Every finding on record at Edenbrook at Hampton

Based on clinical record review and interviews with the resident, resident representative, and facility staff, it was determined the facility failed to honor the resident's preferences and failed to provide written notice, including the reason for the room change, prior to a facility-initiated room change for one of 22 residents reviewed (Resident 17).Findings include: Review of the facility policy titled Room Change last reviewed by the facility on January 16, 2026, indicated that the residents' preferences should be considered when making a room or roommate change. Whenever a resident is transferred from one room to another within the facility, a written notice of transfer must be provided to the resident and/or family prior to the move, according to state law. The resident should be provided with a tour of the new location, a chance to meet his/her new roommate and express any concern about the move. The notice is given in advance, except in situations outside the facility's control such as change in level of care, change in their medical or treatment program, or for their own or another residents' welfare as documented in the medical record. At the time of the survey ending April 10, 2026, all beds in the facility were licensed and dually certified for participation in both the Medicare and Medicaid programs. A review of Resident 17's clinical record revealed the resident was admitted to the facility on [DATE], and initially resided on B Hall. Documentation indicated the resident was transferred to a room on A Hall on January 23, 2026. During an interview on April 9, 2026, at 2:15 PM Resident 17, a cognitively intact resident with a BIMS score of 15 (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 13-15 equates to intact cognition), stated that after returning from a five-day hospitalization on January 22, 2026, she awoke to staff packing her belongings. She reported she was not informed where she was going or who she was rooming with. She was not provided with the opportunity to tour the new room or meet the new roommate. She stated staff informed her only that her current room was being renovated and the move was temporary. The resident reported she was extremely upset and distraught, not only about the room change but that she was given no advance notification to prepare for the move. She acknowledged she was hospitalized for 5 days but stated that her daughter, who is her resident representative, was not notified of the room change during the resident's hospitalization. During a telephone interview on April 9, 2026, at 3:00 PM, the resident's daughter reported dissatisfaction with how the facility handled the room change. The daughter stated she received a telephone call from Social Services on the morning of January 23, 2026, informing her that her mother would be moving to A Hall that afternoon. The daughter stated she did not receive advance notice or written notification of the room change. She reported that Social Services informed her the resident would be assigned to a window bed, which conflicted with the resident's expressed preference for a bed closer to the door and bathroom. The daughter stated the resident was upset and had not been provided the opportunity to see the new room or meet the roommate prior to the move. Review of the clinical record revealed no documentation that written notice, including the reason for the room change, was provided to the resident or the resident representative prior to the relocation. There was no documented evidence that the resident's preferences were considered or that the resident was offered the opportunity to view the new room or meet the roommate prior to the move. During an interview on April 9, 2026, at 2:00 PM, Social Services provided a document titled Room Change Request Letter for Resident 17. Review of the document indicated verbal notification was provided on January 23, 2026. The facility was unable to provide evidence that written notification, including the reason for the move, was provided to the resident and/or representative prior to the room change. 28 Pa Code 201.29 (a) Resident Rights.28 Pa Code 211.10 (c)(d) Resident Care Policies.

Based on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to establish mechanisms for documenting and communicating a resident's refusal of ordered laboratory monitoring to the interdisciplinary team (group of professionals from two or more disciplines who collaborate to plan and evaluate care) and failed to ensure staff followed facility policy regarding refusal of treatment for one of 22 residents reviewed (Resident 12).Findings include: Resident 12 was admitted to the facility on [DATE], with diagnoses including epilepsy, nonintractable, without status epilepticus (a chronic neurological disorder characterized by recurrent seizures caused by abnormal electrical activity in the brain). A review of Resident 12's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 5, 2026 revealed that Resident 12 was moderately cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 7 indicates substantial challenges in cognitive abilities). A review of the facility policy titled, Resident Rights: Refuse and/ or Discontinue Care or Treatment, last reviewed January 16, 2026, indicated residents have the right to refuse care or treatment prescribed by the healthcare provider. The policy defined treatment as services provided for purposes of maintaining / restoring health, improving functional level, or relieving symptoms. The procedure indicated if a resident refuses care or treatment, the Director of Nursing or designee will meet with the resident to determine the reason for refusal, attempt to resolve concerns, discuss alternative options and potential consequences of refusing treatment, and document detailed information related to the refusal in the medical record. A review of Resident 12's physician orders revealed an order dated February 26, 2025, for laboratory monitoring of Keppra (levetiracetam, an anticonvulsant medication used to prevent seizures), Vimpat (lacosamide, an anticonvulsant medication used to control seizure activity), and Vitamin D level (a nutrient that supports bone and neurological health). The physician ordered these laboratory tests every 90 days to evaluate whether medication levels remained within a therapeutic range (the level at which a medication is effective without causing harmful side effects) and to support clinical decision-making related to seizure prevention and medication management. Monitoring Vitamin D levels is clinically relevant because low Vitamin D levels have been associated with increased seizure frequency in some individuals, and anticonvulsant medications may contribute to reduced Vitamin D levels. Keppra and Vimpat are commonly prescribed together to improve seizure control in individuals with epilepsy. A clinical record review of the document titled Laboratory Services Requisition dated September 9, 2025, indicated Resident 12 refused to allow the laboratory staff to obtain blood work and evaluate the laboratory values, Keppra, Vimpat, and Vitamin D. The specific laboratory values, Keppra, Vimpat, and Vitamin D, are important for clinical decision-making as it pertains to Resident 12's primary diagnosis reflective of the potential for seizure activity. The clinical record lacked documentation that the interdisciplinary team assessed the reason for the refusal, discussed alternative options such as rescheduling the laboratory draw, evaluated the potential clinical impact of refusal, or communicated the refusal to the practitioner for further medical decision-making. The medical record did not include evidence that staff implemented the facility policy requiring follow-up evaluation, documentation, and communication regarding refusal of treatment. There was no evidence in the medical record, including narrative progress notes or physician orders, that a member of the interdisciplinary team met with Resident 12 to determine why Resident 12 refused to allow blood work to be obtained on September 9, 2025. The medical record did not include evidence the facility attempted to address the reason for refusal, discuss alternative options (e.g. attempt at another time), and the potential outcomes related to the refusal. The absence of specific laboratory values places one at risk for inadequate medication management pertaining to seizure control since the laboratory values support clinical decision making, including seizure prevention and control. The medical record lacked detailed information related to the refusal of treatment (laboratory services) as stated in the facility policy. During an interview on April 10, 2026, at 11:00 AM, the Director of Nursing acknowledged the medical record did not contain documentation demonstrating the interdisciplinary team evaluated Resident 12's refusal of laboratory testing or followed the facility's policy regarding refusal of treatment. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 201.29 (a)(b) Resident rights.

