Every finding on record at Edenbrook of Greenwood Hill

Based on a review of select facility policy, minutes from the facility Resident Council meetings, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to resolve continued resident complaints expressed during Resident Council meetings, including those voiced by nine out of 9 residents attending a resident group meeting (Residents 5, 51, 68, 87, 48, 98, 95, 10, and 114). Findings include: A review of the facility's policy titled Grievance/Concerns, last reviewed by the facility on March 18, 2026, indicated that all residents have the right to voice grievances to the facility or other agency or entity that hears grievances without reprisal and without fear of discrimination, interference, coercion, or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns of their stay at the facility. The facility will make prompt efforts to resolve all grievances. The residents have the right to file grievances orally or in writing; and they have the right to file grievances anonymously. At any time, comments, suggestions, or complaints by the residents are encouraged to direct their concerns to; the Administrator, Social Services Director, Director of Nursing or designee, or any appropriate manager. A review of Resident Council meeting minutes from March 2026 through May 2026 revealed residents raised concerns regarding facility staff failing to respond timely to residents' requests for assistance, facility staff conducting unprofessional conversations at the nursing stations, and concerns regarding the behavior of other residents. A review of the Resident Council meeting minutes dated March 18, 2026, revealed that during the February 2026 meeting, residents voiced ongoing concern regarding staff engaging in personal conversations in the common areas, poor call bell response times, and concerns with another resident walking the halls without pants on. There was no indication in the meeting minutes that a grievance was filed regarding the concerns voiced during the February 2026 meeting. The March 2026 meeting minutes indicated that the residents continue to express frustration with staff conducting personal and unprofessional conversations at the nurses station, nurses not knowing what specific medications are used for, and staff use of cell phones on the floor. There was no indication in the March 2026 meeting minutes that a grievance was filed from the ongoing and newly reported concerns voiced during the March 2026 meeting. A review of Resident Council meeting minutes dated April 1, 2026, revealed the residents in attendance expressed concern regarding facility staff failing to respond timely to residents' requests for assistance. There was no documentation in the meeting minutes indicating a grievance was filed on behalf of the residents in attendance that expressed these concerns. A review of Resident Council meeting minutes dated May 6, 2026, revealed that residents in attendance continued to express concerns regarding facility staff conducting personal conversations at the nursing stations and concern regarding the behavior of another resident yelling at night. There was no documentation in the meeting minutes indicating a grievance was filed related to these concerns. A review of grievances provided by the facility from January 2026 through June 1, 2026, revealed no record that grievances were filed on behalf of the Resident Council meeting members as a result of the concerns voiced during the February, March, April and May 2026 meetings. During a resident group interview on June 3, 2026, at 10:00 AM, four out of 9 residents (Residents 51, 5, 87, and 68) reported that the behaviors of a resident reported during the May 2026 Resident Council meeting was still a significant concern, impacting their quality of life and ability to rest. The residents described frequent episodes of yelling and screaming that they reported could be heard throughout the unit and during various times of the day and night. Five out of the 9 residents (Residents 48, 98, 95, 10, and 114) reported that staff continue to conduct unprofessional conversations in common areas and at the nursing station, despite continually bringing up this issue at Resident Council meetings. All residents in attendance expressed frustration that the issues have not been resolved. During an interview on June 3, 2026, at 11:10 AM, the Nursing Home Administrator (NHA) and Director of Activities confirmed there were no grievances filed on behalf of residents who raised concerns during Resident Council meetings. The NHA was unable to provide documented evidence regarding actions the facility had taken to implement effective changes and resolution to resident concerns voiced during the Resident Council meetings.Refer F74028 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on a review of facility policy, clinical records, resident council documentation, resident interviews, staff interviews, and observation, it was determined that the facility failed to implement and evaluate effective interventions to address persistent behavioral symptoms for one of 27 sampled residents reviewed for behavioral health services (Resident 94).Findings include: