Every finding on record at Concordia at Spiritrust Sprenkle Drive

Based on review of facility policy, record review, and staff interview, it was determined that the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one of five residents reviewed (Resident 8).Findings include: Review of facility provided policy, Drug Regimen Review, revised February 2023, revealed that recommendations to the physician should be responded to prior to the following medication regimen review. Further review of the policy failed to reveal a timeframe for the physician's orders to be acted upon by the facility staff. Review of Resident 8's medical record revealed diagnoses that included major depressive disorder (a serious mental health condition marked by persistent sadness, hopelessness, and a loss of interest in activities that significantly impairs daily functioning) and anxiety disorder (excessive and persistent fear and distress that interferes with daily life). Review of Resident 8's consultant pharmacist recommendation to the physician, dated July 14, 2025, revealed a recommendation to decrease Resident 8's dose of haloperidol (antipsychotic medication) from 1 mg at bedtime to 0.5 mg at bedtime. Further review revealed that the physician responded to the recommendation on July 21, 2025, and agreed to decrease the dose of haloperidol from 1 mg at bedtime to 0.5 mg at bedtime and also ordered monitoring for a change in behavior for 14 days following the change in medication. Review of Resident 8's consultant pharmacist recommendation to nursing staff, dated August 25, 2025, revealed that the physician's order to decrease Resident 8's dose of haloperidol from 1 mg at bedtime to 0.5 mg at bedtime was not reflected in the current physician's orders and a request to update the orders. Review of Resident 8's physician orders revealed an order for haloperidol 0.5 mg at bedtime, with a start date of August 28, 2025. Review of Resident 8's medication administration record revealed that Resident 8 was receiving haloperidol 1 mg at bedtime until August 26, 2025 (35 days after the physician wrote an order to decrease the dose). Interview with the Nursing Home Administrator on October 1, 2025, at 1:35 PM, revealed that she would expect the physician's order for a decrease in the dose of Resident 8's haloperidol be acted upon in a timely manner. 211.12(d)(1)(3)(5) Nursing services

Based on staff interview and available documentation review, it was determined that the facility administration failed to ensure care policies were reviewed and approved by the administration and Medical Director yearly. Findings include: During an entrance staff interview on November 3, 2024, at approximately 10:20 AM, a request was made of the Nursing Home Administrator (NHA) to provide evidence that the facility's care policies had been reviewed and approved within the past year. In an electronic communication on November 5, 2024, at 2:56 PM, NHA revealed the facility was unable to locate a signatory page indicating the last care policy review date. Review of the care policy review binder that was stored near the nurses station, provided by the Director of Nursing (DON), on November 6, 2024, at approximately 9:45 AM, revealed the signatory page confirming that the NHA, DON, and Medical Director had reviewed and approved of the care policies was dated March 9, 2022. As of November 6, 2024, at 11:45 AM, the facility had no further information or evidence to provide regarding conducting a care policy review within the last year of the survey. 28 Pa code 201.18(d) Management

Based on review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of one quarters reviewed (FY Quarter 3 - April 1, 2024, to June 30, 2024). Findings include: According to Section 6106 of the Affordable Care Act (ACA), facilities are required to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered. Review State Operations Manual, under section 483.70(q), revealed Mandatory submission of staffing information based on payroll data in uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Under section 483.70(q)(4), The facility must submit direct care staffing information in the uniform format specified by CMS. Under section 483.70(q)(5), The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Review of PBJ staffing data reports for fiscal year third quarter 2024 revealed the facility triggered for Failed to Submit Data for the Quarter. During a staff interview on November 5, 2024, at approximately 10:30 AM, Nursing Home Administrator revealed the submission would have been conducted by a prior administration and was unaware if the submission to PBJ was completed or not. As of November 6, 2024, at 11:45 AM, the facility had no further information to provide. 28 Pa. Code 201.18(a) Management

Based on observation, clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered plan of care for four of 19 residents reviewed (Residents 44, 48, 57, and 64). Findings Include: A review of the facility's policy, titled Comprehensive Care Planning Standard, revised November 15, 2017, read Each .center will develop a comprehensive care plan for each resident that includes their strengths, measurable objectives and timetables. Goal is to meet a resident's medical, nursing (physical/symptom control), mental, intellectual, emotional, social, spiritual, psychosocial and cultural needs that are identified during baseline care planning and in the comprehensive assessment. Care Plans are formatted in the 'I Care Plan' format to ensure resident centered/resident directed living. Review of Resident 44's clinical record revealed diagnoses that included chronic venous hypertension with ulcer of the left and right lower extremity (damage to veins that prevent blood from flowing back to the heart causing increased blood pressure, ulcers, swelling, and pain in the legs) and type two diabetes mellitus (the bodies inability to use insulin to process blood sugar for energy). Review of Resident 44's physician orders revealed orders for bilateral lower extremity ace wraps for edema (swelling) to be applied in the morning and taken off at night. Further review of Resident 44's physician orders also revealed orders for spironolactone (diuretic used to help the body remove excess fluid) and furosemide (diuretic used to help the body remove excess fluid) once daily for edema. Review of Resident 44's comprehensive plan of care failed to revealed focus areas or interventions for edema, bilateral leg wraps, and diuretic use. An email communication on November 6, 2024 at 9:11 AM, with the Nursing Home Administrator (NHA), revealed Resident 44's comprehensive plan of care should have been updated to include edema, bilateral legs wraps, and diuretic use and that a revision had been done. A review of Resident 48's clinical record revealed diagnoses that included bilateral cataracts (a clouding of the lens inside the eye, which normally is clear, causing blurry or cloudy vision due to the obstruction of light passing through to the retina; cataracts are most commonly associated with aging and can lead to blindness if left untreated) and hypertension (elevated blood pressure). An interview with Resident 48 on November 3, 2024, at 10:01 AM, revealed she needed cataract surgery and is awaiting the surgery to be scheduled. A review of Resident 48's interdisciplinary plan of care revealed no documentation of the Resident's visual function, bilateral cataracts, or staff interventions to assist the Resident with her visual function as needed. Electronic mail correspondence with the Nursing Home Administrator (NHA) on November 5, 2024, at 2:42 PM, revealed a vision care plan for Resident 48 was created and had now been added to the Resident's clinical record. A review of Resident 57's clinical record revealed diagnoses that included muscle weakness, abnormality of gait (a person's manner of walking), and mobility (the ability to move or be moved freely and easily). An observation of Resident 57 while in bed revealed bilateral enabler bars attached to the bed. A review of Resident 57's device review evaluation dated October 31, 2024, revealed the need for the use of the enablers for bed mobility. A review of Resident 57's interdisciplinary plan of care revealed no documentation of the Resident's need or use of those bilateral enabler bars. An interview with the facility's Corporate Excellence Nurse on November 6, 2024, at 10:36 AM, revealed no enabler care plan was in place, but has now been developed and added to the Resident's clinical record. A review of Resident 64's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and congestive heart failure (CHF - decreased ability of the heart to pump blood through the body). During a resident interview on November 4, 2024, it was observed that Resident 64 appeared to have no natural teeth. A review of a physician assessment conducted on October 10, 2024, revealed the physician noted Resident 64 was edentulous (without teeth). A review of Resident 64's comprehensive plan of care revealed no dental care plan identifying that the Resident had no natural teeth. During a staff interview on November 6, 2024, at approximately 11:45 AM, the NHA confirmed that Resident 64's comprehensive plan of care did not include a care plan that addressed Resident 64's dental status of lacking natural teeth. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that five residents have the right to a dignified dining experience during meal service in one of one dining rooms observed (Residents 9, 17, 24, 35, and 64). Findings include: Review of facility policy, titled Residents Rights Standard, read, in part, All residents in long term care maintain the same rights assured all Americans under Federal and State law. This standard is intended to assure each resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center. Observations in the main dining room on November 3, 2024, between 11:34 AM and 12:02 PM, revealed Employee 4 (Dietary Employee) was serving tables throughout the dining room without completing one table at a time. The following observations were also made in the dining room during that time: Observation on November 3, 2024, at 11:34 AM, revealed Resident 26 was sitting at a table with Resident 35. Resident 26 had been previously served but Resident 35 was sitting without food, and Employee 4 was serving other tables. Observation on November 3, 2024, at 11:35 AM, Resident 35 was observed to state to Employee 4 could you get me something to eat please? During an interview with Resident 35 on November 3, 2024, at 11:37 AM, she revealed she is never sure when and if she is going to be served when she eats in the dining room. Resident 35 was observed to be served at 11:40 AM. Observation on November 3, 2024, at 11:34 AM, revealed Residents 17 and 56 were sitting at a table together, and Resident 56 had been previously served. Resident 17 was observed to be served at 11:42 AM. Observation on November 3, 2024, at 11:34 AM, revealed Residents 9, 27, and 46 were sitting at a table together, Resident 27 and 46 had been previously served. Observation on November 3, 2024, at 11:40 AM, revealed Resident 9 was observed to state where is my meal? I have been here since 11:00 AM. Resident 9 was observed to be served at 11:43 AM. Observation on November 3, 2024, at 11:36 AM, revealed Residents 2, 37, and 64 were sitting at a table together, Resident 2 and 37 had been previously served. Observation on November 3, 2024, at 11:43 AM, revealed Resident 64 was observed to state to Employee 10 did you fix mine yet? Resident 64 was observed to be served at 11:45 AM. Observation on November 3, 2024, at 11:35 AM, revealed Residents 3, 24, and 28 were sitting at a table together, Resident 3 and 28 had been previously served. Resident 24 was observed to be served at 11:53 AM. During an interview with the Nursing Home Administrator on November 4, 2024, at 1:39 PM, she revealed her expectation that residents would be served considering dignity during meal service. 28 Pa Code 201.29(d) Resident Rights

