Every finding on record at Cross Keys Village-Brethren Home Community, The

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and implement interventions to prevent falls, which resulted in actual harm as evidenced by a fall resulting in a laceration requiring sutures for one of three residents reviewed (Resident 1).Findings include: Facility policy, titled Fall Risk Program, reviewed March 2026, read, in part, Objectives: to decrease the number of falls and to prevent injury to Residents. Procedure Responsibility 3. Individualized interventions identified to decrease falls will be placed on Resident Care Guide (RCG) to communicate to staff.5. The interdisciplinary team will review falls daily during clinicals and revise care plans as necessary to ensure interventions are in place to prevent reoccurrence. Facility policy, titled Fall Prevention & Post Fall Intervention Program, reviewed March 2026, read, in part, Objectives: 1. To reduce or eliminate the number of Resident falls. 2. To ensure that appropriate measures were and/or need to be implemented. 3. To obtain information related to why the fall had occurred. 4. To assist with the development of interventions to be used to prevent and /or decrease the number of falls where possible and minimize or prevent injury to Residents. Review of Resident 1's clinical record revealed diagnoses that included glioblastoma (aggressive primary malignant brain tumor) with craniotomy (removal of a section of skull) and seizures (sudden uncontrolled surge of electrical activity in the brain). Review of Resident 1's care plan revealed a focus area for, at risk for falls, with an intervention for, Resident may sit in reclining lift chair, unplugged, and operated by staff only. Start date April 23, 2026. Review of Resident 1's Resident Care Guide (the nurse aid reference for resident care) revealed TRANSFER/AMBULATION/FALL PREVENTION . Resident is safe to sit in recliner chair. Chair to be unplugged and operated by staff only. Further review of Resident 1's clinical record revealed that Resident 1 was admitted to the facility from home on April 22, 2026. Resident 1 sustained three falls from her recliner chair on May 15, 2026; and June 9 and 10, 2026. Review of the fall incident report, dated May 15, 2026, revealed that Resident 1 had an unwitnessed fall in her room at 5:21 PM. Further review of the report revealed that Resident 1 was found lying on the floor in front of her recliner and that the recliner was in an elevated position. The report further indicated that therapy would re-screen Resident 1 for recliner safety. Review of the form titled Recliner Lift Chair Screen revealed that therapy evaluated Resident 1 on May 18, 2026. The form indicated that Resident 1 could not safely operate the reclining lift chair on her own and that the chair was to be unplugged and operated by staff only. Review of the fall incident report, dated June 9, 2026, revealed that Resident 1 had an unwitnessed fall in her room at 8:40 PM. Review of witness statements attached to the incident report revealed that Resident 1 was sitting on the ground with her chair raised. Review of the fall incident report, dated June 10, 2026, revealed that Resident 1 had an unwitnessed fall with injury in her room at 4:00 PM. Review of the incident report questionnaire dated June 10, 2026, at 11:38 PM, completed by Employee 3, revealed Additional contributing factors: recliner was not unplugged. Review of a witness statement from Employee 4, dated June 10, 2026, indicated that Employee 4 went to Resident 1's room around 3:40 PM - 3:45 PM to administer medications and that Resident 1 was sitting in the recliner. Review of a witness statement from Employee 5 (CNA assigned to Resident 1 at the time of the fall), dated June 10, 2026, indicated that she completed rounds at 2:30 PM and that Resident 1 was in the recliner. Witness statements did not note if staff observed the recliner chair to be plugged in. Review of progress notes revealed a nursing note that read, in part, Called to assess resident for unwitnessed fall on 06/10/2026 at 1600. Neurochecks initiated. Resident was observed Lying on the floor slightly to her left side in front of her recliner. Laceration to upper outer corner of the left eye brow. Bright red bleeding noted from area. Glasses laying on floor with the left arm broken off . Review of the post fall assessment, stated the following: Injury noted at this time: Laceration to outer corner of left eye brown and ecchymosis [bruise] to left side of nose. Treatment provided: Laceration cleansed with NSS [Normal saline solution] and steri strips applied. Further review of the post fall assessment, in the comments section, stated that the family initially wanted Resident to remain in the facility, but when they came to visit the Resident, they requested that Resident be sent to ER for eval and treatment. Review of Resident 1's hospital emergency room summary dated June 10, 2026, revealed that Resident 1 was evaluated after sustaining a fall with a head strike. Hospital records indicated that Resident 1's laceration was approximately 2 centimeters long and required five sutures. During an interview with the Nursing Home Administrator (NHA) on June 15, 2026, at 1:00 PM, the NHA confirmed that she would expect staff to follow a resident's care plan and follow proper care techniques to prevent accidents. The facility failed to follow the plan of care for the Resident's recliner chair to be unplugged. The chair was left plugged in and the Resident sustained a fall from the chair, resulting in a head laceration that required sutures. 201.14(a) Responsibility of licensee201.18(b)(1)(e)(1) Management.211.10(c)(d) Resident care policies.211.12(d)(1)(2)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions in the main facility kitchen. Findings include: Review of the facility policy titled, Uniform Dress Code, last revised January 2025, stated, Restrain all facial hair with beard net/restraint. Observation on March 10, 2025, at 10:54 AM revealed Employees 3 and 4 (Dietary Aides) working in and around the kitchen with uncovered beards. During an immediate interview with Employee 2 (Director of Dining Services) he stated that he would review the policy. During an interview with the Nursing Home Administrator on March 12, 2025, at 1:46 PM he agreed that Employees 3 and 4 should have been wearing beard nets. He also revealed that Employee 2 had rectified the situation. 28 Pa. Code 211.6(f) Dietary services

Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by using proper hand hygiene techniques for one of one medication observations (South Mountain). Findings Include: Review of facility policy titled, Hand Hygiene, last reviewed and revised January 2025, revealed that staff should perform hand hygiene immediately before touching a resident, after touching a resident or the resident's immediate environment, and immediately after glove removal. Observation on March 12, 2025, at 8:00 AM, revealed Employee 1 (Licensed Practical Nurse) preparing Resident 42's medications. The medications included oral medications and injectable medication. Employee 1 then administered the medications to Resident 42 by feeding Resident 42 the oral tablets on a spoon, then applying gloves, cleaning Resident 42's abdomen with an alcohol pad, and injecting Resident 42's medication into Resident 42's abdomen. Employee 1 then returned to her medication cart and prepared oral medication, injectable medication, and topical medication for Resident 7. Employee 1 then went to Resident 7's room and fed Resident 7 the oral medications with a spoon. Employee 1 then applied gloves, cleaned Resident 7's abdomen with an alcohol pad, and injected Resident 7's injectable medication into Resident 7's abdomen. Employee 1 then applied Resident 7's topical pain relief gel to Resident 7's left shoulder using the same gloves that she was wearing to inject Resident 7's injectable medicine. Employee 1 then proceeded to her medication cart and moved it down the hall to Resident 18's room. Employee one then prepared Resident 18's medication for administration. These medications included oral medications, injectable medication, topical medication patches, and eye drops. Employee 1 then entered Resident 18's room and provided Resident 18 her oral medications on a spoon. Employee 1 then applied gloves and administered Resident 18's eye drops. Employee 1 then removed her gloves and applied a new pair. Then Employee 1 applied a pain relief patch to the back of Resident 18's neck. She then applied a pain relief patch to Resident 18's lower back. Employee 1 then removed her gloves and applied new gloves, cleaned Resident 18's abdomen with an alcohol pad, and administered Resident 18's injectable medication in Resident 18's abdomen. Employee 1 then returned to her medication cart. At no time during the medication administration observation did Employee 1 perform hand washing or use hand sanitizer. An interview with Employee 1 at the end of the medication administration observation revealed that Employee 1's medication cart was stocked with hand sanitizing gel. An interview of the Nursing Home Administrator on March 13, 2025, at 11:15 AM, revealed that Employee 1 should have washed her hands or used hand sanitizer, as appropriate, and staff reeducation had already begun. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to ensure each resident is informed periodically of items and services not covered under Medicare for one of three residents reviewed after their Medicare stay (Resident 6). Findings Include: A review of the Skilled Nursing Facility Beneficiary Notification Review form revealed Medicare services ended for Resident 6 on February 19, 2025. A continued review of documents provided by the facility revealed that Resident 6 was not provided with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form to notify Resident 6 and/or her Representative of the cost of the facility's items and services no longer covered under Medicare. An interview with the Director of Nursing on March 11, 2025, at 1:46 PM, confirmed that the facility could not locate the SNF-ABN form and that Resident 6 should have been provided with the notice at the conclusion of her Medicare coverage. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of eighteen residents reviewed (Resident 42). Findings include: Review of the facility policy titled, Medication Administration, with a last reviewed and revised date of February 2025, revealed, in step a., Proceed to resident's room and open resident's EMAR (electronic medical administration record)- pull out resident's medication packs. Review of Resident 42's clinical record revealed diagnoses that included diabetes (when the body either doesn't produce enough insulin or can't use insulin properly) and anxiety disorder (a group of mental health conditions characterized by excessive fear or worry, interfering with daily life and causing distress). Observation of Resident 42 on March 12, 2025, at 8:00 AM revealed resident 28 sitting a wheelchair in the dining room waiting to be served breakfast. Employee 1 (Licensed Practical Nurse) prepared Resident 28's oral medication and insulin for administration. Employee 1 then approached Resident 28, gave Resident 28 their oral medications, and then lifted Resident 28's shirt and injected Resident 28's insulin into the left side of her abdomen. Review of Resident 42's care plan failed to reveal a focus area or intervention that Resident 28 preferred to receive her medication in the dining room or in common areas. During an interview on March 13, 2025, at 10:28 AM with the Director of Nursing, she revealed that Employee 1 should not have given the insulin in the dining room, and that Resident 42 did not have a care plan or preference to receive medication and insulin in the dining room or common areas. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on policy review, observations, manufacturer packaging, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main kitchen and four of four pantries. Findings include: Review of facility policy, titled Cross Keys Village- The Brethren Home Food Storage Policy and Procedures last revised [DATE], revealed Any prepared foods, leftovers, or open containers must be stored in refrigeration at a temperature under 41 degrees Fahrenheit, be labeled and dated and must be discarded after 3 days. Observation in the main kitchen walk-in freezer on [DATE] at 10:14 AM, revealed: one bag of frozen corn with a use by date of [DATE]; and one open bag of sweet potato fries without a label or date. Further observation in the main kitchen walk-in refrigerator revealed one open container of Dijon mustard and labeled with a use by date of [DATE]. Observation during initial tour of the Somerset pantry area on [DATE], at 10:35 AM, revealed: one container of Cheerios cereal with a use by date of [DATE]; one container of sherbet frozen dessert without a date; one bag of hamburger buns with a use by date of [DATE]; one package of wheat dinner rolls with a use by date of [DATE]; two bags of unknown snacks revealed to be potato chips without a label or date; and one container of brown sugar with a spoon stored inside. Interview with Employee 5 on [DATE], at 10:37 AM, revealed a spoon should not be stored inside the brown sugar container. Observation during initial tour of the Sun Valley pantry area on [DATE], at 10:46 AM, revealed: three containers of sherbet frozen dessert without a date; one open container of prune juice, half full and not dated; one container of fruit cocktail with a use by date of [DATE]; one bag of dinner rolls labeled use by [DATE]; one open bag of dinner rolls without a date; and one container of brown sugar with a spoon stored inside. Observation during initial tour of the East Valley pantry area on [DATE], at 10:55 AM, revealed: five containers of sherbet frozen dessert without a date; one open container of prune juice with a use by date of [DATE]; one open container of chocolate milk with a use by date of [DATE]; one container of English muffins not labeled or dated; and one bag of unknown snacks revealed to be potato chips without a label or date. Observation during initial tour of the South Mountain pantry area on [DATE], at 11:04 AM, revealed: two boxes of Rice Krispies cereal without a date; and one open container of honey thickened lemon water dated use by [DATE]. Further observation of the honey thickened lemon water revealed no open date, and directions on the package revealed discard after open for 7 days. Interview with the Food Service Director on [DATE], at 9:26 AM, revealed that items should be labeled and dated per policy and discarded once expired; and food items are stored in accordance with professional standards. Interview with the Nursing Home Administrator on [DATE], at 10:44 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to provide timely eating assistance for residents dependent on staff for this activity of daily living for one of 21 residents reviewed (Resident 23). Findings include: Review of Resident 23's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Observation on June 26, 2023, at 11:57 AM, revealed that Resident 23 had been served her meal in the dining area. At that time, it was observed that Employee 7 (Nurse Aide) cued Resident 23 to start eating, fed her two bites of food, then left to assist other residents. It was observed that from 11:57 AM to 12:38 PM Resident 23 sat in front of her plate, but was not able to successfully feed herself. During this time it was observed that the Resident did attempt to eat using her spoon, but was not able to get any food to her mouth. It was also observed at one point that she attempted to eat, she spilled food with her hands. At 12:38 PM, it was observed that Resident 23 was assisted by staff with eating her meal. During an interview with Employee 6 (Licensed Practical Nurse) on June 28, 2023, at 1:06 PM, she revealed that Resident 23 was on hospice (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness), her ability to feed herself varied, and that Resident 23 did need assistance with eating. Review of Resident 23's current care guide revealed that staff are to assist her with meals. Review of Resident 23's current care plan revealed that she required increased assistance with meals. During an interview with the Nursing Home Administrator on June 28, 2023, at 1:17 PM, she revealed that she spoke with nursing staff and confirmed that Resident 23 needed assistance with eating. She also revealed the expectation that Resident 23 should have received timely assistance with eating. 28 Pa. Code 211.12(b)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's nutritional interventions and care plan for one of 21 residents reviewed (Resident 27). Findings include: Review of facility policy, titled The Brethren Home Community Supplements and Bulk Nourishments Policy and Procedure revealed, Nourishments and supplements are delivered every day to each unit. Review of Resident 27's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 27's care plan on June 26, 2023, revealed cheese cubes at lunch, fortified chocolate milk with breakfast, lunch and dinner. Review of Resident 27's clinical record revealed a nutrition note dated May 10, 2023, with a nutrition diagnosis of increased nutrient needs for wound healing, and intervention of fortified chocolate milk three times per day. Review of Resident 27's clinical record revealed a nutrition note from June 20, 2023, that stated change cheese cubes from breakfast to lunch. Observation of Resident 27 during lunch meal in the dining room on unit on June 26, 2023, at 12:28 PM, revealed cheese cubes and fortified chocolate milk were not provided. Review of Resident 27's lunch meal ticket on June 27, 2023, revealed fortified chocolate milk at meals and 3-4 cheese cubes. Observation in Resident 27's room on June 27, 2023, at 9:05 AM, revealed the Resident eating the breakfast meal, and fortified chocolate milk was not provided. Observation in the dining room on unit on June 27, 2023, at 12:06 PM, revealed Resident 27 at the lunch meal, and cheese cubes were not provided. Interview with Employee 3 on June 27, 2023, at 1:51 PM, revealed cheese cubes were not brought to the unit that day or provided to Resident 27 because he believed the facility was out of cheese cubes. Interview with the Food Service Director (FSD) on June 28, 2023, at 9:26 AM, revealed cheese cubes could be obtained from personal care and will be available for Resident 27 at lunch meal. FSD further revealed he would expect nourishment items on tray tickets to be provided when available or substituted when not available. Interview with Employee 2 (Dietitian) on June 28, 2023, at 11:42 AM, revealed she would expect nutritional interventions put in place for wound healing to be provided and the care plan to be followed. Observation in the dining room on June 28, 2023, at 12:09 PM, revealed Resident 27 had completed his lunch meal, and fortified chocolate milk and cheese cubes were not provided. Interview with Employee 4 on June 28, 2023, at 12:11 PM, revealed Resident 27 was not provided cheese cubes and that she would go get them. Employee 4 further revealed Resident 27 preferred to only have soda as the lunch beverage and that she would communicate that information to the dietitian. Interview with Nursing Home Administrator on June 28, 2023, at 10:44 AM, revealed she would expect nutritional interventions put in place for wound healing to be provided and the care plan to be followed. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for one of 21 residents reviewed (Resident 27). Findings include: Review of Resident 27's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 27's physician orders included: a lipped plate (a plate with a curved, heightened edge that makes it easier to put food on utensils for those with self-feeding difficulties) for all meals, with a revision date of December 22, 2022; bent weighted utensils (heavy, curved utensils to make it easier for those with self-feeding difficulties, such as tremors related to Parkinson's disease) at meals, with a revision date of July 21, 2022; and mug with twist on lid and straw, with a revision date of May 13, 2023. Review of Resident 27's care plan on June 26, 2023, included a focus area: at risk for impaired nutrition related to diagnoses of Parkinson's disease and dementia. Interventions included adaptive equipment as ordered, with a revision date of September 30, 2020. Review of Resident 27's tray tickets revealed: Adaptive Equipment: Lip plate, right hand weighted utensils, cup with twist on lid and straw, assist as needed. Observation of Resident 27 during the lunch meal in the dining room on June 26, 2023, at 12:01 PM, revealed regular silverware was provided, and the Resident began to attempt to feed himself. Further observation on June 26, 2023, at 12:05 PM, revealed the Resident's regular fork was replaced with one weighted fork that was not bent. Observation on June 26, 2023, at 12:09 PM, revealed Resident 27 with difficulty feeding himself with the regular weighted fork. The surveyor observed the food on the fork fell to the ground when brought to the Resident's mouth. Further observation on June 26, 2023, at 12:14 PM, revealed two additional bites of food were attempted to be brought to mouth and were dropped on Resident 27's lap. No feeding assistance was provided throughout duration of the lunch meal. Resident completed his meal at 12:28 PM, with a total of five observations of unsuccessful bites of food that fell to the floor. Observation on June 27, 2023, at 9:05 AM, revealed Resident 27 was in his room, eating his breakfast meal off a regular plate with regular silverware and had a regular cup without a lid. Further observation on July 27, 2023, at 9:15 AM, revealed three bites of food fell from the regular fork to the floor. No feeding assistance was provided throughout duration of the meal. Interview with the Food Service Director on June 28, 2023, at 9:26 AM, revealed he would expect adaptive equipment to be provided, as ordered, at all meals. During an interview with the Nursing Home Administrator (NHA) on June 28, 2023, at 10:44 AM, surveyor revealed the concern with Resident 27 not receiving a lipped plate at one observed meal, receiving a regular cup without a lid at one meal, and improper utensils at two meals. NHA revealed she would expect adaptive equipment to be provided, as ordered, at all meals. 28 Pa code 211.6(b)(d) - Dietary Services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the assessment accurately reflects the resident's status for one of 21 residents reviewed (Resident 17). Findings Include: Review of Resident 17's clinical record revealed diagnoses that included Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and muscle weakness. Review of Resident 17's physician orders revealed an order dated April 14, 2023, that read Admit to . hospice services . Hospice services are defined as a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life. Continued review of Resident 17's clinical record revealed the Resident to be admitted to hospice services on the physician's order date of April 14, 2023. Review of Resident 17's Significant Change Minimum Data Set (MDS- a tool used to assess all care areas specific to the resident), with an Assessment Reference Date of April 22, 2023, under Section O Special Treatments, Procedures and Programs revealed staff had not marked sub-section k Hospice care for the Resident within the past 14 days. An interview with the Nursing Home Administrator on June 28, 2023, at 2:33 PM, confirmed Resident 17's MDS was incorrectly coded, and staff have submitted a modification to the assessment to capture the hospice services being provided at the time of the assessment. 28 Pa. Code 211.5 (f) Clinical records