A review of the facility's Behavior Management Policy, reviewed by the facility on March 18, 2026, revealed that the purpose of this policy was to identify residents who exhibit behaviors that decrease their physical and psychosocial well-being. The facility will evaluate resident progress of behavioral goals as identified on the plan of care. A clinical record review revealed Resident 94 had diagnoses that included major depressive disorder (a mental health condition characterized by persistent feelings of sadness and loss of interest), traumatic brain injury (damage to the brain caused by an external force), bipolar disorder (a mental health disorder characterized by episodes of mood elevation and depression), and disruptive behaviors. A review of Resident 94's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 6, 2026, revealed that Resident 94 was moderately cognitively impaired with a BIMS score of 8 (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 8 through 12 indicates moderate cognitive impairment). This assessment also indicated that the resident exhibited behavioral symptoms including screaming, cursing, and threatening others up to three days during the seven-day assessment period. During a resident group interview conducted on June 3, 2026, at 10:00 AM, multiple residents residing on the same nursing unit reported that Resident 94's yelling, screaming, and calling out behaviors had persisted for an extended period and significantly affected their quality of life, ability to rest, and ability to sleep through the night. Residents described frequent episodes of yelling and screaming that could be heard throughout the unit and during various times of the day and night. The resident council members indicated that this has been going on for a long time, but they were trying to be understanding and patient with the situation, but there has been no evidence that things are improving. Resident 87 stated that Resident 94's yelling and screaming was ongoing and disruptive. He reported, I was in the shower last night around 7:00 PM and I could hear the resident yelling. Resident 5 reported that Resident 94's behavior significantly affected her ability to sleep. She stated, You wake up in the morning, and it feels like you never slept. Staff put her at the nursing station at night, and she screams and yells for hours. Resident 51 reported being awakened repeatedly by Resident 94's vocalizations during the night. She stated, I don't even get out of bed some days because I've been kept up all night long. Resident 68 reported that despite residing across the hall, she could still hear Resident 94's yelling and stated, I'm across the hall, and I'm hearing her. How can I sleep? Residents 87, 5, 51, and 68 indicated that they had consistently reported that the yelling and screaming continued to disrupt sleep, rest, and daily activities for multiple residents residing on the first-floor nursing unit. Review of the May 6, 2026, Resident Council Meeting minutes revealed that the facility received a verbal grievance from Resident 51 related to Resident 94 yelling for help during nighttime hours. A review of nursing documentation revealed repeated episodes of behavioral symptoms, including yelling, screaming, calling out, cursing at staff, cursing at other residents, whining, and inability to be redirected. Documentation further revealed the behaviors occurred primarily during evening and nighttime hours and continued despite staff interventions. April 16, 2026, at 3:57 AM, the resident was in the hallway yelling and cursing at staff. April 19, 2026, at 5:36 AM, the resident was calling out, yelling, and cursing and could not be redirected. April 20, 2026, at 2:30 AM, the resident continuously called out and cursed at staff and could not be redirected. April 22, 2026, at 11:49 PM, the resident was yelling and calling out and could not be redirected. April 25, 2026, at 10:27 PM, the resident had been yelling on and off since 7:30 PM and redirection was unsuccessful. May 2, 2026, at 6:47 AM revealed that the resident slept till 5:00 AM and was yelling on and off; redirection was unsuccessful. May 4, 2026, at 3:28 AM, staff documented attempts to redirect the resident at the nurses' station were only slightly effective. May 4, 2026, at 11:07 PM, the resident was occasionally yelling out despite staff efforts. May 5, 2026, at 1:41 AM, attempts to redirect the resident at the nurses' station were unsuccessful. May 5, 2026, at 5:02 AM, staff documented the yelling escalated as the shift progressed. May 12, 2026, at 1:16 AM, the resident had been yelling since 10:50 PM when the nightshift nurse arrived on the unit. May 17, 2026, at 1:59 AM, the resident was calling out, yelling, cursing at staff, and unable to be redirected. May 17, 2026, at 4:02 AM, the resident continued yelling and cursing in the hallway. May 19, 2026, at 1:39 AM, the resident was yelling and cursing at the nurses' station and could not be redirected. May 23, 2026, at 2:07 AM, the resident was yelling and cursing at the nurses' station. May 28, 2026, at 7:37 AM, the resident yelled on and off during the prior shift and could not be redirected. May 28, 2026, at 10:34 PM, the