Every finding on record at Concordia Lutheran Health and Human Care

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.A review of facility policy Food Safety and Sanitation dated 1/3/25, indicated all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. During an observation on 8/4/25, at 10:55 a.m., of the walk-in cooler in the main kitchen, conducted with Dietary Supervisor (DS) Employee E2, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and the area of the condenser immediately around the fans. DS Employee E2 confirmed observation by surveyor when viewed. During an interview on 8/4/25, at 10:57 a.m., DS Employee E2 confirmed that the facility failed to properly maintain kitchen equipment, walk-in cooler, in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of six residents sampled with facility-initiated transfers (Residents R11, R42, R143, and R201), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of six resident hospital transfers (Residents R4, R11, and R143).Findings include: Review of facility policy Transfer and Discharge (including AMA) dated 1/7/25, indicated for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner who was responsible for care of the resident; Resident representative information, including contact information; Advance directive information; All other information necessary to meet the resident's needs, which includes, but may not be limited to: resident status, diagnoses and allergies, medications (including when last received), and most recent relevant labs, other diagnostic test, and recent immunizations All special instructions and/or precautions for ongoing care, as appropriate; The resident's comprehensive care plan goals Document assessment findings and other relevant information regarding the transfer in the medical record. Review of facility policy Bed Hold Notice dated 1/7/25, indicated in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/19/25, indicated diagnoses of muscle wasting, constipation, and dependence on supplemental oxygen. Review of the clinical record indicated Resident R4 was transferred to the hospital on 7/9/25, and did not return to the facility. Review of Resident R4's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 7/9/25. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's MDS dated [DATE], indicated diagnoses of reduced mobility, constipation, and chronic pain. Review of the clinical record indicated Resident R11 was transferred to the hospital on 5/27/25, and returned to the facility on 6/2/25. Review of Resident R11's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R11's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 5/27/25. Review of the clinical record indicated Resident R42 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R42's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anemia (too little iron in the body causing fatigue), and anxiety (a feeling of worry, nervousness, or unease). Review of the clinical record indicated Resident R42 was transferred to the hospital on 2/21/25, and returned to the facility on 2/26/25. Review of Resident R42's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 8/8/25, at 9:19 a.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Resident R42. Review of the clinical record indicated Resident R143 was admitted to the facility on [DATE]. Review of Resident R143's MDS dated [DATE], indicated diagnoses of anemia (too little iron in the blood), muscle wasting, and need for assistance with personal care. Review of the clinical record indicated Resident R143 was transferred to the hospital on 3/21/25, and returned to the facility on 3/24/25. Review of Resident R143's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R143's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/21/25. Review of the clinical record indicated Resident R201 was admitted to the facility on [DATE]. Review of the clinical record indicated Resident R201 was transferred to the hospital on 8/6/25. Review of Resident R201's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs at the receiving facility including a list of current medications. During an interview on 8/7/25, at 2:14 p.m. the Nursing Home Administrator confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for three of six resident hospital transfers (Residents R4, R11, and R143). During an interview on 8/7/25, at 2:51 p.m. the DON confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Residents R5, R11, and R201. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications for one of four residents (Resident R171) the pharmacy driver left medications unattended and unsecured during a delivery during one observation. Findings include: Review of the facility Medication Storage in the Facility policy dated 1/7/25, stated medications and biologicals are stored safely, securely, and properly following manufactures recommendations or those of the supplier. The medication supply is only accessible to licensed nursing personal, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of Resident R171's admission record indicated she was admitted [DATE], with diagnosis that included pulmonary hypertension, atrial fibrillation (irregular heartbeat), and polycythemia vera (rare type of blood cancer). During an observation on 8/4/25, at 1:12 p.m. the following was observed on Resident' R171's bedside dresser.-(1) tube of Muscle Rub-Methyl salicylate/menthol-(1) bottle Nystatin-100,000 units per gram, 30 gram bottle -(1) bottle Deep Sea Premium Saline bottle During an interview on 8/4/25, at 1:15 p.m. Registered Nurse, Employee E8 confirmed the above observations and that the facility failed to properly store medications for Resident R171. During an observation on 8/7/25, at 12:05 p.m. three bins of unsecured medications from pharmacy were observed left on a utility cart in the hallway. A total of 333 resident medication cards were observed throughout the three bins. During an interview on 8/7/25, at 12:09 p.m. Pharmacy Driver, Employee E9 indicated they were in the middle of restocking medication carts. Pharmacy Driver, Employee E9 confirmed three bins of medications were left unsecure in the hallway. During an interview on 8/7/25, at 12:11 p.m. the Director of Nursing confirmed the facility failed to properly store medications for one of four residents (Resident R171) and the pharmacy driver left medications unattended and unsecured during a delivery during one observation. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of two residents (Residents R5 and R143), and failed to ensure enhanced barrier precautions (EBP) were implemented for two of three residents (Resident R10 and R40). Findings include: Review of facility policy Enhanced Barrier Precautions dated 1/3/25, indicated the facility will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions may be implemented for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. During an observation on 8/4/25, at 10:50 a.m. Resident R5 had a small personal refrigerator in their room. The temperature log had data recorded for 8/1/25, but no documented temperatures for 8/2/25, and 8/3/25. During an observation on 8/4/25, at 10:56 a.m. Resident R143 had a small personal refrigerator in their room. The temperature log had data recorded for 8/1/25, but no documented temperature for 8/2/25, and 8/3/25. During an interview on 8/4/24, at 10:58 a.m. Licensed Practical Nurse (LPN) Employee E1 stated, The temperatures are supposed to be done on the day shift and usually the next shift will get them if it's missed. During an interview on 8/4/25, at 11:33 a.m. LPN Employee E1 confirmed that the facility failed to properly monitor a resident's personal refrigerator to ensure that food is properly stored and maintained for Residents R5 and R143. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/25, indicated diagnoses of humerus (upper arm) fracture, protein-calorie malnutrition, and diabetes mellitus (group of diseases that affect how the body used blood sugar (glucose)). Section M0210, Unhealed Pressure Ulcers/Injuries was coded 1, indicating current number of unhealed pressure ulcer/injuries. Review of Resident R10's Skin and Wound Evaluation dated 7/28/25, revealed that a Stage III (full-thickness skin loss) pressure ulcer was developed in-house on 6/11/25 to Resident R10's coccyx (commonly known as the tailbone - small, triangular bone located at the bottom of the vertebral column); current measurements - length 1.3 centimeters, width 0.7 centimeters, and depth 0.1 centimeters. Review of Resident R10's current physician order dated 7/7/25, indicated to cleanse: coccyx wound with NSS (normal saline solution), apply Santyl (prescription medicine that removes dead tissue from wounds) nickel thick layer to wound bed followed by calcium alginate (wound care treatment for the management of highly draining wounds). Apply Magic Mix (Lidocaine gel 3%, Triamcinolone 0.25%, Nystatin cream, Zinc oxide 40%, 1:1:1:2) to peri wound (skin around the wound that is affected by the wound). Cover with a bordered foam, every day shift for wound. Review of Resident R10's clinical record and direct observation of Resident R10's room on 8/6/25, revealed no evidence that the facility implemented Enhanced Barrier Precautions (EBP) for Resident R10 due to current pressure ulcer. During an interview on 8/6/25, at 10:00 a.m., Infection Preventionist (IP) Employee E4 confirmed that the facility failed to implement EBP's for Resident R10. Review of the admission record indicated Resident R40 was admitted to the facility on [DATE]. Review of R40's MDS dated [DATE], included diagnoses of anemia (the blood doesn't have enough healthy red blood cells), malnutrition, and muscle wasting. Review of Resident R40's physician order dated 8/2/25, indicated to implement contact isolation precautions due to ESBL (E. Coli) of the urine. During an observation on 8/6/25, at 8:16 a.m. contact isolation signage was posted at the entrance of Resident R40's door. Licensed Practical Nurse Employee E7 entered Resident R40's room without a gown and failed to wash their hands. LPN Employee E7 administered Resident R40's medication without any PPE (personal protective equipment). During an interview on 8/6/25, at 8:43 a.m. the IP Employee E4 confirmed the facility failed to enter the correct order for isolation and implement isolation precautions for Resident R40. IP Employee E4 confirmed Resident R40's order for isolation should have been enhanced barrier precautions. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to identify and assess a resident for smoking safety in a timely manner for one of two residents (Resident R89).Findings include: Review of the facility policy Resident Smoking dated 1/7/25, indicated that all residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS (Minimum Data Set- periodic assessment of resident care needs) assessment process. Residents who smoke will be further assesses, using a smoking assessment tool designated by the facility, to determine whether or not supervision is required for smoking, or of the resident is safe to smoke at all. Review of Resident R89's clinical record revealed documentation from the hospital dated 2/3/25, that resident is a smoker and smokes one pack of cigarettes per day, and has been smoking for the past 40 years. Review of clinical record revealed that Resident R89 was admitted to the facility on [DATE]. Review of clinical record revealed a history and physical completed by the physician on 2/18/25, that indicated that Resident R89 uses tobacco products at least daily and smokes 1 pack of cigarettes per day. Review of Resident R89's MDS dated [DATE], indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Section J1300 stated yes to current tobacco use. Review of Resident R89's clinical record revealed that a Smoking- Safety Screen was completed on 3/24/25, and indicated that resident would like to smoke two to five cigarettes per day in the mornings, and evenings, and that resident requires supervision to smoke. Review of Resident R89's plan of care revealed interventions for smoking were initiated on 4/2/25. During an interview on 8/7/25 at 10:29 a.m. the Nursing Home Administrator (NHA) confirmed that the facility does allow smoking. The NHA confirmed that Resident R89's Smoking - Safety Screen was not completed in a timely manner, as it was completed on 3/24/25, five weeks after her 2/17/25 admission, and that care plan interventions were not implemented un 4/2/25. During an interview on 8/8/25 at 11:45 a.m. the Nursing Home Administrator confirmed that the facility failed to properly identify Resident R89 as a smoker upon admission, and that the facility failed to timely assess and care plan Resident R89 for smoking safety. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of five residents (Resident R5). Findings include: Review of facility policy Wound Treatment Management dated 1/7/25, indicated to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence based - treatments in accordance with current standards of practice and physician orders. Treatments will be documented on the Treatment Administration Record (TAR). Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/11/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and hyperlipidemia (high levels of fat in the blood). Review of a physician order dated 7/1/25, indicated to cleanse coccyx (tailbone) wound with NSS (normal sterile saline), apply collagen particles (used to promote new tissues growth) to wound bed followed by medical grade honey (a gel used to promote wound healing), place calcium alginate (a highly absorbent dressing) in wound bed over the honey and cover wound with a large bordered gauze every day shift for wound. Review of Resident R5's July 2025 TAR indicated the treatment was not documented as completed during the day shift on 7/6/25. Review of a physician order dated 7/16/25, indicated to cleanse coccyx wound with NSS, apply calcium alginate, collagen particles, medical grade honey, house antifungal ointment to peri (surrounding) wound every day. Cover with a bordered gauze dressing every day shift for wound. Review of Resident R5's July 2025 TAR indicated the treatment was not documented as completed during the day shift on 7/24/25. During an interview on 8/8/25, at 1:12 p.m. Licensed Practical Nurse (LPN) Wound Nurse Employee E3 confirmed that the facility failed to make certain Resident R5 received proper treatment for a pressure ulcer as required. 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of two residents reviewed (Resident R84), relating to visual impairment.Findings include: Review of the facility policy Comprehensive Care Plans dated 1/7/25, indicated that the comprehensive, person-centered care plan included measurable objectives and time frames, to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified to meet the resident's needs. Review of the clinical record revealed that Resident R84 was admitted to the facility on [DATE]. Review of Resident R84's MDS (Minimum Data Set, periodic assessment of care needs) dated 7/20/25, indicated diagnoses of hip fracture, depression, and migraine. Section B1000. Vision revealed the resident's ability to see in adequate light was highly impaired. Review of Resident R84's progress note dated 8/1/25, stated the resident was legally blind-staff to assist in belongings within reach. Review of Resident R84's care plan on 8/5/25, failed to include a care plan for the resident's visual impairment. During an interview on 8/6/25, at 12:45 p.m. Licensed Practical Nurse (LPN), Employee E5 confirmed Resident R84 failed to have a care plan for the resident's visual impairment. Interview with the Director of Nursing and the Nursing Home Administrator on 8/6/25, at 12:49 p.m. confirmed the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for one of two residents reviewed (Resident R84), relating to visual impairment. 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of four residents (Resident R10).Review of facility policy Use of Psychotropic Medication(s) date 1/3/25, indicated that residents only receive psychotropic medications when other nonpharmacological interventions are clinically ineffective. Additionally, these medications should only be used to treat the resident's medical symptoms and not used to discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. Psychotropic medications are the be used only when a practioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to medication(s).Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE].Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/26/25, indicated diagnoses of humerus (upper arm) fracture, protein-calorie malnutrition, and diabetes mellitus (group of diseases that affect how the body used blood sugar (glucose)).Review of Resident R10's Medication Administration Record (MAR) for July 2025, indicated Lorazepam oral tablet (a psychotropic medication used to treat anxiety) 1 milligram, give 1 tablet by mouth every four hours as needed for severe anxiety, initiated 6/5/25, and discontinued 7/16/25.Review of Resident R10's current physician order dated 7/16/25, indicated to administer Lorazepam tablet (a psychotropic medication used to treat anxiety) 0.5 milligram, give 0.5 milligram by mouth every eight hours as needed (PRN) for anxiety.Review of Resident R10's current care plan indicated use of psychotropic medication for anxiety and depression, with interventions to monitor for side effects and effectiveness every shift; Monitor/document/report as needed any adverse reactions of psychotropic medications.Review of Resident R10's MAR dated July 2025 through August 2025, indicated that resident received Lorazepam PRN (as needed) 10 times per order.Review of Resident R10's current physician order dated 5/16/25, indicated to administer Duloxetine HCl Capsule Delayed Release Particles (a psychotropic medication used to treat anxiety and nerve pain) 60 milligrams, give 1 capsule by mouth in the morning for neuropathy.Review of Resident R10's clinical record failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R10's Lorazepam PRN. Further review of Resident R10's clinical record revealed no evidence that the facility had implement side effect or behavior monitoring for psychotropic medication use.During an interview on 8/7/25, at approximately 1:05 p.m., the Director of Nursing (DON) confirmed that the facility did not have documentation of non-pharmacological interventions used prior to administering of as needed psychotropic medication. DON also confirmed that the facility did not have side effect monitoring nor behavior monitoring in place for the safe and effective use of Resident 10's psychotropic medication use.28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations and staff interview it was determined that the facility failed to have complete contact information for the State Long Care Ombudsman program posted at the facility.Findings include: During an observation on 8/8/25, from 10:07 a.m. to 10:38 a.m. poster were noted on bulletin boards in three places for the ombudsman but they did not have the name, address and correct email listed. During an interview on 8/8/25, at 11:25 a.m. the NHA was informed that the ombudsman postings failed to have complete contact information State Long Care Ombudsman program. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R80).Findings include: Review of facility policy Call Lights: Accessibility and Timely Response dated 1/7/25, indicated staff will ensure the call light is within reach of resident and secured, as needed. Review of the clinical record indicated Resident R80 was admitted to the facility on [DATE]. Review of Resident R80's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/25, indicated diagnoses of high blood pressure, reduced mobility, and repeated falls. During an observation on 8/4/25, at 11:05 a.m. Resident R80 was sitting in a recliner in their room. The call bell was placed on Resident R80's bed, out of the resident's reach. During an interview on 8/4/25, at 11:25 a.m. Licensed Practical Nurse Employee E1 confirmed Resident R80's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R80's call bell needs. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, resident and staff interviews it was determined that the facility failed to offer residents the opportunity to vote for the May 2025 election. Findings include: Based on review of facility policy, resident and staff interviews it was determined that the facility failed to offer residents the opportunity to vote for the May 2025 election. Findings include: Review of policy Resident Rights dated 1/7/25, indicated: Exercise of rights The resident has the right to exercise his or her as a resident of the facility and as a citizen of the United States. Review of resident council minutes for three months failed to include information of the facility asking residents about voting. During a resident group on 8/6/25, residents indicated they were not offered the opportunity to vote for the May 2025 election. During an interview on 8/8/25, at 10:57 a.m. Director of Activities Employee E10, confirmed that the facility failed to offer resident the opportunity to vote for the May 2025 election. 28 Pa. Code 201.29(a) Resident rights

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to complete Influenza vaccination consent and administer the Influenza vaccination in a timely manner for one of five residents (Resident R3).Findings include: Review of facility policy Infection Prevention and Control Program dated 4/28/25, indicated all residents and employees will be offered the influenza vaccine. Between October 1st and March 31st each year, the influenza vaccine shall be offered. The resident or employee will be provided information and education regarding the benefits and potential side effects. Education shall be documented in the residents or employee's medical record. Review of the admission record indicated that Resident R3 was admitted to the facility on [DATE]. Review of R3's Minimum Data Set (MDS-periodic assessment of care needs) dated 1/7/25, included diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Resident R3's immunization record failed to include evidence the resident was offered and received the influenza vaccination for the 2024-2025 flu season. During an interview on 8/7/25, at 10:30 a.m. the Director of Nursing confirmed that the facility failed to complete Influenza vaccination consent and administer the Influenza vaccination in a timely manner for one of five residents (Resident R3). 28 Pa. Code 211.5(f) Clinical records

Based on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's transfer destination prior to disposition of a body for two of three residents (Resident CRR1 and CRR2). Findings include: A review of the facility policy Postmortem Care last reviewed [DATE], indicated it is the procedure of this facility to perform postmortem care for a resident who has deceased in the facility to include but not inclusive to: . The family will be contacted and follow up and/or confirmation of the disposition of the body will be determined. . Notify the designated disposition location of a resident's death and fill out any postmortem paperwork as per facility policy. Review of Resident CRR1's clinical record indicate admitted [DATE], with diagnosis of malignant neoplasm of the lung (lung cancer), hypertension (high blood pressure) and chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing). Review of Resident CRR1's clinical progress dated [DATE], indicated Resident CRR1 ceased to breath (CTB) at 2:32 a.m. Further review indicated communication with family and funeral home of choice was [NAME] W. Trenz Funeral home. Review of CRR1's clinical progress note dated [DATE], indicate funeral home picked up body at 4:52 a.m. Review of Resident CRR1's Transfer/discharge report dated [DATE], indicated a signature for the transfer, however failed to identify funeral home name. Review of Resident CRR2's clinical record indicates an admitted [DATE], with diagnosis of malignant neoplasm of cervix (cervical cancer), anxiety and hypertension. Review of Resident CRR2's clinical progress notes dated [DATE] indicate Resident CRR2 CTB [DATE], 1:55 a.m. son came into facility, Skirpan Funeral Home notified. Review of Resident CRR2's transfer/discharge report dated [DATE], indicated signature of transfer to Trenz Funeral home. A review of facility investigation indicated the facility that took possession of Resident CRR2, went to start services, and realized the face sheet was not the same name as the individual who was expected. Family confirmed not their family member. Facility was notified and contacted Skirpan funeral home who inspected body in possession and confirmed via face sheet the individual was resident CRR1 not Resident CRR2. Facility immediately planned for transfer to correct facility. Resident CRR1's family was notified. Transfer to correct facilities was completed. During an interview on [DATE] at 1:25 p.m. the Nursing home administrator confirmed that the transfer form completed for Resident CRR2 indicated Trenz funeral home took possession of deceased not Skirpan funeral home and that the Licensed Practical Nurse on duty failed to verify the correct funeral home and that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of residents transfer destination prior to disposition of a body for two of three residents (Resident CRR1 and CRR2). 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen. Findings include: Review of the facility policy Date Marking for Food Safety dated 1/16/24, indicated the facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. During an observation of the main designated kitchen on 8/25/24 at 10:00 a.m, at the following was observed: - 1 bag of life cereal- no label or date - 2 boxes of pineapple juice- no dates - 1 bag of elbow pasta-no date - 2 boxes of [NAME] Buddy-no date - 1 box of Oatmeal Cream Pie- no date - 1 box of Fudge Rounds-no date Walk in Freezer-(1) bag of meat- no label or date Walk in cooler-(3)crates of drinks, stored on the floor During an observation of the main designated kitchen on 8/25/24, at 10:15 a.m. the following was observed: (1) Wall fan's above clean side of dishwasher, brown debris (1) Floor fan clean side of dishwasher, brown debris During an interview on 8/25/24 at 10:25 a.m., Dietary Supervisor Employee E10 confirmed that the facility failed to properly label and date food products and maintain sanitary conditions which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of license

Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for three of six residents (Residents R24, R77, and R281). Findings include: Review of the facility policy Resident Self-Administration of Medication dated 1/16/24, indicated it is the policy of the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The care plan must reflect resident self-administration. Review of the admission record indicated Resident R77 was admitted to the facility on [DATE]. Review of Resident R77's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/18/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), atrial fibrillation (irregular heart rhythm), and high blood pressure. Review of Resident R77's current physician orders on 8/25/24, failed to include an order for Preparation H (a medication for hemorrhoids), an order for roll on muscle relaxant, and any order indicating self-administration of these medications. Review of Resident R77's care plan on 8/25/24, failed to include use of the medications or a plan to manage/determine self-administration practices. Review of the clinical record on 8/25/24, failed to include that the facility's interdisciplinary team had determined which medications may be self-administered safely. Observation on 8/25/24, at 11:00 a.m. Resident R77 was in bed resting. A bottle of Preparation H and a bottle of roll-on muscle relaxant were noted on the bedside stand. Interview on 8/25/24, at 11:05 a.m. Registered Nurse (RN) Employee E7 confirmed the two medications at bedside and that the resident did not have an order for the medications, or any documentation that it was safe for the resident to do so. Review of the clinical record indicated Resident R281 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), asthma, and bronchitis. Review of Resident R281's physician order dated 8/14/24, indicated Trelegy inhaler (inhaled medication to make breathing