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident and/or resident representative received written notice of the facility bed-hold policy at the time of transfer for one of one residents reviewed for hospitalization s (Resident 50). Findings include: Review of facility policy, titled Bed-Hold last reviewed April 2023, revealed, A Resident and/or Resident Representative will be notified in writing of the bed-hold policy at the time of admission, and if the bed-hold policy under the state plan or the facility's policy were to change. A second notice, which specifies the duration of the bed-hold policy, must be given at the time of transfer to a hospital or for therapeutic leave. Review of Resident 50's clinical record revealed diagnoses that included Alzheimer's (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and history of urinary tract infection. Further review of Resident 50's clinical record revealed that on April 8, 2023, she was transferred to the hospital for evaluation following a change in condition, and was subsequently admitted . During an interview with the Nursing Home Administrator on June 28, 2023, at 1:16 PM, she confirmed that a written notice of bed-hold was not provided to Resident 50 or her Representative upon transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on record review, interview, and facility policy review, it was determined that the facility failed to provide reasonable care of resident's personal property when they failed to complete the personal belongings sheet for one of twenty-two residents reviewed (Resident 349). Findings include: A review of the facility policy titled, Personal Belongings Sheet, last revised June 2009, states the facility will maintain records of Resident's personal belongings with monetary or sentimental value at admission and during their stay. A review of the clinical record for Resident 349 on July 12, 2022, revealed the Resident was admitted to the hospital on September 28, 2012, and passed away at the hospital on February 26, 2022. During an interview with Social Worker (SW 1) on July 13, 2022, SW 1 stated that family arrived at the facility lobby to retrieve the personal belongings of Resident 349. The POA stated that a quilted blanket was missing, and also stated that Resident had a quilted wall hanging (Christmas theme) that was not present. SW 1 was unable to locate the items described by the family. SW 1 also stated Resident 349 never had a favorite blanket, and that she has worked there since 2014, and didn't recall any quilted wall hanging. SW 1 stated that the POA rarely visited and, when she did, would drop off shampoo and conditioner without actually visiting Resident 349. Further review of Resident 349's clinical record failed to reveal a Personal Belongings Sheet to verify what personal belongings Resident 349 had in her possession, while at the facility. During an interview with the Nursing Home Administrator and Director of Nursing on July 13, 2022, at approximately 1:30 PM, they agreed that the Personal Belongings Sheet should be part of the clinical record, and that the sheet was not present after reviewing Resident 349's record back to 2012. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that interventions were put into place to prevent accident hazards resulting in multiple fractured ribs following a fall for one of three residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included multiple [CONDITION(S)] (disease in which the immune system eats away at the protective covering of nerves disrupting communication between the brain and the body) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of nursing progress note entered by LPN 1 (Licensed Practical Nurse), dated August 8, 2021, revealed, 1400 - Writer heard a noise and then a yell. CNA [certified nurse aide] reported resident rolled out of bed onto the floor. When writer entered residents room, she was on her right side between the bed and the wall. CNA present. Per CNA report, she was assisting resident with care while resident was in the bed laying on her left side. CNA states went to wet a wash cloth and heard a noise and found resident laying on the floor. RN [registered nurse] supervisor notified. Review of progress noted entered by RN 1, also dated August 8, 2021, revealed, 1400 - While giving care to resident, assigned CNA walked away from elevated bed, with resident in left side lying position, to moisten a washcloth in the bathroom. CNA came out of the bathroom and observed resident rolling on the floor, between the bed and the wall, on her right side. No injury noted. Resident reports she did hit her head. Neuro check benign. Denies pain .Reiterated to staff the importance of ensuring bed in low position when not at the bedside Review of witness statement written by LPN 1 on August 8, 2021, revealed, Writer was in the nurses station charting when I heard a loud noise. CNA then called out that resident had rolled out of bed. Upon entering the room, bed was at waste [sic] level + resident was on the floor between the wall + her bed. CNA was at her feet. CNA stated she was in the residents bathroom at time of incident wetting a wash cloth. Review of witness statement written by NA 1 (Nurse Aide) on August 8, 2021, revealed, On 8/8/21 at 2 pm I went into [Resident 2's] room to check and change her. I rolled her over on her side. She was a bit messy, so I step away from the bed, leaving her on her Lt [left] side, to wet a wash cloth. On returning to the room I was just in time to see her rolling out of bed landed on her Rt [right] side. I called the charge nurse to check her. During an interview with NA 1 on August 25, 2021, at 10:45 AM she revealed that she was providing incontinence care to Resident 2 when she noticed the resident had bowel movement smears on her after rolling her on her side. She revealed that she had wash cloths within reach, but they were dry so she went into the bathroom to wet them. When she returned, she saw Resident 2 falling, but could not reach her in time. NA 1 revealed Resident 2 only required assistance from one person for check and change. NA 1 revealed that the bed was at waist height when she left the bedside. She stated that she didn't expect Resident 2 to roll because she did not typically move on her own. NA 1 also confirmed that she was taught, and the facility expectation was, that the bed should be lowered when leaving the bedside. NA 1 stated it was not her intention for Resident 2 to fall. Review of Resident 2's care plan that was in place at the time of the fall on August 8, 2021, revealed a care plan related to the resident being at risk for falls with an intervention to ensure that the bed is locked and in lowest position. Review of hospital history and physical dated August 8, 2021, revealed that Resident 2 presented with a [CONDITION(S)] (unrelated to fall) with likely diagnosis of [CONDITION(S)]. During testing performed at the hospital on this date, imaging results revealed multiple acute right-sided rib fractures. Review of statement written by ADON (Assistant Director of Nursing), dated August 9, 2021, and signed by both the ADON and NA 1, revealed, August 9, 2021 reviewed with team member proper bed safety and mechanics. Bed should be in lowest position when not present with resident. Resident body should be kept in straight position. When being rolled knee farthest from team member should be bent over the resident. Arm farthest from team member should be crossed over the resident's body. Resident should be rolled toward the team member. During a interview with the Nursing Home Administrator on August 25, 2021, at approximately 11:30 AM, she revealed the expectation that NA 1 should have lowered the bed before leaving the bedside. NA 1 left Resident 2 unattended in bed with the bed elevated and the resident placed in the side lying position. The occurrence resulted in Resident 2 falling from the bed and acquiring multiple rib fractures. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, facility incident reports, and staff interviews it was determined that the facility failed to ensure that residents were free of neglect which resulted in actual harm, evidenced by multiple rib fractures, for one of three residents reviewed (Resident 2). Findings include: Review of facility policy, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Reporting and Investigation of Allegations, revised November 2018, revealed, [The facility] shall provide a safe environment where residents are not subject to mental, physical, sexual or verbal abuse, neglect, exploitation, or misappropriation of residents' property by staff, residents, visitors, family members or other individuals Neglect - means failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress .Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. Review of Resident 2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing progress note entered by LPN 1 (Licensed Practical Nurse), dated August 8, 2021, revealed, 1400 - Writer heard a noise and then a yell. CNA [certified nurse aide] reported resident rolled out of bed onto the floor. When writer entered residents room, she was on her right side between the bed and the wall. CNA present. Per CNA report, she was assisting resident with care while resident was in the bed laying on her left side. CNA states went to wet a wash cloth and heard a noise and found resident laying on the floor. RN [registered nurse] supervisor notified. Review of progress note entered by RN 1, also dated August 8, 2021, revealed, 1400 - While giving care to resident, assigned CNA walked away from elevated bed, with resident in left side lying position, to moisten a washcloth in the bathroom. CNA came out of the bathroom and observed resident rolling on the floor, between the bed and the wall, on her right side. No injury noted. Resident reports she did hit her head. Neuro check benign. Denies pain .Reiterated to staff the importance of ensuring bed in low position when not at the bedside Review of witness statement written by LPN 1 on August 8, 2021, revealed, Writer was in the nurses station charting when I heard a loud noise. CNA then called out that resident had rolled out of bed. Upon entering the room, bed was at waist level and resident was on the floor between the wall and her bed. CNA was at her feet. CNA stated she was in the residents bathroom at time of incident wetting a wash cloth. Review of witness statement written by NA 1 (Nurse Aide) on August 8, 2021, revealed, On 8/8/21 at 2 pm I went into [Resident 2's] room to