resident had multiple instances of yelling and screaming. May 30, 2026, at 7:03 AM, the resident was yelling on and off and whining throughout the morning. May 30, 2026, at 2:15 PM, the resident was yelling and screaming at staff and other residents and redirection was ineffective. June 2, 2026, at 5:54 AM, the resident exhibited behaviors throughout the night and could not be redirected. An interview with Employee 3 Licensed Practical nurse (LPN) on June 3, 2026, at 10:30 AM revealed Resident 94's behaviors routinely escalated during the 3:00 PM to 11:00 PM shift and the 11:00 PM to 7:00 AM shift due to the resident's diagnosis and declining mental ability. Employee 3 stated the resident's behaviors were generally more manageable during the day shift because staff had interventions available and the resident's daughter, who worked in the facility on the day shift, frequently assisted with behavior management. A review of the resident's care plan dated March 14, 2026, revealed interventions intended to address behavioral symptoms. However, the record contained repeated documentation over several weeks that the resident continued to yell, scream, call out, curse, and disrupt the unit despite implementation of those interventions. The facility failed to demonstrate that it evaluated the effectiveness of the interventions or revised the care plan to address the resident's consistent pattern of behavioral escalation during evening and nighttime hours. The facility failed to identify interventions specific to the resident's documented behavioral pattern, declining cognitive abilities, or the times of day when the behaviors most frequently occurred. Observations conducted on June 3, 2026, at 9:00 AM, June 4, 2026, at 9:00 AM and 11:00 AM, and June 5, 2026, at 11:45 AM revealed Resident 94 sleeping in a chair at the nurses' station. During an interview on June 5, 2026, at 9:00 AM, the Director of Nursing and Nursing Home Administrator were unable to provide evidence demonstrating the facility had evaluated the effectiveness of the resident's behavioral interventions or revised interventions in response to the persistent pattern of yelling, screaming, calling out, and cursing documented during evening and nighttime shifts. The Director of Nursing and Nursing Home Administrator further acknowledged that after surveyor inquiry, staff implemented additional interventions, including a busy box (a container of activity items intended to provide engagement and redirection) and interventions related to the resident's past smoking habits. Staff reported those interventions were successful during the evening and nighttime shifts beginning June 4, 2026, into June 5, 2026. The facility was unable to provide evidence these interventions had been considered or implemented earlier despite ongoing behavioral symptoms documented throughout April, May, and June 2026, repeated resident complaints, and a resident council grievance. Refer to F-565. 28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies.

Based on staff interviews and a review of facility training and orientation records, the facility failed to provide training to agency staff on the facility's procedures related to activities that constitute abuse, neglect, exploitation, or the misappropriation of resident property and resident abuse prevention for four of the six employees reviewed (Employees 4, 5, 6, and 7). Findings included: During an observation conducted on the third floor on June 2, 2026, at 1:25 PM, Employee 4 (Licensed Practical Nurse) was observed working on the facility's medication cart (a secure, mobile rolling workstation used by nurses to transport, organize, and administer residents' daily medications). An interview at the time of the observation revealed Employee 4 was employed by a nurse staffing agency and working at the facility for the first time on the day of this interview. Employee 4 stated the facility had not provided training on the facility's abuse prohibition policy and procedures to identify and report abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention. There was no documentation that Employee 4 was trained on the facility's abuse prohibition policies and procedures as part of staff orientation and training on the prohibition of all forms of abuse, neglect, and exploitation prohibition. Review of three additional nurse staffing agency personnel records revealed the facility failed to provide education and training of the facility's abuse prohibition policy and procedures to identify and report abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention to Employee 5 (Licensed Practical Nurse), Employee 6 (Registered Nurse), and Employee 7 (nurse aide). During an interview on June 4, 2026, at 2:14 PM, the Nursing Home Administrator confirmed the facility had not provided agency staff, Employees 4, 5, 6, and 7, training on the prohibition of all forms of abuse, neglect, and exploitation prohibition and the specifics of the facility's abuse prohibition policies and procedures. 28 Pa. Code 201.20(b)(d) Staff development. 28 Pa Code 201.18 (e)(1) Management. 28 Pa. Code 201.29(a)(c) Resident rights. 28 Pa. Code 201.19 (7) Personnel policies and procedures.