Based on clinical record review, review of facility policies, and staff interview, it was determined the facility failed to ensure nursing services were provided in accordance with professional standards of quality, in accordance with Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure that only qualified staff performed and documented the administration of intravenous therapy via a central venous catheter and failed to ensure accurate and consistent documentation of medication administration for one of 22 residents reviewed (Resident 86).Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145b. IV therapy curriculum requirements: (f) An LPN may perform only the IV therapy functions for which the LPNpossesses the knowledge, skill and ability to perform in a safe manner, except aslimited under S 21.145a (relating to prohibited acts), and only under supervisionas required under paragraph (1).(1) An LPN may initiate and maintain IV therapy only under the directionand supervision of a licensed professional nurse or health care provider authorizedto issue orders for medical therapeutic or corrective measures (such as aCRNP, physician, physician assistant, podiatrist or dentist).(g) An LPN who has met the education and training requirements of S 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145a and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. Review of the facility policy titled Administering Medications last reviewed by the facility on January 16, 2026, indicated that only staff licensed or permitted by the State may prepare, administer, or record the administration of medications. The policy further required that the individual administering the medication must sign the resident's Medication Administration Record (MAR) for the specific time and day the medication was administered. Review of the facility policy titled Parenteral Nutrition General Policies last reviewed by the facility on January 16, 2026, indicated that only a nurse with documented education and training in infusion therapy, including parenteral nutrition administration, and central venous access device management as designated by the facility and as allowed by state regulations, may administer parenteral nutrition. Parenteral nutrition is a method of delivering essential nutrients, including carbohydrates, proteins, fats, electrolytes, vitamins, and minerals, directly into the bloodstream intravenously, completely bypassing the digestive tract. It is used when a person cannot consume, digest, or absorb adequate nutrients through food or feeding tubes. Clinical record review revealed that Resident 86 was admitted to the facility on [DATE], with diagnosis to include severe protein-calorie malnutrition ( a life-threatening, extreme nutritional deficiency characterized by significant weight loss) and surgical aftercare following surgery on the digestive system, and was admitted to the facility with a Total Parenteral Nutrition (TPN) central intravenous catheter (a specialized long-term intravenous line used to deliver concentrated nutrients directly into a large vein near the heart, because the digestive system cannot be used). Review of a physician's order dated April 5, 2026, directed staff to flush the central line with 10 cc (cubic centimeters, a metric used to measure liquid volume or the capacity of a substance, with 1 cc being equal to 1 milliliter) of normal saline before and after TPN administration twice daily (sterile salt solution used to maintain patency/keep the line open and functioning). Review of Resident 86's April 2026 Medication Administration Record (MAR) revealed that between April 5 through April 9, 2026, Employee 2 (Licensed Practical Nurse, LPN), Employee 3 (LPN), Employee 4 (LPN), and Employee 5 (LPN) signed the MAR as administering the central line flush before and after the administration of the TPN to Resident 86 through the TPN central catheter. However, review of nursing progress notes for April 6 through April 9, 2026, indicated that the Registered Nurse (RN) completed the central line flushes. Review of a physician's order dated April 6, 2026, instructed staff to administer TPN Electrolytes Intravenous Concentrate, 100 milliliters/hour intravenously one time a day for parenteral nutrition. Review of Resident 86's April 2026 MAR revealed that between April 6 through April 9, 2026, Employee 3 and Employee 4 documented on the MAR that they administered the TPN IV electrolyte infusion via the central venous catheter. However, corresponding nursing progress notes for April 6 through April 9, 2026, indicated that the RN performed the TPN administration. During an interview on April 9, 2026, at 1:00 PM, Employee 3 (LPN) stated she did not administer the TPN infusion or central line flushes because these procedures were outside her training and scope of practice. Employee 3 stated she notified the RN to perform these procedures. Employee 3 further stated that despite not performing the procedures, she documented on the MAR that she had administered the treatments, while separately documenting in the clinical record that the RN completed the procedures. During an interview on April 9, 2026, at 2:15 PM, the Director of Nursing confirmed that, according to facility policy, only RNs are permitted to administer TPN and perform central line flushes via a TPN central venous catheter. The Director of Nursing further confirmed that facility policy requires the nurse who administers the medication or treatment to accurately document the administration on the MAR. The facility failed to ensure that only qualified staff performed specialized intravenous therapy via a central venous catheter and failed to ensure accurate and consistent documentation of medication administration. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d) Nursing Services. 28 Pa Code 211.10 (c)(d) Resident Care Policies.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to physician-ordered parameters for one of 22 residents reviewed. (Resident 9)Findings include: A review of the facility policy titled Administering Medications last reviewed on January 16, 20026, revealed the purpose of the policy was to ensure safe and effective administration of medication in accordance with physician orders and applicable state and federal regulations. The policy required medications to be administered in accordance with the provider's written or verbal orders after verification of the right medication, right dose, right route, right time, and confirmation of the resident's identity, and only when no contraindications (a clinical reason a medication should not be given because it may cause harm) were present. Resident 9 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus (a chronic brain disorder characterized by recurrent seizures from abnormal electrical activity in the brain) and Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by elevated blood sugar levels due to insulin resistance or inadequate insulin production). A review of Resident 9's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2026 revealed that Resident 9 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 14 indicates cognitive function with minimal memory or thinking changes). A review of the physician's order dated September 1, 2025, directed staff to administer Insulin Aspart Injection Solution 5 units subcutaneously (method of administering medication into the fatty tissue layer just beneath the skin, allowing slow and sustained absorption into the body) two times a day. The physician order further directed staff to hold the insulin dose if Resident 9's blood glucose level was below 110 mg/dL (milligrams per deciliter, a measurement used to indicate the amount of glucose present in the blood). A review of the December 2025 Medication Administration Record (MAR), a clinical document used by nursing staff to record medication administration, revealed Aspart insulin 5 units was administered on the following dates and times despite blood glucose readings below the physician-ordered parameter of 110 mg/dL:December 12, 2025, at 4:00 PM - blood glucose reading of 97 mg/dLDecember 23, 2025, at 4:00 PM - blood glucose reading of 99 mg/dLDecember 26, 2025, at 4:00 PM - blood glucose reading of 106 mg/dL A review of the January 2026 Medication Administration Record (MAR) revealed Aspart insulin 5 units was administered on the following dates and times despite blood glucose readings below 110 mg/dL: January 13, 2026, at 12:00 PM - blood glucose reading of 104 mg/dLJanuary 15, 2026, at 12:00 PM - blood glucose reading of 81 mg/dL Administration of insulin when blood glucose levels were below the physician-ordered parameter prevented nursing staff from determining whether the medication was clinically appropriate to administer and increased the risk for hypoglycemia (abnormally low blood sugar levels that may cause dizziness, confusion, loss of consciousness, seizures, or other serious complications). The findings demonstrated that the medication was repeatedly administered without adherence to physician-ordered parameters and contrary to facility policy and accepted standards of nursing practice, which require nurses to follow medication orders accurately and ensure safe medication administration practices. The above findings were reviewed with the Director of Nursing on April 9, 2026, at 9:50 AM, who confirmed nursing staff failed to follow the physician order and administered insulin outside the ordered parameters on the dates identified above. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to ensure physician orders were followed for one resident (Resident 7) out of 22 residents reviewed. Findings include: A review of the facility policy, titled Pain Management and Assessment last reviewed on January 16, 2026, indicated the facility established a standardized method for assessing, monitoring, evaluating, managing and documenting pain in both cognitively intact and cognitively impaired residents. The policy directed staff to assess and document pain using a consistent and standardized pain assessment method appropriate to the resident's cognitive level. The policy required staff to assess and document pain including onset and duration, location, severity, alleviating, and aggravating factors, possible causes and accompanying sign and symptoms. Clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic medical condition in which the body does not properly use insulin, resulting in elevated blood glucose levels). A review of Resident 7's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 27, 2026 revealed that Resident 7 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 15 indicates no impairment in memory or thinking). Clinical record review indicated Resident 7 had a physician order dated July 16, 2025, for Oxycodone HCL (hydrochloride) oral tablet 5 milligrams (mg), (narcotic medication used to treat moderate to severe pain). The order directed staff to administer one tablet by mouth every six hours as needed (PRN) for severe pain rated 7 through 10. A numeric pain rating scale used to measure pain intensity, with 0 indicating no pain and 10 indicating the worst possible pain.Review of the September 2025 Medication Administration Record (MAR, a clinical document used to record medications administered to a resident) revealed staff administered Oxycodone HCL 5 mg outside the ordered parameters for severe pain (7-10) on the following dates: September 7, 2025, for a documented pain level of 0September 13, 2025, for a documented pain level of 0September 5, 2025, for a documented pain level of 5September 26, 2025, for a documented pain level of 6Administration of Oxycodone for pain levels of 0, 5, and 6 did not correspond with the physician's order specifying the medication was to be administered only for severe pain rated 7 through 10. Additional clinical record review indicated Resident 7 had a physician order dated July 23, 2025, for Tramadol HCL oral tablet 50 mg (narcotic-like medication used to treat pain). The order directed staff to administer 25 mg (one-half tablet) by mouth every six hours as needed for pain rated 4 through 6 on the numeric pain scale. Review of the October 2025 MAR revealed staff administered Tramadol 25 mg on October 9, 2025, for a documented pain level of 8. Administration of Tramadol for a pain level of 8 did not correspond with the physician's order specifying the medication was to be administered for moderate pain rated 4 through 6. During an interview conducted April 9, 2026, at 10:50 AM, the Director of Nursing reviewed the above findings related to administration of pain medications outside physician-ordered parameters on five occasions. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, observations, and staff interviews, it was determined the facility failed to ensure the ready availability of necessary emergency dialysis supplies for one of three residents reviewed who received hemodialysis (Resident 11).Findings include:According to clinical standards referenced by the National Kidney Foundation and Centers for Disease Control and Prevention (CDC), residents receiving hemodialysis (a life-sustaining treatment used when the kidneys are no longer able to adequately remove waste and excess fluid from the blood) are at risk for serious complications, including hemorrhage (severe bleeding) and bloodstream infection. Hemodialysis requires access to the bloodstream through either a central venous catheter (a tube inserted into a large vein to allow blood to circulate through the dialysis machine) or an arteriovenous fistula (a surgically created connection between an artery and a vein, typically located in the arm, that provides reliable vascular access for dialysis treatments). If a dialysis access device becomes dislodged, disconnected, or begins to bleed, immediate firm pressure must be applied and emergency medical assistance obtained to prevent rapid and potentially fatal blood loss. Clinical standards of practice indicate that emergency supplies, such as clamps (devices used to stop blood flow through dialysis tubing or catheters) and pressure dressings (bandages designed to apply sustained pressure to control bleeding), must be readily available to allow prompt intervention. A review of the policy Care of Hemodialysis Resident last reviewed January 16, 2026, indicated the facility will ensure the needs of the resident receiving hemodialysis are met by both the facility and the dialysis center. The policy indicated residents who require dialysis will receive care consistent with professional standards of practice, the comprehensive person-centered plan of care, and the resident's goals and preferences. The policy included post-dialysis care procedures and directed staff to monitor the dialysis access site for complications. The policy instructed staff to apply pressure for five to ten minutes to control bleeding from a fistula site (the surgically created access between the artery and vein used for dialysis) and to repeat pressure as needed until bleeding stops. Resident 11 was admitted to the facility on [DATE], with diagnosis which included end stage renal disease (the final stage of chronic kidney disease, where the kidneys no longer function adequately to sustain life). A review of Resident 11's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 25, 2026, revealed that Resident 11 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 15 indicating intact cognition).Clinical record review revealed a comprehensive care plan initiated March 20, 2026, which addressed Resident 11's need for ongoing hemodialysis treatments. The care plan directed staff to monitor the fistula site located in the left upper extremity (upper arm) for bleeding and instructed staff to apply pressure and obtain assistance in the event of bleeding or other complications. The care plan further specified that an emergency dialysis supply kit was to be maintained at the bedside to allow immediate response to complications related to dialysis access. Observation conducted on April 7, 2026, at 11:20 AM revealed no emergency dialysis supply kit, clamps, pressure dressings, or other dialysis access emergency supplies present at the bedside, mounted on the wall, or otherwise readily accessible in Resident 11's room. During the observation, Employee 1, Licensed Practical Nurse (LPN), confirmed the absence of emergency dialysis supplies in the resident's room. Employee 1 stated that an emergency kit containing appropriate dialysis emergency supplies should have been present and readily accessible according to the care plan. On April 7, 2026, at 2:15 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) regarding the absence of required emergency supplies for residents receiving hemodialysis. 28Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 22 residents reviewed (Resident 3).Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). A review of Resident 3's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 20, 2026, revealed Resident 3 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). The MDS further revealed that the resident was assessed as yes to having a PTSD diagnosis. The resident's current care plan, in effect at the time of review on April 9, 2026, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. The facility failed to develop and implement an individualized person-centered plan to address this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Nursing Home Administrator on April 9, at 12:30 PM confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure the timely acquisition and availability of prescribed medications for one of five residents reviewed for unnecessary medications (Resident 29).Findings include: Review of the facility policy titled Ordering and Receiving Non-Controlled Medications last reviewed by the facility on January 16, 2026, indicated that medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. A clinical record review revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety. Review of a physician's order dated November 20, 2025, revealed an order for Levothyroxine Sodium (medication use to treat hypothyroidism, underactive thyroid) 125 mcg by mouth in the morning for thyroid disease. Review of the resident's Medication Administration Record (MAR) for April 1, 2026, through April 10, 2026, revealed the resident did not receive the prescribed Levothyroxine Sodium which was ordered to be administered at 6:00 AM, on April 8, April 9, or April 10, 2026. During an interview on April 10, 2026, at 12:15 PM the Director of Nursing (DON) confirmed the facility failed to ensure Levothyroxine Sodium 125 mcg was received from pharmacy prior to the depletion of the supply of the medication for Resident 29. There was no documented evidence the facility ensured the medication was obtained and available for administration as ordered. 28 PA. Code 211.10 (c)(d) Resident care policies. 28 PA. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observations, review of clinical records, select facility policy, and interviews with resident, family and staff, it was determined the facility failed to establish and maintain an effective infection prevention and control program by failing to implement Transmission-Based Precautions in accordance with facility policy to reduce the potential spread of infection for one resident of 22 residents reviewed (Resident 86).Findings include:Review of the facility policy titled Isolation Precautions last reviewed by the facility on January 16, 2026, indicated that Transmission- Based Precautions (TBP) will be initiated when a resident is suspected or confirmed to have a communicable disease/infection that can be transmitted to another. Transmission-Based Precautions are additional infection control practices used along with Standard Precautions (routine infection prevention practices applied to all residents, such as hand hygiene and use of protective equipment when exposure to body fluids is anticipated) to prevent the spread of highly transmissible or epidemiologically significant organisms. Transmission-Based Precautions may include Contact Precautions used for infections spread through direct contact with the residents or indirect contact with contaminated surfaces or equipment. These precautions require use of gloves and gown when entering the room to prevent the spread of organisms by touch., Droplet Precautions - used for infections spread through respiratory droplets produced when a person coughs, sneezes, or talks. These precautions generally require the use of a mask., Airborne Precautions used for infections spread through very small particles that remain suspended in the air for long periods. These precautions typically require specialized respiratory protection, or Enhanced Barrier Precautions (EBP) infection control measures requiring gown and gloves during high-contact resident care activities when multidrug-resistant organisms are present, even if the resident does not have symptoms of infection.The procedure for implementing TBP include:1. TBP will be used when transmission cannot be reasonably prevented by standard precautions alone.2. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (personal protective equipment e.g. gown and gloves).3. For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves.4. Make PPE, including gowns and gloves available immediately outside of the resident room.5. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.6. Ensure hand sanitizer is easily accessible by the resident's room. In addition, the policy indicated that contact precautions will be implemented for residents suspected or confirmed to be infected with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces/equipment in the resident's environment. Residents should be placed in a private room when available. Prior to entering the isolation room, the following steps are required:a. perform hand hygiene and apply gloves and gown prior to entering room.b. while providing direct resident care, wear gloves and wash hands after coming in contact with infectious material.c. remove gloves and perform hand hygiene before leaving room.d. adequately clean and disinfected items with an approved solution prior to removing the item from the room and before use on another resident A review of clinical records revealed Resident 86 was admitted to the facility on [DATE], with diagnoses to include infective endocarditis (a rare but life-threatening infection of the hearts inner lining or valves, typically caused by bacteria entering the bloodstream and attaching to the damaged heart tissues), vancomycin-resistant enterococci (VRE) bacteremia (a serious infection caused by enterococcus bacteria resistant to the antibiotic vancomycin), and bacterial peritonitis (a serious infection of the abdominal fluid). Review of the resident's plan of care dated April 6, 2026, indicated the resident required intravenous therapy, including Total Parenteral Nutrition (TPN, a method of delivering essential nutrients, including carbohydrates, proteins, fats, electrolytes, vitamins, and minerals, directly into the bloodstream intravenously, completely bypassing the digestive tract. It is used when a person cannot consume, digest, or absorb adequate nutrients through food or feeding tubes. TPN is administered via a central intravenous catheter, a specialized long-term intravenous line used to deliver concentrated nutrients directly into a large vein near the heart, because the digestive system cannot be used), and intravenous antibiotics for infection, including VRE in the blood. The care plan identified the need for Contact/Isolation Precautions due to the presence of VRE in the bloodstream. Observation on April 7, 2026, at 12:40 PM revealed no precaution signage posted at the entrance to Resident 86's room to inform staff and visitors of required Contact Precautions or necessary PPE prior to entry. Additionally, no appropriate waste receptacle or linen hamper was observed inside the room near the exit to allow proper disposal of PPE prior to leaving the room. Interview with Resident 86 and the resident's husband at the time of observation revealed they had not been informed of the need for Contact Precautions or the associated infection prevention practices. The resident and representative reported that staff had not consistently worn gowns when entering the room since admission. Observations on April 8, 2026, at 11:18 AM and 2:30 PM revealed multiple staff entered and exited the resident's room without wearing required PPE, including gowns and gloves, during resident care activities. During an interview on April 10, 2026, at 9:00 AM, the Director of Nursing and Infection Preventionist confirmed that the facility failed to implement its Infection Control policy related to Transmission-Based Precautions for Resident 86. Specifically, they acknowledged that appropriate precaution signage was not posted, required equipment such as linen and waste receptacles, were not in place, the resident and family were not educated regarding precautions, and staff did not consistently adhere to PPE requirements. 28 Pa Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policies, internal investigative documentation, and resident and staff interviews, it was determined the facility failed to ensure that two residents (Residents 27 and 31) out of a sample of 21 residents were free from abuse from a resident with a known history of physical aggression (Resident 82). Findings including: A review of the current facility policy entitled Policy and Procedure Vulnerable Adult Abuse and Prevention, last reviewed by the facility March 1, 2025, revealed it was the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation and to enhance the life of all residents through strong programming and appropriate care and treatment. There is a zero tolerance for abuse or harm of any type. Residents and staff will be monitored for protection. The facility's policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, hitting, slapping, kicking, punching, biting, or corporal punishment of a vulnerable adult. Additionally, residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. As part of the facility's resident protection program the facility was to assess the facility's population for behaviors that could result in maltreatment of residents. It included that the facility would assess, care plan, and monitor resident's needs and behaviors such as entering other resident's rooms, wandering behaviors, verbal outbursts, residents with communication disorders, those who are nonverbal and those that require heavy care and/or totally dependent on staff. A review of Resident 82's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with behavioral disturbance (behavioral and psychological symptoms such as agitation, anxiety, and psychosis), and anxiety (is a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). A review of Resident 82's comprehensive person-centered plan of care, initiated on April 23, 2025, indicated the resident used antipsychotic, antianxiety, and antidepressant medications for Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown) with behaviors such as aggression and history of intrusive wandering. Planned interventions included encourage activities for socialization and diversion, administer antipsychotic medication as ordered by physician and monitor for side effects and effectiveness, consult with pharmacy, MD to consider dosage reduction when clinically appropriate and consult psychiatric services. Review of Resident 82's quarterly MDS (Minimum Data Set a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed the resident had a BIMS score (Brief Interview for Mental Status a tool to assess the residents attention, orientation and ability to register and recall new information) of 3, which indicated the resident had severe cognitive impairment, a score of 00-07 indicates severe cognitive impairment. A review of facility-provided investigative documentation completed by Employee 3, agency registered nurse (RN), dated May 23, 2025, at 5:45 PM, revealed that Resident 82 was observed placing his arms around the neck of Resident 27, who was seated in a wheelchair in the television lounge. Staff intervened, and neuro checks for both residents were within normal limits. Resident 82 was placed on one-to-one supervision for safety, and the physician, responsible party, and local authorities were notified. Psychiatric consultation was ordered. A witness statement by Employee 4, an activity aide, dated May 23, 2025, described overhearing Resident 27 ask Resident 82 to stop pushing him. Upon returning to the area, Employee 4 observed Resident 82 with both arms around Resident 27's neck. Staff separated the residents. A witness statement completed by Employee 4, an activity aide, dated May 23, 2025, revealed that around 5:30 PM I was walking a resident to the dining hall, and I overheard Resident 27 asking Resident 82 to stop pushing him with his wheelchair and when I came out of the dining room I witnessed Resident 82 choking (arms around neck) Resident 27 and then I intervened and called for help. Employee 4 observed Resident 82 with both arms around Resident 27's neck. Staff separated the residents. A review of a witness statement provided by Resident 27 dated May 23, 2025, noted, I was in the TV room watching TV when Resident 82 came in from the hallway. He began slamming the back of my wheelchair. I asked him what he was doing and to stop! Resident 82 stood up and came behind me and put his arms around my neck. I got really mad and reached my right arm above my head and hit Resident 82. Then, staff entered and removed Resident 82 from the room. Further review of the investigation revealed that Resident 82, the alleged perpetrator, often became agitated following the departure of his significant other after visits. Documentation indicated that Resident 82's significant other had left the facility only minutes prior to the incident involving Resident 27. Facility staff were educated on assisting the resident with transition-related behaviors and offering diversionary activities upon her exit. The significant other informed the facility that she would notify the unit nurse prior to leaving the premises in the future. Facility staff also indicated that efforts would be made to keep Resident 82 separated from the residents involved in the physical altercations during activities, use of common areas, and in dining settings. A review of physician's orders dated May 23, 2025, for 1:1 supervision every shift for behaviors until May 24, 2025, at 11:59 PM, for safety/behaviors after which every 30-minute safety checks were ordered. A review of the facility's consulted psychiatric services PMHNP (Psychiatric Mental Health Nurse Practitioner) dated June 6, 2025, at 3:25 PM, revealed that Resident 82 was seen for follow up visit and staff reported the resident had episodes of verbal and physical aggression and was not always able to be easily redirect. Recommendations included to monitor and document any changes in mood such as increased signs and symptoms of depression or anxiety, mood lability, or generalized psychiatric decline, encourage social interactions/participation in group activities in facility to prevent feelings of isolation, provide supportive care as needed, non-pharmacological interventions and safety interventions, and routine follow up in 2 weeks or earlier if needed. A clinical record review from May 24, through June 6, 2025, revealed that nursing staff documented that Resident 82 had episodes of yelling and cursing at staff and other residents with unsuccessful redirection with activities and emotional support, and frequently self-propelled in his wheelchair throughout the unit and observed walking unassisted. Additionally, a review of a nurse progress note dated June 6, 2025, at 2:44 PM, documented Resident 82 was combative and aggressive this tour. Offered nap, tv, music, activities food and fluids. Frequently looking for significant other. A review of facility-provided investigative documentation completed by Employee 5, a registered nurse (RN), dated June 7, 2025, at 6:45 PM, revealed a second incident occurred involving Resident 82 and Resident 31 (BIMS of 15, indicating intact cognition). Facility documentation completed by Employee 5, a registered nurse, revealed that Resident 31 exited his room and reported that Resident 82 had grabbed him by the neck and pushed him. Redness was noted on Resident 31's neck. The residents were separated, and Resident 82 was moved to another room. A witness statement completed by Employee 6, a licensed practical nurse (LPN), dated June 7, 2025, indicated that when the incident occurred between Resident 82 and Resident 31, I was in the dining room. The last time I saw both residents was at approximately 6:15 PM, and they were both in their room. Resident 82 was sitting in his chair and Resident 31 was sitting on his bed. After dining room began, I began passing medication when Resident 31 came to me and told me that his roommate (Resident 82) put his hands around his neck and then his arms and seemed very upset. I immediately brought Resident 31 to the supervisor to discuss what the resident just explained. Resident 31's witness statement dated June 7, 2025, no time noted, indicated, My roommate and I were both standing in our room and out of nowhere he pushed me against the wall and told me not to bother the girls. I told him I won't, and he grabbed my neck, and I pushed him and ran out of the room, I started crying. Further review of the facility-provided investigative documentation completed by Employee 5, revealed that Resident 82 was not able to describe what happened. Residents were separated and Resident 82 room was changed. Additional interventions included 1:1 supervision for safety/behaviors and consult psychiatric services. On June 12, 2025, at approximately 11:00 AM, an interview was conducted with Resident 31, a cognitively intact resident, regarding the incident that occurred with his previous roommate, Resident 82, on June 7, 2025, at 6:45 PM. Resident 31 stated, that guy is a brut, everything was fine and then he just snapped. I didn't provoke him, he just pushed me up against the wall and then put his hands around my neck, and then held my arms. I pushed him away and ran out to tell my nurse and they helped me. Additionally, Resident 31 reported that after the incident he was shaken up but felt safe because Resident 82 was moved to another location in the facility. Despite documented history of aggression, physical altercations, and psychiatric recommendations, the facility failed to maintain consistent and adequate supervision of Resident 82 to prevent repeated incidents of physical aggression. The second incident, which involved physical harm and emotional distress to Resident 31, occurred after a prior event involving similar aggression had already been identified. Additionally, the facility failed to substantiate abuse allegations made by Resident 31 despite evidence including witness statements and physical signs of injury. During an interview conducted on June 12, 2025, at approximately 10:35 AM, the facility's Nursing Home Administrator (NHA) stated the facility could not confirm that abuse had occurred because staff had not directly witnessed the incident involving Resident 31. The NHA reported the allegation could not be substantiated, despite facility investigative documentation noting visible red marks on Resident 31's neck and no documented history of the resident making false allegations in the clinical record or comprehensive care plan. The NHA also acknowledged that Resident 82 should have been provided with increased staff supervision due to his history of outbursts, aggressive behavior, and intrusive wandering, in order to prevent potential harm to other residents. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of clinical records and staff interview, it was determined the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 21 sampled (Resident 31). Findings include: A review of the clinical record revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses to include major depressive disorder (a mood disorder characterized by persistent low mood and anxiety (feelings of worry and unease). Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated April 14, 2025, indicated the resident had a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). Further review of the clinical record revealed a progress note dated June 7, 2025, at 6:33 PM, indicating Resident 31 revealed his roommate grabbed his throat. A review of facility-provided investigative documentation completed by Employee 5, a registered nurse (RN), dated June 7, 2025, at 6:45 PM, revealed some redness noted on Resident 31's neck. No bruises or abrasions noted to skin. Resident 31 reported that Resident 82 caught him by surprise and pushed him and told him not to bother the girls. The incident occurred while both residents were in their shared room. Immediate interventions included separating the residents and initiating a room change. A progress note dated June 10th, 2025, at 5:25 PM showed the resident was still feeling upset about the incident with his roommate and expressed a need for support in managing his distress, including education from a psychiatric provider. An interview with Employee 1 (Social Services) on June 12, 2025, at approximately 11:30AM confirmed that no social services visit or intervention had been provided to Resident 31 in response to the altercation to address his psychosocial needs. An interview with the Nursing Home Administrator (NHA) on June 12, 2025, at approximately 12:00 PM confirmed there was no documented evidence that social services interventions were provided to support Resident 31's psychosocial well-being following the incident with his roommate. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.16 (a) Social Services.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (C Hall). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility March 1,2025, indicated that multi-use medication vials/bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes. An observation of the medication cart located on C Hall unit on June 11, 2025, at 8:22 AM, in the presence of Employee 2 (Licensed Practical Nurse ) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Lispro (a fast acting insulin medication used to lower blood sugar) and two (2) multi-dose pens of Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for use, but not dated when initially opened. Further observation revealed one (1) multi-dose insulin pen of Insulin Glargine with a date on the cap of the pen indicating the pen was opened April 30, 2025. Review of manufacturer safety information revealed the multi-dose pen of Insulin Glargine is to be discarded 28 days after opening indicating the dated pen should have been discarded on May 27, 2025. An interview with Employee 2 (LPN) on June 11, 2025, at 8:24 AM, confirmed all three (3) multi dose insulin pens one (1) Insulin Lispro and two (2) Insulin Glargine were opened, available for use, currently being used for administration, and not dated when initially opened with one pen of insulin glargine being used past the expiration date. Interview with the Nursing Home Administrator (NHA) on June 11, 2025, at approximately 11:00 AM, confirmed the facility failed to adhere to acceptable storage and labeling practice for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on review of Resident Council Meeting minutes and maintenance work orders, observation, and resident and staff interviews, it was determined the facility failed to ensure all residents had access to a resident-only telephone for one of 20 residents sampled (Resident 1) and failed to provide privacy for residents when having telephone calls on three out of three clinical nursing units. Findings include: Interview with Resident 1 on January 29, 2025, at 11:40 AM revealed that the resident-only telephone, located in the B-Wing Resident Lounge, was non-operational. Resident 1 stated that for three months, the facility had informed him that the guy isn't available to fix it. He reported the issue during the January 22, 2025, Resident Council Meeting, but the facility had not addressed his concern. Observation of the B-Wing Resident Lounge on January 29, 2025, at 12:06 PM revealed a landline telephone on a countertop without a dial tone. Further observation showed the phone jack pulled out from the wall with exposed phone cable wires. Interview with Employee 2 (licensed practical nurse) on January 29, 2025, at 12:09 PM indicated that the telephone in the B-Wing Resident Lounge was available for resident use, but only when operational. Employee 2 further revealed that residents could use the landline telephone located behind each nursing station but would need to request assistance from staff. The phone was positioned on the nursing station counter, requiring the resident to sit in front of the nursing station during the call. Employee 2 verified that this arrangement did not provide residents with privacy for their conversations. Review of the January 22, 2025, Resident Council Meeting minutes revealed documentation of a concern regarding the non-functional phone in the B-Wing Resident Lounge. Review of maintenance work orders from December 1, 2024, through January 29, 2025, showed no evidence that a work order had been placed to repair the phone in the B-Wing Resident Lounge. Interview with the Nursing Home Administrator on January 29, 2025, at 2:45 PM confirmed the facility failed to provide telephone access to all residents and failed to provide privacy for resident telephone calls. This failure resulted in residents not having access to a functional, resident-only telephone and not being provided with privacy for telephone communications, impacting their ability to communicate confidentially and independently. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observations, a review of clinical records, review of facility grievances, Resident Council Meeting minutes, and resident and staff interviews, it was determined the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced the facility's inability to appropriately manage and supervise the wandering and aggressive behaviors of two residents (Residents 4 and 20) out of 20 sampled. Findings include: Review of clinical record of Resident 4 revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia with other behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), and violent behavior. Resident 4 resided on the B-Wing. An End of PPS Part A Stay Minimum Data Set assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 18, 2025, indicated that Resident 4 was severely cognitively impaired with a BIMS (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information) score of 3 (0-7 represents severe cognitive impairment), and the resident was able to ambulate independently. Review of Resident 4's plan of care dated November 22, 2024, revealed a focus area related to elopement risk/wanderer due to disoriented to place and impaired safety awareness. Interventions included: distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, TV, and books; notify appropriate departments of resident risk for elopement; every 15-minute checks, redirect as needed if resident found in other rooms. Another focus area identified regarding physical aggressiveness due to dementia and poor impulse control with interventions to: administer medications as ordered; assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc.; provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated; encourage activity participation for socializing with staff and peers; when resident becomes agitated, intervene before agitation escalates. Guide resident away from source of distress. Engage calmly in conversation. If response if aggressive, staff to walk resident calmly away and approach later. Despite these interventions, nursing documentation from November 21, 2024, through January 29, 2025, showed frequent incidents of wandering into other residents' rooms, exit-seeking behaviors, and aggression toward staff and other residents as follows: November 21, 2024, at 9:42 PM - resident was wandering into other residents' rooms and pushing on exit doors. Redirected by staff multiple times. November 22, 2024, at 2:59 PM - resident put on 15-minute checks for wandering/safety. November 23, 2024, at 4:35 PM - resident wandering in hall and in and out of other resident's rooms. November 23, 2024, at 7:45 PM - awake, alert and verbal with confusion. Going in and out of other residents' rooms. Constant redirection needed. November 24, 2024, at 3:50 PM - resident wandering in and out of residents' rooms. November 24, 2024, at 10:18 PM - wandering into other residents' rooms. Consistent redirection needed. November 25, 2024, at 4:30 AM - resident with abnormal behavior, wandering and entering other residents' rooms. Redirected may times. November 25, 2024, at 2:45 PM - resident continues to continuously ambulate up and down hallways, and in and out of activities. November 29, 2024, at 9:55 PM - wandering in other residents' rooms. Constant redirection needed. December 2, 2024, at 2:28 PM - resident insists on ambulating with increased agitation noted on redirection. Exit seeking behaviors observed majority of shift. December 3, 2024, at 4:14 - wandering up and down halls, not easily redirected. Some aggression when showing resident his room. December 3, 2024, at 6:04 PM - resident with behaviors this shift seen yelling in dining room, trying to go behind the counter by the food trays. December 9, 2024, 11:36 PM - resident does go into other residents' rooms but is easily redirected. December 11, 2024, at 8:01 PM - wandering in other rooms. Constant redirection needed. December 12, 2024, a 7:46 AM - resident with behaviors at start of shift. Resident taking clothing from roommate's closet. Roommate upset with resident. Wandering in hall until 1:00 AM. December 14, 2024, at 20:42 AM - wandering in and out of room, redirected several times. December 20, 2024, at 3:01 PM - frequent redirection needed often. In/out of other residents' rooms. December 21, 2024, at 4:30 AM - resident sitting in bed in room B2D (resident's room is B1D). Upon standing from bed, resident had pillow under his foot and started to slide and was lowered to floor by nurse. 15 min checks maintained. December 21, 2024, at 2:34 PM - wandering in and out of rooms on B Wing. December 21, 2024, at 9:33 PM - wandering in other rooms. Redirected by staff multiple times. December 22, 2024, at 2:50 PM - wandering in and out of other resident rooms. December 22, 2024, at 6:58 PM - ambulating up and down hall, going into other rooms. Redirected multiple times. December 23, 2024, at 2:18 PM - ambulates in and out of other residents' rooms. December 24, 2024, at 8:58 PM - Res complained of pain left foot. Xray results: subacute fracture of 5th metatarsal (bone in the foot). New order to be non-weight bearing (NWB) to left foot. Ortho consult. December 30, 2024, at 11:03 PM - ambulating up and down hall, constant redirection needed to use wheelchair due to NWB status to left leg. January 16, 2025, at 10:55 AM - reviewed with CRNP (certified registered nurse practitioner) recommendations from ortho appointment. New order received to discharge NWB statue to left lower extremity. January 17, 2025, at 2:56 PM - wandering in and out of other residents' rooms. January 21, 2025, at 7:48 AM - wandering into next room at times. January 24, 2025, at 2:36 PM - ambulating up and down the hall, going into other residents' rooms. January 25, 2025, at 10:18 PM - wandering into other resident rooms. On December 24, 2024, Resident 4 sustained a subacute fracture (break of a bone in the healing stage which causes pain) of the left foot, raising concerns regarding the adequacy of supervision Review of clinical record of Resident 20 revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). The resident resides on the B- Wing. An Admission Minimum Data Set assessment dated [DATE], indicated Resident 20 was severely cognitively impaired with a BIMS score of 3, and the resident was able to ambulate with supervision or touching assistance. Review of Resident 20's plan of care dated November 29, 2024, revealed a focus area of elopement risk due to disoriented to place, impaired safety awareness, noncompliant with assist to transfer and ambulate with interventions to include: social service visit as needed; wander guard system (system to alert staff of location); and when redirecting resident, approach in calm manner. Another focus area identified regarding physical aggressiveness due to dementia and swinging cane at staff with interventions to include: assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc.; monitor/document/report as needed, any signs/symptoms of resident posing danger to self and others; offer wheelchair when behaviors escalate; and when resident becomes agitated, intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Nursing documentation from November 29, 2024, through January 29, 2025, revealed frequent incidents of wandering into other residents' rooms, threats toward staff, verbal aggression, and physical aggression, including attempting to strike multiple staff members. Behaviors as follows: December 6, 2024, at 5:52 PM - resident ambulates in hallways, can be nasty at times, cursing at staff. December 7, 2024, at 4:57 AM - wandering in hall at start of shift, easily redirected. Resident went to sleep at approximately 2:00 AM. Noted steady gait with walking with cane. December 9, 2024, at 2:21 PM - resident with confusion this shift with behaviors present. Ambulating with cane in hall. Confusion present, attempting to go into other residents' rooms. Upon staff redirection, resident had times of increased agitation. At one point, attempting to hit multiple staff with cane. Resident also calling staff inappropriate names. December 10, 2024, at 3:34 AM - wandering earlier in shift. Resident went in room B15. When asked to move back to his own room, the resident began yelling at the other resident. December 11, 2024, at 2:41 PM - resident periodically agitated. Pulling away and swinging fist when staff offers assistance. Continues to urinate in garbage cans and personal green tote. December 11, 2024, at 10:29 PM - wandering in other residents' rooms, redirected with success. December 12, 2024, at 7:06 AM - resident wandering at start of shift in and out of other resident rooms, difficult to redirect. Went to bed at approximately 2:00 AM. December 13, 2024, at 11:27 AM - resident cursed, threw a wet rag, and told the nurse to get the f*** away from him! December 15, 2024, 7:01 AM - awake on and off this shift. Difficult to redirect at times. In and out of other resident rooms. December 15, 2024, at 2:14 PM - going in and out of other resident rooms, redirection often difficulty. December 17, 2024, at 3:36 PM - resident spit at nurse, telling nurse to leave him he f*** alone. Ambulating in and out of room. December 18, 2024, at 12:37 AM - resident with behaviors at the time. Sitting in wrong room. When asked to go back to own room, he refused and tried to hit the nurse with his cane. Resident eating and drinking other resident's snacks. Resident stating that the men in this room are his cousins and unable to redirect. Transferred back to room in chair, cursing at nurse. December 18, 2024, at 3:38 AM - continues to wander into other resident rooms and becomes agitated when asked to leave the room. December 18, 2024, at 10:33 PM - wandering into rooms. December 20, 2024, at 10:47 PM - wandering into other resident rooms. Difficult to redirect. December 21, 2024, at 4:48 AM - resident with behaviors all shift, in and out of other resident rooms, in other resident beds, eating other residents' snacks. Very difficult to redirect, swinging at staff when assisted to own room. December 30, 2024, at 4:41 AM - currently resting in empty bedroom B1W. Wandered there after using the connecting bathroom. Resident refusing to get out of this bed despite several attempts. December 31, 2024, at 8:40 PM - wandering up and down hall into rooms, constantly redirected by staff. January 7, 2025, at 9:11 PM - resident with behaviors this shift, going in and out of other resident rooms, coming behind nurse's station, threatens staff when attempting to redirect, distractions ineffective. January 8, 2025, at 9:46 PM - ambulating up and down hall with cane, wandering into other rooms. Constant redirection needed. January 11, 2025, at 10:15 PM - resident wanders throughout unit. On occasion, has threatened others with his cane. Resident also yells at others January 12, 2025, at 11:20 AM - resident with increased aggressive behaviors with staff. Swung cane and used vulgar language at nurse aide. January 15, 2025, at 2:04 PM - in and out of other resident rooms. January 16, 2025, at 6:51 AM - in and out of resident rooms. Redirection given multiple times. Aide sat one-on-one with resident for part of shift to monitor. January 21, 2025, at 7:44 AM - wandering all shift in other resident rooms. January 27, 2025, at 10:40 PM - he did act up when fell ow nurse tried to get him out of nurse's station. January 28, 2024, at 4:18 AM - ambulating through all from start of shift until approximately 1:30 AM. In and out of resident rooms. Despite documented aggressive behaviors, the facility failed to ensure that adequate staff were present to effectively supervise and manage these behaviors. Interviews conducted on January 29, 2025, between 11:39 AM and 1:00 PM with four cognitively intact residents residing on the B-Wing indicated following: Resident 1 reported he is afraid to leave this room because Resident 20 comes into my room to see what he can steal. He stated that the facility provided him with a Velcro stop sign to place at the entrance to his room but noted that staff do not consistently put the stop sign in place when they exit his room, leaving him vulnerable to unwanted wandering residents. Observation on January 29, 2025, at 11:38 AM, prior to entering Resident 1's room, revealed that the stop sign was not in place on the entryway, allowing easy access into Resident 1's room. Continued interview with Resident 1 revealed that is scared to death of Resident 4 and Resident 20. He stated a few days ago he was in the hallway and Resident 4 was coming down the hall and raised his fist and said, do you want to fight. Resident 1 moved to the other side of the hall and went back to his room. Then Resident 4 came into his room asking, Where is Margaret? He made a fist and came after me and then the nurse took him out. Resident 1 reported another incident occurred on January 25, 2025. He stated that Resident 20 came into his room and stole one of his shirts. He stated, he keeps coming back into my room even though the nurse and myself keep telling him it's not his room. The resident stated he filed two grievances for both occurrences, but the facility has not addressed his recent concerns. He also stated he voiced his concern regarding Resident 4 and 20 at previous Resident Council Meetings. Review of facility's grievance for December 2024, and January 2025, revealed no grievance filed on behalf of Resident 1 or any grievances filed regarding Residents 4 and 20. Review of the Resident Council Meeting minutes for December 2024, and January 2025, revealed no concerns documented regarding intrusive wandering residents in the meeting minutes. Interview with Resident 18, Resident Council President, revealed concerns reported by Resident 1 regarding Residents 4 and 20 were brought up in past meetings. He indicated the January 22, 2025, meeting was conducted by the Nursing Home Administrator (NHA) and the Director of Human Resources. He stated that the NHA said she would follow up with Resident 1's concern. Continued interview with Resident 18 revealed that Residents 4 and Resident 20 wander into resident rooms frequently with Resident 20 making threatening remarks. Interview with Resident 19 reported that Residents 4 and Resident 20 have wandered into her room. She stated, everyone knows to stay away from them. She stated that they have entered her room, uninvited, multiple times, even at Two or three in the morning, keeping me up. She indicated a few weeks ago Resident 4 walked into her room, sat down on her chair and made a phone call. She said she is claustrophobic but sleeps with the door closed in order keep unwanted wanderers out and to keep her feeling safe. Interview with Resident 17 stated Resident 20 was here last night. He sat down on my bed, and he wouldn't leave. My daughter was here and rang the buzzer. She continued, that's the second or third time he's been in my room, mostly in the evening. She stated when she calls for help, staff come in to remove him, but it makes her feel very uncomfortable and uneasy. Interview with two staff members on January 29, 2025, at approximately 11:30 AM, who wish to remain anonymous, indicated Resident 4 and Resident 20 are difficult to manage and keep track of due to their dementia, behaviors, and ability to ambulate independently. They feel the facility does not assign enough staff members to the B-Wing to manage behaviors and conduct the 15-minute checks required of multiple residents who reside on the B-Wing. One staff member revealed staff are afraid of Resident 20 due to his violent outburst and physical aggressiveness. Interview with Employee 1 (activity aide) on January 29, 2025, at approximately 12:20 PM confirmed that Residents 4 and Resident 20 do not engage in group activities as they either refuse to attend or will get up and leave the group activity. The Nursing Home Administrator (NHA) and Director of Nursing (DON) admitted they were unaware of the extent of these behavioral incidents and could not provide evidence that sufficient staff with appropriate skills were assigned to the B-Wing. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 29, 2025, at approximately 2:45 PM reported they were unaware of the extent to Residents 4 and 20's intrusive wandering and the negative effects it was having on the residents on the B-Wing. They were unaware of the grievances filed by Resident 1 and denied knowledge of his voiced concern regarding the intrusive wanderers during the January 2025 Resident Council Meeting. They could not provide evidence that sufficient staff with appropriate skills were assigned to the B-Wing.could not provide evidence that sufficient staff with appropriate skills were assigned to the B-Wing. The facility failed to provide adequate staffing levels with the necessary competencies to ensure the supervision and safety of residents with dementia, leading to repeated incidents of resident-on-resident intrusions, aggressive behaviors, and safety concerns, to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. 28 Pa Code 211.12 (d)(3)(4)(5) Nursing services 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.20 (a)(6) Staff development