check and change her. I rolled her over on her side. She was a bit messy, so I step away from the bed, leaving her on her Lt [left] side, to wet a wash cloth. On returning to the room I was just in time to see her rolling out of bed landed on her Rt [right] side. I called the charge nurse to check her. During an interview with NA 1 on August 25, 2021, at 10:45 AM she revealed that she was providing incontinence care to Resident 2 when she noticed the resident had bowel movement smears on her after rolling her on her side. She revealed that she had wash cloths within reach, but they were dry so she went into the bathroom to wet them. When she returned, she saw Resident 2 falling, but could not reach her in time. NA 1 revealed Resident 2 only required assistance from one person for check and change. NA 1 revealed that the bed was at waist height when she left the bedside. She stated that she didn't expect Resident 2 to roll because she did not typically move on her own. NA 1 also confirmed that she was taught, and the facility expectation was, that the bed should be lowered when leaving the bedside. NA 1 stated it was not her intention for Resident 2 to fall. Review of Resident 2's care plan that was in place at the time of the fall on August 8, 2021, revealed a care plan related to the resident being at risk for falls with an intervention to ensure that the bed is locked and in lowest position. Review of hospital history and physical dated August 8, 2021, revealed that Resident 2 presented with a [CONDITION(S)] (unrelated to fall) with likely diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During testing performed at the hospital on this date, imaging results revealed multiple acute right-sided rib fractures. Review of statement written by ADON (Assistant Director of Nursing), dated August 9, 2021, and signed by both the ADON and NA 1, revealed, August 9, 2021 reviewed with team member proper bed safety and mechanics. Bed should be in lowest position when not present with resident. Resident body should be kept in straight position. When being rolled knee farthest from team member should be bent over the resident. Arm farthest from team member should be crossed over the resident's body. Resident should be rolled toward the team member. During an interview with the Nursing Home Administrator on August 25, 2021, at 11:30 AM, she revealed that NA 1 was re-educated, and suspended for one day during the course of the investigation. She also revealed that the facility determined that NA 1 did not act willfully to make the resident fall and therefore did not consider it an incident of abuse or neglect. The facility failed to ensure that Resident 2 was free from neglect when NA 1 did not follow Resident 2's care planned interventions and deliberately left the bedside while the bed was elevated at waist height and the resident was positioned in a side lying position. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy and incident investigation documentation as well as staff interview, it was determined that the facility failed to identify and report an incident of neglect to the required agencies within the specified timeframes for one of three residents reviewed (Resident 2). Findings include: Review of facility policy, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Reporting and Investigation of Allegations, revised November 2018, revealed, [The facility] shall provide a safe environment where residents are not subject to mental, physical, sexual or verbal abuse, neglect, exploitation, or misappropriation of residents' property by staff, residents, visitors, family members or other individuals Neglect - means failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress .Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. Further review of this policy revealed that allegations of neglect must be reported orally to the statewide Protective Service Hotline for residents under the age of 60 (Resident 2 was noted to be under the age of 60) followed by a written report within 48 hours to Liberty Healthcare using the mandatory abuse form. The report must be faxed as well. Additionally, the policy states that within five days of an incident revealing an abuse issue, the Administrator or Director of Nursing shall submit a Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property to the Department of Health Event Reporting System. Finally, review of the policy revealed that for residents under the age of 60, an immediate oral report is to be made to the Department of Human Services via the mandatory abuse reporting line. Review of Resident 2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress noted entered by RN 1, dated August 8, 2021, revealed, 1400 - While giving care to resident, assigned CNA walked away from elevated bed, with resident in left side lying position, to moisten a washcloth in the bathroom. CNA came out of the bathroom and observed resident rolling on the floor, between the bed and the wall, on her right side. No injury noted. Resident reports she did hit her head. Neuro check benign. Denies pain .Reiterated to staff the importance of ensuring bed in low position when not at the bedside Review of witness statement written by LPN 1 on August 8, 2021, revealed, Writer was in the nurses station charting when I heard a loud noise. CNA then called out that resident had rolled out of bed. Upon entering the room, bed was at waste [sic] level + resident was on the floor between the wall + her bed. CNA was at her feet. CNA stated she was in the residents bathroom at time of incident wetting a wash cloth. Review of witness statement written by NA 1 (Nurse Aide) on August 8, 2021, revealed, On 8/8/21 at 2 pm I went into [Resident 2's] room to check and change her. I rolled her over on her side. She was a bit messy, so I step away from the bed, leaving her on her Lt [left] side, to wet a wash cloth. On returning to the room I was just in time to see her rolling out of bed landed on her Rt [right] side. I called the charge nurse to check her. During an interview with NA 1 on August 25, 2021, at 10:45 AM she revealed that she was providing incontinence care to Resident 2 when she noticed the resident had bowel movement smears on her after rolling her on her side. She revealed that she had wash cloths within reach, but they were dry so she went into the bathroom to wet them. When she returned, she saw Resident 2 falling, but could not reach her in time. NA 1 revealed Resident 2 only required assistance from one person for check and change. NA 1 revealed that the bed was at waist height when she left the bedside. She stated that she didn't expect Resident 2 to roll because she did not typically move on her own. NA 1 also confirmed that she was taught, and the facility expectation was, that the bed should be lowered when leaving the bedside. NA 1 stated it was not her intention for Resident 2 to fall. Review of Resident 2's care plan that was in place at the time of the fall on August 8, 2021, revealed a care plan related to the resident being at risk for falls with an intervention to ensure that the bed is locked and in lowest position. Review of hospital history and physical dated August 8, 2021, revealed that Resident 2 presented with a [CONDITION(S)] (unrelated to fall) with likely diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During testing performed at the hospital on this date, imaging results revealed multiple acute right-sided rib fractures. The facility failed to ensure that Resident 2 was free from neglect when NA 1 did not follow Resident 2's care planned interventions and deliberately left the bedside while the bed was elevated at waist height. During an interview with the Nursing Home Administrator on August 25, 2021, at 11:30 AM, she revealed that NA 1 was re-educated, and suspended for one day during the course of the investigation. She also revealed that the facility determined that NA 1 did not act willfully to make the resident fall and therefore did not consider it an incident of abuse or neglect. During an additional interview with the Nursing Home Administrator on August 26, 2021, at approximately 1:50 PM she confirmed that no report of neglect was made to required agencies since facility investigation did not determine that an incident of neglect occurred. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on observation, interviews, policy review, and the manufacture's guidelines for glucose meter (device used to check blood sugar levels) cleaning, it was determined that the facility failed to utilize a product that was effective against bloodborne pathogens (infectious microorganisms that can cause disease in humans) when disinfecting the glucose meter on 3 medication carts with glucose meters of five reviewed. (South Mountain Medication Cart 1, South Mountain Medication Cart 2, Sun Valley A Medication Cart) Findings include: A review of the facility policy titled, Procedure for Use of Blood Glucose Monitoring System Meter, last reviewed November 4, 2020, states to maintain transmission of infectious organisms via equipment used in blood glucose monitoring .cleanse with EPA (Environmental Protection Agency) approved disinfecting wipes between each resident. A review of the manufacturer's recommendations for cleaning the facility's glucose meter specified four types of disinfectants that are EPA approved for use and effective against bloodborne pathogens. A review of the sanitizing wipes used by the facility to clean the glucose meters before and after use stated the following: Single-use, disposable wipes for easy cleaning and sanitizing. Wipes are pre-measured with sanitizing solution. No more buckets and dirty rags. Prevent cross-contamination and protect against foodborne pathogens like E. coli (Esherica coli-commonly found in the lower intestines of warm blooded organisms) and salmonella (bacteria-commonly caused by contaminated food or water). Towel/Wipe Type: Disinfecting Wipes; Application: Chairs; Countertops; Foodservice; Tables; Applicable Material: Hard Surfaces; Stainless Steel. During an Interview with LPN 5 on May 25, 2021, at 8:45 AM she revealed the use of sanitizing wipes to clean the glucose meter between and after use on the residents. She went to the rear of the nurse's station to show the container of sanitizing wipes which are approved for use for foodborne pathogens. During an interview with LPN 6 on May 25, 2021, at 8:50 AM she revealed the use of sanitizing wipes to clean the glucose meter between, and after use on the residents. She opened the bottom drawer of the medication cart to show the container of sanitizing wipes. During an interview with LPN 7 on May 25, 2021, at 9:05 AM she revealed the use of sanitizing wipes to clean the glucose meter between, and after use on the residents. She opened the bottom drawer of the medication cart to show the container of sanitizing wipes. During interviews with the Nursing Home Administrator (NHA) both on 5/25/2021, at approximately 2:00 PM, and 5/26/2021, at approximately 10:00 AM, she stated that she believes the sanitizing wipes are appropriate. During an interview with the NHA on May 27, 2021, at approximately 8:30 AM she revealed that the sanitizing wipes are no longer used to clean the glucose meters, and are being replaced by a product that is effective against bloodborne pathogens, and approved by the manufacturer of the glucose meter. 28 Pa. Code 201.18(b)(1)Management. 28 Pa. Code 211.12(d)(1)(2)(5)Nursing services.

