. Code 211.11(a) Resident care plan. Previously cited 12/15/14 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 09/11/14, 12/15/14, 01/02/15, 01/22/15, 05/05/15, 07/17/15 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 09/11/14, 12/15/14, 01/22/15, 05/05/15

Based on review of closed clinical records, facility documentation, facility policy and procedure and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident who left the facility without a physician's discharge order or the staff's knowledge (Resident CL1). Findings include: Review of Resident CL1's clinical record revealed an admitted [DATE], and [DIAGNOSES REDACTED]. blood stream to cells for nourishment). Review of the physician's orders [REDACTED]. It is placed into a large vein in the arm and threaded (guided) into the main vein near the heart, where the blood flows quickly). Further review revealed a physician's orders [REDACTED].) IV, twice a day at 6:00 a.m. and 6:00 p.m., and Levaquin 750 mg. IV, once a day at 9:00 a.m. Both orders read to give the IV antibiotics until July 8, 2015. Review of the Nursing Comprehensive Admission Evaluation form, dated June 17, 2015, revealed a risk for elopement section that considered Resident CL1 not to be a risk for elopement (to leave the facility without the staff knowledge), even though the resident was cognitively independent, had a history of [REDACTED]. Review of the New Admission Notification form, dated June 17, 2015, revealed a physician's section that noted that the, resident does not explain well his absence from the skilled nursing facility setting - he states that he went to an event on the street. This statement was interpreted as a past elopement by Employee E2, the Director of Nursing, during an interview on July 16, 2015 at 12:30 p.m. Review of the facility's policy titled, Elopement Prevention and Management, dated May 1, 2011, indicated, The facility defines elopement as follows: Definition-Elopement: When a cognitively impaired resident/patient leaves the physical structure of the facility unattended and without staff knowledge. Refer to Discharge/Leave against Medical Advice Procedure for the cognitively intact resident/patient. The facility policy did not address when an alert and oriented resident leaves the building without the facility knowledge. Review of the nurses' notes dated June 26, 2015, revealed, any time the charge nurse makes rounds to this room resident always complains stating that I want to go home now and very inappropriated comments. An interview with Employee E3 and Employee E4, Social Service employees, on July 16, 2015 at 1:00 p.m., revealed that they spoke to the resident at length about his history of leaving other long term care facilities and a hospital, and the need to stay at the facility for treatment with the IV antibiotics. Review of the nurses' notes dated June 29, 2015, at 6:00 p.m., revealed that the Charge Nurse walked into Resident CL1's room to give the IV antibiotic, Doxycycline, and noted the resident was not present. Further review revealed that the resident did not sign the LOA (leave of absence) log so the 3:00 p.m.-11:00 p.m. supervisor was notified. Review of a prior nurses' notes on June 29, 2015 at 12:48 p.m., revealed that the resident was alert and the PICC line site was intact. A telephone interview with the 3:00 p.m.-11:00 p.m. supervisor on July 17, 2015, at 12:00 p.m., revealed that the activity room, the physical therapy room, the wings of the facility, and the front parking lot were searched; however, the resident was not found. Interview with the Nursing Home Administrator and Director of Nursing on July 16, 2015, at 2:00 p.m., revealed that the police were not notified that the resident was missing. Further interview revealed that no investigation was initiated as to when the resident was last seen. There were no interviews conducted to ascertain if any staff saw the resident leaving the building, and no event was entered into the event reporting system to the Department of Health. Further interview on July 16, 2015, at 2:00 p.m., revealed that the resident never returned to the facility and his health status and location are unknown. The facility failed to correctly assess and adequately monitor one resident, with an intact PICC line, who had a history of [REDACTED]. The resident was last seen by the staff approximately five hours before it was discovered that he was actually missing. The facility failed to initiate an investigation, failed to perform an extensive search, failed to contact the police and failed to notify the Department of Health of the event regarding the resident's elopement. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 12/15/14. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 1/22/15, 1/2/15, 2/27/14. 28 Pa. Code: 201.14(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. Perviously cited 1/22/15, 1/2/15, 12/15/14. 28 Pa. Code: 211.10(a)(b)(d) Resident care policies. 28 Pa. Code: 211.10(c) Resident care policies. Previously cited 1/22/15, 1/2/15. Pa. Code: 211.12(c) Nursing services. Previously cited 12/15/14. Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 1/22/15, 1/2/15, 12/15/14, 9/11/14. Pa. Code: 211.12(d)(2) Nursing services. Previously cited 1/22/15, 1/2/15, 9/11/14.