easier) one puff in the morning. The order did not indicate self-administration of the medication. Review of Resident R281's care plan on 8/25/24, failed to include a plan to manage/determine self-administration practices. Review of the clinical record on 8/25/24, failed to include that the facility's interdisciplinary team had determined which medications may be self-administered safely. Observation on 8/25/24, at 12:09 p.m. Resident R281 was in his recliner chair. A Trelegy inhaler was noted on the bedside stand. Interview on 8/25/24, at 12:11 p.m. Licensed Practical Nurse (LPN) Employee E6 indicated, Yeah he gives it to himself in the morning, so I just leave it in there. Review of Resident R24's clinical record indicate admitted [DATE] with the diagnosis of chronic obstructive pulmonary disease (difficulty breathing), anemia (low iron in the blood) and dysphagia (difficulty swallowing). Review of Resident R24's physician order dated 8/14/24, indicated Trelegy inhaler (inhaled medication to make breathing easier) one inhalation in the morning. The order did not indicate self-administration of the medication. Review of Resident R24's care plan on 8/25/24, failed to include a plan to manage/determine self-administration practices. Review of Resident R24's clinical record on 8/25/24, failed to include that the facility's interdisciplinary team had determined which medications may be self-administered safely. Observation on 08/25/24, at 12:20 p.m. resident was sitting in her chair, the Trelegy inhaler was sitting on the bedside stand. During an interview on 08/25/24, at 12:26 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the Trelegy inhaler was on the bedside stand and Resident R24 did not have an order for self-administration. Interview on 8/25/24, at 2:00 p.m. the Director of Nursing confirmed the facility failed to determine the ability to self-administer medications for three of six residents (Residents R24, R77, and R281). 28. Pa. Code 211.12(d)(1)(2) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that appropriate treatment and services were provided for five of seven residents with a urinary catheter (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) (Resident R38, R63, R78, R93 and R99). Findings include: Review of facility policy Indwelling Catheter Use and Removal dated 1/16/24, indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards and practice of resident care policies and procedures that include but are not limited to: . Keeping the catheter anchored to prevent excessive tension on the catheter. . Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. Review of Resident R38's clinical record indicate re-admission to facility on 8/23/24, with the diagnosis of heart failure (heart doesn't pump the way it should), atrial fibrillation (abnormal heartbeat), and diabetes (high sugar in the blood) Review of Resident R38's physician orders dated 8/10/24, indicate urinary catheter. Observation on 08/25/24, at 12:00 p.m. Resident R38's urinary drainage bag did not have a dignity/privacy cover. During an interview on 8/25/24, Licensed Practical Nurse (LPN) Employee E 1 confirmed Resident R38's urinary drainage bag did not have a dignity/privacy cover. Review of Resident R63's clinical record indicate an admitted [DATE]. Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/12/24, indicated diagnoses of hypertension (high blood pressure), Parkinson's disease (long term degenerative neurological disorder), and neurogenic bladder (bladder dysfunction). Review of Resident R63's physician orders dated 5/10/24, indicate urinary catheter. During an observation on 8/25/24, Resident R63 was in bed with her urinary drainage bag in a wash basin on the floor. During an interview on 8/25/24, at 11:37 a.m. LPN Employee E2 confirmed Resident R63's urinary drainage bag was in a wash basin on the floor. Review of Resident R78's clinical record indicate an admitted [DATE]. Review of Resident R78's MDS dated [DATE], indicated diagnoses of cancer, Hypertension (high blood pressure), and obstructive uropathy (blockage of urinary flow). Review of Resident R78's physician orders dated 8/5/24, indicate urinary catheter. During an observation on 8/26/24, resident R78 was sitting in his chair in the common area, his urinary drainage bag was sitting in his lap. During an interview on 8/26/24, Registered Nurse (RN) Employee E3 confirmed Resident R78's urinary drainage bag was in his lap and moved it to below his bladder. Review of Resident R 93's clinical record indicate admitted [DATE], with the diagnosis of atrial fibrillation (abnormal heartbeat), obstructive uropathy (blockage of urinary flow), and anemia (low iron in the blood. Review of resident R93's physician orders dated 8/5/24, indicate urinary catheter. During an observation on 8/25/24, at 11:10 a.m. Resident R93 was sitting in his chair, his urinary drainage bag did not have a dignity/privacy cover. During an interview on 8/25/24, at 11:35 a.m. LPN Employee E2 confirmed Resident R93's urinary drainage bag did not have a dignity/privacy cover. Review of Resident R99's clinical record indicate an admitted [DATE]. Review of Resident R99's MDS dated [DATE], indicated diagnoses of anemia (low iron in the blood), obstructive uropathy (blockage of urinary flow), and hypertension (high blood pressure) Review of Resident R99's physician orders dated 6/20/24, indicate urinary catheter. During an observation on 8/5/24, at 11:29 a.m. Resident R99 was in his bed, his urinary drainage bag did not have a dignity/privacy cover. During an interview on 08/25/24, at 11:37 a.m. LPN Employee E2 confirmed that Resident R99's urinary drainage bag did not have a dignity/privacy cover. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12 (d)(2) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of seven residents to accurately reflect the current status of the resident (Resident R54 and R86). Findings include: A review of the facility policy Care Plan Revision Upon Status Change dated 1/16/24, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Residents R54's clinical record indicates an admitted [DATE]. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/24, indicated diagnosis of hypertension (high blood pressure), coronary artery disease (common type of heart disease) and diabetes (high sugar in the blood). Review of Resident R54's physician orders dated 7/17/23, indicate tubigrips bilateral lower extremities on in the a.m. off in the p.m. Review of Resident R54's Treatment administered record for August 2024 indicate tubigrips applied as ordered. Review of Resident R54's care plan failed to include interventions for tubigrips. Review of Residents R86's clinical record indicates an admitted [DATE]. Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/24, indicated diagnosis of congestive heart failure (inefficient myocardial performance, resulting in compromised blood supply to the body), left artificial hip joint and chronic kidney disease. Review of Resident R86's physician orders dated 8/8/24 indicate wanderguard every shift. Review of Resident R86's care plan failed to include interventions for wanderguard. During an interview on 8/28/24, at 10:10 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to revise/update Resident R54's care plan to include interventions for tubigrips and Residents R86's interventions for wanderguard. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, facility procedure review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care of a medical device for one of four residents (Resident R283). Findings include: Review of the facility procedure Closed Suction Drain with Bulb: Management dated 1/16/24, indicated to assess the closed suction drain and tube for proper functioning. Ensure patency, airtight connections, and presence of any leaks or kinks in the drainage system. Secure the drain to the patient's clothing with a safety pin. Ensure the suction device is below the level of the wound and does not pull at the insertion site. Review of the clinical record indicated Resident R283 admitted to the facility on [DATE], with the diagnoses of rib fractures, atrial fibrillation (irregular heart rhythm), heart failure (heart doesn ' t pump blood as well as it should), s/p cholecystitis with possible perforation (gallbladder inflammation and possible rupture), and placement of a percutaneous drain (a plastic tube placed into the body, usually the abdomen, to drain infected fluids). Review of Resident R283's physician order dated 8/21/24, indicated JP Drain (Jackson Pratt a plastic tube placed into the body): Empty drain every shift and document drainage (right abdomen). Review of Resident R283's care plan dated 8/22/24, indicated JP drainage catheter will be free of complications through next review. Review of Resident R283's progress note dated 8/26/24, indicated JP drain output was 30cc (cubic centimeters) of dark green bile (a fluid produced by the liver that helps digest fats). Observation on 8/25/24, at 1:35 p.m. Resident R283 was out of bed in a stationary, recliner chair and the JP drain was dangling over the right-side arm of the chair. Observation on 8/27/24, at 10:04 a.m. Resident R283 was out of bed in wheelchair and the JP drain was dangling to the right side down in the wheelchair. Interview on 8/27/24, at 10:04 a.m. Resident R283 indicated it's sore and it's pulling on her skin. Interview on 8/27/24, at 10:08 a.m. Registered Nurse (RN) Employee E5 indicated he would look for a pin to anchor the drain to Resident R283's clothing. Interview on 8/27/24, at 11:00 a.m. the Director of Nursing confirmed the facility failed to make certain that residents were provided appropriate treatment and care of a medical device for one of four residents (Resident R283). 