Based on review of facility policy, observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Cleaning Dishes: Manual Dishwashing last reviewed by the facility on April 17, 2024, indicated that sink 1 - wash procedure should include cleaning the sink and measure the appropriate amount of water into the sink to the water line and determine the amount of detergent to be used, following the manufactures directions for use. Sink 2 - rinse procedure was to include preparing the sink with hot water (120 degrees - 140 degrees Fahrenheit) and rinse the dishes thoroughly before placing in the sanitizing sink. Sink 3 - sanitize procedure was to include measuring the appropriate amount of sanitizing chemical into the appropriate amount of water (following manufacture's guidelines) and testing the sanitizing solution using the manufacture's suggested test strips to assure appropriate level before placing the dishes into the sanitizing sink. Further review of a posted procedure guide entitled Pot and Pan Cleaning and Sanitizing Procedures revealed the level of sanitation testing solutions should be between 200 - 400 parts per million (PPM is a unit of measurement used to express concentrations of a substance in a solution or mixture). The initial tour of the kitchen conducted with the facility's Food Service Manager on August 20, 2024, at 8:58 a.m., revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Observed inside the 3-compartment sink (is a piece of manual equipment used for cleaning and sanitizing dishes, utensils, and equipment used in the kitchen) labeled sanitize observed that cooking/baking equipment, such as whisks, pans, pots, etc., were soaking inside of the compartment in a pale pink solution. A test strip test was conducted, and the test strip turned an orange color and indicated zero (0) parts per million (ppm) of sanitation solution. The Food Service Manager confirmed the observation and the test strip results and indicated the sanitize compartment should have read between 200 - 400 PPM and was not sure why the sanitize solution was so weak. Observations of the ceiling tiles of the dietary department revealed several tiles throughout the department that were splattered with a brownish colored substance. Outside of the dish room area and near the cook's preparation area, mobile garbage reciprocal with no lid was overflowing with bagged trash. Observed that the wall exiting the kitchen and leading into the dining room had an accumulation of dust and debris adhered to the wall surfaces. Observations of the exhaust hood over the stove/cook top revealed two dried, hard, discolored white rags that stuck inside two corners of the hood. Observed a white plastic container with a label bulk hard-boiled eggs with dry white rice stored inside. Also, one of the four lid corners was cracked and exposed the contents making it available to contamination. Further observation of the dietary department revealed the hosing attached to the water filter and coffee maker were heavily corroded with dust and debris. Interview with the Food Service Manager on August 20, 2024, at 9:30 a.m., confirmed the above observations and indicated the kitchen areas should be maintained in a sanitary manner to prevent opportunities for contamination and foodborne illness. 28 Pa. Code 201.18 (e)(1) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of four of 20 residents sampled (Resident 12, 47, 86, and 46). Findings include: A review of the clinical record revealed Resident 12 was admitted to the facility on [DATE], and had diagnoses that included bipolar disorder (serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most bipolar individuals experience alternating episodes of mania and depression). A review of an April 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident was recently admitted with an order for Quetiapine Fumarate (antipsychotic medication) oral tablet 25mg three times a day related to bipolar disorder and the medication needed to be evaluated for the effectiveness and if a GDR (gradual dose reduction) could be attempted. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she (CRNP) reviewed it. A review of the clinical record revealed Resident 47 was admitted to the facility on [DATE], and had diagnoses that included depressive disorder and mood disorder. A review of a January 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident has an order for Depakote sprinkles (anti-seizure medication that is effective to treat bipolar disorder) 250mg by mouth one time a day for mood. The medication was due for an assessment in accordance with CMS (Centers for Medicare Medicaid Services) guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief resident specific rationale. A second recommendation was made by the pharmacist during the month of January 2024 indicating the resident had an order for Lexapro (antidepressant) 15 mg for depressive disorder. This medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction was indicated please include a brief resident specific rationale. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it. A review of a March 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident had an order for Seroquel 25mg every day for reoccurring depressive disorder. The pharmacist noted the resident's behaviors appear to occur mostly around bedtime, but the medication was being administered at 9:00 AM. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it. A review of the clinical record revealed Resident 86 was admitted to the facility on [DATE], and had diagnoses that included dementia. A review of a May 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident had an order for Seroquel (antipsychotic) 50 mg twice a day for unspecified dementia. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it. A review of Resident 64's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition). A review of a January 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident had an order for Depakote 250 mg three times per day for a mood disorder. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it. A review of a Resident 64's May 2024 Note to Attending Physician/Prescriber revealed the consultant pharmacist indicted the resident had an order for Trazadone 25 mg daily at bedtime for anxiety disorder. The medication was due for an assessment in accordance with CMS guidelines for psychopharmacological medications and if no dose reduction is indicated, please include a brief patient specific rationale. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it. Further review revealed the resident's attending physician failed to document an individualized response to the pharmacy recommendations. Instead, the facility's consultant psychiatric CRNP had responded to the pharmacy recommendation and signed off as she reviewed the recommendations. In an interview with the Director of Nursing on August 23, 2024, at approximately 1:30 PM confirmed that consultant psychiatric CRNP was responding to the pharmacy recommendations and not the resident's attending physician as noted in the regulation. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director