Based on resident observation, clinical record review and staff interview it was determined that the facility failed to ensure the review and revision of the interdisciplinary person-centered plan of care for two of twenty-eight residents reviewed (Residents 34 and 47). Findings Include: Review of Resident 34's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 34 on May 24, 2021, at 11:38 AM revealed resident in her room wearing plastic safety goggle-style glasses. During an interview with resident at that time she revealed that she was wearing the glasses to help with the headache she was experiencing. During an interview with LPN 6 (Licensed Practical Nurse) on May 27, 2021, at approximately 10:05 AM she revealed that Resident 34 did have orders to wear the plastic glasses following eye surgery that occurred in April 2020, but that the order had been discontinued. She further revealed that Resident 34 prefers to continue wearing the glasses, but is not required to. During an interview with the Director of Nursing on May 27, 2021, at 10:39 AM, he revealed that Resident 34 likes the dark and prefers to wear the plastic glasses because they are room darkening. He also confirmed that the order for the plastic glasses had been discontinued 14 days after eye surgery in April 2020. Additionally he revealed the expectation that the care plan should reflect Resident 34's preference to wear the glasses and confirmed that the care plan had been updated. Review of Resident 34's progress notes revealed that it was documented that Resident 34 complained of one or more of the following symptoms on the following dates: chest/epigastric pain/ indigestion/ upset stomach/ heartburn on March 22, 28, April 18, 22, May 2, 7, 18, and 21, 2021. Review of nursing progress note dated May 7, 2021, revealed, Weight review. Resident with notable wt loss of 2.5% x 30 and 7.7% x 180 days and intake has decreased from 87% to 62% over past 6 months. Spoke with resident - reported she is not trying to lose weight and c/o [complained of] poor appetite r/t [related to] frequent GI [gastrointestinal] pain, upset and nausea. Review of Resident 34's current orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with LPN 6 on May 27, 2021, at approximately 10:05 AM, she revealed that Resident 34 has frequent complaints of indigestion and related chest pain at which time she is offered [MEDICATION(S)] or gingerale which is effective. Review of Resident 34's comprehensive care plan failed to reveal any care area related to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing on May 27, 2021, at approximately 12:40 PM he revealed that nursing provides resident with gingerale and medication which is noted to be effective, but that resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of Resident 47, on May 24, 2021, at 10:34 AM revealed the resident to be sitting with their spouse participating in an activity in the common area. An interview with the Nursing Home Administrator (NHA), on May 25, 2021, at 2:30 PM revealed Resident 47 and their spouse spend time together during activity programming and confirmed the married couple have room visits. The interview also revealed familial preference that the couple do not share a room based on Resident 47's desire to assist the spouse with care prompting concerns regarding safety, as well as couple preference. Review of the facility's admission packet revealed no policies regarding accommodation of preferences and/or accommodations related to married couples residing within the facility/household. Review of Resident 47's interdisciplinary plan of care revealed none developed addressing the preferences of the married couple residing in the facility, spousal visits, or the option of sharing a room. Correspondence with the NHA on May 26, 2021, reviewed at 9:13 AM revealed staff created a person-centered care plan specific to Resident 47's preferences related to sharing a room with their spouse. An interview with the NHA on May 27, 2021, at 11:21 AM confirmed a person-centered plan of care related to resident/spousal preferences should have been previously developed. 28 Pa. Code 201.29 (j) Resident rights. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility provided documentation and staff interview it was determined that the facility failed to report allegations of abuse not resulting in serious bodily injury to other officials including the state's adult protective services agency within 24 hours for one of two allegations of abuse reviewed and one of twenty-eight residents reviewed (Resident 37). Findings Include: Review of Resident 37's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Reporting and Investigation of Allegations, most recently reviewed on October 16, 2020, reads, in part, The Administrator and/or Director of Nursing must report the incident . no later than 24 hours if the events do not involve abuse or result in serious bodily injury . Review of a facility provided incident report, dated April 9, 2021, revealed an Employee from the maintenance department reported observing a verbal conversation between the NA [nursing assistant 1] . which was loud and harsh. NA 1 was suspended per policy, pending investigation. Review of the facility's investigation revealed a determination that verbal/emotional abuse was unsubstantiated. [NA 1] would return to work and complete additional education on dementia behaviors and communication. Continued review of the facility's incident report investigation documents revealed the allegation of abuse to be documented on April 9, 2021 and the date of reporting to the Pennsylvania Department of Aging to have occurred on April 13, 2021. An interview with the Nursing Home Adminstrator, on May 25, 2021, at 2:12 PM revealed an acknowledgement of the reporting not in the required timeframe per regulation. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.12 (d) (2) Nursing services

Based on facility provided documentation and staff interview it as determined that the facility failed to ensure the resident's right to be free from verbal abuse for one of twenty-eight residents reviewed ( Resident 265). Findings Include: Review of Resident 265's May 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Reporting and Investigation of Allegations, most recently reviewed on October 16, 2020, describes verbal abuse as any use of oral, written, gestured language that includes disparaging and derogatory terms to residents or their families, or within hearing distance to describe residents, regardless of their age, ability to comprehend, or disability. Review of the facility's provided incident report, dated September 17, 2020, revealed a report of an allegation of the nursing assistant (NA 2) being verbally abusive to [Resident 265] in the dining room and in his room while being transferred from wheelchair to recliner. Further review of the incident report revealed NA 2 was witnessed having an inappropriate tone and calling [Resident 265] a 'whiner' and ' stop your fine.' Also, Na 2 told [Resident 265] to stop complaining. Additional review of the incident report revealed the facility investigation to determine Resident 265 as a victim and NA 2 as the alleged perpetrator and therefore substantiating the verbal abuse towards Resident 265. As a result of the substaicanted abuse, NA 2 was terminated from employment with the facility on September 21, 2020. An interview with the Nursing Home Administrator on May 25, 2021, at 2:12 PM revealed an acknowledgement of the verbal abuse and confirmed NA 2 to no longer be employed by the facility based on the outcome of the investigation. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.12 (d) (2) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident the right to formulate an advance directive and/or a living will for one of twenty-eight residents reviewd (Resident 72). Findings Include: Review of Resident 72's May 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's admission documents revealed an advance directive described as a written document that you may use, under certain circumstances, to tell others what care you would like the receive or not receive should you become unable to express your wishes at some time in the future. Further review of the admission documents revealed a living will described as a written document that describes the kind of life-sustaining treatment you want or do not want if you are later unable to tell your doctor what kind of treatment you wish to receive Review of Resident 72's Advance Directive Acknowledge document, dated February 26, 2016 revealed the resident documented having no living will and no designated health care power of attorney. Review of Resident 72's clinical record revealed no advance directive or living will documents. An interview with the Nursing Home Administrator, on May 25, 2021, at 2:02 PM confirmed Resident 72 has no advance directive or living will on file. 28 Pa. Code 201.14 (a) Management 28 Pa. Code 211.5 (f) Clinical records

Based on a review of facility documents and clinical records, as well as staff interview, it was determined that the facility failed to ensure each resident receives food that accommodates his or her allergies for one of three residents reviewed (Resident 1) resulting in harm from a swollen throat, difficulty breathing, unresponsiveness, and hospitalization . Findings include: Review of a facility provided policy, Meal Identification, last revised January 2018, disclosed all meal services from the Dining Services Department have a menu/card/roster marked with the resident's name, room number and diet (according to community's HIPPA policy). Information includes resident's name, room number, diet allergies and miscellaneous information such as adaptive eating equipment or portion size request. Review of Resident 1's clinical record revealed he was admitted to the nursing facility on Septmber 19, 2019, his admission physician orders [REDACTED]. Further review of Resident 1's physician orders [REDACTED]. Review of Resident 1's Initial Dietary interview and his Nutrition Risk assessment, both dated September 19, 2019, revealed a food allergy to shellfish. Review of Resident 1's meal card revealed a diet ordered as low fat/low carbohydrate, no added salt, with a food allergy listed as shellfish. Review of a facility incident report dated September 27, 2019, at 5:15 PM, revealed that Resident 1 has an allergy to shellfish, he was served shrimp salad for dinner. He ate the shrimp before realizing what he was eating. After eating, he stated to the NA (nurse aide) that he had a reaction in the past. The report goes on to state that the resident was unable to say what the reaction was but stated he became violently ill. Resident's spouse was updated and noted that he 'closed up. The physician was notified and gave orders for [MEDICATION NAME] (a medication used in emergencies to treat serious allergic reactions) and [MEDICATION NAME] (a medication used to treat allergies) as needed. Review of witness statements attached to the incident report revealed that in an interview, with the Nursing Home Administrator on September 30, 2019, at 3;00 PM to 4:15 PM, Registered Nurse (RN) 1 stated that she and RN 2 went to Resident 1's room and found he was laying back in recliner, unresponsive with saliva. Oxygen saturation (a measurement of oxygen saturated hemoglobin relative to total hemoglobin in the blood, normal being 95-100%) was 40%, oxygen was placed on resident at 10 liters and Oxygen saturation increased to 75%, crash cart was brought to resident's room, non-rebreather mask (a device used to assist in the delivery of oxygen) initiated. When paramedics arrived, oxygen was increased to 15 liters and saturation raised to 85%. Review of interdisciplinary notes dated September 28, 2019, at 12:12 AM revealed that on September 27, 2019, at 7:17 PM Resident 1 stated I am having trouble breathing. His neck was notably swollen and Licensed Practical Nurse (LPN) 1 alerted the supervisor and went to get the [MEDICATION NAME] which was administered at 7:20 PM. The physician was alerted and gave orders for Resident 1 to be sent to the hospital emergency room for evaluation and treatment. 