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and one of one nourishment area. Findings include: Review of facility policy, titled Labeling and Dating of All Food Products, not dated, read, in part, Each label must contain the following information: Product name or common name or identifying description, use by date, date the product was prepared or opened, date thawed, if applicable. When a product is removed from the box the individual items must be labeled individually. Review of facility policy, titled Maximum Storage Period of Dried Goods, last revised [DATE], read, in part, Flour and spices that are opened are good for six months. Review of facility policy, titled Storage of Refrigerated & Frozen Foods, last revised [DATE], read, in part, [NAME] onions and cut-up cooked poultry have a maximum storage period of up to 7 days, and Readycare Frozen Shakes that are thawed and unopened are good for up to 14 days. Observation of the dry storage area on [DATE], at 9:37 AM, revealed: a bin of breadcrumbs labeled use by [DATE]; three bags of hamburger buns labeled use by [DATE]; one bag of hamburger buns labeled use by [DATE]; one bag of dinner rolls not dated; one sugar bin not labeled or dated; one flour bin labeled use by [DATE]; two boxes of fudge brownie mix not dated; one bag of sliced almonds open with a use by date of [DATE]; one bag of cane sugar labeled use by [DATE]; and one can of pimentos not dated. Observation in the main kitchen on [DATE], at 9:50 AM, revealed one case of bananas that were black and some had started to peel open; and one container of brown sugar not labeled or dated. Observation of reach in refrigerator 1 on [DATE], at 9:54 AM, revealed an individual covered side dish not labeled or dated, further observation when uncovered revealed moldy slices of cut watermelon; and one Readycare Frozen Shake that was thawed without a thawed date. Observation of the walk in refrigerator on [DATE], at 9:59 AM, revealed two bags of deli turkey labeled they were sliced on [DATE], and had a use by date of [DATE]; one contained of seafood salad labeled use by [DATE]; one bag of green onions not labeled with a use by date, further observation revealed most of them were dark green and wilted and were received at the facility [DATE]. Observation in the main kitchen on [DATE], at 10:08 AM, revealed one container of whole celery seed with an open date of [DATE]; one open container of dill with an open date of [DATE]; and one open container of nutmeg with an open date of [DATE]; further observation of the spice rack revealed 23 containers of spices labeled with a use by date of one year from opening. Observation of the three-compartment sink in the main kitchen on [DATE], at 10:29 AM, revealed Employee 2 (General Dietary Manager) tested the concentration (unit of measure) of the sanitizer water utilizing a test strip that had an expiration date of February 1, 2023. Observation of the skilled pantry area refrigerator on [DATE], at 10:34 AM, revealed five Readycare Frozen Shakes that were thawed without a thawed date; nine yogurts labeled use by [DATE]; one container of thickened lemon water open without an open date; one container of thickened cranberry juice open without an open date; one container of thickened orange juice open without an open date; and one container of regular orange juice open without an open date. Interview with Employee 2 on [DATE], at 10:41 AM, revealed the expectation of storing food and utilizing equipment considering foodservice safety and in accordance with professional standards. Interview with the Nursing Home Administrator on [DATE], at 1:38 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion receives the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one resident reviewed for range of motion services (Resident 57). Findings Include: A review of Resident 57's clinical record revealed diagnoses that included muscle weakness, abnormality of gait (a person's manner of walking), and mobility (the ability to move or be moved freely and easily). A review of the facility's policy, titled Restorative Program Standard, revised July 23, 2015, described its purpose: Nursing team members direct and provide the service with input and support from the Nursing Department/Therapy Department to increase or preserve the highest level of self-performance of residents as appropriate. Restorative Nursing is defined as nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A review of Resident 57's Occupation Therapy discharge summary dated October 16, 2024, revealed recommendations that included Restorative Range of Motion Program. Also, BUE [bilateral upper extremities] AROM [active range of motion] of shoulders, elbows, wrists, and fingers x 15 reps x3. A review of Resident 57's clinical record revealed no documentation of the restorative nursing program or staff implementing or providing the recommended active range of motion activities by the Occupational Therapist. An interview with the Nursing Home Administrator on November 6, 2024, at 10:39 AM, revealed the restorative nursing program was not implemented for Resident 57 upon discharge from occupational therapy on October 16, 2024, and will now be implemented by staff going forward. 28 Pa. Code 211,12 (d) (1) (2) (3) (5) Nursing services

Based on observations, select facility meal ticket review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, during meal service, for five of 20 residents in one of one dining rooms observed (Resident's 3, 11, 27, 37, 45). Findings include: Observation of Resident 3 in the main dining room on November 3, 2024, between 11:34 AM and 11:39 AM, revealed she was sitting at a table with her food sitting in front of her not eating. Review of Resident 3's meal tickets revealed she requires full assistance with her meals; Employee 5 (Registered Nurse), was observed to sit down and start providing feeding assistance to Resident 3 at 11:39 AM. Observation in the main dining room on November 3, 2024, at 11:42 AM, revealed Resident 11 was served her meal by Employee 4 (Dietary Employee) and was sleeping. Review of Resident 11's meal tickets revealed she requires full assistance with her meals; Employee 3 (Nurse Aide), was observed to start providing feeding assistance to Resident 11 at 11:55 AM. Observation in the main dining room on November 3, 2024, between 11:37 AM and 11:57 PM, revealed Resident 27 was not eating the food she had been served. Further observation in the dining room on November 3, 2024, at 11:58 AM, revealed Employee 10 cued Resident 27 to pick up her silverware and eat her meal. Review of Resident 27's meal tickets revealed she requires supervision at meals. Review of Resident 27's clinical record revealed she has sometimes required staff to provide cueing during meals or full feeding assistance over the past fourteen days due to a noted decline. Observation in the main dining room on November 3, 2024, between 11:36 AM and 11:40 AM, revealed Resident 37's food was sitting in front of her and she was repeating What do I do? Observation of Employee 11 on November 3, 2024, at 11:40 AM, revealed she walked up to Resident 37 and stated, You have a peanut butter and jelly sandwich. Employee 11 started unwrapping Resident 37's silverware and cued her to pick up the sandwich. Review of Resident 37's meal tickets revealed she requires set-up assistance at meals. Review of Resident 37's clinical record revealed she had required oversight, encouragement, or cueing in four of the past 14 days, including that day at lunch. Observation in the main dining room on November 3, 2024, at 11:42 AM, revealed Resident 45 had been served, and was asking if someone was going to help her. During an interview with Resident 45 on November 3, 2024, at 11:44 AM, she revealed she needs help at her meals to eat. Review of Resident 45's meal tickets revealed she requires full assistance with her meals; Employee 3 (Nurse Aide), was observed to start providing feeding assistance to Resident 45 at 11:48 AM. During an interview with the Nursing Home Administrator on November 4, 2024, at 1:39 PM, she revealed her expectation that residents should be provided eating assistance, supervision, and cueing as required; and residents should not be served who require feeding assistance until nursing is ready to help them. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four residents on transmission-based precautions (Residents 61). Findings include: Review of facility policy, titled Transmission Based Precautions, with a revision date of June 2024, read, in part, I. Enhanced Barrier Precautions (EBP): is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and MDROs. G. Enhanced Barrier Precautions b. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: i. Wounds or indwelling medical devices, regardless of MDRO colonization status .g. gowns and gloves required when performing high-contact resident care activities associated with MDRO transmission (e.g. dressing, bathing, showering, toileting, transferring, changing linens, etc.). Review of Resident 61's clinical record revealed diagnoses that included parkinsons's disease (chronic, progressive brain disorder that affects movement and other parts of the body) and muscle weakness (loss of muscle strength). Review of Resident 61's physician orders revealed orders for wound care and enhance barrier precautions (EBP). An observation on November 3, 2024, at 10:34 AM, of Resident 61's room revealed signage indicating EBP and a personal protective equipment (PPE) caddy containing gowns and gloves. Observations made on November 6, 2024, at 9:45 AM, of Resident 61's wound care and dressing change revealed Employee 7 and Employee 8 failed to don gowns while performing high-contact Resident care. During an interview on November 6, 2024, at 10:00 AM, with Employee 7, revealed that Resident 61 is on EBP and gowns should have been worn. An interview on November 6, 2024, at 10:40 AM, with the Nursing Home Administrator, Director of Nursing, and Employee 1, revealed it was the facility's expectation that employees wear appropriate PPE. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa. Code 211.10 (d) Resident care policies