Based on review of clinical records, facility policies and procedures, facility documentation, the electronic Event Reporting System, manufacturer's medication guidelines and interviews with staff, it was determined that the facility failed to provide adequate assessment and monitoring for a resident who sustained a fall, for one of four residents reviewed (Resident CL1), resulting in actual harm to that resident. Findings include: Review of the facility policy, "Neurological Assessments," dated last revised [DATE], revealed that a neurological assessment included assessment of vital signs (blood pressure, pulse, and respiration's) and to notify the physician of any changes. Review of the facility policy, "Notification of Resident/Patient Change in Condition," dated last revised [DATE], revealed that if there is a crucial/significant change in the resident's condition, the physician would be notified regardless of the time. The policy further indicated that if the resident's attending physician was not available or did not respond to the physician notification, the nurse can call the facility's Medical Director regarding the resident change in condition. Review of the facility policy, "Falls Management," dated [DATE], contained a subsection entitled "Fall Injury Management - Post Fall," which revealed that neurological checks should be done for all unwitnessed falls. The policy also states that anticoagulant (blood thinning) medications are more commonly associated with injuries from a fall. Review of the manufacturer's guidelines for the medication [MEDICATION NAME], a platelet inhibitor (blood thinning medication that lowers the chance of blood clots forming in the body), dated [DATE], revealed that [MEDICATION NAME] can cause bleeding which can be serious and sometimes lead to death. The manufacturer's guidelines also stated that taking [MEDICATION NAME] with certain other medications including, but not limited to, Aspirin (a blood thinning medication) may increase a person's risk of bleeding. Review of the clinical record for Resident CL1 revealed a quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs) dated [DATE], indicating [DIAGNOSES REDACTED]. The MDS further revealed that Resident CL1 was independent with making decisions regarding tasks of daily life. Review of a physician's order dated [DATE], and monthly thereafter, instructed the staff to administer [MEDICATION NAME] 75 mg (milligrams) orally every day. Review of another physician's order dated February 20, 2014, and monthly thereafter, instructed staff to administer [MEDICATION NAME]-Coated (long-acting) Aspirin 81 mg orally every day. Review of a nurses' note dated [DATE], at 12:30 a.m., revealed that Resident CL1 was found on the floor after the staff was notified by the resident's roommate. The nurses' note further revealed that Resident CL1 was found lying on the resident's right side with a skin tear noted behind the right ear lobe and a possible closed head injury (a head injury in which the scalp and mucous membrane remain unbroken). Review of the Neurological Assessment Flowsheet dated [DATE], for Resident CL1, revealed the resident's vital signs were as follows: blood pressure ,[DATE], pulse (heart rate) 82, respiration's 16 at 12:45 a.m. (at the time of the fall); blood pressure ,[DATE], pulse 96, respiration's 20 at 1:00 a.m.; blood pressure ,[DATE], pulse 110, respiration's 22 at 1:15 a.m.; blood pressure ,[DATE], pulse 76, respiration's 24 at 1:30 a.m.; blood pressure ,[DATE], pulse 80, respiration's 26 at 1:45 a.m.; blood pressure ,[DATE], pulse 122, respiration's 28 at 2:45 a.m.; and blood pressure ,[DATE], pulse 122, respiration's 28 at 2:55 a.m. Review of another nurses' note dated [DATE], revealed Resident CL1's condition was observed to get worse while checking the vital signs and neurological responses after the fall, the resident's blood pressure, "kept going down," and the resident's pulse oximetry (measurement of percent of oxygen in the blood) level was recorded as 81 percent (100 percent is fully [MEDICATION NAME]) on room air and the resident required oxygen to be delivered via a non-rebreather mask (mask used to deliver oxygen). The note further indicated that the resident stated, "I feel very weak." The note indicated the resident was sent to the hospital for evaluation via 911 emergency services at 2:55 a.m., and that the Registered Nurse Supervisor notified the resident's physician. Review of the Pennsylvania Department of Health Event Reporting System (electronic computer incident reporting system for long term care facilities) revealed that Resident CL1 was sent to a trauma center hospital for evaluation after the fall on [DATE], and while being evaluated in the hospital, the resident expired. Review of the facility's incident report dated [DATE], revealed that Resident CL1's fall occurred on [DATE], at 12:30 a.m., the resident hit his head, and the resident's physician was initially contacted at 12:51 a.m., on [DATE]. Further review of the incident report revealed that the resident's physician responded to the facility on [DATE], at 2:30 a.m., approximately two hours after the resident fell . Further review of the clinical record and the facility's incident investigation report revealed no documentation that the nurse attempted to contact the resident's physician when the resident experienced a significant change in the resident's vital signs upon the second and third neurological checks which were documented at 1:00 a.m., and 1:15 a.m., on [DATE]. Additionally, the incident investigation report revealed no documentation that the facility's Medical Director was contacted related to the lack of response by the resident's attending physician upon the initial telephone contact after Resident CL1's fall. An interview with the Director of Nursing on [DATE], at 2:45 p.m., confirmed that Resident CL1 experienced an acute and significant decline in vital signs after sustaining a fall on [DATE], at approximately 12:30 a.m., confirmed the nurse did not ensure Resident CL1's physician was notified of the resident's ongoing change in status, and confirmed the nurse did not conduct complete, thorough and accurate assessment and monitoring of the resident after sustaining the fall. The facility failed to ensure that Resident CL1, a resident receiving blood thinning medication which is identified as a serious risk factor for bleeding, was adequately assessed and monitored by the facility staff after a fall which was unwitnessed by the staff and a questionable closed head injury occurred. 42 CFR 483.25 Quality of Care. Previously cited [DATE], [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE]. 28 Pa. Code 211.5(f) Clinical records. Previously cited [DATE]. 28 Pa. Code 211.10(c) Resident care polices. Previously cited [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE].