911 was called and resident was transported to the hospital where he was subsequently admitted with a [DIAGNOSES REDACTED].) Review of a interview with Nurse Aide 1 (NA) 1 on September 28, 2019, at 12:40 PM by the Nursing Home Administrator revealed the dietary aide made a row of meal trays. The menu slip was there but not the diet card. She stated she normally checks them prior for changes but didn't as the dietary aide put the cards away. NA 1 went on to say she assisted Resident 1 to the side of his bed and set up his tray. She is aware she should have the dietary card with her when she delivers trays. Review of an interview with Dietary Aide 1 (DA) on September 30, 2019, at 4:45 PM by the Nursing Home Administrator revealed the nurses provide him with menu selections and diet cards. He looks at the name, diet and utensils and makes up plates. He provides the plate on the counter with dome lid on and meal selection and diet card on top of dome. The nurses review the cards and put the food on trays. The aides (nurse aide) keep menu selections and give him the diet cards back. DA 1 went on to say he didn't look at the pink highlighted (allergies) area as he thought the nurses did that. He stated he was trained on South Mountain neighborhood and those aides tell him allergies and preferences so he thought it was the same on New Hope neighborhood . Review of a interview with Nurse Aide 2 (NA) on October 1, 2019, at 10:30 AM by the Nursing Home Administrator revealed NA 2 came on shift at 6:30 PM and received report from NA 1 who reported that Resident 1 was given seafood salad even with an allergy to shellfish. NA 2 asked NA 1 did she realize what shellfish is and NA 1 responded no. NA 1 stated she knew he had an allergy. An interview with the Nursing Home Administrator, on November 6, 2019, at 2:10 PM confirmed the shrimp salad was served inaccurately to Resident 1 resulting in hospitalization . 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility call bell audits, review of clinical records, and resident and staff interview, it was determined that the facility failed to protect the resident's from accidental falls for one of 30 Residents reviewed resulting in harm (Resident 3). Findings include: Review of the clinical record for Resident 3 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool used to periodically review residents' needs for care and services) dated March 19, 2015, revealed that Resident 3's BIMS (Brief Interview for Mental Status - a tool used to assess a residents cognition) was 15, indicating the resident is cognitively intacted. Review of the facility, Incident Investigation report dated March 14, 2015, revealed that Resident 3 experienced an unwitnessed fall on March 14, 2015 at 6:20 p.m. Review of the Incident Investigation report revealed that Resident 3 required the assistance of one person for walking in her room and for transfers. Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool used to periodically review residents' needs for care and services) dated March 19, 2015, revealed that Resident 3's cognitive status was assessed as a 15 (indicating that the resident was cognitively intact) and Resident 3's functional status was assessed as needing the assistance of one person for ambulation in the room. Further review of the, Incident Investigation report revealed that Resident 3 had made a statement, if they would answer my call bell and not let it ring and ring and ring, I wouldn't have to get up on my own .Sometimes they come in and turn off the light and then say they will be right back and they don't always come right back. Review of the, Incident Investigation report dated March 14, 2015, also revealed that as a result of Resident 3's comments, a call bell audit was done and revealed that there was an 18 minute response to the call bell. Follow-up action by the facility included the presentation of an in-service education for staff on March 19, 2015, regarding the answering of call bells. A note on the in-service attendance sign-in sheet dated March 19, 2015, revealed, Call bells need to be answered/acknowledged in a timely manner. It is expected that call bells be answered/acknowledged within 5 minutes. Review of the facility, Incident Investigation report also revealed an unwitnessed fall on April 1, 2015. The Incident Report dated April 1, 2015, revealed in the Describe Incident section the following statement, Resident was found by staff kneeling on one knee attempting to transfer self from toilet to wheelchair. Resident stated that when she gets the urge that she needs to go, she doesn't want an accident in her chair or bed. Continued review of the facility, Incident Investigation reports revealed an Incident Report dated May 29, 2015, which described that Resident 3 experienced an unwitnessed fall on May 29, 2015 at 12:30 a.m. Review of the nursing note dated May 29, 2015, revealed that Resident 3's statement, I waited a long time after pushing my call light, I didn't want to pee my pants. I was on my (way) back from the restroom when I fell . Review of the report indicated that Resident 3 suffered a fracture of the right femur (the thigh bone, the upper leg). Resident 3 required admission to the hospital. Review of the, Incident Investigation report dated May 29, 2015, revealed that employee statements were taken. Employee NA 1, a Nurse Aide, stated, there was only one other aide . she was busy answering lights I had no idea Resident 3's light was even on I didn't know anything had happened until (the) nurse came to ask me if my phone was working and I said it wasn't doing anything at the time . Employee NA 2, a Nurse Aide, stated, no, I remember lots of lights being on from (the) start of the shift to until (the) time of the fall I did not know her light was on for (an) extended period of time . Review of the facility, Alarm Average Response Time Report for May 29, 2015, revealed that after Resident 3 activated her call bell for help there was a lapse of 25 minutes and 6 seconds before anyone entered her room, at which time it was discovered that she had fallen. Review of the facility, Incident Investigation dated May 29, 2015, revealed that the resident was sent to the hospital and diagnosed with [REDACTED]. 42 CFR 483.25(h)Accidents Previously cited 08/21/14, 09/27/13. 28 Pa. Code 201.14(a) Responsibility of the licensee. Previously cited 09/27/13. 28 Pa. Code 201.18(b)(1) Management. Previously cited 08/21/14, 09/27/13. 28 Pa. Code 201.20(a) Staff development. Previously cited 09/27/13. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 08/21/14, 09/27/13.

Based on review of facility call bell audits, review of clinical records, and resident and staff interview, it was determined that the facility failed to ensure that each residents' right to be free from neglect was ensured for one of 30 Residents reviewed resulting in harm (Resident 3). Findings include: Review of the clinical record for Resident 3 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool used to periodically review residents' needs for care and services) dated March 19, 2015, revealed that Resident 3's BIMS (Brief Interview for Mental Status - a tool used to assess a residents cognition) was 15, indicating the resident is cognitively intacted. Review of the facility, Incident Investigation report dated March 14, 2015, revealed that Resident 3 experienced an unwitnessed fall on March 14, 2015 at 6:20 p.m. Review of the Incident Investigation report revealed that Resident 3 required the assistance of one person for walking in her room and for transfers. Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool used to periodically review residents' needs for care and services) dated March 19, 2015, revealed that Resident 3's cognitive status was assessed as a 15 (indicating that the resident was cognitively intact) and Resident 3's functional status was assessed as needing the assistance of one person for ambulation in the room. Further review of the, Incident Investigation report revealed that Resident 3 had made a statement, if they would answer my call bell and not let it ring and ring and ring, I wouldn't have to get up on my own .Sometimes they come in and turn off the light and then say they will be right back and they don't always come right back. Review of the Incident Investigation report dated March 14, 2015, also revealed that as a result of Resident 3's comments, a call bell audit was done and revealed that there was an 18 minute response to the call bell. Follow-up action by the facility included the presentation of an in-service education for staff on March 19, 2015, regarding the answering of call bells. A note on the in-service attendance sign-in sheet dated March 19, 2015, revealed, Call bells need to be answered/acknowledged in a timely manner. It is expected that call bells be answered/acknowledged within 5 minutes. Review of the facility Incident Investigation report also revealed an unwitnessed fall on April 1, 2015. The Incident Report dated April 1, 2015, revealed in the Describe Incident section the following statement, Resident was found by staff kneeling on one knee attempting to transfer self from toilet to wheelchair. Resident stated that when she gets the urge that she needs to go, she doesn't want an accident in her chair or bed. Continued review of the facility, Incident Investigation reports revealed an Incident Report dated May 29, 2015, which described that Resident 3 experienced an unwitnessed fall on May 29, 2015 at 12:30 a.m. Review of the nursing note dated May 29, 2015, revealed that Resident 3's statement, I waited a long time after pushing my call light, I didn't want to pee my pants. I was on my (way) back from the restroom when I fell . Review of the report indicated that Resident 3 suffered a [MEDICAL CONDITION] femur (the thigh bone, the upper leg). Resident 3 required admission to the hospital. Review of the Incident Investigation report dated May 29, 2015, revealed that employee statements were taken. Employee NA 1, a Nurse Aide, stated, there was only one other aide . she was busy answering lights I had no idea Resident 3's light was even on I didn't know anything had happened until (the) nurse came to ask me if my phone was working and I said it wasn't doing anything at the time . Employee NA 2, a Nurse Aide, stated, no, I remember lots of lights being on from (the) start of the shift to until (the) time of the fall I did not know her light was on for (an) extended period of time . Review of the facility Alarm Average Response Time Report for May 29, 2015, revealed that after Resident 3 activated her call bell for help there was a lapse of 25 minutes and 6 seconds before anyone entered her room, at which time it was discovered that she had fallen. In an interview with the Director of Nursing (DON) on September 24, 2015 at 10:45 a.m., the DON revealed the expectation that call bells be answered in a timely manner. 42 CFR 483.13(c)Abuse Policies 28 Pa. Code 201.14(a) Responsibility of the licensee. Previously cited 09/27/13. 28 Pa. Code 201.18(b)(1) Management. Previously cited 08/21/14, 09/27/13. 28 Pa. Code 201.20(a) Staff development. Previously cited 09/27/13. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 08/21/14, 09/27/13.