Based on observations, a review of facility pest service records and staff interview, it was determined the facility failed to maintain an effective pest control program throughout multiple areas of the facility. Findings include: An observation of the A hall nursing unit medication room on August 22, 2024, at approximately 9:05 AM revealed a strong mildew and sewage smell throughout the room. A flying bug was seen in the med room. An observation of the A hall nursing unit shower room on August 22, 2024, at approximately 9:15 AM revealed a large amount of sewer flies in the shower room. These flies were noted to be covering the walls of the shower room. They were noted by the tub and in both shower stalls. There was multiple dead flies noted on the floor, in the tub, or flattened on the wall. An interview with Employee 1 LPN (license practical nurse) on August 22, 2024, at approximately 9:25 AM revealed the employee stated the bugs have been an ongoing issue in the facility. She stated that they have been a problem for at least four months and have become worse over the summer. The employee stated she has observed the bugs in the shower room and in the medication room. A review of the contracted pest control company's service reports for general pest control maintenance for the facility revealed the pest control company did not begin to treat for the flies until July 9, 2024, despite staff indicating the fly infestation has been going on for at least four months. A review of a pest control report dated July 9, 2024, revealed the company treated the A wing shower room for drain flies. The pest company failed to provide recommendations to the facility about providing treatments to the drains to ensure the flies would be controlled between visits. A review of a pest control report dated July 23, 2024, revealed the flies remained a problem in the A wing shower room and a treatment was provided again. The pest control once again failed to provide any recommendations to the facility on how to continue to treat the drains to ensure the files would be controlled between visits. A review of a facility work order dated July 30, 2024, revealed the treatment to the drains did not work and it was reported there were bugs that were all over the walls of the A wing shower room. At that time the facility sprayed to kill the flies, but no treatments were provided to the drains to try to eradicate the flies. A review of a pest control report dated August 6, 2024, revealed once again the pest company noted the presence of flies in the shower room and now in the medication room of the A wing nursing unit. The pest company applied the same treatment as the last two visits that failed to work. The pest control company suggested at that time that better sanitation and treatment should be completed but failed to identify the treatment should. An interview with the Nursing Home Administrator (NHA) on August 23, 2024, at 1:30 PM, confirmed that the facility failed to complete the necessary measures to maintain an effective pest control program. 28 Pa. Code 201.18 (e)(2.1) Management