Based on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to consistently ensure oxygen therapy was administered per a physician's orders for two residents out of 27 residents reviewed (Resident 12 and 102).Findings include: A review of the facility's policy titled Oxygen Administration and Storage, last reviewed on March 18, 2026, revealed the purpose of the policy was to provide guidelines for safe oxygen administration and storage. The policy directed staff to check the oxygen delivery system, including the mask, oxygen tank, and humidifier bottle (also known as the humidifier reservoir, the container that holds sterile or distilled water through which oxygen passes to add moisture before being delivered to the resident) to ensure they were in good working order and securely fastened. The policy required staff to verify there was an adequate water level in the humidifier bottle so that the water bubbled as oxygen flowed through and to change oxygen tubing weekly. A clinical record review revealed that Resident 12 was admitted to the facility on [DATE], with a diagnosis to include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and respiratory failure (a serious condition that makes it difficult to breathe). 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 May 4, 2026, revealed the resident was cognitively intact with a BIMS score of 13 (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). A review of the physician's orders dated April 8, 2026, directed that Resident 12 receive oxygen at 2.0 liters per minute (L/min) by nasal cannula (a flexible medical tube with two prongs that fit into the nostrils, used to deliver supplemental oxygen), change oxygen tubing weekly, and change humidification bottle every week and as needed when empty. An observation on June 2, 2026, at 11:50 AM revealed Resident 12 was in bed receiving oxygen at 3.0 liters per minute (L/min) via nasal cannula with no date on the tubing and with no humidifier bottle attached to the oxygen flowmeter. This observation was confirmed, and the tubing was replaced and the oxygen liter was corrected, and humidifier bottle was added by Employee 2, a Licensed Practical Nurse (LPN) on June 2, 2026, at 11:55 AM. A clinical record review revealed that Resident 102 was admitted to the facility on [DATE], with diagnosis to include chronic obstructive pulmonary disease and pulmonary hypertension (a type of high blood pressure that specifically affects the arteries in the lungs and the right side of the heart). A review of Resident 102's Quarterly Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15. A review of the physician's orders dated January 8, 2026, directed that Resident 102 receive oxygen at 2.0 liters (L/min) per minute continuously by nasal cannula. An observation on June 2, 2026, at 11:35 AM revealed Resident 102 was seated in a wheelchair in the dining room with an oxygen tank attached to the back of the wheelchair. The oxygen tank was not turned on. This observation was confirmed by Employee 2 LPN. During an interview with the Director of Nursing on June 3, 2026, at 1:05 PM, the above findings were reviewed and confirmed it is the facility's responsibility to ensure oxygen therapy is administered in accordance with the physician's orders. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure that written notice, including the reason for a room change, was provided to residents and/or their resident representatives prior to a facility-initiated room change for two residents of 27 residents reviewed (Resident 51 and 93).Findings include: Review of the facility policy titled Room Change last reviewed by the facility on March 18, 2026, revealed the residents' preferences should be considered when making a room or roommate change. The policy further indicated that whenever a resident is transferred from one room to another within the facility, a written notice of transfer must be given to the resident and/or family prior to the move, according to state law. Additionally, the policy stated the resident should be provided with an opportunity to tour the new location, meet the new roommate and express any concerns regarding the move. Advanced notice was to be provided except in circumstances outside the facility's control, such as a change in level of care, change in medical or treatment program, or for the resident's welfare as documented in the medical record. At the time of the survey ending June 5, 2026, all beds in the facility were licensed and dually certified for participation in both the Medicare and Medicaid programs. Review of the clinical record revealed Resident 51 was admitted to the facility on [DATE], and resided in the same first-floor room from June 25, 2025, until February 20, 2026. On February 20, 2026, the facility initiated a room change and relocated the resident to another room on the first floor. There was no documented evidence that the resident or the resident's representative was provided with written notice or an explanation for the room change prior to the move. Additionally, there was no documented evidence that circumstances existed which would have exempted the facility from providing advance notice as outlined in the facility policy. During an interview on June 3, 2026, at 11:10 AM, Resident 51, a cognitively intact resident with a BIMS score of 14 (Brief Interview for Mental Status, a tool 