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that interventions were implemented to reduce the risk of falls for 2 of 30 residents reviewed (Residents 8 and 18). Findings include: Review of Resident 8's August 2014, physician's orders [REDACTED]. Review of Resident 8's quarterly Minimum Data Set assessment (MDS - an assessment tool) dated May 24, 2014, indicated that Resident 8 had a history of [REDACTED]. Review of Resident 8's Fall Incident Report dated April 18, 2014, revealed that Resident 8 was in the Woodbury Lounge, sitting with several other residents rolling a ball on the table. This activity was being supervised by Registered Nurse (RN) 1. Mid-way through the activity, RN 1 left the room to get a resident a snack from the kitchen. When RN 1 left the room, the residents were still rolling the ball, so RN 1 did not take the ball with her. Resident 8 then stood up and fell on her left side, hitting her head on the fireplace. According to the fall report, RN 1 saw Resident 8 stand up and bend down to get the ball, but RN 1 could not reach Resident 8 before the resident fell . Resident 8 was sent to the hospital and seen by the physician on April 18, 2014, at 9:25 p.m., with a complaint of neck and joint pain. An X-ray of the left hip was done revealing a fracture and Resident 8 was admitted to the hospital. An interview with RN 1 was conducted by phone with the surveyor, the Nursing Home Administrator and the Director of Nursing (DON) 1 on August 21, 2014, at 12:05 p.m. During the telephone interview, RN 1 revealed that she had about eight residents in the lounge area playing with a ball and if the ball went on the floor, she would pick it up for the residents. RN 1 indicated there was a diabetic resident in the group that a snack was required for, so she went into the kitchen area for the snack. From the kitchen area, RN 1 observed Resident 8 stand up and was not able to get to the resident before she fell . RN 1 stated, "I should have taken the ball with me when I was in the kitchen area for the resident's snack." Review of the clinical record for Resident 18 revealed [DIAGNOSES REDACTED]. Review of Resident 18's Fall Incident Reports revealed that Resident 18 sustained falls on February 15, 2014, and March 21, 2014. Review of Resident 18's Fall Incident Report interventions dated February 15, 2014, included to add Resident 18 to the physical therapy caseload to assess if the lift chair use contributed to Resident 18's falls. Review of Resident 18's Fall Incident Report dated March 21, 2014, indicated Resident 18 had been restless all day except during dinner. Interventions listed on the March 21, 2014 fall report included to check the resident's urine and glucose, to assess if Resident 18's fall may have been caused by a change in blood sugar or a urinary tract infection. Review of Resident 18's clinical record revealed that there was no evidence that physical therapy had assessed Resident 18 for the lift chair or that Resident 18's urine and glucose were checked. An interview with the DON on August 20, 2014, at 2:25 p.m., confirmed that there was no evidence that physical therapy assessed the resident's lift chair or that a urinalysis and glucose were done. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.11(a)(c) Resident care plan. 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on a review of facility policy, review of clinical records, and staff interviews, it was determined the facility failed to follow physician orders [REDACTED]. Findings include: Review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], following an emergent Coronary Artery Bypass surgery. Admitting [DIAGNOSES REDACTED]. Review of the facility physician orders [REDACTED]. in 12 hours. Review of the facility Bowel Management/Retraining Program policy dated September 30, 2012, revealed objectives were to achieve control of bowel evacuation on a regular basis and avoid constipation. Responsibilities of staff include provide an adequate fluid intake, approximately 1000-1500 ml per day, adequate bulk food intake, collect data, document each shift, follow facility bowel protocol, and review progress or lack of progress with physician. The bowel protocol written into the facility policy is as follows: MOM 30 ml at bedtime, if no bowel movement after 6 shifts, if ineffective in next 3 shifts repeat times 1, if second dose of MOM not effective by 5 a.m. the following day, give suppository, if suppository not effective by 12 hours, give [MEDICATION NAME] enema, if no results from enema contact physician. In addition, the policy states that residents on a regular bowel regimen will have constipation addressed in the care plan. Review of the facility Physician Notification policy dated October 17, 2012, revealed the Medical Concern form is used for communicating consultant physician or pharmacist recommendations, requesting treatments, and physician requested updates. The guidelines for telephone notification indicate the physician should be notified of vomiting/diarrhea, constipation, and gradual deterioration over a period of time at the RN (Registered Nurse) discretion. Review of the clinical record revealed Resident 1 was at the facility for 55 days. There was a documented fluid intake of less than 1000 ml on 40 days of his stay on the following dates: December 13, 2012 through December 28, 2012, December 30, 2012, December 31, 2012, January 2, 2013 through January 7, 2013, January 12, 2013, January 13, 2013, January 15, 2013, January 22, 2013 through January 24, 2013, January 26, 2013, January 27, 2013, January 29, 2013, January 30, 2013, February 1, 2013, February 3, 2013, and February 4, 2013. During an interview on April 3, 2013 at 2:30 p.m., the Nursing Home Administrator (NHA) revealed that not all fluids are documented in the clinical records. When asked if all fluids consumed should be documented, she stated they should be. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the clinical record revealed no documentation of a bowel movement for a period of six days from December 17, 2012 to December 22, 2012. MOM was given daily and documented as ineffective from December 19, 2012 to December 22, 2012. The suppository was documented as refused on December 21, 2012, which is one day beyond the day specified in the physician ordered regimen. The suppository was documented as given and effective on December 23, 2012, which was three days beyond the day specified in the physician ordered regimen. Review of nursing notes dated December 23, 2012, revealed "encouraged to get out of bed because he has not moved bowels in several days, he refuses, states will accept enema when he wants it." There was no evidence in the clinical record that the physician was notified of a resident refusal or ineffective regimen. There was no documentation of a bowel movement for a period of seven days between December 24, 2012 and December 30, 2012. MOM was documented as given and ineffective on December 26, 2012, and a suppository was documented as given and effective on December 31, 2012, four days beyond the day specified in the physician ordered regimen. There was no evidence in the clinical record that the physician was notified of a resident refusal or ineffective regimen. There was no documented evidence of a bowel movement for a period of three days from January 11, 2013 to January 14, 2013. MOM and a suppository were given and effective on January 14, 2013. Nursing notes dated January 12, 2013, revealed "resident vomited and stated he was nauseous." Nursing notes dated January 15, 2013, revealed "resident complains of feeling nauseous the past couple days and has vomited on several occasions." A medical concern form dated January 15, 2013, (three days after the first documented episode of vomiting) revealed, "resident complains of nausea/vomiting a few times last week, may we have a [MEDICATION NAME] order as needed." Review of the physician orders [REDACTED]. There was no documented evidence of a bowel movement for a period of four days from January 16, 2013 to January 19, 2013. MOM was documented as given and ineffective on January 17, 2013 and January 19, 2013. There was no evidence MOM was given on January 18, 2013. MOM was given and effective on January 20, 2013. There was no documented evidence the suppository or enema were given or refused. There was no documented evidence the physician was notified of resident refusals or an ineffective regimen. There was no documented evidence of a bowel movement for a period of three days from January 23, 2013 to January 25, 2013. MOM was documented as given and ineffective on January 24, 2013. There is no documentation MOM was given on January 25, 2013. The suppository was documented as given and effective on January 26, 2013. There is no documented evidence the physician was notified of resident refusal or an ineffective regimen. During an interview on April 3, 2013 at 1:55 p.m., Licensed Practical Nurse (LPN) 1 stated a bowel list is printed nightly to verify which residents have not had a bowel movement. She stated the protocol staff follow is to give MOM on the second evening after no bowel movement, then a second dose on the third evening, a suppository the fourth morning, then an enema. When asked what she would do if the resident refuses or the regimen did not work, she stated she would start with the MOM again. When asked if the physician would be notified, she initially stated she was not sure. LPN 1 stated she had never encountered that before, but she would pass the information along in shift report. She then added the physician should be notified for a resident refusing or regimen not working. During an interview on April 3, 2013 at 3:45 p.m., the Registered Nurse (RN) Consultant stated that it does not appear from the clinical documentation that the bowel policy was followed. Review of the nursing notes dated February 4, 2013 at 2:43 p.m., revealed, "resident having increased lethargy, easily aroused, temperature 100.4, updated physician by fax and placed on medical concern board." A note dated February 4, 2013 at 6:27 p.m., revealed "increased lethargy persists, periods of apnea observed, audible loose secretions in upper respiratory, no adventitious sounds heard in lungs, O2 sats decreased to 88% on room air, O2 therapy started per order, resident difficult to arouse, spouse updated, will continue to monitor for status changes." There was no documented evidence the physician was notified of the change in level of consciousness and ability to arouse, or of the apnea. Review of an RN Assessment for Significant Change in Status form dated February 4, 2013 at 2:04 p.m., revealed "care giver alerted care leader resident seemed very warm. Upon arrival elevated temp noted, sheets were damp with perspiration." Assessment included, "skin warm and moist, mucous membranes moist, respiration non-labored and shallow, no oxygen, lungs clear, abdomen soft." The bowel function and bowel sounds were not documented as assessed. During an interview on April 3, 2013 at 1:50 p.m., RN 1 stated she assessed Resident 1 because he was sweaty and had a temperature. She was unable to state why she did not document bowel sounds, but feels that she did listen to his bowel sounds. She stated she remembers palpating Resident 1's abdomen and he did not complain of pain. During an interview on April 3, 2013, at 3:45 p.m., the RN Consultant stated that the Significant Change Form would not have to be documented completely as standards of practice dictate the nursing assessment should be driven by the resident's clinical presentation, and at that time, the staff were assessing for a suspected fever and respiratory symptoms. Review of the York Hospital Emergency Department Physician Impression and Plan dated February 5, 2013, revealed: 1.) partial small bowel obstruction, 2.) fecal impaction in large bowel, 3.) Pneumonia, 4.) septic shock, and 5.) respiratory distress. A physical assessment stated dry oral mucous, abdomen very distended, bowel sounds quiet. Review of a CT scan dated February 5, 2013, revealed pronounced colonic distention, the rectum is mildly distended with stool and may be secondary to fecal impaction. Review of the death certificate for Resident 1 dated February 7, 2013, revealed the immediate cause of death was bowel obstruction. Review of the clinical record revealed no care plan was initiated for constipation. During an interview on April 3, 2013 at 3:15 p.m., with the Nursing Home Administrator (NHA) and the Registered Nurse Assessment Coordinator (RNAC), the RNAC stated that Resident 1 did not have a care plan for constipation. She stated that an admitting [DIAGNOSES REDACTED]. She stated the care plan would be initiated only if the issues continued. 483.25 Provide Care/Services for Highest Well Being. Previously cited 9/14/12, 8/4/11. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 9/14/12, 8/4/11.