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 18 Residents reviewed (Resident 12). Findings include: Review of Facility Policy, titled Trauma Informed Care Standard, with an effective date of November 1, 2019, read, in part, Definition: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social and emotional, or spiritual well-being. Events- can include actual or extreme threat or harm, or severe, life-threatening neglect for a child. Factors include: How an individual assigns meaning to the event. For residents: Initial screening on admission and with plan of care review, to determine if there may be a history of trauma. (See Getting to know our residents or guest form #8-204A). If identified, follow-up screening will occur to support development of the plan of care. Review of Resident 12's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), anxiety disorder (a persistent feeling of worry, nervousness, or unease), and muscle weakness. During an interview with Resident 12 on November 3, 2024, at 11:22 AM, she was discussing her history of her career, but then started to become tearful as she stated she experienced childhood trauma. Review of Resident 12's care plan failed to reveal notification of having a history of trauma. Further review of Resident 12's care plan revealed she had a care plan focus area for depression and anxiety, with an intervention for arrange for psychiatric or psychological consult, follow up as indicated, with a start date of December 13, 2022. During an email correspondence with the Nursing Home Administrator (NHA) on November 3, 2024, at 12:57 PM, the surveyor revealed her interview with Resident 12 regarding her trauma, and requested information if that had been previously assessed, and if she follows with psychology services. Review of Resident 12's Psychosocial Assessment document provided dated December 13, 2022, failed to reveal questions regarding if the Resident had experienced a history of trauma, other than Describe significant life events over the past year. Review of Resident 12's PsychoGeriatric Services notes provided from May 22, 2024, and September 17, 2024, failed to reveal notation of a history of trauma. During an interview with the NHA and Employee 6 (Social Services Director) on November 5, 2024, at 10:28 AM, the surveyor inquired if there are any PsychoGeriatric Services assessing her history of trauma, or if the form mentioned in the facility policy is utilized the assess a history of trauma for residents upon admission. Interview with the NHA and Employee 6 on November 6, 2024, at 10:31 AM, revealed they are unable to locate documentation to indicate Resident 12 was assessed for her history of trauma. Follow-up email correspondence with the NHA on November 7, 2024, at 9:23 AM, revealed the facility is moving away from utilizing the form mentioned in the trauma informed care policy, they instead use a different form titled Psychosocial Assessment that assesses for a history of trauma. No further information was provided. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.10(a) Resident care policies

Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to provide nutritional supplements as ordered by the physician for one of six residents observed during medication administration observations (Resident 4), and failed to to notify the physician of a significant weight change for one of five residents reviewed for nutrition (Resident 54). Findings include: Review of facility policy, titled Weight Record Monitoring, last revised August 2024, read, in part, The physician and resident's responsible party are notified by the RD/designee of significant weight change (gain or loss) and of the IDT recommendations that would require further intervention/securing of new orders from the physician for the resident. Review of Resident 4's clinical record revealed diagnoses that included dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and diabetes type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 4's physician orders revealed an order dating March 18, 2024, for a dietary supplement (house supplement) three times a day, 4 ounces, between meals for the indication of poor meal intake. During medication observations conducted on November 5, 2024, at approximately 10:00 AM, Employee 9 was observed preparing medications for Resident 4. During preparation, Employee 9 was observed pouring approximately 8 ounces of chocolate milk in a cup. Employee 9 then stated, I usually give chocolate milk instead of the shake, the nutritional shake, because [the residents] usually like it more. Review of the nutritional value of the chocolate milk revealed the chocolate milk did not offer an equivalent nutritional value when comparable to the house supplement that Resident 4 was ordered. During a staff interview on November 5, 2024, at approximately 10:30 AM, Nursing Home Administrator (NHA) revealed that chocolate milk should not have been used as a substitute to the house supplement that Resident 4 was ordered. Review of Resident 54's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), muscle weakness, and Alzheimer's disease (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 54's clinical record revealed she had a significant weight loss of 5.7% in one month from September to October 2024. Further review of Resident 54's clinical record revealed a nutrition assessment in response to the weight loss that stated Medical Doctor to be notified. During an email correspondence with the NHA on November 4, 2024, at 12:17 PM, the surveyor requested information related to a physician notification of Resident 54's weight loss. Follow-up interview with the NHA on November 5, 2024, at 10:28 AM, revealed she is unable to locate any documentation to indicate the physician was notified of the weight loss, that her last physician assessment was prior to the noted weight loss, and she would expect that documentation to be available. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and resident representative and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 19 residents reviewed (Resident 61). Findings include: Review of Resident 61's clinical record revealed diagnoses that included Parkinson's disease (progressive brain disorder that causes unintended or uncontrolled movements) and lack of coordination (difficulty controlling movements of the body). During an interview on November 3, 2024 at 10:37 AM, with Resident 61's Responsible Party, it was revealed that Resident 61 used an electric recliner and that the facility had taken the remote, preventing Resident 61 from being able to recline when sitting in the chair. Review of Resident 61's comprehensive plan of care revealed a focus area for impaired function of daily living due to Parkinson's with an intervention to recline chair and to put adjusting remote in pouch to chair. During an interview on November 5, 2024 at 12:15 PM, with the Director of Nursing (DON), it was revealed that Resident 61 recently had a fall after sliding out of the recliner due to not being able to work the remote and put the footrest down independently when reclined. The DON also revealed that due to Resident 61's cognitive level and inability to independently operate the chair's remote, that reclining Resident 61's chair would be considered a restraint and the remote was removed. An email on November 5, 2024 at 4:43 PM, from the NHA revealed that Resident 61's comprehensive plan of care should have been updated to reflect elevating Resident 61's legs as needed and removing the chair's remote from the room for safety. The NHA stated a care plan revision would be done. 42 CFR 483.21(b) Comprehensive Care Plans 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to accurately assess the dental status of one of two residents reviewed for dental services (Resident 64). Findings include: Review of Resident 64's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and congestive heart failure (decreased ability of the heart to pump blood through the body). During a resident interview on November 4, 2024, it was observed that Resident 64 appeared to have no natural teeth. Review of a physician assessment conducted on October 10, 2024, revealed the physician noted Resident 64 was edentulous (without teeth). Review of Resident 64's Admission Minimum Data Set (MDS - standardized assessment utilized to identify a residents' physical, psychological, and psychosocial needs), with an assessment reference date of October 4, 2024, revealed that section L - Oral/Dental Status, was not accurately coded for L0200 Dental, B. No natural teeth or tooth fragments (edentulous). During a staff interview on November 6, 2024, at approximately 10:30 AM, Nursing Home Administrator and Director of Nursing confirmed that Resident 64 did not have any natural teeth and that Resident 64's Admission MDS was coded incorrectly. 28 Pa code 211.12(d)(5) Nursing services

Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a 4.5 cm (centimeter) x 4 cm skin tear (a wound that occurs when the skin separates from itself, usually due to trauma or friction) for one of five residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Limited Lift Environment Standard, most recently dated August 7, 2015, revealed Resident Transfer- Responsibilities: When a mechanical lift is used, two (2) team members are required. Review of Employee 1's (Nurse Aide Trainee) form titled Procedure Evaluation Checklist (Comprehensive), revealed on September 23, 2024, Employee 1 was marked off by Employee 2 (Nurse Aide Trainee Instructor) that Employee 1 Demonstrates Proper Use of Assistive Devices when Assisting the Client to Transfer Using a Mechanical Lift. Review of Resident 1's clinical record revealed diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness; cerebral infarction is a stroke), congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Review of Resident 1's care plan revealed an intervention, revised September 15, 2023, stating that Resident 1's transfer status is by a sit-to-stand (a lift designed to assist individuals with limited mobility in transitioning from a seated to a standing position). Review of Resident 1's nursing progress note dated October 8, 2024, revealed that at 7:30 AM, Resident 1 was being transferred via standing lift into the bathroom. Residents back left arm was rubbed against door frame causing a 4.5 [cm] x 4 cm skin tear. The note further stated that the skin tear was cleansed with normal saline solution, steri-strips (used to keep the edges of a cut together and help it heal) were applied and the area was covered with non-adherent gauze and was wrapped. Review of facility reported incident dated October 8, 2024, revealed that Employee 1 transferred Resident 1 independently using a sit-to-stand lift, causing a skin tear to the back of Resident 1's arm as a result of hitting it on the door frame. Review of the facility's investigation revealed that on October 8, 2024, Employee 1 was interviewed by the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 2. Review of the interview revealed that Employee 1 was completing morning care with Resident 1 and he requested to go to the bathroom. Employee 1 stated she went into the hall looking for a staff member but couldn't find anyone. She stated she went back into the Resident's room to tell him she couldn't find anyone, and stated that the Resident began to rush her. Since she was feeling rushed, Employee 1 decided to use the sit-to-stand lift independently. Employee 1 stated that the Resident said something along the lines of don't you need someone with you. The interview further states that Employee 1 admitted she did make the decision to transfer him, and she subsequently bumped his arm on the door frame causing a skin tear. Further review of the facility's investigation revealed that Resident 1 was interviewed by Employee 3 (Registered Nurse) on October 8, 2024. Review of Resident 1's interview revealed that Resident 1 stated 'That girl took me out of the bathroom and I bumped my elbow', 'I asked her don't you need help, and she told me she couldn't find anyone'. During an interview with Resident 1 on October 23, 2024, at 12:35 PM, when asked about the incident on October 8, 2024, Resident 1 stated I told her [Employee 1] she needed help and she wouldn't listen. She said I was rushing her but I wasn't. I told her to go get help. Resident 1 stated that Employee 1 did not attempt to find someone to help her and she transferred him alone, using the sit-to-stand lift. Review of facility's investigation findings revealed that Employee 1 admitted to transferring Resident 1 independently instead of using a two-person assist with the lift. Employee 1 was removed from the nurse aide training program and terminated from the facility. During an interview with the NHA and Employee 2 on October 23, 2024, at 11:03 AM, the NHA stated that every kind of lift used in the building requires two-person assist for use. It was also stated that Employee 1 knew she wasn't supposed to transfer Resident 1 alone, but did anyway, because she said she felt rushed. Employee 1 failed to provide the appropriate assistance level when transferring Resident 1 using a sit-to-stand lift, resulting in Resident 1 hitting his arm on the door frame, causing a 4.5 cm x 4 cm skin tear. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm, as evidenced by a 4.5 cm (centimeter) x 4 cm skin tear (a wound that occurs when the skin separates from itself, usually due to trauma or friction) for one of five residents reviewed (Resident 1). Findings include: Review of facility policy, titled Limited Lift Environment Standard, most recently dated August 7, 2015, revealed Resident Transfer- Responsibilities: When a mechanical lift is used, two (2) team members are required. Review of facility policy, titled Abuse/Neglect Exploitation Prevention Standard for Skilled Care, most recently revised October 4, 2017, revealed Residents have the right to be free from verbal, physical, mental, sexual abuse, neglect corporal punishment and involuntary seclusion and exploitation. Neglect: 483.13(c) failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (42 CRF 488.301). 28 Pa Code 201.3 Definitions - the deprivation by a caretaker of goods or services which are necessary to maintain physical or mental health. Act 13 of 1997 the willful deprivation by a caretaker of goods or services which are necessary to maintain physical or mental health. Review of Employee 1's (Nurse Aide Trainee) form titled Performance Checklists for Nurse Aide Trainees/Students in Pennsylvania revealed that Explains the responsibility to identify, prevent and report abuse, exploitation, and neglect as legislated in Act 14 of 1997 (P.L.), the Nurse Aide Resident Abuse Prevention Training Act, was documented as being demonstrated by Employee 1 on September 30, 2024. This was marked S, meaning satisfactory, and was signed off on by Employee 2 (Nurse Aide Trainee Instructor). Further review of Employee 1's performance checklist revealed Follows nursing care principles to prevent client abuse, neglect, exploitation .Provides appropriate restorative care to prevent abuse, neglect, and exploitation, was documented as being demonstrated by Employee 1 on September 30, 2024. These were also marked S and signed off on by Employee 2. Review of Resident 1's clinical record revealed diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness; cerebral infarction is a stroke), congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Review of Resident 1's care plan revealed an intervention, revised September 15, 2023, stating that Resident 1's transfer status is by a sit-to-stand (a lift designed to assist individuals with limited mobility in transitioning from a seated to a standing position). Review of Resident 1's nursing progress note dated October 8, 2024, revealed that at 7:30 AM, Resident 1 was being transferred via standing lift into the bathroom. Residents back left arm was rubbed against door frame causing a 4.5 [cm] x4 cm skin tear. The note further stated that the skin tear was cleansed with normal saline solution, steri-strips (used to keep the edges of a cut together and help it heal) were applied and the area was covered with non-adherent gauze and was wrapped. Review of facility reported incident dated October 8, 2024, revealed that Employee 1 transferred Resident 1 independently using a sit to stand lift, causing a skin tear to the back of Resident 1's arm as a result of hitting it on the door frame during the transfer. Review of facility's investigation revealed that on October 8, 2024, Employee 1 was interviewed by the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 2. Review of the interview revealed that Employee 1 was completing morning care with Resident 1 and he requested to go to the bathroom. Employee 1 stated she went into the hall looking for a staff member but couldn't find anyone. She stated she went back into the Resident's room to tell him she couldn't find anyone, and that the Resident began to rush her. Since she was feeling rushed, Employee 1 decided to use the sit-to-stand lift independently. Employee 1 stated that the Resident said, something along the lines of don't you need someone with you. The interview further stated that Employee 1 admitted she did make the decision to transfer him, and she subsequently bumped his arm on the door frame causing a skin tear. Further review of the facility's investigation revealed that Resident 1 was interviewed by Employee 3 (Registered Nurse) on October 8, 2024. Review of Resident 1's interview revealed that Resident 1 stated 'That girl took me out of the bathroom and I bumped my elbow', 'I asked her don't you need help, and she told me she couldn't find anyone'. Review of a quiz taken by Employee 1 dated September 24, 2024, revealed the question For a safe transfer with a full mechanical lift, use at least , with the multiple choice answers being 1 assist, 2 assist, 3 assist or 4 assist. Employee 1 answered the question correctly by answering 2 assist. Review of Employee 1's form titled Performance Checklists for Nurse Aide Trainees/Students in Pennsylvania, revealed that Demonstrates the proper use of assistive devices, when assisting the client to: b. Transfer (such as mechanical lift, stand aid, etc.), was documented as being demonstrated by Employee 1 on September 30, 2024. This was marked S, meaning satisfactory, and was signed off on by Employee 2. During an interview with Resident 1 on October 23, 2024, at 12:35 PM, when asked about the incident on October 8, 2024, Resident 1 stated I told her [Employee 1] she needed help and she wouldn't listen. She said I was rushing her but I wasn't. I told her to go get help. Resident 1 stated that Employee 1 did not attempt to find someone to help her, and she transferred him alone, using the sit to stand lift. Review of facility's investigation findings revealed that Employee 1 admitted to the allegation and not following the care plan. Employee 1 was removed from the nurse aide training program and terminated from the facility. During an interview with the NHA and Employee 2 on October 23, 2024, at 11:03 AM, the NHA stated that every kind of lift used in the building requires two-person assist for use. It was also stated that Employee 1 knew she wasn't supposed to transfer Resident 1 alone, but did anyway, because she said she felt rushed. The facility failed to ensure that Resident 1 was free from neglect when Employee 1 did not follow Resident 1's care planned interventions for two-person assist with the sit-to-stand lift, resulting in Resident 1 hitting his arm on the door frame, causing a 4.5 cm x 4 cm skin tear. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of the facility's Dental Services policy, observations, staff and resident interviews, and record review, it was determined that the facility failed to provide routine and emergency dental services for one of 22 residents reviewed (Resident 1). Findings: Review of the facility's Dental Services policy, revised November 28, 2017, read, in part, the facility must assist residents in obtaining routine and emergency dental care. Routine services include an annual inspection of the oral cavity including fitting dentures. Emergency dental services includes treatment of acute pain of teeth or gums by a dentist. Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. The Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility. Observation on January 2, 2024, at 10:01 AM, revealed Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened. On January 2, 2024, review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], payor source as of October 14, 2023, was Community Heath Choices AmeriHealth caritas (Pennsylvania medical assistance managed care health plan), and was cognitively intact per Brief Interview For Mental Status (BIMS- a test to evaluate cognition) score of 14, completed on December 28, 2023. Resident 1's December 2023 physician orders included: consult podiatry, vision, dental and audiology services as ordered (360Care Podiatry, vision, dental), start date February 3, 2023; and Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023. Resident 1's December 2023 Medication Administration Record (documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash - medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered. Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, physician was made aware and ordered Orajel three times a day until healed. Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days. Review of nursing note on December 27, 2023, documented the Resident receiving Orajel for recent mouth sores. During an interview with the Nursing Home Administrator (NHA) on January 3, 2024, at 11:10 AM, it was revealed that, per 360Care, prepayment is needed before scheduling an appointment. During an interview with the Director of Nursing (DON) on January 3, 2023, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures, and is able to care for his dentures himself. It was also revealed that the physician followed-up with Resident 1 regarding his pain in his lower jaw. DON stated that there wasn't a white patch on Resident 1's lower jaw. DON reiterated that the facility provided information stating 360Care required prepayment before scheduling an appointment. Resident 1's lower gum line slightly erythematous with no open area. Recommendation made to keep lower denture out between meals, continue use of Orajel and follow-up with dentist to evaluate need for new dentures. this seems out of place or needs more info? Interview with Corporate Nurse on January 3, 2024, at 2:40 PM, revealed that, with the new contract, 360Care does require prepayment for residents who are Medicaid pending. Census documentation revealed Resident 1 was Medicaid pending September 16, 2022, through December 21, 2022, then was on skilled services October 22, 2022, through October 13, 2023, and was on Medicaid services as of October 14, 2023. During an interview with NHA on January 3, 2024, at 2:40 PM, it was revealed that he wasn't aware that Resident 1 was in emergent need to see a dentist. Resident 1 is able to eat and has not lost weight. Resident 1's family opted for dental services to be on hold until Resident 1 was on Medicaid. The dentist requires prepayment for services for certain payor sources. During an interview with the DON and Employee 7 (Unit Manager) on January 4, 2024, at 11:20 AM, it was revealed that Resident 1 wasn't on Medicaid until October 14, 2023, the family wasn't willing to prepay for routine dental services, and the family opted to wait until Resident 1 was on Medicaid services. It was also revealed that dental pain would not be considered need for emergent dental services, and the physician was managing and monitoring Resident's dental health. It was confirmed that the dentist is expected in the facility March 2024, the dental office should be aware that Resident 1's payor source was Medicaid, and should be scheduled for a routine dental visit; however, they weren't able to confirm that Resident 1 was on the dentist schedule to be seen March 2024. During the interview with DON and Employee 7 on January 4, 2024, at 12:00 PM, revealed Resident 1 was not seen for routine dental due to having dentures without concerns and not being active on Medicaid. It was also revealed that Resident 1 is scheduled to be seen by the facility dentist on February 28, 2024, at 9:00 AM. The facility failed to provide routine and emergent dental services in a timely manner as evidence by treatment for dental pain initiated December 1, 2023, with additional intervention December 11, 2023. Further, the facility failed to evaluate/monitor Resident 1's oral health and dental pain prior to surveyor questioning Resident 1's oral pain and, at that point, the physician did complete a follow-up visit on January 3, 2024, recommending Resident 1 be seen by a dentist. 28 Pa Code 211.15 Dental services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 22 residents reviewed (Resident 12). Findings Include: Review of Resident 12's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and atrial fibrillation (A-fib- irregular heart rhythm). Review of Resident 12's annual MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated August 4, 2023, revealed that section C- Cognitive Patterns, and section D- Mood, were marked with dashes (-), meaning not assessed. During an interview with the Nursing Home Administrator, Director of Nursing, and Employee 3 on January 4, 2024, at 10:29 AM, when asked about the dashes on Resident 12's MDS assessment, Employee 3 stated that it was missed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 1 and 77). Findings Include: Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking). During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility. Observation on January 2, 2024, at 10:01 AM, Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened. Resident 1's December 2023 physician orders included Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023. Resident 1's December 2023 Medication Administration Record (MAR - documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash- medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered. Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, and the physician was made aware and ordered Orajel three times a day until healed. Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days. Review of nursing note on December 27, 2023 documented the Resident receiving Orajel for recent mouth sores. Review of Resident 1 care plan on January 2, 2023, failed to include documentation of dentures and mouth pain/ulcers. During an interview with the Director of Nursing (DON) on January 3, 2024, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures and is able to care for his dentures himself. Further review of Resident 1's care plan on January 4, 2024, documented a focus area for dental health problems due to injury related to dentures with complaint of mouth pain, initiated on January 3, 2024; with interventions that included mouth inspections as needed, report changes to nurse, and to observe/document/report to provider signs or symptoms of dental problems. During an interview with the DON on January 4, 2024, at 10:36 AM, it was revealed a dental care plan should've been initiated prior to January 3, 2024. Review of Resident 77's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD- acid reflux) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of Resident 77's current physician orders, revealed an order dated September 21, 2023, for a hospice consult evaluation and treatment. Review of Resident 77's progress notes revealed a note dated September 28, 2023, stating that Resident 77 is on hospice services as of September 28, 2023. Review of Resident 77's significant change MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated October 11, 2023, revealed that Resident 77 was marked as receiving hospice services. Review of Resident 77's current care plan failed to reveal a hospice care plan. On January 3, 2024, at 1:13 PM, the DON provided a hospice care plan for Resident 77 that was initiated on January 3, 2024. At that time, the DON stated that the hospice care plan should have been initiated prior to this date. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interviews, record review, and facility policy review, it was determined that the facility failed to ensure that the comprehensive care plan was revised to include changes in the resident's status and plan of care for one of 19 residents reviewed (Resident 26). Findings include: Review of the facility policy, titled Comprehensive Care Plan Standard, last reviewed July 2023, revealed that it requires the resident's care plan to be reviewed and revised, if applicable, by the interdisciplinary team after each annual and quarterly assessment. Review of Resident 26's clinical record on January 2, 2024, revealed diagnoses that include diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and hypertension (elevated blood pressure). Review of the current care plan on January 3, 2024, at 10:30 AM, revealed a care plan for pain related to lower left leg cellulitis (bacterial skin infection). Resident 26 was admitted with a diagnosis of cellulitis on July 2, 2022, and the cellulitis was resolved after treatment with antibiotics. The cellulitis was never removed from the care plan. During an interview with the Nursing Home Administrator and Clinical Consultant on January 4, 2024, at 10:30 AM, both were in agreement that the care plan should have been revised to remove the cellulitis diagnosis. 28 Pa. Code 211.12(d)(1)(3)Nursing services