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 intact cognition) stated the room changed occurred unexpectedly. The resident reported she was not informed why the move was necessary and did not receive advance notice. She expressed frustration stating, I didn't know about the room change until the day they moved us. I didn't want to move. Resident 51 further stated she had not been informed of her right to refuse the room change, was not provided written notification explaining the reason for the room change, was not offered an opportunity to tour the new room or meet the new roommate before the move, and was not asked whether she had concerns regarding the move. Review of the clinical record revealed Resident 93 was admitted to the facility on [DATE], and resided in the same first-floor room from February 28, 2025, until February 20, 2026. On February 20, 2026, the facility initiated a room change and relocated the resident to another room on the first floor. There was no documented evidence that the resident or the resident's representative was provided with written notice or an explanation for the room change prior to the move. Additionally, there was no documented evidence that circumstances existed which would have exempted the facility from providing advance notice as outlined in the facility policy. Further review of the clinical record revealed Resident 93 was moderately cognitively impaired with a BIMS score of 10 (a score of 8 through 12 indicates moderate cognitive impairment). During an interview on June 4, 2026, at 1:15 PM, Resident 93 stated the room change was very sudden. The resident reported staff entered her room while she was lying in bed and stated, You're moving. Resident 93 stated staff packed her belongings, took her to a different room and informed her it was her new room. The resident stated she was not informed of the reason for the room change prior to the move and did not receive written notice explaining the room change. She stated she was not given an opportunity to voice concerns regarding the room change and would have objected to the move had she been given the opportunity to do so. During an interview on June 5, 2026, at 9:17 AM the Director of Nursing was unable to provide documented evidence that the facility provided any written explanation of the reasons for the facility-initiated room changes to the residents and/or their representatives. 28 Pa Code 201.29 (a) Resident Rights. 28 Pa Code 210.11 (c) Resident Care Policies.

Based on review of clinical records, select facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to ensure the resident's environment remained free of accident hazards for one out of 27 residents reviewed (Resident 59).Findings include: Review of the facility Equipment and Supplies Policy last reviewed March 18, 2026, indicated the facility provides and maintains equipment to meet the needs of residents. Equipment provided for the general use of all residents may not be permanently assigned to any resident. A clinical record review revealed Resident 59 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and anxiety. A review of Resident 59's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 16, 2026, revealed that Resident 59 was severely cognitively impaired with a BIMS score of 0 (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 0 through 7 indicates cognition is severely impaired) and was dependent on staff for bed mobility and transfers. A physician's order dated May 9, 2026, directed staff to administer Ceftriaxone Sodium (an antibiotic used to treat bacterial infections) 1 gram intravenously (through a vein) for two days. A nursing note dated May 11, 2026, documented that the intravenous (IV) catheter was removed in accordance with the physician's order, indicating the IV treatment had been completed. A review of facility investigative documentation dated May 25, 2026, at 11:00 PM revealed that Employee 1, a nurse aide, was lowering Resident 59's bed when the bed frame became caught on the cord of an IV pole located in the resident's room. The IV pole tipped over and struck the resident in the right eyebrow area. Facility documentation revealed the resident sustained a 4 centimeter(cm) laceration (a tear or cut in the skin) to the right eyebrow area. Staff cleansed the wound and applied Steri-Strips (adhesive skin-closure strips used to hold the edges of a wound together). A small amount of bleeding was observed. Due to the resident's severe cognitive impairment, the resident was unable to describe the event. The physician and resident representative were notified. Interview with the Director of Nursing on June 4, 2026, at 1:00 PM confirmed the IV pole should have been removed from Resident 59's room when the IV therapy was discontinued on May 11, 2026. The Director of Nursing further confirmed staff are expected to ensure equipment and cords are positioned away from bed frames and other moving equipment to prevent items from becoming caught, tipping, or falling.Interview with the Nursing Home Administrator on June 4, 2026, at 1:30 PM confirmed the facility was responsible for maintaining an environment free of avoidable accident hazards for Resident 59. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records and documentation provided by the facility, observations, and staff interviews, it was determined that the facility failed to develop, revise, and consistently implement an individualized, person-centered plan of care to identify, prevent, and manage dementia-related behaviors for one resident out of eight residents sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarct (a stroke caused by interrupted blood flow to the brain) and alcohol-induced persisting dementia (long-term cognitive impairment resulting from chronic alcohol use causing permanent brain damage). A review of an quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 25, 2025, revealed Resident 1 was moderately cognitively impaired with a BIMS score of 9 (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 8-12 indicates moderately, cognitively impaired). A review of the resident's care plan revealed a problem addressing behavioral symptoms was initiated on October 2, 2025, identifying behaviors that included cursing at staff, resisting care, noncompliance with transfers, statements wishing she was dead, and wandering into other residents' rooms. Interventions listed included placing a name sign outside the resident's room, identifying broad behavioral triggers, one-to-one conversation, offering cooling-off periods or naps, administering medications, and anticipating needs. The care plan lacked specific, individualized, and actionable interventions tailored to the resident's repeated aggressive behaviors, unsafe wandering, and escalation toward residents, staff, and visitors. Further review of the resident's Activities of Daily Living (ADL) care plan initiated June 3, 2025, indicated the resident required assistance of one staff member for ambulation with a rolling walker. Despite this, nursing documentation throughout September and October 2025 repeatedly reflected the resident ambulating independently throughout the unit during episodes of agitation and behavioral escalation, without evidence the care plan was revised to address safety risks or supervision needs. A review of nursing documentation revealed that beginning in September 2025, Resident 1 demonstrated a pattern of escalating dementia-related behaviors, including repeated verbal aggression, inability to be redirected, wandering into other residents' rooms, and threatening or unsafe actions:September 4, 2025, at 7:21 AM:Nursing documentation reflected that during the prior 11:00 PM to 7:00 AM shift, Resident 1 was observed going through her roommate's personal belongings. Staff redirected the resident multiple times during the shift, after which the resident became angry and yelled at staff. Later the same day, the Social Services Director met with Resident 1 to discuss personal space. During that interaction, Resident 1 stated she was missing a box and reported she was only searching for it. The resident denied yelling at staff.September 13, 2025, at 4:02 PM:Resident 1 was observed yelling at her roommate and stating, Get this thing out of here. Staff removed Resident 1 from the room and escorted her to the dining room to de-escalate the situation. Resident 1 requested a room change due to ongoing conflict with her roommate. The responsible party was notified and agreed to the room change. Resident 1's was changed. September 21, 2025, at 6:37 AM:Nursing documentation indicated that during the 11:00 PM to 7:00 AM shift, Resident 1 exited her room into the hallway multiple times yelling for staff assistance. When staff approached, the resident became verbally combative. Documentation reflected the resident was disruptive to other residents who were sleeping on the unit and was unable to be redirected. September 26, 2025, at 12:31 PM:Resident 1 was documented as ambulating independently out of her room while yelling for help and being verbally abusive toward staff and other residents. The resident's verbal abuse toward staff was again documented during the month of October 2025.October 7, 2025, at 1:43 PM:During the lunch meal, Resident 1 stated, If I had a gun, I would kill myself, after expressing dissatisfaction with the food on her lunch tray. Nursing staff remained with the resident in her room for a documented cooling-off period. Documentation indicated the resident had previously been seen by contracted psychiatric services. The note identified the resident as her own responsible party; however, the clinical record reflected the resident's niece was the responsible party. The responsible party was not contacted or notified of the incident. Interventions documented at the time included encouraging the resident to use deep breathing techniques to calm herself and to talk with staff when issues were bothering her. October 11, 2025, at 4:05 AM:Resident 1 was observed on her roommate's side of the room repeatedly shutting the window after the roommate asked several times for her to stop. Later during the same shift, Resident 1 was documented as verbally abusive toward nursing staff. Documentation reflected the resident was ambulating independently in her room and was not calling staff for assistance. October 26, 2025, at 10:57 AM:Nursing documentation indicated Resident 1 was found in another resident's room stating the room belonged to her and that others needed to leave. The resident was redirected back to her assigned room. The documented intervention was to move Resident 1 to a different room with a new roommate. October 27, 2025, at 1:07 PM:Documentation from the Social Services Director reflected receipt