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and obtain physician orders regarding the dressing displacement for one of three residents (Resident R100). Findings include: Review of the facility policy Negative Pressure Wound Therapy (NPWT-wound vac- used to draw out fluid and infection from a wound to help it heal) dated 1/16/24, indicated to avoid leaving the NPWT device off for more than two hours. If this occurs, remove the old dressing and initiate an NPWT dressing or apply an alternative absorptive dressing as prescribed by the practitioner. Review of the clinical record indicated Resident R100 admitted to the facility on [DATE], with the diagnosis of sepsis (extreme response to an infection), depression, and pressure ulcer of the sacral region (a triangular bone that connects the spine with the hip and pelvic cavity. Review of Resident R100's physician orders dated 8/8/24, indicate wound vac to sacrum, setting 125 millimeters of mercury (mm/hg) continuous. Review of Resident R100's physician orders failed to include orders for displacement of the wound vac device. During an interview on 8/28/24, at 2:05 p.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the facility failed to follow standards of practice and obtain physician treatment orders for dressing displacement for one of three residents (Resident R100). 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, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of eight residents reviewed (Residents R38 and R281), and failed to care plan use and management of respiratory equipment for two of three residents (Resident R5 and R6). Findings include: Review of facility policy Oxygen Concentrator dated 1/16/24, indicated that oxygen is administered under orders of the attending physician, except in the case of an emergency. Review of Resident R5's clinical record indicated admission to the facility on [DATE], with the diagnoses of heart failure (heart doesn't pump blood as well as it should), Parkinson's Disease (disorder of the nervous system that results in tremors), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R5's physician orders dated 5/11/24, indicated: -Change CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) mask and filter every night shift every three months. -Check and ensure CPAP/BIPAP mask and water chamber is cleaned daily. Machine is wiped down with damp cloth every day. -Check CPAP/BIPAP headgear and tubing are cleaned every day shift. Review of Resident R5's progress note dated 8/26/24, indicated resident currently resting in bed, CPAP on per orders. Review of Resident's care plan dated 6/27/24, failed to include interventions and goals for use and management of the CPAP/BIPAP machine. Interview on 8/27/24, at 2:30 p.m. the Director of Nursing confirmed Resident R5's care plan failed to include use and management of the CPAP/BIPAP machine. Review of the clinical record indicated Resident R6 was admitted to the facility 1/10/18, with the diagnoses of cerebral infarction (occurs when a blood vessel in the brain is blocked, leading to inadequate blood supply and oxygen to brain cells), major depressive disorder, and dementia (loss of cognitive functioning which interferes with a person's daily life and activities). Review of Resident R6's current physician orders dated 8/23/24, indicated Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two times a day for sob (shortness of breath) for 2 Weeks, and Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 4 hours as needed for Shortness of Breath. Further review of current physician orders indicated for respiratory status to be monitored every shift, initiated 7/27/22. Review of Resident R6's recapitalization of physician orders dated 4/24/24, indicated Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath and 3 milliliter inhale orally via nebulizer at bedtime for sob (shortness of breath), which was discontinued 8/23/24. Review of Resident R6's care plan dated 3/26/24, failed to include interventions and goals for use and management of respiratory breathing treatments. During an interview on 8/28/24, at 1:50 p.m., Resident Nurse Assessment Coordinator (RNAC) Employee R11 confirmed that Resident R6's care plan failed to include use and management of nebulization breathing treatments. Review of the clinical record indicated Resident R281 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), asthma, and bronchitis. Review of Resident 281's physician order dated 8/14/24, indicated night nurse to check every week if oxygen used, to make sure filter is cleaned and oxygen tubing and humidifier has been changed every night shift. Oxygen at four liters per minute. Review of Resident R281's progress note dated 8/21/24, indicated no respiratory complications noted with oxygen on via nasal cannula. Observation on 8/25/24, at 12:09 p.m., Resident R281 was noted to have oxygen via nasal cannula on, the concentrator flow rate indicated three liters per minute and the oxygen tubing or humidification was not dated as required. Interview on 8/25/24, at 12:10 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the concentrator was on the incorrect flow rate of three, instead of four as ordered, and that there were not dates on the oxygen tubing or humidification as required. Review of the clinical record indicate Resident R38 was readmitted to facility on 8/23/24, with the diagnosis of heart failure (heart doesn't pump the way it should), atrial fibrillation (abnormal heartbeat), and diabetes (high sugar in the blood). Review of Resident R38's physician orders dated 8/23/24, indicate oxygen at 3 liters per minute. Review of physician orders dated 8/16/24, indicated night nurse to check every week on (Fridays), if oxygen used, to make sure filter is cleaned and oxygen tubing and humidifier has been changed. every night shift every 7 days. Review of progress notes dated 8/23/2024, 9:44 p.m., respirations easy and nonlabored on oxygen via nasal canula. Observation on 08/25/24, at 12:00 p.m. Resident R38 was noted to have oxygen on per nasal canula the oxygen tubing failed to be labeled with a date. During an interview on 8/25/24, Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R38's oxygen tubing was not labeled with a date as required. Interview on 8/29/24, at 1:30 p.m. the Nursing Home Administrator (NHA) Director of Nursing (DON) confirmed the facility failed to maintain sanitary conditions of respiratory equipment for two of eight residents reviewed (Residents R38 and R281), and failed to care plan use and management of respiratory equipment for two of three residents (Resident R5 and R6). 28. Pa. Code 211.12(d)(1)(2) Nursing services.

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of eight residents who were identified as at risk for elopement (Resident R1). Findings include: Review of the facility policy Incidents and Accidents dated 1/16/24, indicated an incident is an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. Incident and accidents requiring an incident/accident report include an elopement. Review of the facility policy Elopements and wandering Residents dated 1/16/24, indicated the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Alarms are not a replacement for necessary supervision. Staff are vigilant in responding to alarms in a timely manner. Adequate supervision will be provided to help prevent accidents or elopements. Review of Communication Form dated 6/27/24, indicated please be alert to an alarm sounding (fire alarm, door alarm, wander guard alarm). Do not assume that someone else is checking on it. If an alarm is going off, immediately respond and notify others to complete a head count to check residents. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 4/30/24, indicated the diagnoses of Dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) with agitation (a symptom of dementia includes verbal and physical aggression, restlessness, and pacing), difficulty walking, reduced mobility, wandering (traveling aimlessly from place to place), depression, high blood pressure, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Section C indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) as a score of 5 - severe impairment. Review of Resident R1's current physician orders on 7/9/24, indicated check skin integrity under wanderguard (a bracelet that sets an alarm if resident passes through) left lower extremity every shift. Check function weekly. Review of Resident R1's care plan dated 3/26/24, indicated risk for wandering/elopement identified. Goal is the resident's safety will be maintained. Intervention to clearly identify resident's room and bathroom. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Wander alert bracelet. Review of Resident R1's Kardex dated 7/9/24, indicated limited assistance of one staff for transfers and toileting. The Kardex failed to have wander alarm checked off. Review of Resident R1's Progress notes indicate escalation of wandering, resisting care, agitation, confusion, and anxiety on seven occasions from 6/13/24 - 6/26/24, prior to the elopement and accident event on 6/26/24. -On 6/13/24, at 3:24 p.m. Registered Nurse (RN) Employee E1's progress note indicated staff found resident on the floor in the [NAME] Hall kitchenette area. Staff assisted resident back into her wheelchair, resident aggressive towards staff members, kicking staff. Writer re-approached resident and medicated with as needed Ativan (anxiety medication) for behaviors, completed ROM (range of motion) exercises to all four extremities. -On 6/14/24 at 10:20 a.m. Certified Registered Nurse Practitioner (CRNP) Employee E2's Provider Note indicated Chief Complaint fall, skin tear - resident does have some cognitive impairment noted related to dementia with behavioral disturbance, continue Ativan PRN and added 0.5mg (milligrams) routinely as well for increased anxiety and agitation. Continue Seroquel (antipsychotic medication) 50mg twice daily due to increased behaviors. Consider increasing this to three times a day if behaviors continue. -On 6/15/24, at 4:32 a.m. Licensed Practical Nurse (LPN) Employee E3's progress note indicated resident self-transferred into another resident's room this shift and staff assisted with resident transfer back into her own bed. -On 6/16/24, at 7:11 p.m. RN Employee E4's progress note indicated resident is very aggressive with staff. Going into resident's rooms and breaking their personal items. Resident self-transferring throughout the shift and in the hallway. Resident is very mean and uncooperative with all care. Attempting to hit and bite staff members. Fire doors were shut and resident was banging on those and screaming to get out. Resident finally went to sleep after many episodes of bad behavior. Resident needs a stronger medication from the doctor to combat these outbursts. -On 6/17/24, at 3:22 p.m. Physician Employee E5's Provider Note indicated Chief Complaint aggression, going in others' rooms. Patient has had aggressive behaviors. The behaviors are frequently happening in the evening. On 6/26/24, 12:00 a.m. LPN Employee E6's elopement evaluation indicated: -History of elopement while at home - Yes -Wandering behavior a pattern or goal-directed - Yes -Wanders aimlessly or non-goal directed - Yes -Wandering behavior likely to affect the safety or well-being of self/others - Yes -Wandering behavior likely to affect the privacy of others - Yes -Recently admitted or readmitted and has not accepted the situation - No. On 6/26/24, at 9:56 p.m. LPN Employee E7's SBAR (Situation, Background, Assessment, Recommendation Form) Event indicated a nurse aide notified writer that resident was observed in the stairwell. Writer observed resident sitting in wheelchair at the bottom of 10 steps. Resident stated that her and the wheelchair fell down the first flight of stairs. Resident exited to the steps through a locked fire door. Alarm did not sound. Resident last seen 45 minutes prior in the dining room by nurse aide. Pain score five out of ten being highest. Physician notified at 8:00 p.m. Recommendation maintain wander guard on resident. Physician order to send to emergency department due to resident stating her face, head, and neck hurt. Review of facility provided Unwitnessed fall document dated 6/26/24, at 9:36 p.m. indicated Nurse Aide (NA) notified writer (LPN Employee E7) that resident was observed in the stairwell by the nurse on the other unit. Writer observed resident sitting in a wheelchair at the bottom of 10 steps with the wheelchair facing up the steps. Resident stated that her and the wheelchair rolled down the first flight of stairs. Resident exited to the steps through a locked fire door. Per staff the alarm did not sound throughout the event. Resident indicated she had to get out to feed her dog. She opened the door and rolled her wheelchair down the stairs. She stated she hit her head off the wall. Review of facility provided documentation indicated LPN Employee E24's witness statement dated 6/27/24, at 10:38 a.m. indicated I heard over the walkie (two way radio) staff needed assistance in the Blank Stairwell. RN Employee E1 followed me over where RN Employee E27 and LPN Employee E12 were assessing Resident R1 amazingly in her wheelchair. Assessing vitals seems like baseline. How we going to get her out of the stairwell? We decided to go down to the first floor. Not sure how she got in stairwell assuming door would have alarmed. Review of the Emergency Hospital visit document dated 6/26/24, indicated Staff states they saw the door open and found patient sitting at the bottom of steps in her wheelchair. Review of LPN Employee E7's statement dated 6/27/24, at 12:53 p.m. indicated Who saw resident last? NA Employee E25 saw Resident R1 forty-five minutes prior in the dining room, unsure who saw her in stairwell, just that LPN Employee E12 got a call saying she was there. NA Employee E28 I think, said she saw her going down the hall with a tray on her lap. I just reported to the call over the walkie she was sitting in her chair at bottom of steps. I did not hear any alarms go off leading up to incident. Review of NA Employee E25's statement dated 6/27/24, at 2:27 p.m., indicated NA Employee E26 was walking down the hall asking has anyone seen Resident R1? Maybe around 8:00 p.m. though she was on the rehab unit as she used to have a room over there. RN Employee E27 going to check locked doors, utility rooms, I was at the end of hallway and heard over walkie stairwell NA Employee E28 said found in stairwell. Opened the door and saw her. She was at the fish tank earlier. Went to stairwell, four or five staff were there assisting resident so didn't assist. She was on first landing she had her dinner tray at top of landing by ladder, she had flowers on the tray, we didn't hear any beeping. Two women always leave out that door after dinner, but I didn't see them that day. Review of LPN Employee E19's statement dated 6/27/24, at 3:47 p.m. indicated LPN Employee E7 on the [NAME] unit said she couldn't find Resident R1, maybe around 8:00 p.m. Aides started looking someone went to the stairwell to look, and said they found her. I did not hear any alarms. Music Therapy Employee E31's statement indicated on 6/26/24, at 5:30 p.m. and 6:30 p.m. was conducting music activities in the lounge and saw Resident R1 at 5:30 p.m. in dining room and Resident R1 did not attend evening activity that day. Review of NA Employee E28's statement dated 6/27/24, at 4:08 p.m. indicated she last saw her coming down hall between 7:00 p.m. and 8:00 p.m., unsure of exact time, she had a tray with flowers on it. She usually goes to back of the Blank unit and sits there, not all the time but sometimes came out of room after helping serve didn't see her. They said over walkie they were looking for her. They found Resident R1 in stairwell. Think it was 8:15 p.m. She was in stairwell sitting facing towards steps, black marks on tile at bottom of steps like chair had skidded. No blood, no bruising said her lip hurt, said she hit lip. Tray was at top of steps tried to ask her, but she couldn't tell us. Initially looked like she was sweating a little under the eyes. She didn't say anything hurt. Once we opened the door the alarm went off. Review of NA Employee E30's statement dated 6/27/24, at 5:16 p.m. indicated went to find Resident R1 around 8:30 p.m. or 9:00 p.m. to see if she wanted to go to bed. Went to the dining room where I last saw her at 7:30 p.m. and started walking rooms, went to rehab, went over walking and said anyone else see her. Someone saw her in the staircase, down the steps sitting in the wheelchair. Said she was trying to feed her dog. She has a stuffed Dalmatian in her room. She complained of her neck and head hurting. No alarm heard when an unidentified Priest was trying to go through exit earlier in the day. Did not see visitor use stairwell on the Blank unit. Observation on 7/9/24, at 9:58 a.m. NA Employee E8 reset the alarm to the elevator. There were no residents present in the area. NA indicated she didn't see anybody, so she turned it off. Indicated it meant that someone with a wander bracelet got close to the elevator. A head count was not initiated as required. Interview on 7/9/24, at 9:59 a.m. the Nursing Home Administrator confirmed that a head count should be initiated and directed staff to do so. Observation on 7/9/24, at 10:01 a.m. Resident R1 was not in her room, her wheelchair was in room and was empty. Resident noted to be in her bathroom alone, despite instructions on the Kardex to use limited assist of one for transfers and toileting. Observation on 7/9/24, at 10:04 a.m. NA Employee E10 and NA Employee E11 entered room to take care of Resident R1. During an interview on 7/9/24, at 10:04 a.m. the Survey Agency (SA) asked NA Employees E10 and E11 to show where Resident R1's wander guard was located on her body, they verified the resident did not have one on her person or her wheelchair as ordered. NA Employee E10 indicated Resident R1 is very confused and does what she wants. As soon as I knew she was in there alone we came in to assist. Interview on 7/9/24, at 10:07 a.m. LPN Employee E9 verified Resident R1's physician orders indicated wander guard bracelet should have been on the left lower extremity. Observation and interview on 7/9/24, at 10:14 a.m. with NA Employee E10 indicated if they go near the elevator or by the steps, it alarms, I think. In the Blank Unit stairwell SA pushed on the door for 15 seconds and alarm went off. SA and NA Employee E10 entered the stairwell. Black scuff marks noted to right wall of stairs under the handrail area. Wide metal ladder like steps to the upper level to the left of the door's