Based on interviews, it was determined the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings include: During interview with the Nursing Home Administrator (NHA) on January 19, 2023, at 9:30 AM, the facility was unable to provide a policy that addressed water management or a list of water management team members. During the interview with the NHA on January 19, 2023, additional data was requested and unable to be provided that would support implementation of a water management program, such as legionella risk assessment, a water system flow chart that identifies risk areas, testing of shower heads, and professional water testing to determine any contaminants. The facility was unable to show control measures to prevent growth and spread of water-borne contaminants, no water quality parameter measurements, no validation for routine environmental sample results of Legionella testing, no monitoring of high risk areas, and no plan for when control limits are not met and/or control measures are not effective. During an interview with Employee 5 (Director of Building and Grounds) on January 19, 2023, at approximately 11:30 AM, Employee 5 was unaware of the requirement to develop a water management program. During a final interview with the NHA on January 19, 2023, at 11:45AM, the NHA confirmed the facility hasn't developed a water management program. 28 Pa. Code 201.18(b)(1)(d)(e)(1)Management

Based on review of select facility policy, clinical records, and interviews, it was determined that the facility failed to ensure that the residents were free from significant medication errors regarding the administration of medications within the parameters established by the resident's physician, for one of four residents reviewed, when the resident was administered an anticoagulant medication with an abnormal INR (international normalized ratio, a number evaluating the extrinsic pathway and common pathway of coagulation), resulting in harm, evaluation at the emergency room , and admission to the hospital with an abdominal bleed (Resident 197). Findings include: Review of facility's policy titled, Medication Administration General Guidelines with a revision date of (MONTH) (YEAR) revealed in the section labeled, Medication Administration step 1, Medications are administered in accordance with written orders of the prescriber. Review of Resident 197's clinical record revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of lab report indicated that Resident 197's INR was 2.5 when the resident's blood was drawn on (MONTH) 14, 2019, at 5:50 AM. The lab report also indicated that it was faxed to the facility on (MONTH) 14, 2019, at 11:10 AM. Review of Resident 197's Medication Administration Record [REDACTED]. Review of Resident 197's progress notes revealed that on (MONTH) 18, 2019, at 11:39 AM the resident was seen by Medical Doctor with c/o severe left sided abdominal pain, concerned about abdominal wall hematoma (localized bleeding outside of blood vessels as he is on anticoagulation) Vs (versus) diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract). Recommend Abdominal CT (computerized tomography scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images). Discussed with patient will transfer him to ER for expedited evaluation and management. Further review of Resident 197's progress notes revealed that on (MONTH) 18, 2019, at 3:59 PM Resident 197 was admitted to the hospital with [REDACTED]. Review of history and physical, completed upon arrival to the emergency department on (MONTH) 18, 2019, at 3:00 PM revealed that Resident 197 had hypovolemic shock (a life-threatening condition in which organs are not getting enough blood or oxygen) and rectus sheath hematoma (an accumulation of blood in the sheath of the rectus abdominus muscle). It is also noted that Resident 197's [MEDICATION NAME] ([MEDICATION NAME] time, a measure of how long it takes your blood to clot) was 44.0 (normal range is 9.4-12.4) and INR was 4.6 (normal range is 1.0-1.2). The Director of Nursing indicated during an interview on (MONTH) 27, 2019, at 2:35 PM that she would expect the physician's orders [REDACTED]. During an additional interview with the Nursing Home Administrator on (MONTH) 27, 2019, at 2:45 PM he indicated that he would expect the physician's orders [REDACTED]. The facility failed to ensure that the resident was free from significant medication errors for one of four residents reviewed, which resulted in harm, requiring evaluation at the emergency room , and admission to the hospital with an abdominal bleed (Resident 197). 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/19/18, 2/28/28, 3/2/17. 28 Pa. Code 201.18(b)(3)(e)(1) Management. Previously cited 4/19/18, 3/2/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/19/18, 3/2/17. 28 Pa. Code 211.12(d)(2) Nursing services. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 4/19/18, 2/28/28, 3/2/17.

Based on review of clinical records, facility documentation, facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that the residents were protected from neglect by failing to provide turning and repositioning per the care plan for six out of 66 residents reviewed who required turning and repositioning by staff on December 17, 2017, (Residents 4, 19, 31, 35, 45, 49). The failure to turn and reposition for one resident resulted in actual harm to the resident (Resident 1) who acquired a pressure ulcer (a soft tissue injury from soft tissue being compressed over a bony area for a long time causing tissue death) from not being turned and repositioned. This situation was identified as an Immediate Jeopardy to the residents' health and safety. Findings include: During an interview on January 9, 2017, at 9:30 a.m. with the Nursing Home Administrator, it was disclosed that the facility implemented a program on December 5, 2016, on all neighborhoods in the facility called Open Floor. The NHA explained that according to the Open Floor program the Nurse Aides (NA) were not given specific residents to care for. She also disclosed that the facility had no policy or procedure for the Open Floor program and the staff were not provided with any written or educational training as to what they were required to do. A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan titled, Potential for Skin Breakdown, which was initiated on July 18, 2013 and was current at the time of the Open Floor implementation, revealed that the Resident 1 was to be turned and repositioned every 2 to 3 hours as to comfort level and preference. Review of the comprehensive annual Minimum Data Set (MDS -an assessment tool of all care areas specific to the resident) dated September 21, 2016, Section G Functional Status revealed under G0110 Activities of Daily Living Assistance, assessment A, bed mobility (turning from side to side and positioning) was coded as a 2 (indicating the resident needed a one person physical assist). During an interview with Nurse Aide (NA) 1 on January 9, 2017, at 11:55 a.m. it was revealed that on December 17, 2016, all the nurse aides did the Open Floor program and were responsible for everybody on the unit. NA 1 stated they were never given any staff education on how the procedure should work. NA 1 stated, I felt lost. During an interview with NA 2 on January 9, 2017, at 1:10 p.m. it was revealed that NA 2 was on the Snapdragon Neighborhood (Resident 1's neighborhood) on December 17, 2016, during the evening shift. NA 2 was never given education on how the Open Floor program was to work. NA 2 revealed that they also needed to provide 1 to 1 care for one of the residents on the unit. An interview with NA 3 on January 9, 2017, at 3:40 p.m. revealed that the Open Floor program started the beginning of December 2016. NA 3 was on the Snapdragon Neighborhood on the December 17, 2016, during the evening shift. NA 3 provided 1 to 1 care for three hours and cared for 11 residents. NA 3 revealed that, No education was provided for doing open hall. The NA's were to take care of who they wanted and with colored markers were to check what they had done. A paper was kept in the clean utility room. NA 3 stated that during a review of the sheet in the clean utility room, he/she noticed that Resident 1 had no care. He/she notified NA 4 An interview with NA 4 on January 9, 2017, at 4:10 p.m. revealed that the Open Floor program started in December 2016 and no procedure or class was given as to how the program was to work. NA 4 was on the Snapdragon Neighborhood on the December 17, 2016, during the evening shift. There was 1 to 1 being provided during the shift and everyone took turns. In the clean utility room, everyone had different colored markers and highlighted the sheet when the work was done. About 8:30 p.m. or 9:00 p.m. NA 4 rolled Resident 1 to provide care and noticed a spot on the buttock. NA 4 stated, I did not know who needed turned and repositioned on Snapdragon. Review of a staff witness statement dated December 17, 2016, from 3:00 p.m. to 3:00 a.m. by Licensed Practical Nurse (LPN) 1 revealed that they were called into Resident 1's room at approximately 9:00 p.m. NA 4 had noticed an area on Resident 1's buttocks. The area was noted, measured and reported to Registered Nurse (RN) 1. LPN 1 asked when Resident 1 last provided care and by whom. When NA 5 was asked if she checked on Resident 1 during the shift, she stated, no. NA 3 stated she was working in the back of the hallway doing 1 to 1 care. NA 2 came on shift at 6:30 p.m. and did not provide any care to Resident 1. A review of the nurses' notes dated December 17, 2016, at 21:00 (9:00 p.m.) by RN 1 revealed, Resident (Resident 1) has a new area on buttock. Left buttock has a horizontal stripe measuring 6 cm (centimeters-metric unit of measurement). It is dark purple and non-blanching (white appearance), slightly raised. The margins are normal in color. Below it on the left buttock is a 4 cm. stripe that is red and non-blanching with a small purple spot on the area closest to the cleft (groove between the buttocks). That area is still closed and measures 0.7 x (by) 0.5 cm. The margins are slightly pink. There is a third area measuring 3 cm to the right of the cleft. This is dark pink and is blanchable. The sacral (bones at the bottom of the spine) crease is pink and blanchable from top to bottom. Review of the facility investigation completed by the Director of Nursing on December 17, 2016, for the incident occurring on December 17, 2016, revealed that the Root Cause identified for the pressure ulcer development was identified as the poor execution of a new process called the Open Floor program, where the NA's were not assigned specific residents to care for and everyone was to take care of all of the residents. The investigation revealed that on December 17, 2016, the resident was incontinent at 12:53 p.m. and then had AROM (Active Range Of Motion- movement of the extremities by staff) for 15 (minutes) documented at 1:53 p.m. On the evening shift, the resident was assisted with her meal at 6:54 p.m. LPN (Licensed Practical Nurse) gave the resident her medications at 7:33 p.m. and at 8:14 p.m. Evening care was then provided as well as incontinent care at 10:17 p.m. Upon investigation into why the resident was not checked for incontinence/turned or repositioned (T & R) between 12:53 p.m. and 10:17 p.m. (a period of almost 9 ½ hours) it was found that none of the NA's realized that she had not been cared for. Due to the Open Floor program, there was no one specifically assigned to this resident. Although the resident was significantly at risk due to illness/decline, the investigation indicated that the Root Cause of the skin breakdown was due to missed T & R and incontinence care. Ultimately, this missed T & R and incontinence care was due to the poor execution of the new Open Floor program for NA's. Review of the turning and repositioning report for December 17, 2016, for the evening shift revealed that Residents 4, 19, 31, 35, 45, and 49 were documented as not turned and repositioned for the evening shift. Review of the assignment sheet dated December 20, 2016, revealed that all of the NA's were assigned specific residents to provide care for and the DON discontinued the Open Floor program. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 9, 2016, at 5:17 p.m. related to Resident 1 being not being turned and repositioned from 12:53 to 10:17 p.m. or checked for incontinence resulting in harm and an acquired pressure ulcer (a soft tissue injury from soft tissue being compressed over a bony area for a long time causing tissue death) to the left buttock on December 17, 2017. An immediate corrective action plan was requested from the Nursing Home Administrator and the Director of Nursing on how re-education was going to be provided to all nursing personnel regarding neglect. An acceptable corrective action plan was received from the facility on January 9, 2016, at 8:15 p.m. that included re-educating staff on turning and repositioning per the care plans. The Immediate Jeopardy was removed on January 10, 2016, at 1:00 p.m. after the implementation of the corrective action plan was verified. During an interview with the NHA on January 10, 2017, at 12:30 p.m. it was revealed that her expectation was that the plan of care should have been followed and that Resident 1 should have been turned and repositioned and checked for incontinence. The facility neglected to create and provide staff with a policy and procedure for implementing the Open Floor program for resident care and failed to provide education related to the procedure resulting in harm to Resident 1. Resident 1 was not being turned and repositioned as well as checked for incontinence for over 8 hours and acquired a pressure ulcer (a soft tissue injury from soft tissue being compressed over a bony area for a long time causing tissue death) to the left buttock which required physician's orders [REDACTED]. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/26/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/11/16, 3/26/15.

Based on observation, clinical record review and staff interviews, it was determined that the facility failed to provide care designed to prevent pressure sore development resulting in harm regarding the acquiring of an unstageable (under the skin) pressure ulcer (a soft tissue injury from soft tissue being compressed over a bony area for a long time causing tissue death) for one of three residents reviewed (Resident 1). Findings include: During an interview on January 9, 2017, at 9:30 a.m. with the Nursing Home Administrator it was disclosed that the facility implemented a program on December 5, 2016, on all neighborhoods in the facility called Open Floor. The NHA explained that according to the Open Floor program the Nurse Aides (NA) were not given specific residents to care for. She also disclosed that the facility had no policy or procedure for the Open Floor program and the staff were not provided with any written or in-class training as to what they were required to do. A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan titled Potential for Skin Breakdown, which was initiated on July 18, 2013 and was current at the time of the discovery of the Open Floor implementation, revealed that Resident 1 was to be turned and repositioned every 2 to 3 hours as to comfort level and preference. Review of the comprehensive annual Minimum Data Set (MDS -an assessment tool of all care areas specific to the resident) dated September 21, 2016, section G Functional Status revealed under G0110 Activities of Daily Living Assistance, assessment A bed mobility (turning from side to side and positioning) was coded as a 2 (indicating the resident needed a one person physical assist). During an interview with Nurse Aide (NA) 1 on January 9, 2017, at 11: 55 a.m. it was revealed that on December 17, 2016, all the nurse aides did the Open Floor program. Everybody was responsible for everybody. NA 1 stated they were never given any staff education on how the procedure should work. I felt lost. During an interview with NA 2 on January 9, 2017, at 1:10 p.m. it was revealed that NA 2 was on the Snapdragon Neighborhood (Resident 1's neighborhood) on the December 17, 2016, evening shift. NA 2 was never given education on how the Open Floor program was to work. NA 2 revealed that they provided 1 to 1 care for one of the residents on the unit. An interview with NA 3 on January 9, 2017, at 3:40 p.m. revealed that the Open Floor program started the beginning of December 2016. NA 3 was on the Snapdragon Neighborhood on the December 17, 2016, evening shift. NA 3 provided 1 to 1 care for three hours and cared for 11 residents. NA 3 revealed that No education was provided for doing open hall. The NA's were to take care of who they wanted and with colored markers to check what they had done. A paper was kept in the clean utility room. NA 3 stated that a review of the sheet in the clean utility room, he/she notice that Resident 1 had no care. He/she notified NA 4. An interview with NA 4 on January 9, 2017, at 4:10 p.m. revealed that the Open Floor program started in December 2016. NA 4 indicated there was no procedure or class given as to how it works. NA 4 was on the Snapdragon Neighborhood on December 17, 2016, during the evening shift and indicated there was 1 to 1's going on during the shift and everyone took turns. NA 4 stated that in the clean utility room everyone had different colored markers and highlighted the sheet when the work was done. About 8:30 p.m. or 9:00 p.m. rolled Resident 1 to provide care and NA 4 noticed a spot on the buttock. NA 4 stated, I did not know who needed turned and repositioned on Snapdragon. Review of a staff witness statement dated December 17, 2016, from 3:00 p.m. to 3:00 a.m. by Licensed Practical Nurse (LPN) 1 revealed that they were called into Resident 1's room at approximately 9:00 p.m. NA 4 had noticed an area on Resident 1's buttocks. The area was noted, measured and reported to Registered Nurse (RN) 1. LPN 1 asked when Resident 1 last cared for and by whom, NA 5 when asked if she checked on Resident 1 all shift she stated no. NA 3 stated she was working in the back of the hallway doing 1 to 1. NA 2 came on shift at 6:30 p.m. and did not provide any care to Resident 1. A review of the nurses' notes dated December 17, 2016, at 21:00 (9:00 p.m.) by RN 1 revealed Resident (Resident 1) has a new area on buttock. Left buttock has a horizontal stripe measuring 6 cm (centimeters-metric unit of measurement). It is dark purple and non-blanching (white appearance), slightly raised. The margins are normal in color. Below it on the left buttock is a 4 cm. stripe that is red and non-blanching with a small purple spot on the area closest to the cleft (the groove between the buttocks). That area is still closed and measures 0.7 x (by) 0.5 cm. The margins are slightly pink. There is a third area measuring 3 cm to the right of the cleft. This is dark pink and is blanchable. The sacral (bones at the bottom of the spine) crease is pink and blanchable from top to bottom. Review of the facility investigation completed by the Director of Nursing (DON) on December 17, 2016, for the incident occurring on December 17, 2016, revealed that the Root Cause identified for the pressure ulcer development was identified as the poor execution of a new process called the Open Floor program, where the NA's were not assigned specific residents to care for and everyone was to take care of all of the residents. The investigation revealed that on December 17, 2016, the resident was incontinent at 12:53 p.m. and then had AROM (Active Range Of Motion- movement of the extremities by the staff) for 15 (minutes) documented at 1:53 p.m. On the evening shift, the resident was assisted with her meal at 6:54 p.m. LPN (Licensed Practical Nurse) gave the resident her medications at 7:33 p.m. and at 8:14 p.m. Evening care was then provided as well as incontinent care at 10:17 p.m. Upon investigation into why the resident was not checked for incontinence/turned or repositioned (T & R) between 12:53 p.m. and 10:17 p.m. (a period of almost 9 ½ hours) it was determined that none of the NA's realized that the resident had not been provided care. Due to the Open Floor program, there was no one specifically assigned to this resident. Although the resident was significantly at risk due to illness/decline, the investigation indicated that the Root Cause of the skin breakdown was due to missed T & R and incontinence care. Ultimately, this missed T & R and incontinence care was due to the poor execution of the new Open Floor program for NA's. Review of the turning and repositioning report for December 17, 2016, evening shift revealed that Residents 4, 19, 31, 35, 45, and 49 were documented as not turned and reposition for the evening shift. Review of the assignment sheet dated December 20, 2016, revealed that all of the NA's were assigned specific residents to provide care for and the DON discontinued the Open Floor program. During an interview with the NHA on January 10, 2017 at 12:30 p.m. it was revealed that her expectation was that the plan of care should have been followed and Resident 1 should have been turned, repositioned and toileted. The facility failed to ensure that the staff turned and repositioned the resident as well as checked for incontinence resulting in harm to Resident 1 who acquired a pressure ulcer to the left buttock which required physician's orders [REDACTED]. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/26/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/11/16, 3/26/15.