Based on observation, and staff interviews it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on August 20, 2024, at approximately 1:30 PM revealed in Room B14 Resident 25's tube feeding pump and pole were soiled with dried tube feeding solution dried to the pump and pole. In addition there were dried spots of tube feeding solution on the floor. An observation of the A hall nursing unit medication room on August 22, 2024, at approximately 9:05 AM revealed there was dirt and debris on the floor. A strong mildew and sewage smell was noted throughout the room. A flying bug was observed flying around in this medication room. An observation of the A hall nursing unit shower room on August 22, 2024, at approximately 9:15 AM revealed a large amount of sewer flies in the shower room. These flies were noted to be covering the walls of the shower room. They were observed by the tub and in both shower stalls. There were multiple dead flies noted on the floor, in the tub, or splattered on the walls. There were wet clumps of paper on the shower room floor. The shower curtain was noted to have brown stains on the bottom. There were cracked tiles observed on the wall near the floor. An observation on August 23, 2024, at approximately 8:55 AM revealed Room B14, Resident 25's tube feed pump and pole still had dried tube feeding solution on the pump and pole. The dried spots tube feeding solution remained on the floor. Interview with the Director of Nursing and Nursing Home Administrator on August 23, 2024, at approximately 1:30 PM confirmed the facility is to be maintained on a daily basis to ensure a clean and sanitary environment for the residents. Refer F925 28 Pa. Code 201.18 (e)(2.1) Management

Based on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that include individual medication therapy for one resident out of 20 sampled (Resident 12). Findings include: A review of the clinical record revealed Resident 12 was admitted to the facility on [DATE], with diagnoses to include hypertension (high blood pressure). A review of a physician order, initially dated April 30, 2024 revealed the resident was receiving Eliquis Oral Tablet 2.5 MG (anticoagulant medication-commonly known as a blood thinner, chemical substance that prevents or reduces the coagulation of blood, prolonging the clotting time) give twice a day for history of pulmonary embolism (blood clot in the lung). A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's anticoagulant therapy and interventions to monitor for bleeding. Interview with the Nursing Home Administrator and Director of Nursing on August 23, 2024, at approximately 1:30 PM confirmed the facility failed to ensure that comprehensive care plans were developed. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records, and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure physician ordered medication, an antibiotic, and additive were timely obtained and administered to treat a urinary tract infection for one resident (Resident 93) out of 20 sampled residents. Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of Resident 93's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Guillain-Barre Syndrome (a disorder of the immune system where the nerves are attacked by immune cells that causes weakness and tingling in arms and legs), neuromuscular dysfunction of the bladder (a type of bladder dysfunction caused by nerve, brain, or spinal cord damage with symptoms that include loss of bladder control and retaining urine), and urine retention (an inability to completely empty the bladder). A review of urine analysis (UA is a common diagnostic test that evaluates the content, concentration, and appearance of urine and helps detect and manage a wide range of disorders such as urinary tract infections, kidney disease, and diabetes), and culture and sensitivity (urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) results that were received by the facility on July 24, 2024, at 11:03 a.m., revealed that Resident 93 had positive urine cultures and confirmed a urinary tract infection. A review of a nurse progress noted completed by Employee 1, a Licensed Practical Nurse (LPN), dated July 25, 2024, at 2:28 p.m., revealed that C& S results were reviewed with the CRNP (Certified Registered Nurse Practitioner) with new orders for Ceftriaxone (an antibiotic in the form of an injection that treats bacterial infections), give 1 gram (gm) intramuscularly ( a technique used to deliver a medication deep into the muscles) for 7 days. The Physician, resident, and responsible party (RP) were aware. A review of a physician's order dated July 26, 2024, at 4:12 p.m., revealed an order for an antibiotic, Ceftriaxone SodiumInject 1 gram intramuscularly one time a day for UTI for 7 Days reconstitute (restore to a former condition by adding water) with Lidocaine (numbing medication). A review of Resident 93's medication administration record (MAR) is the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) dated July 2024, revealed on July 27, 2024, the resident did not receive the prescribed IM antibiotic Ceftriaxone Sodium. Further review of the clinical record revealed an order administration note completed by Employee 1, dated July 27, 2024, at 7:01 p.m., indicated the Ceftriaxone Sodium Injection was not administered due to the facility waiting for Lidocaine from the pharmacy. During an interview with the Director of Nursing (DON) on August 22, 2024, at 1:45 p.m., it was reported that in the event a physician prescribed treatment was not provided by the facility's primary contracted pharmacy, nursing staff were to contact the contracted emergency pharmacy to prevent a delay in the medication administration. Resident 93's clinical record failed to reveal the resident's physician was timely notified of the missed dose of antibiotic therapy. The facility failed to ensure that Resident 93 received the antibiotic doses as prescribed by the physician to treat the UTI and failed to utilize services of the facility's contracted emergency pharmacy to prevent a delay in treatment. Interview with the DON on August 23, 2024, at 11:00 a.m., confirmed the facility failed to administer physician ordered medication as prescribed, and failed to ensure the MD was notified of a missed dose. Additionally, the DON confirmed that nursing staff failed to implement emergency provisions to contact the contracted emergency pharmacy to prevent a delay in treatment. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation, a review of select facility policy, clinical records, and facility provided documentation, resident and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent skin breakdown, promote healing of existing wounds, and prevent worsening and infection of pressure sores for two out of four residents sampled with pressures sores (Resident 7 and 87). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility Pressure Ulcer Prevention and Management Program Policy last reviewed June 1, 2022, revealed the facility is committed to providing a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers, do not develop them unless the resident's clinical condition demonstrates they are unavoidable. Any resident with a pressure ulcer will receive treatment and services consistent with the resident's goals of treatment. Typically, the goal will be one of promoting healing and preventing infection, unless resident preferences and medical condition necessitate palliative care as the primary focus. Wound treatment plans are re-evaluated by the attending physician, as recommended by the treatment nurse designee, if a clean un-infected PU shows no evidence of healing within 2-4 weeks. A review of the clinical record revealed that Resident 7 had diagnoses, which include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), [CONDITION(S)] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and Down Syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays). A review of a quarterly Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was severely cognitively impaired, was totally dependent requiring the assistance of two people for activities of daily living, was at risk for pressure ulcers, and had one Stage 3 (full-thickness skin loss) pressure ulcer, which was not present on admission or reentry. A current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly wound consult note dated July 26, 2022, indicated the resident had a Stage 3 pressure ulcer on the sacrum, which measured 2 cm x 0.8 cm x 1 cm with moderate serosanguinous exudate(wound drainage) and 100% granulation. Review of Resident 7's July 2022 Treatment Administration Record (TAR) revealed that on July 8, July 10, and July 24, 2022, there was no documented evidence that nursing performed the prescribed treatment to the resident's sacral pressure ulcer. Review of Resident 7's August 2022 TAR revealed that on August 29, 2022, there was no documented evidence that nursing performed the prescribed treatment to the resident's sacral pressure ulcer. Review of Resident 7's September 2022 TAR revealed that on September 22, 2022, there was no documented evidence that nursing performed the prescribed treatment to the resident sacral pressure ulcer. Review of Resident 7's October 1 through October 20, 2022 TAR revealed that on October 6, 2002, there was no documented evidence that nursing performed the prescribed treatment to the resident sacral pressure ulcer. A weekly wound consult note dated October 21, 2022 indicated the resident's Stage 3 pressure ulcer on the sacrum was 2.3 cm x 0.5 cm x 1cm with moderate serosanguinous exudate and 100% granulation. No change was noted in the pressure ulcer. Interview with the director of nursing (DON) on October 21, 2022, at approximately 10:00 AM confirmed the prescribed wound treatment was to be completed daily and as needed according to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident 87 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 87's Braden Scale Assessment (a standardized, evidence -based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated April 6, 2022, revealed that the resident scored a 14 (total score of 13-14 indicates the resident is at moderate risk) for developing a pressure sore. A review of a Significant Change Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS score of 13 (13 - 15 represents cognitively intact), and required extensive assist of 2 staff members for bed mobility, dressing, toileting, personal hygiene (combing hair, brushing teeth) and is totally dependent on staff for transfers. The resident was identified as being at risk for developing pressure areas. A review of Resident 87's care plan date-initiated June 17, 2021, revised on October 18, 2022, indicated that the resident has the potential for skin impairment related to contractures, impaired mobility, and history of pressure ulcers. The interventions planned were to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, use caution during transfers and bed mobility, incontinent care, and use draw sheet or lifting device to move resident. The resident's care plan initiated January 19, 2022, revised on October 18, 2022, also indicated that the resident has a Stage 4 pressure area to her sacrum, vascular areas to the right medial ankle, right 1st toe, left lateral leg and right heel, and an abrasion to her mid back. The interventions planned were to administer treatments as ordered, if the resident refuses treatment confer with the resident, interdisciplinary team (IDT), family, inform resident/family caregivers of any new areas of skin breakdown, monitor/document/report any changes including signs/symptoms (s/s) of infections, pillows between knees, ProSource for healing, specialty mattress and pressure reducing chair cushion, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The resident's care plan was updated October 5, 2022, to identify the problem that the resident refuses to get out of bed (OOB) and/or be repositioned. Nurses notes dated July 12, 2022, at 8:44 AM, indicated that a new abrasion was found on the resident's right back measuring 1 x .7 x .1 with granulating tissue and moderate amount serosanguineous drainage (wound drainage). MD aware, and treatment ordered. A review of facility incident/accident report, entitled Pressure, dated July 12, 2022, at 8:37 AM, revealed an abrasion was found on right back measuring 1 cm x 0.7 cm x .1 cm with granulating tissue and moderate amount serosanguineous drainage. A review of facility provided document entitled Witness Statement, dated July 12, 2022, indicated, that Employee 3, (Registered Nurse) had written/taken a statement from Resident 87 regarding the mid back abrasion. According to the witness statement, Resident 87 doesn't know how it got there. A skin/wound note, dated July 12, 2022, at 9:04 AM, indicted that an outside wound consultant evaluated the resident's right back abrasion, but provided no documented evaluation to include the size/measurements, shape or appearance of the skin injury. Interview with the Director of Nursing (DON) on October 21, 2022, at approximately 8:50 A.M., confirmed that there was no documentation of the results of the evaluation by the wound consultant on July 12, 2022. The wound care consultant evaluated the again area on the resident's right back on July 22, 2022. This assessment revealed a right back abrasion measuring 1 cm x 0.7 cm x 0.1 cm, with moderate serosanguinous exudate (drainage - fluid that has seeped out of blood vessels or an organ). The wound was 100 % slough (dead tissue separating from living tissue, a mass of dead tissue). The plan is for [MEDICATION(S)] (a wound and burn gel), DPD everyday (QD) and as needed (PRN). Wound consultant evaluations dated July 26, 2022 and August 9, 2022, revealed that the resident's skin injury was unchanged. A wound care consultant evaluation of the abrasion on the resident's right back dated August 19, 2022, revealed that the resident's wound had deteriorated. The area had increased in size to 3 cm x 1 cm x 0.1 cm, with moderate serosanguinous exudate. The tissue was 75 % slough, and 25 % epithelial (thin tissue forming the outer layer of a body's surface). According to the wound care evaluation the resident's right back abrasion was surgically debrided (removal of necrotic tissue) was performed. The plan was for the use of Santyl (an ointment - medication that removes dead tissue from wounds so they can start to heal), and DPD, QD and PRN. Wound consultant evaluations dated August 26, 2022 and August 30, 2022, revealed that the resident's wound remained unchanged. A wound care consultant evaluation dated September 9, 2022, indicated that the wound had deteriorated measuring 3 cm x 2 cm x 0.1 cm, without exudate. The tissue was 100 % slough. The right back abrasion was surgically debrided. The plan continued to treat with Santyl, and DPD, QD and PRN. A wound care consultant evaluation dated September 27, 2022, noted that the wound progress was deteriorating with the area increasing in size and measuring 3 cm x 3.5 cm x 0.2 cm, moderate serosanguinous exudate, with a strong odor. The tissue is 100 % slough, and a 6 x 5 cm induration superior to the wound was found. The wound was surgically debrided. The treatment plan was for Dakins Solution (a solution to prevent and treat skin and tissue infections that could result from cuts, scrapes and PU) 1/25 and foam dressing QD and PRN, and to culture the abrasion on the right back. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes dated September 28, 2022, at 2:20 PM, indicated that a wound culture of the resident's mid back was obtained as ordered and sent to the lab. Nursing notes dated September 30, 2022, at 10:39 PM, indicated that a new order was received for [MEDICATION(S)] (an antibiotic used to treat infections) 2G IV Q 24 hrs x 7 days. The resident was made aware. A wound care consultant evaluation dated October 4, 2022, noted that the resident' wound was continuing to deteriorate, measuring 5 cm x 6 cm x 0.9 cm, moderate serosanguinous exudate. The tissue was 80 % slough, and 20 % granulation (tissue that forms as chronic inflammation evolves) tissue. The treatment plan was Santyl, Dakins wet to moist QD and PRN. A wound care consultant evaluation dated October 11, 2022, indicated that the resident's wound further deteriorated and now measured 7 cm x 5 cm x 1 cm, with heavy serosanguinous exudate, and moderate odor. The tissue was 40 % slough, and 60 % granulation tissue. The procedures indicated that the resident's right back abrasion was surgically debrided and the treatment plan was for Dakins wet to moist twice a day (BID) and PRN. Observation of the resident's right back abrasion on October 20, 2022, at approximately 10:30 AM, with the resident's permission, and in the presence of Employee 4, Licensed Practical Nurse (LPN), revealed that the resident had a roundish - oval shaped wound along right side of the lower spine. The undated, foam dressing appeared to be saturated with a tan substance, minimal odor, with light serosanguinous drainage was present. The wound bed appeared to be red, and at its superior end white with darkened tissue (necrotic, as stated by Employee 4). The right back abrasion measured 8 cm x 5 cm x 1 cm (as measured by Employee 4 LPN). During observation of Resident 87's right back abrasion, on October 20, 2022, at approximately 10:30 AM, Employee 4, LPN, placed the wound supplies directly on the resident's bedside table without any barrier (towel, or disposable chuck) and next to personal items that were present on the bedside table. Employee 4 failed to change her gloves during the dressing change from dirty dressing to clean dressing. The red hazardous waste isolation can, was at the foot of the resident's bed, rather than at the door entrance to allow for immediate disposal upon doffing of the soiled gown as the nurse exited the room without the need to cross the room wearing soiled PPE. The facility provided Documentation Survey Reports v 2 (tasks staff completed for the resident) for July 2022, August 2022, September 2022 and October 2022, through the time of the survey revealed lack of documented evidence that staff had consistently repositioned the resident, revealed extended periods of time ranging from 4 hours to 10 consecutive hours during which there was no evidence that the resident had been repositioned. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with alert and oriented Resident 87, on October 19, 2022, at approximately 8:50 A.M., revealed that the resident was lying in bed, wearing a hospital gown. She was pleasant, and cooperative. During the interview, the resident easily recalled how she sustained the mid back abrasion during the summer. The resident explained that staff placed her in a blue, high back chair, while she was wearing her gown (which she prefers to wear), which is open in the back. The resident's bare back was in direct contact with the back of the chair. She further stated that staff left her in that chair in that position for 9 hours. The resident stated that staff ignored her and left her in the chair without turning/repositioning. The resident stated that when staff finally removed her from the chair, her skin stuck to the surface of the chair because of moisture and her skin was damaged as a result. An additional interview with the alert and oriented Resident 87, on October 20, 2022, at approximately 10:00 A.M., revealed that she was in bed wearing a hospital gown. The resident again relayed the same details as she did the prior day regarding how she sustained the abrasion to her back. The resident explained that it the wound was caused by her skin sticking to the chair after 9 hours without repositioning. The resident was asked about her refusal to be repositioned, that was noted on her care plan in October 2022. The resident confirmed that she does refuse to be placed into the chair because once in the chair, staff ignores her and do not reposition her. Resident 87 stated that she would not refuse to to be turned/repositioned in bed. During the survey Resident 87 twice recounted her identical exact version of events that led to the skin breakdown, however, according to the facility's investigation into the skin injury, the resident did not know how it happened. The facility failed to demonstrate timely and consistent repositioning of a resident at risk for skin breakdown to prevent a skin injury and , which progressively worsened and became infected requiring IV antibiotic therapy. Interview with the Director of Nursing (DON) on October 21, 2022, at approximately 8:50 A.M., confirmed the information above and was unable to provide any additional information at the time the survey ended. Interview with the Nursing Home Administrator (NHA) on October 21, 2022, at approximately 10:00 AM, confirmed the information above, was unable to provide any additional information at the time the survey ended, and that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent development and worsening of pressure sores and to promote healing. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f) Clinical records.