entrance. Upon exit of the stairwell, four staff members (Nursing Home Administrator, ADON Employee E13, LPN Employee E14, and NA Employee 10) were unable to deactivate the alarm and were unaware of what the code was. Interview on 7/9/24, at 10:20 a.m. the Nursing Home Administrator indicated the codes are supposed to be behind the nurses' station instead of posted at the stairwell doorway where we used to have it prior to Resident R1's event. At the time of the event (6/26/24, at 9:36 p.m.), the door alarm did not sound so it was assumed Resident R1 must have entered the code that was posted on the doorway. Review of Elopement Risk Program dated 7/8/24, indicated eight residents were at risk for wandering. Interview with the NHA on 7/9/24, at 11:20 a.m. indicated the list is not accurate as one resident had the incorrect room listed. Interview on 7/9/24, at 11:24 a.m. LPN Employee E15 indicated If they are wandering or exit seeking, you do the assessment. I'd redirect them if they are wandering and maybe get a bracelet. Interview on 7/9/24, at 11:28 a.m. Registered Diet Technician Employee E16 indicated We keep an eye on them I see them wandering and put them in the close to the nurses station, If it don't know where they belong I take them to the nurses or supervisor. Interview on 7/9/24, at 11:29 a.m. LPN Employee E9 indicated We check every shift with wander guards. Some get 15-minute checks depending on the behaviors it depends on the situation. The code is posted at the door for stairs if you hold it the alarm goes off, but I wasn't here that day. Elopement assessment on admission if they're at risk I think it's every 14 days. Interview on 7/9/24, at 11:32 a.m. LPN Employee E17 indicated A new wander behavior, I'd do a reassessment and place wanderguard even for a little while. We have to go downstairs to get a wander guard. Once a week they are checked for function. We take them to the elevator an make sure it goes off. They took access codes down. If I made it to the first floor elevator it alarms and the door way to the lobby. I'm pretty sure it does. Interview on 7/9/24, at 11:39 a.m. Housekeeping Employee E18 indicated I'm supposed to keep an eye on them (wandering residents). I know who they are just from being here. If they are too close to the door I'll bring them back or if I need help I get help. No searches since I've been here. I think they have fake drills probably on other shifts. I've never been here for a fake drill. Interview on 7/9/24, at 11:41 a.m. RN Employee E19 indicated We have wander guards. There are codes at the exits and elevators and you place a code to make them stop. Interview on 7/9/24, at 1:09 p.m. NA Employee E20 indicated It depends who it is. Like one resident wanders and we try to guide her back to the [NAME] Unit because they know her better. For Resident R1, the [NAME] Unit keeps their eyes out. The codes were posted at doorways and now are taken down. Interview on 7/9/24, at 1:28 p.m. NA Employee E21 indicated We try to give them puzzles keep their minds occupied. Sometimes I'll take someone to the balcony to get some fresh air. Usually two of us NA's will switch on and off while a resident is active. Interview on 7/9/24, at 1:30 p.m. NA Employee E22 indicated We share when there's an active resident we are worried about. The bracelet will set off an alarm at the elevator and if we can't see what happened then we walkie talkie for a head count and we shut off the alarm. Interview on 7/9/24, at 1:33 p.m. RN Employee E23 indicated, I work evenings sometimes, around 9:00 p.m. people are being put to bed and showers are being done. She had a wanderguard on stairwell doesn't alarm from bracelet just elevators. Switch off with us keep them behind the desk with us or place in the living room (area referred to as the Lobby). Interview on 7/9/24, at 1:36 p.m. RN Employee E19 indicated I was here training the day Resident R1 went down the stairs, I was on Blank Unit and the [NAME] Unit called and said they were missing a resident. We started looking in rooms bathrooms, closets, hallways, and one of the nurses found her in the stairwell. That's all I know. My trainer went to help and I continued on task. Telephonic interview on 7/11/24, at 9:31 a.m. NA Employee E25 indicated I saw her down by the music room one of our NA's had to leave around 7:00 p.m. or 7:15pm because of something personal, at the time we had to switch assignments, I can't remember how many we were running with that day. I think we started with nine and ended up with eight after she left that day. I went and spoke to my other co-worker and asked are we switching groups or what? Can someone tell me what's going on. I was a little stressed because now I have residents that I didn't have before and had to ask can you tell me what's been done with the residents, showers, changed, etc. I was going room to room around 7:30 p.m. I had four residents still in the four season room and Resident R1 was not in the 4-seasons room at that time. They asked have you seen Resident R1? I said, the last time I had her she would sit on Rehab at the nurses desk. We're going to start looking behind locked doors and I was on Blank Unit. I hear stairwell over the walkie. Two people were going down to the stairwell. Usually, the door is locked so I was confused. I told them I don't know if they are workers or visitors but there are two older ladies that go down that stairwell after dinner time usually an alarm goes off. Maybe the door doesn't shut all the way? I don't know how to work the doors. Maybe it popped back open. Resident R1 was sitting in her chair on the landing. She was on the right side of the landing. The chair looked normal. Honestly, everyone was in shock that she was not bleeding, and the chair was intact. Observation on 7/11/24, at 12:20 p.m. two unidentified female food service workers were at the elevator. The first female reset the wander guard alarm that was sounding. The second stood there without action and waited for the elevator to arrive. No residents were present in the area. A head count was not initiated as required. Interview on 7/11/24, at 12:20 p.m. SA asked, What does the alarm sounding mean? The first food service worker indicated I don't know, it goes off all the time. It has a mind of its own. The second food service worker indicated It goes off if someone with a wander guard goes near it. Interview on 7/11/24, at 2:08 p.m. RN Employee E27 indicated I found her (Resident R1). I had to leave my trainee during the 8:00 p.m. med pass, so at least after 7:00 p.m. We were down the hall towards the Blank Unit stairwell. I was walking to the desk for something, and a few nurses were in that area saying they can't find Resident R1. Somebody said should we start looking for her? I headed back down the hallway I started at the front of the hall but decided to start at the other side instead so I could cover more ground. I checked two rooms and the housekeeping closet. I went to cross the hall, I glanced, and she was sitting in her wheelchair the next flight of steps down. Her back was facing the wall and her front facing up towards the stairs. The door was closed, not alarming, I put the code in to get into the stairwell. I saw her through the window at first. The door was not visibly propped open that I recall and knowing it's a locked door I didn't even try to enter without the code. Interview on 7/12/24, at 10:15 a.m. Blank Unit Clerk Employee E32 indicated Resident R1 is over here daily. She likes the male nurse on this side, so she hangs out with us a lot. She used to live over here. Interview on 7/12/24, at 10:17 a.m. LPN Employee E9 indicated Resident R1 has always wandered aimlessly about. I do not recall her ever removing her wander guard in the past. Interview on 7/12/24, at 10:17 a.m. NA Employee E33 indicated Resident R1 is always roaming around. I've seen her redirected as times, for example some things that would work would be telling her to go to the opposite hall to get her hair done. She can become very violent. We have to stay near her though so she won't fall if she's walking. It takes six of us just to get her out of the shower. Interview on 7/12/24, at 10:21 a.m. NA Employee E34 indicated Resident R1 has days she irritated and throws punches. We do 15-minute rounds on her and other days she roams aimlessly. When she roams, she's less agitated. Resident R1 has a strong mind of her own and does what she wants, when she wants. The Nursing Home Administrator and Director of Nursing were made aware that an Immediate Jeopardy situation existed for residents on 7/11/24, at 11:04 a.m. and an immediate action plan was requested. On 7/11/24, at 11:04 a.m. the Immediate Jeopardy template was provided to the facility administration. On 7/11/24, at 2:00 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. Resident R1 was evaluated at the hospital on 6/26/24, and suffered no injury related to unwitnessed fall. 2. Resident R1's care plan was updated to reflect wandering behaviors and ensure supervision and monitoring are in place. 3. All residents will be evaluated with the elopement risk assessment to ensure wandering/elopement behaviors were identified and care planned as needed and reflect adequate supervision and monitoring. This will be completed through the Electronic Health Record Behavior Monitoring. 4. The elopement policy remains unchanged. New steps implemented were verified of codes to doors removed and door alarm audits initiated. Facility obtained quotes to install wander guard system to all second-floor exit doors. 