Based on observation, clinical record review, and staff interview the facility failed to ensure the resident environment remained free of accidental hazards and that the residents receive adequate supervision and assistance devices to prevent accidents for four of 18 residents reviewed ( Residents 1, 4, 13, & 19). Findings include: Review of clinical record for Resident 1 on March 10, 2014 at approximately 10:00 a.m., revealed [DIAGNOSES REDACTED]. Review of clinical record for Resident 1 on March 11, 2014 at approximately 12:30 p.m. revealed Resident 1 experienced a fall from his wheelchair on July 8, 2013 that resulted in no injuries. The intervention recorded on the facility incident report stated, " Intervention is for therapy to assess resident ' s (wheelchair) and the position of resident while in (wheelchair) " . Review of Resident 1 ' s clinical record on March 11, 2014 at approximately 1:15 p.m. revealed no physical/occupational therapy screen was performed as a result of the fall. Review of the resident care plan revealed no update for therapy screen was added to care plan. Interview with the Director of Nursing on March 12, 2014 at approximately 3:00 p.m. revealed the consult to physical therapy related to fall on July 8, 2013 by Resident 1 was never done and should have been. Review of Resident 4's clinical record revealed on August 11, 2013 at 1:55 p.m. Resident 4 rose from the wheelchair, walked a few feet and then fell on the carpeted part of the floor. Resident 4 sustained no injuries. Intervention was for physical therapy to evaluate resident for safe positioning in the wheel chair. Review of Resident 4's Plan of Care dated August 9, 2013 revealed Resident 4 is at Risk for Falls related to weakness, restlessness, climbing out of bed, poor and safety awareness. Intervention dated August 9, 2013 revealed Physical and Occupational Therapy evaluation and treat as needed. Interview with Therapy Director on March 11, 2014 at 1:40 p.m. revealed Physical Therapy never received a consultation to evaluate Resident 4 related to a fall on August 11, 2013. Interview with the Director of Nursing on March 12, 2014 at 3:00 p.m. revealed the consult to physical therapy related to fall on August 11, 2013 by Resident 4 was never done and should have been. Review of Resident 19's clinical record revealed on November 8, 2013 at 10:35 a.m. resident was found in room sitting on floor in front of recliner; sensor alarm was not in place. Facility's investigation revealed Resident 19's sensor alarm was not moved from wheelchair to recliner when returned from therapy. Resident 19 sustained no injury. Review of resident 19's Plan of Care revealed resident is at Risk for Falls related to history of fall and right hip fracture repair. Intervention was chair clip alarm. Interview with the Director of Nursing on March 13, 2014 at 11:15 a.m. revealed the Resident 19 chair clip alarm should have been moved from the wheel chair to the recliner when the resident was brought back from therapy on November 8, 2013. Upon entering the facility on March 10, 2014 at approximately 11:00 a.m., Resident 13 was observed lying supine on the floor in the hallway adjacent to the kitchen. Resident 13 was observed to have a pool of blood collected underneath her head while staff appeared to be applying pressure to the back area of her head. A walker was observed in the general vicinity of the resident. During observation of Resident 13, Nursing Home Administrator (NHA) stated that the resident had just sustained a fall. Review of Resident 13 ' s clinical record on March 12, 2014 at approximately 12:30 p.m. revealed admission medical [DIAGNOSES REDACTED]. (a progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality contact and functioning ability), generalized weakness, osteoporosis, and history of cerebral vascular accident (stroke). Review of clinical records revealed facility document titled " Team Conference Record for Transfer " was not complete and did not specify Resident 13 ' s level of assistance needed for transfer. Review of Resident 13 ' s clinical record revealed she was care-planned for " (Activities of daily living) function impaired (related to): recent hospital stay, syncope, (urinary tract infection), (Parkinson ' s disease), dementia, (restless leg syndrome), depression " . Resident 13 ' s transfer status was not documented within this care-plan. During staff interview on March 13, 2014, Director of Nursing acknowledged that Resident 13 had no determination or documentation of assistance needed for transfer or transport upon admission. Review of facility " incident note " on March 12, 2014 at approximately 1:00 p.m. stated, " Resident was walking with therapy volunteer (down) hall across from kitchen " when the fall on March 10, 2014 occurred. Review of document titled, " Event Details " on March 12, 2014 at approximately 1:15 p.m. stated resident, " ...was being accompanied to her first therapy session with assist of 1 and rolling walker, which was her norm, according to hospital records " . During staff interview on March 13, 2014 at approximately 9:10 a.m. with Therapy Director it was revealed that responsibility for transporting residents to therapy is shared between therapy staff, facility staff, and volunteers. She revealed volunteers received no training on transporting residents who use walkers and that no protocols and/or procedures for transporting residents were in place at the time of Resident 13 ' s fall. During phone interview on March 13, 2014 at approximately 10:50 a.m., Volunteer 1 stated he had not received training on transporting residents who use a walker, nor who are deemed to need assistance of 1 to be transported. Volunteer 1 stated he had received no instruction from nursing or therapy staff prior to escorting the resident to physical therapy on March 10, 2014. Volunteer stated while escorting Resident 13 from her room to the therapy room, resident was walking, " ...a step or two ahead of me, " when she began to accelerate and, " get away from me. " Resident fell to her knee and fell to her back. Clinical record review on March 13, 2014 at approximately 10:00 a.m. revealed resident sustained [REDACTED]. During staff interview on March 10, 2014 at approximately 3:00 p.m., Director of Nursing (DON) revealed Resident 13 was transported to Memorial Hospital, via ambulance, for evaluation and possible treatment. Staff interview on March 13, 2014 at approximately 11:20 a.m., NHA stated volunteers are not trained how to transport residents who require assistance of one. During this interview NHA stated that Resident 13 should not have been transported by Volunteer 1. 483.25 (h) Accidents. Previously cited 4/11/13 28 Pa. Code: 201.18 (e) (1) Management. Previously cited 4/11/13 28 Pa. Code: 201.29 (d) Resident Rights. Previously cited 4/11/13, 3/1/12. 28 Pa. Code: 211.10 (d) Resident Care Policies. Previously cited 4/11/13 28 Pa. Code: 211.12 (d)(3)(5) Nursing Services. Previously cited 4/11/13, 3/1/12. 28 Pa. Code: 211.12 (d) (2) Nursing Services. Previously cited 4/11/13