Based on a review of clinical records and select incident investigation and staff interviews, it was determined that the facility failed to provide necessary assistance as planned to safely provide care for a resident identified at risk for falls, to prevent a fall resulting in a serious injury, multiple fractures, sustained by one resident out of 13 residents reviewed for accidents/falls (Resident 1). Findings included: Review of Resident 1's clinical record revealed admission to the facility on [DATE], with diagnoses that included [CONDITION(S)], muscle weakness and [CONDITION(S)] disease of the nervous system. A review of a quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 5, 2022, revealed her to be cognitively intact, required extensive assistance of two people for bed mobility, transfers and personal hygeine. The resident's care plan related to ADL care dated March 29, 2022 revealed that the baseline care plan did not identify the level of assistance with bed mobility, transfers and personal hygiene. A physical therapy discharge evaluation dated May 5, 2022, revealed that Resident 1's functional skills assessment identified the resident as dependent on staff for bed mobility. A review of a facility investigation and information dated November 10, 2022, at 2:12 A.M. submitted by the facility revealed that Employee 1, a nurse aide was changing the resident in the bed, Employee 1 placed the resident on her left side, in bed, facing the window. Employee 1 then left the resident to get a cream from the resident's closet. The resident rolled out of bed onto the floor. The resident required the assistance of two staff members for bed mobility and personal hygiene, but Employee 1 was providing ADL care without the assistance of second person. There was no assist bar on the opposite of the resident's bed or another person to prevent the morbidly obese resident from rolling out of bed. Employee 1 also failed to use safe technique by rolling the resident away from her and then also leaving the resident in an unsafe position to obtain resident care supplies. Employee 1 further failed to ensure all necessary supplies were readily available to provide incontinence care. A review of a witness statement dated November 10, 2022 at 4 A.M., Employee 1 stated I was in {Resident 1's} room providing incontinence care and {Resident 1} was in bed, rolled onto her side facing the window. I turned away to get incontinence cream from her closet and she was reaching for her nightstand, pulling herself over and she rolled out of bed. I called for the nurse. A review of nurse staffing for November 10, 2022 11 P.M. to 7 A.M. shift revealed that there was only one nurse aide assigned to the A wing unit where the resident resided on that shift. Nursing documentation dated November 10, 2022 at 4:10 A.M. revealed the resident was rolled out of bed. She was complaining of increased pain in her left shoulder and left knee and had difficulty moving her left arm. Her left lower extremity appears shorter than the right and was complaining of feeling numbness and tingling in the left leg. The physician wa contacted and ordered the resident to the hospital for evaluation and treatment. The resident was transported to the hospital at 4:47 A.M. A review of hospital documentation dated November 10, 2022, at 5:24 A.M. revealed that the resident was admitted to the emergency department after a fall at the facility. Multiple x-rays were ordered. Results of the X-rays to included a fracture of the left humerus (the long bone of the upper arm), closed fracture of the proximal end of the left tibia ( the shinbone just below the knee is called a proximal tibia fracture. The proximal tibia is the upper portion of the bone where it widens to help form the knee joint), Right femur fracture (the thigh bone) and two acute, closed displaced fracture of the body of the left calcaneus (the heel bone). The resident was admitted to the hospital due to ambulatory dysfunction. Orthopedics was consulted and non-operative interventions with splint stabilization initiated for now. The resident was readmitted to the facility on [DATE] at 10:P.M. Interview with the Director of Nursing on December 8, 2022, at 12 p.m. confirmed that Resident 1 required the use of two staff members for safe bed mobility and incontinence care. The Administrator confirmed that Employee 1 failed to use the necessary assistance level to perform bed mobility and personal care for the resident resulting in the resident's fall with serious injuries on November 10, 2022. This deficiency is cited as past non-compliance. The facility's corrective action plan was to assess Resident 1 for proper bed mobility status and to update the care plan. All residents were audited for their current bed mobility status, care plan and Kardex information. Corrections were made when found. Staff inserviced on verification of bed mobility status upon admission, change in condition or discharge from therapy, and quarterly via the MDS process to ensure current status is reflected in the electronic record for staff instruction. Audits were completed weekly with results reported to the QAPI committee by the Director of Nursing. This plan of correction was completed by November 17, 2022. 28 Pa. Code: 211.11(d) Resident Care Plans 28 Pa. Code: 211.12 (a)(c)(d)(3)(5) Nursing Services

Based on a review of select facility policy, standards established by the Centers for Medicare and Medicaid Services and the facility's employee vaccination data and staff interviews, it was determined the facility failed to fully develop and implement policies and procedures to ensure that all staff were vaccinated for COVID-19. Review of facility employee vaccination status information revealed, that as of February 2, 2022, the facility's staff vaccination rate was 82.0 % and there were seven COVID resident infections since January 27, 2022 (Residents 8, 12, 28, 23, 5, 27 and 30). Findings include: According to the CMS Memorandum QSO-22-07, on November 5, 2021, CMS published an IFC with comment period (86 FR ), entitled Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination, revising the infection control requirements that most Medicare- and Medicaid-certified providers and suppliers must meet to participate in the Medicare and Medicaid programs. These changes are necessary to protect the health and safety of patients and staff during the COVID-19 public health emergency. A review of the facility's policy entitled Covid-19 vaccination program dated January 25, 2022, indicated that staff who receive accommodations for not receiving the Covid-19 vaccination due to a religious exemption and medical exemptions must always wear an N95 respirator and eye protection during the duration of the scheduled shift when providing services at the facility. Observations of unvaccinated staff with qualifying exemptions conducted on the resident units throughout the facility on February 2, 2022, revealed that the identified unvaccinated employees were not wearing the required N95 masks according to their accommodations for their qualifying exemptions to the COVID-19 vaccine. Interview with the Nursing Home Administrator (NHA) conducted on February 2, 2022, all unvaccinated staff with qualifying exemptions are required to wear the N95 masks and goggles at all times, even when not providing resident care. Interview conducted on February 2, 2022, with these staff members, including Employee 1 (Registered Nurse), Employee 2 (nurse aide), Employee 3 (nurse aide), Employee 4 (nurse aide).while at the nurses station, revealed that these employees were not wearing N95 masks. The employees stated that they did not receive a COVID-19 vaccination and had religious exemptions, but were not made aware that they were required to wear an N95 mask at all times in the facility as a mitigation effort to prevent the spread of COVID-19. Further review of the facility's policy indicated that all staff will be educated on the Covid-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks consistent with CDC and/or FDA information. All staff will be offered the opportunity to ask questions about the risk and benefits of the vaccination. The education that was provided to the staff regarding education was requested several times throughout the survey, however, it was not provided. Review of facility employee vaccination status information revealed, that as of February 2, 2022, the facility's vaccination rate was 82.0 %. The facility failed to provide evidence that Employee 5 (Housekeeping) and Employee 6(RNAC), Employee 7 (driver), Employee 8 (driver) Employee 9 (driver), Employee 10 (driver), Employee 11 (driver), Employee 12 (driver), Employee 13 (driver), Employee 14 (driver) were vaccinated. The facility also failed to obtain documentation of valid exemptions according to their policy, which indicated that Healthcare personnel without documentation of vaccination or valid exemption will be considered non-compliant with Covid-19 vaccination requirements. If vaccination or acceptable declination has not occurred by January 27, healthcare personnel will receive a written notice that they are not in compliance with the facility Covid-19 vaccination policy. Staff will then be offered [NAME] for 30 days to obtain the Covid-19 vaccine. Review of employee vaccination status information revealed that as of February 2, 2022, Employee 15 (nurse aide) and Employee 16 (nurse aide) obtained religious exemptions, which were not approved by the deadline date of January 27, 2022, making them non-compliant with the facility Covid-19 policy. At the time of the survey, ending February 2, 2022, and based on a review the previous 5 days since the effective date of January 27, 2022, there was a current COVID-19 outbreak of among residents which included a total of 7 residents positive for Covid-19 on these dates (Residents 8, January 17, 2022, Resident 12, January 27, 2022, Resident 28, January 27, 2022, Resident 23, January 27, 2022, Resident 5, January 31, 2022, Resident 27, January 31, 2022 and Resident 30, January 31, 2022). The facility also failed to implement into their policy to obtain vaccination data on all individuals under contract or arrangement, such as pharmacy services, mobile x-ray, hospice, podiatry, optometry, dental, mental health or laboratory services. Interview with the Nursing Home Administrator (NHA) on February 2, 2022, at 4:00 PM, confirmed that not all staff were vaccinated against the COVID-19 virus or had an approved qualifying exemption. The facility failed to obtain the vaccination status of contracted staff and failed to ensure that staff with qualifying exemptions were consistently adhering to the accommodations made, source control at all times, to mitigate the spread of COVID-19 by unvaccinated staff. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(d)(e)(1) Management

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs by failing to adequately monitor laboratory blood values to determine the resident's clinical need and continued dosage of an anticoagulant medication, which resulted in [MEDICATION NAME] toxicity and bleeding requiring a corrective blood transfusion for one resident out of 12 sampled (Resident CR1). Findings include: A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Upon admission, Resident CR1 had a physician order [REDACTED]. A [MEDICATION NAME] time {PT} - is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio {INR} is calculated from a PT result and is used to monitor how well the blood-thinning medication (anticoagulant) [MEDICATION NAME] ([MEDICATION NAME]®) is working to prevent blood). Normal PT level is between 12.0 to 14.1 seconds and INR level for a resident taking oral anticoagulant medications is 2.00 to 3.00. INR is generally used because it allows for easier comparisons of test results from different laboratories and is used if you take blood-thinning medications. Results of the resident's PT/INR dated January 6, 2020, revealed that the resident's PT level was 22.2 and the INR was 1.96. In response to these laboratory results, new physician orders [REDACTED]. The PT/INR dated January 9, 2020, revealed that the PT level was 20.2 and the INR was 1.74. New physician orders [REDACTED]. A review of nursing documentation dated January 11, 2020, at 3:03 p.m. indicated that the resident was having dark stool. The physician and resident's representative were notified and a physician order [REDACTED]. A nurse's note dated January 12, 2020, at 5:38 a.m. indicated that the resident did not have a bowel movement and they were unable to obtain the stool sample for the occult blood test. Subsequently, the sample obtained and results were received at 12:09 p.m. that the stool was positive for occult blood. A physician order [REDACTED]. The resident's PT/INR dated January 13, 2020, revealed that the resident's PT level was elevated 44.3 and the INR was 4.69, also elevated for a resident on oral anticoagulant medications. The physician discontinued the resident's [MEDICATION NAME] and ordered another PT/INR in the morning. A PT/INR completed on January 14, 2020, revealed that the resident's PT level was 29.2 and the INR was 2.[AGE]. The physician ordered another PT/INR for completion on January 17, 2020. No [MEDICATION NAME] was ordered. The PT/INR was completed on January 17, 2020, the PT level was 24.0 and the INR was 2.17. The physician ordered to start [MEDICATION NAME] 3 mg daily and draw another PT/INR on January 20, 2020. The PT/INR was drawn on January 20, 2020, the PT level was 19.1 and the INR was 1.62 and new orders were received to increase the [MEDICATION NAME] to 4 mg daily and draw a PT/INR on January 23, 2020. The PT/INR was drawn on January 23, 2020, the PT level was 20.5 and the INR was 1.78. The physician ordered an increase in the resident's dose of [MEDICATION NAME] to 5 mg daily and draw another PT/INR on January 27, 2020. However, there was no documented evidence of the results of the PT/INR ordered for completion on January 27, 2020, and no evidence that the physician was aware that the resident continued to receive 5 mg of [MEDICATION NAME] daily without an evaluation of a current PT/INR (last completed January 23, 2020). A nurse's note dated February 3, 2020, at 10:30 p.m. indicated that the resident had a bloody stool. Vital signs were taken and the physician was notified and an order was received to transfer the resident to the emergency room for evaluation and treatment. The resident representitive was in visiting and aware. A nurse's note dated February 4, 2020, at 3:09 a.m. indicated that a call was placed to the hospital and Resident CR1 was admitted to the hospital with [REDACTED]. Review of Resident CR1's emergency room and hospital documentation confirmed the [DIAGNOSES REDACTED]. A review of the hospital emergency room laboratory values revealed that Resident CR1's PT level was greater than 99.9 seconds (very high) and the INR was noted as NA. RBC was 2.8 mcL, Hgb was 8.2 g/dl and the HCT was 25.1% (low). (Normal PT level is between 12.0 to 14.1 seconds and INR level for a resident taking oral anticoagulant medications is 2.00 to 3.00. Normal Red Blood Cell (RBC) count is 4.35 to 5.87 mcL, normal hemoglobin (Hgb) is 13.3 to 17.7 g/dl and normal hematocrit (HCT) is 39.8 to 52.2 percent). According to the hospital record dated February 3, 2020, Resident CR1 received a transfusion of fresh frozen plasma and red blood cells in the emergency room and was then admitted to the hospital on February 4, 2020, for further evaluation. The facility failed to demonstrate consistent monitoring of Resident CR1's [MEDICATION NAME] dosage and corresponding PT/INR levels to prevent [MEDICATION NAME] toxicity and increased bleeding. A PT/INR level had not been completed and evaluated by the physician since January 23, 2020, until the resident was transferred and admitted to the hospital on February 3, 2020, and diagnosed with [REDACTED]. Interview with the Director of Nursing on February 27, 2020 at 11:15 a.m. confirmed the resident's PT/INR was not completed as ordered on January 27, 2020, and the resident continued to receive 5 mg of [MEDICATION NAME] daily. Refer F[AGE]0 28 Pa. Code 211.2(a) Physician Services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.9(k) Pharmacy Services