5. Ad Hoc QAPI (Safety Meeting) including the DON, Medical Director, Administrator, Therapy, Social Services, and Human Resources was conducted on 7/1/24. 6. Education on the elopement policy and procedure, wander guard system was initiated on 6/27/24 by DON/designee. 7. A new education will be initiated 7/11/24, to educate on elopement policy, wandering identification and steps to take once risk is identified, education includes process once risk is identified, if resident is actively exit seeking or have any of the signs of elopement risk (ambulate independently or mobile, history of elopement, or attempted elopement, verbal expression of desire to go home, packing belongings to go home, staying near and exit door wandering, wandering pattern with specific destination in mind, wandering aimlessly or non-goal directed, wandering behavior that is likely to affect the safety or well-being of self or others, wandering behavior likely to affect the privacy of others, recently admitted and not accepting of the situation, staff will initiate every 15 minutes checks and ensure wander guard is in place until the interdisciplinary team meet. An Email to the Activities Department to update the elopement risk program posting, then activities will distribute to all units and departments. Education will be completed by 7/12/24, at 11:00 a.m. 8. All staff were previously educated annually, and upon hire on the facility elopement policy as of 6/27/24. 9. All staff will be educated on recognizing signs and symptoms of resident elopement before the start of their next shift with follow-up to ensure understanding and compliance. To be completed by 11:00 a.m. on 7/12/24. 10. Monitoring - all residents identified as exit seeking/wandering will be audited by the DON/Designee for elopement monitoring, supervision, and interventions daily by five days, twice a week by four weeks, and then weekly by one month. Results of the reviews will be submitted to the facility Quality Assurance and Process Improvement Committee for review and development of an action plan as needed. Review of facility documentation on 7/12/24, it was verified the following interventions were completed: 1.Resident R1 was evaluated at the hospital on 6/26/24 and suffered no injury related to unwitnessed fall. 2. Resident R1's care plan was updated to reflect wandering behaviors and ensure supervision and monitoring are in place. 3. All residents were evaluated to ensure wandering/elopement behaviors were identified and care planned as needed and reflected adequate supervision and monitoring. This was completed through the Electronic Health Record Behavior Monitoring. 4. The elopement policy remains unchanged. New steps implemented were verified of codes to doors removed and door alarm audits initiated. Facility obtained quotes to install wander guard system to all second- floor exit doors. 5. Ad Hoc QAPI (Safety Meeting) including the DON, Medical Director, Administrator, Therapy, Social Services, and Human Resources was conducted on 7/1/24. 6. Education on the elopement policy and procedure, wander guard system was completed on 7/11/24. 7. All staff were educated on recognizing signs and symptoms of resident elopement policy and procedure and wander guard system, steps to take once risk is identified, the process once risk is identified if resident is actively exit seeking staff will initiate q 15 minute checks. Activities will be emailed to update the elopement risk program posting, then activities distributes to all units, before the start of the next shift and follow up was conducted to ensure understanding and compliance by 11:00 a.m. on 7/12/24. 8. All residents identified as exit seeking wandering will be audited by the DON/designee for elopement monitoring, supervision and interventions with audit tool created. 9. Survey Agency (SA) confirmed 311/312 staff were educated as stated above with a competency post-test. All staff in house on daylight (71 all departments) were interviewed and verified they had training and did not have any questions. The Immediate Jeopardy was lifted on 7/12/24, at 2:00 p.m. when the action plan implementation was verified. Interview on 7/12/24, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for Resident R1 which resulted in an elopement. This failure created an immediate jeopardy situation for one of eight residents who were identified as high risk for elopement. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20 (a)(c) Staff development. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.

Based on review of facility's policy, clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided the appropriate assistance for transfer that resulted in actual harm (a right leg laceration), for one of six residents reviewed (Resident R1). Findings include: The facility policy entitled, Lift Limiting dated 6/1/18, indicated that upon admission, a transfer order will be written by the admitting nurse for each resident based on the initial assessment. Every effort will be made to ensure that each employee is aware of each resident's lift and transfer requirements. Review of the clinical face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set assessment (MDS- periodic assessment of care needs) dated 10/20/18, indicated that Resident R1 had severe cognitive impairment and required extensive assistance of two staff to transfer. Review of a physician's orders [REDACTED]. Review of the Care Plan Report/Touch Screen documentation (computer system displaying resident care plan information utilized by Nurse Aides) indicated that Resident R1 required maximum assist of two staff to transfer. Review of clinical notes dated 11/12/18, at 6:02 p.m. indicated that Licensed Practical Nurse (LPN) Employee E2, was called to Resident R1's room by Nurse Aide (NA) Employee E1, and noted copious amounts of blood on the floor. NA Employee E1, stated that she had transferred Resident R1 from the bed into the wheelchair and Resident R1 sustained a deep laceration (cut) on her right leg. LPN Employee E2, indicated that Resident R1 was transferred to the emergency room for treatment, by order of the physician. Review of the hospital physician notes dated 11/12/18, indicated that Resident R1 was treated for [REDACTED]. Review of NA Employee E1's, written statement dated 11/12/18, indicated that she transferred Resident R1 without the assistance of another staff person, resulting in the right leg laceration. During an interview on 12/28/18, at 10:55 a.m. the Director of Nursing confirmed that NA Employee E1, failed to provide Resident R1 with adequate assistance during a transfer resulting in a laceration requiring 18 sutures. The facility failed to make certain that Resident R1 was provided adequate staff assistance during a transfer to prevent accidents, thus resulting in actual harm. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 7/31/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/31/18, 7/14/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 7/14/17. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/14/17. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, incident reports and clinical records and staff interview, it was determined that the facility failed to provide a safe transport of a resident in a wheelchair which resulted in actual harm for one of eight residents reviewed (Resident R1). Findings include: The facility policy entitled, Use of Wheelchair dated 6/15/15, indicated that the foot rests should be lowered and the resident's feet put on the foot rests if they are used and wheelchairs should be propelled forward unless it is unsafe to do so. Review of the quarterly Minimum Data Set assessment (MDS - a periodic assessment of care needs) dated 4/19/16, indicated that Resident R1 had [DIAGNOSES REDACTED].) Continued review of the MDS assessment dated [DATE], indicated that Resident R1 had required extensive assistance of two staff for transfers and extensive assistance of two persons for locomotion on or off the unit. Review of the, Care Plan Report (plan of care that identifies resident problems and staff interventions) dated 4/27/16, indicated that Resident R1 was at risk for fractures (breakage) due to osteoporosis. Review of the, Resident Incident Reporting Form (facility form used to document unusual occurances) dated 7/07/16, completed by Registered Nurse (RN), Employee E2, indicated that on 7/07/16, at 4:10 p.m., Resident R1 was being transported via wheelchair to the dining room by Nurse Aide (NA), Employee E1, when Resident R1's left leg was pulled under the wheelchair. Employee E2 indicated that Resident R1 complained of pain of a seven on a scale of one to ten scale (ten being the worst) and stated, on assessment, no leg rests on W/C (wheelchair). Review of a physician's progress note dated 7/08/16, indicated that Resident R1 had an X-ray of the left leg which showed a fracture of the distal (lower end) of the femur (large thigh bone) and is reporting mild to moderate pain. During an interview on 7/27/16, at 10:00 a.m. the Director of Nursing confirmed that Employee E1 failed to put leg rests on Resident R1's wheelchair prior to the transport of the resident resulting in a fracture of the left leg. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/17/14. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/28/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/28/15, 7/17/14.