Based on observations, clinical record reviews, interview with staff and reviews of the facility smoking policy, it was determined that the facility failed to supervise one of two residents reviewed for falls, including falls with major injury, to provide a safe environment, free of accident hazards, while using the outdoor designated smoking area. The resident identified developed a serious head injury as a result of a fall in the outdoor smoking area (Resident R1). Findings include: Clinical record documentation indicated that a psychiatrist (a physician who specializes in the treatment of [REDACTED]. The physician indicated that Resident R1 had [DIAGNOSES REDACTED]. The physician's progress note also indicated that this resident exhibited impulsive behavior (to act on impulse rather than thought). The psychiatrist's progress note dated October 21, 2014, indicated that Resident R1 continues to be impulsive, asks for extra coffee and asks for multiple cigarettes. The physician's orders for medication for Resident R1 included Lorazepam (anti anxiety agent) 1 milligram (mg.) three times a day. According to the Geriatric Dose Handbook twelfth edition, Copy Right 2007, the side effects of Lorazepam use were sedation, dizziness and unsteadiness. The clinical record for Resident R1 indicated that a Minimum Data Set (MDS - an assessment of care needs) assessment was completed on September 19, 2014. The assessment indicated that Resident R1 required limited physical assistance of one person with transfers. The care plan dated March 5, 2014 through November 11, 2014 indicated that for safe transfers and ambulation, Resident R1 required supervision of one person and physical assist of one person. The nurse aide documentation for activities of daily living for October 18, 22, 23 and 24, 2014, indicated that Resident R1 required supervision/limited physical assistance of one person for ambulation in the room and corridor. On October 9, 2014, the nursing staff documented that Resident R1 was a, "cigarette smoker." The nursing assessment indicated that Resident R1 required staff supervision to smoke safely in the designated smoking area (the outdoor courtyard). A review of the facility policy and procedure for safe smoking revealed that any resident who has been classified as requiring supervision for smoking would not be permitted to smoke without the direct supervision of a responsible staff member. The policy indicated that direct supervision must be provided throughout the entire smoking period. On October 31, 2014, at 11:00 a.m., the nursing progress notes and the facility incident form for Resident R1, indicated that a nursing assistant standing down the hall in the lobby of the facility, noticed Resident R1 exiting the facility toward the outdoor "smoking courtyard" unsupervised and unassisted by staff. The nursing assistant observed Resident R1 fall backwards onto the ground behind the doors that led outside. The nursing progress note dated October 31, 2014, indicated that this resident sustained [REDACTED]. The physician was notified of the incident and sent the resident to the hospital emergency department for evaluation. The hospital emergency room report dated October 31, 2014, indicated that Resident R1 had a right posterior parietal subarachnoid hemorrhage (an abnormal discharge of blood located under the membrane covering of the brain within one of the two bones that formed the roof and sides of the skull.) Interview with the Licensed Occupational Therapist at 10:00 a.m., on December 15, 2014, revealed that Resident R1 was not assessed/evaluated for independent use of the "outdoor smoking courtyard." Observation of the "smoking courtyard" at 1:00 p.m., on December 15, 2014, revealed that the entrance to the courtyard was located in an area away from the E Wing Nursing Unit, where Resident R1 resided. The double doors leading out to the courtyard were heavy to manage physically with the upper body. The opened doors led outside onto a cracked, broken and missing cemented walk that sloped downward. Interview with the Nursing Home Administrator and Director of Nursing at 2:30 p.m., on December 15, 2014, confirmed that the facility failed to follow Resident R1's care plan to prevent falls. The facility failed to provide supervision/physical assist of one for ambulation and transfers and failed to follow the "Safe Smoking Policy" to provide direct supervision for this confused resident for the entire smoking process. 28 Pa. Code: 201.18(a)(b)(1) Management 28 Pa. Code: 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code: 211.11(a)(b) Resident care plan