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs by failing to adequately monitor laboratory blood values to determine the resident's clinical need and continued dosage of an anticoagulant medication, which resulted in [MEDICATION NAME] toxicity and bleeding requiring a corrective blood transfusion for one resident out of 12 sampled (Resident CR1). Findings include: A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Upon admission, Resident CR1 had a physician order [REDACTED]. A [MEDICATION NAME] time {PT} - is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio {INR} is calculated from a PT result and is used to monitor how well the blood-thinning medication (anticoagulant) [MEDICATION NAME] ([MEDICATION NAME]®) is working to prevent blood). Normal PT level is between 12.0 to 14.1 seconds and INR level for a resident taking oral anticoagulant medications is 2.00 to 3.00. INR is generally used because it allows for easier comparisons of test results from different laboratories and is used if you take blood-thinning medications. Results of the resident's PT/INR dated January 6, 2020, revealed that the resident's PT level was 22.2 and the INR was 1.96. In response to these laboratory results, new physician orders [REDACTED]. The PT/INR dated January 9, 2020, revealed that the PT level was 20.2 and the INR was 1.74. New physician orders [REDACTED]. A review of nursing documentation dated January 11, 2020, at 3:03 p.m. indicated that the resident was having dark stool. The physician and resident's representative were notified and a physician order [REDACTED]. A nurse's note dated January 12, 2020, at 5:38 a.m. indicated that the resident did not have a bowel movement and they were unable to obtain the stool sample for the occult blood test. Subsequently, the sample obtained and results were received at 12:09 p.m. that the stool was positive for occult blood. A physician order [REDACTED]. The resident's PT/INR dated January 13, 2020, revealed that the resident's PT level was elevated 44.3 and the INR was 4.69, also elevated for a resident on oral anticoagulant medications. The physician discontinued the resident's [MEDICATION NAME] and ordered another PT/INR in the morning. A PT/INR completed on January 14, 2020, revealed that the resident's PT level was 29.2 and the INR was 2.[AGE]. The physician ordered another PT/INR for completion on January 17, 2020. No [MEDICATION NAME] was ordered. The PT/INR was completed on January 17, 2020, the PT level was 24.0 and the INR was 2.17. The physician ordered to start [MEDICATION NAME] 3 mg daily and draw another PT/INR on January 20, 2020. The PT/INR was drawn on January 20, 2020, the PT level was 19.1 and the INR was 1.62 and new orders were received to increase the [MEDICATION NAME] to 4 mg daily and draw a PT/INR on January 23, 2020. The PT/INR was drawn on January 23, 2020, the PT level was 20.5 and the INR was 1.78. The physician ordered an increase in the resident's dose of [MEDICATION NAME] to 5 mg daily and draw another PT/INR on January 27, 2020. However, there was no documented evidence of the results of the PT/INR ordered for completion on January 27, 2020, and no evidence that the physician was aware that the resident continued to receive 5 mg of [MEDICATION NAME] daily without an evaluation of a current PT/INR (last completed January 23, 2020). A nurse's note dated February 3, 2020, at 10:30 p.m. indicated that the resident had a bloody stool. Vital signs were taken and the physician was notified and an order was received to transfer the resident to the emergency room for evaluation and treatment. The resident representitive was in visiting and aware. A nurse's note dated February 4, 2020, at 3:09 a.m. indicated that a call was placed to the hospital and Resident CR1 was admitted to the hospital with [REDACTED]. Review of Resident CR1's emergency room and hospital documentation confirmed the [DIAGNOSES REDACTED]. A review of the hospital emergency room laboratory values revealed that Resident CR1's PT level was greater than 99.9 seconds (very high) and the INR was noted as NA. RBC was 2.8 mcL, Hgb was 8.2 g/dl and the HCT was 25.1% (low). (Normal PT level is between 12.0 to 14.1 seconds and INR level for a resident taking oral anticoagulant medications is 2.00 to 3.00. Normal Red Blood Cell (RBC) count is 4.35 to 5.87 mcL, normal hemoglobin (Hgb) is 13.3 to 17.7 g/dl and normal hematocrit (HCT) is 39.8 to 52.2 percent). According to the hospital record dated February 3, 2020, Resident CR1 received a transfusion of fresh frozen plasma and red blood cells in the emergency room and was then admitted to the hospital on February 4, 2020, for further evaluation. The facility failed to demonstrate consistent monitoring of Resident CR1's [MEDICATION NAME] dosage and corresponding PT/INR levels to prevent [MEDICATION NAME] toxicity and increased bleeding. A PT/INR level had not been completed and evaluated by the physician since January 23, 2020, until the resident was transferred and admitted to the hospital on February 3, 2020, and diagnosed with [REDACTED]. Interview with the Director of Nursing on February 27, 2020 at 11:15 a.m. confirmed the resident's PT/INR was not completed as ordered on January 27, 2020, and the resident continued to receive 5 mg of [MEDICATION NAME] daily. Refer F[AGE]0 28 Pa. Code 211.2(a) Physician Services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.9(k) Pharmacy Services

Based on a review of clinical records and select facility incident reports, observations, and staff interview it was determined that the facility failed to provide necessary supervision and implement effective safety interventions to assure a resident's environment remains as free from potential accident hazards as possible and to prevent ingestion of foreign substances, which compromised the resident's health and required medical intervention at an acute care facility and to deter intrusive wandering and prevent resident altercations for one of two residents reviewed (Resident 75). Findings include: A review of the clinical record revealed that Resident 75 had diagnoses, which included ID (intellectual disability), PICA (craving and eating non-food items) and dysphagia (difficulty swallowing). A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated, (MONTH) 21, (YEAR), indicated that the resident was cognitively impaired, was rarely/never understood, had both a short and long term memory problem and required staff assistance for transfers, ambulation, locomotion, and eating. Review of a facility incident report dated, (MONTH) 26, (YEAR), at 3:30 PM revealed that staff observed Resident 75 in the resident dining room eating a tea bag. Visual inspection of the resident's oral cavity revealed no remnants of the tea bag. Review of a witness statement from Employee 1 (nurse aide) revealed that at the end of a tea party put on by the activity department, the resident was observed grabbing a used, wet tea bag from the table and shoving it in his mouth. The employee ran over while donning a glove to remove the tea bag, but the resident had swallowed the tea bag The resident was immediately rolled to the nurses station and the incident was reported to staff. The physician was notified with an order to monitor for any ill effects. The summary of the critical information noted that the resident has anxiety, is restless, ambulates through the halls in his wheelchair using his feet. The conclusion of the facility investigation was for any food item to be kept out of the resident's reach and for the dining room to be closed during activities that include food and refreshments. Diversion and redirection supervision to ensure safety were planned. A nurses note dated (MONTH) 8, (YEAR), at 1:14 AM noted that while doing incontinent care on the resident a 15 cm x 15 cm piece of plastic was pulled from the resident's rectum. The resident was noted to be yelling out prior to the care and calmed down after the plastic was removed. A nurses noted dated (MONTH) 8, (YEAR), at 11:06 AM noted that the physician and responsible party were notified of the plastic removal. A KUB (x-ray; frontal radiograph of the abdomen) was ordered by the physician. Further review of the clinical record revealed no documented evidence that the facility completed an investigation to determine how the resident, who requires supervision was able to obtain and ingest the 15 cm x 15 cm piece of plastic without staff knowledge. A nurses note dated (MONTH) 8, (YEAR), at 4:46 PM revealed that the x-ray results of the abdomen showed a colonic ileus (lack of movement somewhere in the intestines that leads to a buildup and potential blockage of eaten material. An ileus can lead to an intestinal obstruction, which means no food material, gas, or liquids can get through). A physician order [REDACTED]. A nurses note dated (MONTH) 9, (YEAR), at 7:38 AM noted that the resident was incontinent of bowel movements times three episodes. No foreign objects were observed in the stool. No moaning or groaning and appeared comfortable. A nurses note dated (MONTH) 9, (YEAR), at 2:09 PM noted that the resident was found in the hallway with a sock in his mouth. The resident was returned to his nursing unit. The resident was wearing his own two socks at the time. Review of an x-ray dated (MONTH) 9, (YEAR), again revealed a colonic ileus with a recommendation to a CT (computerized tomography scan which creates cross-sectional images and more detailed information than an x-ray) follow-up. A nurses note dated (MONTH) 10. (YEAR), at 12:37 AM revealed that the resident was out in the hall and yelling very loudly. The resident was returned to his room and an abdominal assessment was completed. The resident's left abdomen was soft with firmness over left upper and mid abdomen. The resident was hitting the arm rest on his chair and was unable to communicate. Nursing noted that the resident had several (4) bowel movements in the past 24 hours, which were soft and unformed as per the resident's normal. Nursing placed a call to the physician. A nurses note dated (MONTH) 10, (YEAR), at 1:01 PM revealed that the resident was out in the hallway and yelling very loudly. An abdominal assessment revealed decreased bowel sounds (decreased or absent bowel sounds often indicate constipation), left abdomen soft, firmness noted over left upper and mid abdomen. The CRNP (Certified Registered Nurse Practitioner was notified and a new order was received to send to the hospital for evaluation and treatment. A nurses note dated (MONTH) 10, (YEAR), at 11:28 PM revealed that the resident was admitted to the hospital with [REDACTED]. The blockage cuts off blood supply to the bowel) secondary to a foreign object and urinary tract infection. Review of a hospital progress note dated (MONTH) 11, (YEAR), noted that the resident was seen following a flexible sigmoidoscopy (exam to evaluate lower part of the intestines in which a thin flexible tube is inserted into the rectum). Intestinal obstruction was relieved and foreign body (large sized glove) was noted in the rectum and retrieved using forceps (surgical tweezers) and manual removal. The resident was readmitted to the facility on (MONTH) 15, (YEAR), following hospitalization and treatment for [REDACTED]. Interview with the Director of Nursing (DON) on (MONTH) 14, (YEAR), at 11:30 AM revealed no documented evidence that the facility had conducted an investigation to determine how the resident was able to obtain and ingest plastic wrap and a glove. The DON also confirmed that the State Survey Agency had not been notified of the resident's transfer to the hospital due to the accident (ingestion of non-edible items). Review of a facility incident report dated (MONTH) 22, (YEAR), at 5:55 PM noted that Resident 75 was found on C Wing (Resident 75 resident resides on A wing) in Resident 15's room. Resident 75 had removed the stop sign from Resident 15's door, entered the resident's room, grabbed the resident's shirt and scratched Resident 15's forearm leaving a 0.1 cm by 0.1 cm scratch. When Resident 15 told Resident 75, no when Resident 75 was attempting to grab Resident 15's over the bed table, on which food was located. Staff heard Resident 15 call for help and staff removed Resident 75 from Resident 15's room. The conclusion of the investigation was to encourage Resident 75 to his room and activities. Observations throughout the days of the survey from (MONTH) 11, (YEAR), through (MONTH) 14, (YEAR), revealed that Resident 75 continued to independently propel in a scoot chair throughout all nursing units without any evidence of increased staff supervision. Interview with the Director of Nursing on (MONTH) 14, (YEAR), at 11:30 AM confirmed that there was no documented evidence that the facility had increased staff supervision at the frequency and level required to prevent Resident 75 from ingesting non-edible items and intrusive wandering and had implemented effective interventions to maintain Resident 75's environment free of potential accident hazards. 483.25(d)(1)(2) Free of accident hazards/supervision/devices Previously cited 1/16/18, 12/15/16 28 Pa. Code 211.12(a) Nursing Services Previously cited 1/16/18, 11/21/17, 10/17/17, 6/15/17, 12/15/16 28 Pa. Code 211.12(c) Nursing Services Previously cited 9/29/18, 1/16/18, 11/21/17, 10/17/17, 12/15/16 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 9/29/18, 1/16/18, 10/17/17, 6/15/17, 12/15/16 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 9/29/18, 1/16/18, 10/17/17, 6/15/17

Based on a review of clinical records and select facility investigative reports and staff interviews it was determined that the facility failed to ensure that necessary assistance devices were in place during mobility to prevent an accident resulting in a fractured lower leg for one resident out of 19 sampled (Resident 36). Findings include: A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A review of an occupational therapy (OT) treatment summary dated November 22, 2016, revealed that Resident 36 was seen by OT for the management of appropriate positioning while out of bed. OT directed that this resident was to be positioned out of bed in a low scoot Broda chair (a low to the ground wheelchair designed to enable a residents feet to touch the ground in an attempt to self propel) with bilateral (both sides) elevating leg rests with a foot buddy ( a positioning device placed on the leg rests). The resident's chair was to be in the tilted position at all times except for eating. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 5, 2017, revealed that the resident was severely cognitively impaired, required maximum assistance with activities of daily living, including transfers, and utilized a low scoot Broda chair with bilateral (both sides) raised footrests for ambulation and a total mechanical lift for transfers. A review of a facility investigation report dated June 19, 2017, at 8:17 PM revealed that Employee 3 (nurse aide) and Employee 4 (nurse aide) transferred Resident 36 from the low scoot Broda chair to her bed via a mechanical lift. During the transfer, Employees 3 and 4 reported to a licensed nurse that Resident 36's left leg was observed to be bruised and swollen. The physician was contacted and directed that ice be applied to the resident's left leg for 20 minutes, for 48 hours and venous Doppler studies (a diagnostic test to identify the adequacy of blood flow in the legs to the feet). An employee witness statement dated June 19, 2017 (no time) revealed that Employee 4 indicated that at 8:15 PM she reported to a licensed nurse that Resident 36's left leg was swollen and black and blue. A review of an employee witness statement dated June 20, 2017, at 4:57 PM Employee 1 (nurse aide) indicated that that on June 19, 2017, at the end of the 7 AM to 3 PM shift, Employee 1 and Employee 2 (nurse aide) were transferring Resident 36 from the bed to the low scoot Broda chair. Employee 1 and Employee 2 removed the lift pad from underneath the resident. Employee 1 then moved the Broda chair away from the cabinet to put on the leg rests. Resident 36's left leg went under the chair and twisted a little bit. Employee 1 noted that she (Resident 36) showed no signs of pain. I rubbed it and it was fine. She didn't flinch, there was nothing abnormal about the leg. I put the leg rests and her foot positioning device on the wheelchair (low scoot Broda chair). A review of an employee witness statement dated June 20, 2017, at 5:05 PM, revealed that Employee 2 noted that I spotted Employee 1 when she got Resident 36 out of bed (via the mechanical lift). We took the sling out from underneath her and Employee 1 said she had it from there. Employee 2 noted that she then left the resident's room. Doppler studies completed on June 20, 2017, were noted to be negative. The physician then ordered an X-ray of the resident's left leg from the knee to the foot. A review of an X-ray report of the left knee dated June 20, 2017, revealed that the resident had a displaced fracture ( fracture in which the two ends of the broken bone are separated from one another) of the left tibia (large bone located in the lower front portion of the leg) and a subacute (rather recent onset) [MEDICAL CONDITION] head (the smaller of the two leg bones and is sometimes called the calf bone; Fibular head fractures occur at the upper end of the fibula at the knee). The physician was notified of the X-ray results and a knee immobilizer (knee brace that limits knee movement) and an orthopedic (the medical specialty concerned with correction of deformities or functional impairments of the skeletal system) appointment was ordered for the resident. During an interview on January 12, 2018, at 2 PM Employee 1 stated that she moved Resident 36 prior to placing the elevated leg rests on the low scoot Broda chair. Employee 1 confirmed that Resident 36 was unable to move her legs by herself and when Employee 1 moved the chair Resident 36's left leg got caught under the wheel and twisted. A review of a facility counseling form provided to Employee 1 dated June 22, 2017, revealed areas that needed improvement included: Resident 36's left foot was caught on the wheel of the Broda chair while chair was moving. Residents need to be positioned in their seating devices to ensure proper alignment of extremity to ensure residents extremities are not affected by the mobility of the seating device. During an interview January 12, 2018, at approximately 2:15 PM the facility's corporate nurse consultant confirmed that Resident 36's leg rests should have been placed on the resident's low scoot Broda chair before Employee moved the chair. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services previously cited 12/15/16, 6/15/17, 10/17/17, 11/21/17