Based on review of facility and clinical records and interviews with staff, it was determined that the facility failed to ensure that timely and necessary care and services were provided for one of three residents (Resident R1) reviewed who had an identified change in condition. Findings include: Review of nurses' notes dated February 19, 2011, at 10:20 a.m., revealed that when Nurse Aide 1 was ambulating Resident R1 to the bathroom with her walker, the resident's right shoe became loose, she lost her balance and fell backwards onto her buttocks and the back of her head hit the floor. A large laceration with a large amount of bleeding and a hematoma (swelling caused by a collection of blood) were noted on her occipital area (lower back of the head) and she was made comfortable, a pillow was placed under her head and an ice pack and pressure were applied. At 10:40 p.m. (20 mins. later), the physician was updated and ordered that she be transferred to the hospital for evaluation and treatment. Subsequently, Resident R1 was emergently transferred to the hospital at 11:00 a.m. (40 mins. after her identified injury). Hospital records reported that the laceration was closed with seven staples and that she had an acute subdural hematoma (accumulation of blood inside the skull) and she returned to the facility at approximately 2:40 p.m. Resident R1's initial nurse notes dated February 19, 2011, at 3:00 p.m., reported that she had a 3.5 centimeter (cm) laceration with seven staples intact with some bleeding from the site. In addition, she had multiple skin tears and bruises. At 3:10 p.m., Resident R1 had nausea, with dry heaves two times. The physician was paged and at 4:00 p.m., new orders were received for [MEDICATION NAME] (medication for nausea/vomiting) 10 milligrams (mg) suppository every 6 hours as needed for nausea/vomiting; treatment for [REDACTED]. Resident R1 vomited three times at 5:45 p.m. but after a dose clarification of the medication which was clarified at 9:45 p.m., she was given [MEDICATION NAME] 25 mg. by suppository for the vomiting at 9:45 p.m. (4 hours later). At 10:30 p.m., she was having a moderate amount of bloody drainage which was noted on the drainage pad from her laceration site. She complained of nausea and the back of her head hurting. At 3:30 a.m. on February 20, 2011, there was a small amount of bloody drainage from the laceration, and at 6:30 a.m., she was tearful with complaints that the back of her head hurt. She was given Tylenol (an [MEDICATION NAME] for mild pain) 650 milligrams (routine order from [DATE]). Tylenol was given again at 12:30 p.m. for moderate pain in the back of her head. At 6:30 p.m., the resident complained of occipital lobe (back of head) pain and was again given Tylenol. There was no evidence that the physician was contacted regarding the resident's vomiting and continued nausea, complaints of pain or bleeding at the laceration site. There were no further nurses' notes until February 21, 2011, at 9:15 a.m., when the resident was assessed as nonresponsive, motionless, her eyes open and rolling back into her head and having ,[DATE] second periods of apnea (not breathing). Registered Nurse 1 called the family at 9:25 a.m., (10 mins. later) to speak with the family regarding the resident's condition prior to calling the physician at 9:30 a.m. (15 mins. after the resident was found with sudden loss of consciousness). The physician ordered the resident to be transferred to the hospital for evaluation and admission, if necessary. Resident R1 was emergently transferred to the hospital at 9:50 a.m. (35 mins after the significant change in her condition). Hospital records dated February 20, 2011, reported that Resident R1 was comatose upon her arrival, her pupils were constricted and responded sluggishly to light and she had "increased thickness involving subdural hemorrhage (active bleeding) concerning for continued or rebleed" and was diagnosed with [REDACTED]." On February 28, 2011, the family decided to provide comfort measures only. She was transferred back to the facility on [DATE], for end-of-life care and expired at 7:20 p.m. on [DATE]. Interview with the Administrator and Assistant Administrator at 1:30 p.m. on [DATE] confirmed that nursing staff failed to communicate neurological changes and symptoms to the physician or Clinical Care Specialist and failed to document those changes on the Neurological Evaluation form per their Neurological Evaluation Policy which resulted in a delay in care and services. 483.25 Quality of Care Previously cited [DATE] 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code: 211.5 (f) Clinical Records. Previously cited [DATE]. 28 Pa. Code: 211.5 (g) Clinical Records. 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code: 211.12 (d)(5) Nursing Services. Previously cited [DATE], [DATE].

Based on a review of clinical records, facility policy and facility documentation and interviews with staff, it was determined that the facility failed to ensure that each resident received adequate supervision to prevent accidents and that the environment remained as free from accident hazards as possible for one of three residents (Resident R1) reviewed. Findings include: Review of the Ambulation Policy and Procedure dated August 31, 2010, revealed that caregivers for residents who are one-person assist (requiring minimal assistance), are to apply a gait belt snugly around the resident's waist, and assist residents to stand and achieve balance before initiating ambulation. If the resident begins to fall, the staff are to use the gait belt to gently ease the resident to the floor and call for help. Review of nurses' notes dated February 19, 2011 at 10:20 a.m., revealed that when Nurse Aide 1 was ambulating Resident R1 to the bathroom with her walker, the resident's right shoe became loose, she lost her balance and fell backwards onto her buttocks and the back of her head hit the floor. A large laceration and hematoma (swelling caused by a collection of blood) was noted on her occipital area (lower back of head) and she was emergently transferred to the hospital. Resident R1 was returned to the facility at 3:00 p.m., she had a 3.5 centimeter laceration that had seven staples in place with some bleeding at the site and was diagnosed to have a subdural hematoma (accumulation of blood inside the skull which builds pressure on the brain). In addition she had multiple skin tears and bruises and complained of pain all over. Review of Nurse Aide 1's statement dated February 19, 2011, reported that Resident R1 took two steps and her right shoe made her foot go to the side and she lost her balance and fell . She also stated that the resident's right shoe never fits very well and it sometimes doesn't stay tight on her foot. Licensed Practical Nurse 1's statement which is also dated February 19, 2011, reported that there was no gait belt on the resident (as required by facility policy) and the resident's right shoe was off. The facility's investigation that ended on February 23, 2011, concluded that Nurse Aide 1 failed to use a gait belt when ambulating the resident and failed to check for proper fitting footwear prior to ambulating Resident R1. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 11/6/09, 12/1/10 28 Pa. Code: 211.10(d) Resident Care Policies. Previously cited 11/6/09, 9/3/10, 12/1/10 28 Pa. Code: 211.5(f) Clinical Records. Previously cited 11/6/09 28 Pa. Code: 211.5(g) Clinical Records. 28 Pa. Code: 211.12(d)(1)(3) Nursing Services. Previously cited 11/6/09, 9/3/10, 12/1/10 28 Pa. Code: 211.12(d)(5) Nursing Services. Previously cited 11/6/09, 9/3/10

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that one of 16 residents reviewed (Resident R1) was free from any significant medication errors. Findings include: Review of Resident R1's physician's orders [REDACTED]. Resident R1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"2" (hurts a little bit) which was described as a generalized pain (aching) and that death was not imminent. Subsequent nurses notes dated [DATE], reported that [MEDICATION NAME] was given at 3:45 p.m., and [MEDICATION NAME] (antianxiety medication) 1 mg was given at 6:20 p.m. At 7:30 p.m., Hospice was contacted regarding Resident R1's inability to swallow and orders were received and verified by the physician for [MEDICATION NAME] 0.25 cubic centimeters sub-lingually (under the tongue) every 2 hours as needed for pain. The Individual Narcotic Record indicated that [MEDICATION NAME] 0.25 cc was given at 7:30 p.m. and 9:45 p.m. There was no evidence that the resident was assessed for pain during this time frame or for the effectiveness of the medication. At 10:45 p.m., on [DATE], Registered Nurse (RN) 2 was notified by RN 1 that Resident R1's Narcotic Count ([MEDICATION NAME]) was incorrect and that Licensed Practical Nurse (LPN)1 told RN 1 that she had spilled some medication earlier in the evening. At 11:00 p.m., LPN 1 stated she gave the wrong dose three times (gave 2.5 cc instead of 0.25 cc, which is 10 times the prescribed dose). RN 1 and RN 3 assessed Resident R1 at 11:15 p.m., and he was unresponsive, his heart rate was irregular, he had deep slow breathing and his blood oxygen level ranged between ,[DATE]% (resident's norm ranged from ,[DATE]). The physician was contacted and informed of the three medication errors. Resident R1 remained unresponsive and his condition continued to decline until he died on [DATE], at 9:45 a.m. Review of the labeling on the [MEDICATION NAME] bottle revealed that it contained 20 mg per milliliter (or cubic centimeter) and listed several doses and their corresponding volume. Resident R1 was to receive 5 mg or 0.25 cc. The calibrated device provided with the bottle was clearly marked in 0.05 cc increments. Statements written by LPN 2 and LPN 3 revealed that on [DATE], at approximately 5:00 p.m. to 5:30 p.m., LPN 1 requested assistance with the dosing calculation for the [MEDICATION NAME]. Both LPN 2 and LPN 3 reviewed the calculation with her using the provided calibrated device (almost 2 hours after the first dose was given). LPN 1 administered three incorrect doses of [MEDICATION NAME], failed to identify that the narcotic declining count was incorrect after the first dose was given, and incorrectly documented the amount given/left on the Individual Narcotic Record. Interview with the Administrator, Director of Nursing and Assistant Director of Nursing on [DATE], at 10:05 a.m., confirmed that LPN 1 administered three overdoses of [MEDICATION NAME] and that the resident's assessments, physical presentation and symptoms, did not warrant the administration of the three doses of [MEDICATION NAME] or the one dose of [MEDICATION NAME]. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10 (d) Resident Care Policies. Previously cited ,[DATE] 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services. Previously cited [DATE]