Based on a review of a clinical record, facility documentation, facility policy and procedure and interviews with staff it was determined that the facility failed to develop and implement adequate interventions to prevent injuries for a cognitively impaired resident identified at risk for falls, resulting in actual harm to Resident R1. Findings include: A review of the facility ' s policy and procedures " Falls Management " dated May 1, 2011 indicated the interdisciplinary team was to work with the resident and family to identify and implement appropriate interventions to reduce the risk of falls or injuries and to adjust/add interventions to the resident ' s plan of care. A review of Resident R1 ' s MDS (Minimum Data Set- a periodic assessment of resident care needs) dated December 2011 indicated that the resident had severe cognitive impairment, dementia and required physical assistance from staff to complete activities of daily living. A review of a fall risk assessment dated [DATE] revealed that the resident was identified as a high risk for falls. A review of an occupational therapy assessment dated [DATE] indicated that the resident had impaired communication, memory and safety awareness. A review of nursing documentation dated February 22, 2012 revealed that the resident was found on the floor with the chair alarm sounding. A review of facility documentation dated February 22, 2012 indicated that the resident ' s fall history and inability to understand directions may have contributed to the resident ' s fall. Facility documentation indicated that the resident would be re-educated about the importance of asking staff for help and that bed/chair alarm are checked for placement and function every shift. A review of nursing documentation dated February 23, 2012 indicated that the resident continued to attempt transfers without assistance from staff and that re-education was frequently provided, however usually had no effect. A review of nursing documentation dated March 2, 2012, revealed that the resident tried to transfer from the bed to wheel chair without assistance and landed on the buttocks. A review of facility documentation dated March 2, 2012 indicated that the resident ' s fall history and confusion/disorientation may have contributed to the resident ' s fall. Facility documentation indicated that the resident would be reminded to use the call bell for assistance and that the resident had bed and chair alarms in place. A review of nursing documentation dated March 2, 2012 indicated that the resident was transferred to the emergency room for an evaluation related to a change in mental status. A review of nursing documentation dated March 3, 2012 revealed that the resident had a CT Scan (Computed Tomography- a procedure that uses x-rays to take detailed pictures of structures inside the body) of the head related to an earlier fall. A review of nursing documentation dated March 9, 2012 indicated that the resident reported to staff that while trying to reach for something on the floor fell from the wheelchair landing on knees but was able to position self back into the wheelchair. A review of facility documentation dated March 9, 2012 indicated that the resident utilized a chair alarm and that there was no witness to the fall and that the resident was very weak and if a fall had occurred the resident would not be able to lift self off of the floor. A review of nursing documentation dated April 4, 2012 revealed that the resident was on the floor against the wall. The resident indicated pain to head and back and was admitted to the hospital. A review of facility documentation dated April 4, 2012 indicated that the resident ' s fall history, confusion/disorientation and inability to understand directions may have contributed to the resident ' s fall. Facility documentation indicated frequent orientation to ask for assistance, call bell within reach and that bed/chair alarm ordered and in place. This fall was un-witnessed. A review of nursing documentation dated April 6, 2012 revealed that Jefferson Hospital contacted the facility and explained that the resident had been transferred there from Chestnut Hill Hospital because the resident had a spinal fracture and was scheduled for spinal surgery. A review of the resident ' s plan of care revealed that adequate interventions had not been developed after each fall/incident to ensure and maintain this resident ' s safety. The facility failed to ensure one resident's safety and develop and implement adequate interventions resulting in a significant injury to this cognitively impaired resident identified at a high risk for falls and impaired safety awareness. These findings were reviewed during an interview with the Nursing Home Administrator and Director of Nurses, on May 3, 2012 at 2:30 p.m. 483.25(h) Accidents. Previously cited state deficiency 01/26/2012. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 01/26/2012. 28 Pa. Code: 201.18(b)(1)(3) Management. Previously cited 01/26/2012. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.11(a) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 01/26/2012.