Based on review of clinical records, an Event Report submitted to the State Survey Agency, resident and incident reports, observation, and resident and staff interviews, it was determined that the facility failed to provide sufficient staff assistance and supervision to prevent a fall with injury for one resident (Resident CR1) and failed to maintain a safe environment free of potential accident hazards for one resident (Resident 8) out of 20 sampled residents. Findings include: A review of Resident CR1's clinical record revealed that the resident had [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set Assessment (MDS - federally mandated standardized assessment completed at specific intervals to define resident care needs) dated May 6, 2014, revealed that the resident was cognitively intact, understood others and was able to make his needs known. The resident was extensive assistance of two staff for transfer and toileting needs. Review of a resident Incident Report dated June 6, 2014, at 4:30 PM, revealed that Employee 1 (nurse aide) assisted Resident CR1 into the bathroom and stood the resident up at the grab bar; the resident then stated that his knees were "giving out." Employee 1 lowered the resident to the floor. The resident complained of pain in both knees and legs. The resident was assessed by the Registered Nurse at that time who notified the physician of the resident's complaints of pain in his left leg. The physician ordered the resident transferred to the emergency room for evaluation and treatment on June 6, 2014. Review of the statement written by Employee 1 revealed that the resident was in the hallway saying he needed to go to the bathroom and stated "No one was (other nursing staff) around so I took him to the bathroom." He was holding the bar, I was getting his pants down and his (Resident CR1) knees gave out. He told me he was falling so "I put him against my body and went to the floor with him, then called for help." During interview conducted by Employee 2 (Registered Nurse Care Coordinator) with Employee 1 (nurse aide), Employee 1 reported that she had toileted the resident before, but this was the first time she did it alone. Employee 1 did not see any other staff members and the resident was yelling he had to go to the bathroom. Employee 1 took the resident to the bathroom in his room and stood him up at the bar in the bathroom. While Employee 1 was getting the resident's pants down when the resident said, "my knees are giving out." Employee 1 then lowered the resident to the floor while resting the resident against her body and pulled the bathroom cord for help. Review of the corresponding Event Report submitted to the State Survey Agency dated June 6, 2014, at 4:30 PM, revealed that the nurse aide (Employee 1) assisted the resident to the bathroom and while standing at the grab bar in the bathroom the residents knees were giving away and the nurse aide proceeded to hold the resident against her and assisted the resident to the floor. The Licensed Nurse assessed the resident who complained of knee pain and weakness in lower extremities (both legs). The physician was notified and ordered the resident transferred to the emergency room for evaluation and treatment. The facility further concluded that during its investigation of this injury that the resident required the assistance of two staff for all transfers. Review of the resident's activities of daily living instruction Kardex revealed that the resident required the assistance of two staff members for transfer. During an interview with Employee 2, RN, on December 10, 2014, at 12:30 PM, Employee 2 stated this Kardex is located in the nurse aide kiosk (computerized screen located on the wall of all the units indicating the individual care needs of the residents. The kiosk is available for review prior to the delivery of care to the residents). Employee 2 stated that Employee 1 knew that the resident required the assistance of two staff for transfer. Review of the resident's ADL (activities of daily living) self-care deficit care plan related to falls revised June 1, 2012, revealed that the resident was an assist of two staff for transfers. Review of the Emergency Medicine Note dated June 6, 2014, at 6:20 PM, revealed that the resident was complaining of left extremity (leg) pain and noted to be shortened and externally rotated (turned outward). The resident complained of pain, which was exacerbated with movement, alleviated by nothing. Review of diagnostic imaging dated June 6, 2014, at 7:41 PM, revealed a CT scan (Computerized Tomography , radiographic imaging completing a more detailed picture of the area reviewed) of the left lower extremity revealing a complete fracture (break) through the distal shaft of the femur (farthest point from the head of the femur). The knee prosthesis (replacement devices) was noted in place. The resident was admitted to the hospital for further treatment. Interview with the Nursing Home Administrator (NHA) and Corporate Nurse on December 12, 2014, at approximately 11:30 AM, confirmed that this resident's injury occurred during transfer of only one staff member, although the resident was assessed to require two staff for all transfers. Observation of the A wing nursing unit on December 9, 2014, at approximately 9:00 AM, and in the presence of Employee 2 (Registered Nurse) revealed that in Resident 8's room was a cabinet with a small television placed on top, in front of his bed. Observation of the placement of the cabinet and television revealed that the electric cord and cable hook-up extended out from the back of the television to the wall and was suspended at a height of approximately three feet, for a distance of approximately five feet. It was also observed that the resident's room was equipped with a flat screen television set mounted to the wall. Interview with Employee 2 (Registered Nurse) at this time revealed that staff push the cabinet against the wall eliminating the risk of an accident hazard from the suspended cords, but the resident continues to move the television and cabinet up to the foot of the bed, which creates the accident hazard observed. Employee 2 (Registered Nurse) stated that this resident had been educated on this unsafe practice and that his continued habit of moving the television and cabinet was included on his care plan since September 8, 2014. Review of a quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively intact. Interview with the resident on December 9, 2014, at approximately 9:15 AM, confirmed that the resident continued to move the cabinet and television closer to his bed. The resident stated that because of the small television screen size he has difficulty viewing the programs and has no other choice, but to move the television closer. The resident relayed that the size of the television screen on the TV mounted to the wall was viewable, however, that television no longer worked. As a result, staff gave him this smaller TV as a replacement. The resident reported that the television mounted on the wall had been broken for a couple of months. Further observation of Resident 8's room at the time of the interview, revealed that the designated night light to illuminate the pathway within the resident's room, and identify tripping hazards during night time hours was not working. Interview with the Nursing Home Administrator on December 12, 2014, at 9:00 AM, confirmed that the television set mounted on the wall was non-functional and was replaced with the smaller TV and the night light in the resident's room was also not working. Observation on December 11, 2014, at 11:15 AM, revealed that the night lights, which were mounted in the wall in rooms C4 and C14 were not working. Interview with Resident 74 at this time revealed that her night light has not been working for a while. Interview with the Nursing Home Administrator on December 12, 2014, at 10:00 AM, confirmed that the night lights were not working in residents' rooms located on the B and C Nursing Units. The Nursing Home Administrator confirmed that all night lights, which were located in residents' rooms were to be maintained in working order. Refer F256 483.25(h) Accidents Previously cited 11/15/13 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5)Nursing services. Previously cited 11/15/13 28 Pa. Code 205.67(e) Electric requirements for existing and new construction

Based on clinical record and Injury/Incident report review and staff interview, it was determined that the facility failed to provide necessary supervision and staff assistance and implement effective safety interventions to prevent falls for two of 19 sampled residents (Resident 54, and 14). Findings include: A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident also had additional [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set Assessment (MDS - a standardized assessment completed at specific times to identify resident care needs) dated August 14, 2013, revealed that the resident was moderately cognitively impaired and required staff assistance for activities of daily living (ADLs- the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring) including the assistance of two staff for transfers and ambulation. Review of Resident 54's initial care plan dated May 8, 2013, revealed that one of the problematic areas was falls due to a history of falls and the resident was assessed at high risk for falls. The facility planned interventions at the time of admission that included to administer medication per physician's orders [REDACTED]. Resident 54, according to his ADL care plan, required the assistance of two staff persons for transfers. On June 21, 2013 when the resident's skilled rehab therapy ended, he was placed on restorative ambulation to ambulate 25-75 feet with roller walker and two person assist, as per the resident's care plan. Review of a nurses' note dated May 18, 2013, at 7:02 p.m., indicated that the resident was frequently attempting to stand from the wheelchair, had poor safety awareness, and did transfer self to bed. The facility implemented the use of non skid socks at this time and included the intervention on the resident's plan of care. Review of a nurses' note dated May 22, 2013, at 11:45 p.m., revealed that the resident was found on the floor of his room between the beds with the bridge of his nose bleeding. Interventions put in place as the result of this fall included the use of a body pillow to the resident's bed for safety and this was added to the resident's plan of care. Review of a nurses' note dated May 23, 2013, at 2:50 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor in another resident's room attempting to self transfer himself to the bed from the wheelchair. No injuries were noted. Following this incident the facility planned a medication review and and a pain evaluation. Review of a nurses' note dated May 24, 2013, at 1:40 a.m., revealed that the since the beginning of the nursing shift there were numerous instances of the resident trying to slide himself off the bed. Intervention the facility used in response to the behavior at the time was redirection. Review of a nurses' note dated May 24, 2013, at 3:44 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor at 11:25 a.m. The resident stated he was transferring himself from the bed to wheelchair when his feet gave out and he fell . No injuries were noted. The facility planned interventions at this time were the use of a self releasing velcro belt to the wheelchair, and education to the resident's family to let staff know when they leave so resident is not unsupervised. These interventions were added to the resident's plan of care. Review of a nurses' note dated May 25, 2013, at 10:43 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor at 3:15 p.m., attempting to self transfer from the bed to wheel chair. No injuries were noted. The facility planned to place the resident in staff line of view for supervision as the result of this fall. The resident's care plan however was not updated to include this form of supervision intervention until June 24, 2013. There is no indication in the nurses notes from May 25, 2013 through May 31, 2013 (the next resident incident) that the resident was placed in staff's line of view for increased supervision. Review of a nurses' note dated May 31, 2013, at 8:51 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor next to his bed on the fall mat. No injuries were noted. Since the resident was found on the floor and the fall unwitnessed there was no evidence that the resident had been in staff's line of view for supervision. Neither the nurse's note nor incident/accident report indicated that the resident had been in staff's line of vision for supervision. Following this incident, the facility instituted the use of hipsters to be worn at all times, removed for hygiene, which was included in the resident's plan of care. Review of a nurses' note dated June 23, 2013, at 4:10 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was again found on the floor next to the resident's bed. No injuries were noted. The nurse's note and incident report both indicated that the resident was found on the floor by the nurse aides. There was no evidence that the resident had been in staff's line of vision for supervision. As the result of this fall the facility planned to educate the resident to use the call bell and signage was placed in the resident's room to remind the resident to seek assistance. The resident was assessed as moderately cognitively impaired, but the facility indicated that the resident verbalized understanding. Review of a nurses' note dated June 23, 2013, at 10:28 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor next to the resident's bed at 9:54 p.m., while transferring self from wheelchair to bed. No injuries were noted. Intervention planned after this fall, included a physician order [REDACTED]. Review of a "Incident/Accident Report" (I/A) dated July 10, 2013, at 4:30 p.m., revealed that the resident was found on his back in front of the bathroom and the wheelchair was found at the room's entrance. No injuries were noted. There was no documentation in the resident's clinical record this fall occurred. Planned intervention after this fall was to offer the resident a nap after lunch and this approach was added to the plan of care. A review of a nurses' note dated August 9, 2013, at 6:00 a.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor attempting to go to the bathroom. No injuries were noted. The resident's care plan was updated to include the approach that if the resident wakes up early, offer assistance with AM tasks and assisting out of bed, and a walker bag for snacks. Review of a nurses' note dated August 24, 2013, at 10:55 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor sitting on fall mat at 4:00 p.m., with his wheelchair next to him. The resident was in the wheelchair prior to the fall according to the report. There was no injury identified at the time of the fall, but later the resident complained of left shoulder pain. An X-ray was ordered and an acute fracture lateral clavicle was noted. After this incident the facility planned to continue the currently planned interventions and no new interventions were put in place. Review of a social services' note dated October 8, 2013, at 2:33 p.m., indicated that Resident 54 was refusing to wear his hipsters and the importance of complying with care was discussed. The resident subsequently accepted the intervention. A review of the facility "Alert Listing Report" indicated that the resident refused to wear the hipsters on October 3, 2013, and October 5, 2013. This report noted that on October 10, 2013 at 9:03 p.m., the resident refused to wear the hipsters, but this was documented after a fall occurred at 7:45 p.m. on that date. Review of a nurses' note dated October 10, 2013, at 10:20 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor in his room at 7:45 p.m., between the two beds. The resident's wheelchair was found between the bed and closet. There was no indication in the clinical record or incident report of how the resident fell and if it was from the wheelchair or from the bed. The resident's left leg was externally rotated and the resident was transferred to the hospital the resident was admitted to the hospital with [REDACTED]. There was no indication in nurses notes that from May 25, 2013 to October 10, 2013 that the resident was sufficiently supervised at the level required based on the resident's unsafe actions, including continued self-transfer attempts, and that the planned intervention of being staff's line of vision for supervision was implemented. Interview with the Administrator and Director of Nursing on November 15, 2013 at 9:30 a.m., revealed that the facility eliminated resident alarms in 2012, when evidence did not support a reduction in falls as a result of alarm use. The Administrator and Director of Nursing, however, were unable to explain why the level of supervision required by the resident was not provided although a form of visual supervision was planned prior to the falls resulting in significant injuries. A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an annual MDS assessment dated [DATE], revealed that the resident was moderately cognitively impaired and required staff assistance for ADLs, including the assistance of two staff for transfers. Review of Resident 14's care plan revised January 28, 2011, revealed that one of the problematic areas was self care deficit related to gait dysfunction. One of the planned interventions at the time called for two nursing assistants to transfer the resident with a mechanical lift using a large size sling for proper placement. A review of a nurses' note dated July 11, 2013, at 4:15 p.m., and a corresponding "Incident Report" (I/A) revealed that the shower chair tipped over while trying to get the sling under the resident causing the resident to slide to the floor. Further review of the Incident Report revealed that one nursing assistant (NA) attempted to apply the sling by herself and that the resident was a two-person assist with transfers. Interview with the Administrator and Director of Nursing on November 14, 2013, at approximately 9:15 a.m., confirmed that when Resident 14 was transferred on above date with the use of a sling, two nurse aides should been involved with the transfer. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited 12/20/12, 8/7/13