of a telephone call from Resident 2's daughter, who reported that Resident 1 had been verbally aggressive toward Resident 2 and family members and often became agitated when visitors were present in the room. The Social Services Director counseled Resident 1 regarding her behavior and offered support. October 30, 2025, at 3:30 PM:Nursing documentation reflected that Resident 1 was present in another resident's assigned room while that resident's family member was visiting. Resident 1 was observed yelling at the family member and stated, You are the devil. Documentation further reflected that Resident 1 attempted to throw her walker toward the family member. October 30, 2025, at approximately 3:30 PM:Resident 1 was escorted by staff out of the other resident's room and returned to her assigned room. The documented intervention at that time was for nursing staff to provide comfort to Resident 1. October 30, 2025, at 10:50 PM:A resident/family grievance submitted by Resident 2's family member (daughter) reported that Resident 1, identified as the roommate, had been verbally aggressive toward her. The family member requested that her mother be assigned to a different roommate due to ongoing behavioral concerns. October 30, 2025 (no time documented):A witness statement from Employee 1 (nursing assistant) indicated that Resident 1 had a room change earlier in the day at approximately 1:00 PM. While the room transfer process was occurring, Resident 2's daughter arrived on the unit to visit her mother. The family member ran into the hallway yelling for help. Upon entering the resident room, Employee 1 observed Resident 1 exiting the room independently, cursing and yelling about the family member. Employee 1 escorted Resident 1 back to her assigned room.October 30, 2025 (no time documented):A witness statement from Employee 2 (nursing assistant) indicated that Resident 1 had a room change earlier in the day. While seated at the nurses' station, Employee 2 heard yelling and ran down the hallway. Employee 2 observed Resident 1 exiting another resident's room and arguing with Resident 2's daughter. The family member reported that Resident 1 threw her walker toward her.Despite this sustained pattern of behaviors, the facility relied primarily on room changes, redirection, and brief calming measures, without evidence of meaningful revision of the resident's care plan to include individualized dementia-specific strategies, environmental modifications, staffing approaches, or structured interventions designed to prevent recurrence.The facility was unable to provide a Dementia Care Program or policy at the time of the survey. While staff education materials addressing dementia care and person-centered interventions were provided, the facility failed to translate this education into individualized care planning and consistent implementation for Resident 1.During an interview with the Nursing Home Administrator and Director of Nursing on December 11, 2025, at 1:00 PM, both confirmed the facility failed to ensure Resident 1's care plan was revised and implemented to address her documented dementia-related aggressive and wandering behaviors using individualized, person-centered interventions consistent with dementia care standards. 28 Pa. Code 201.18 (a)(1) Management. 28 Pa. Code 211.12 (d)(1)(5) Nursing services 28 Pa. Code 211.10 (a) Resident care policies

Based on a review of closed clinical records, select facility policy, documentation provided by the facility, and staff interviews, it was determined the facility displayed past non-compliance by failing to protect one out of four residents sampled (Resident 117) from neglect by not ensuring required vehicle safety devices were in place during transportation, resulting in actual harm in the form of a laceration requiring staples. Findings include: A review of the facility policy titled Vulnerable Adult Abuse and Neglect Prevention, last reviewed by the facility June 19, 2025, revealed it is the facility policy to provide professional care and services in an environment that is free from any type of neglect. The policy defines neglect as (a) the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (b) the failure or omission by a caregiver to supply a vulnerable adult with care or services, including, but not limited to, food, clothing, shelter, healthcare, or supervision, which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety. A clinical record review revealed Resident 117 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis (a condition where the spinal canal narrows, compressing the nerves in the lower back, leading to pain, numbness, tingling, or weakness in the legs). A care plan initiated May 24, 2025, documented that Resident 117 had limited physical mobility related to weakness, used a four-wheel wheelchair for locomotion (movement from place to place), and required assistance with transportation. A progress note dated July 11, 2025, at 11:31 AM documented the facility was notified that Resident 117 had fallen in the facility transport van and was taken by emergency medical services to the community emergency department for evaluation and treatment. A witness statement from Employee 3, Vehicle Transport Driver, dated July 11, 2025, revealed that while accelerating from a traffic light, she heard a bang and observed that Resident 117's wheelchair had tipped over. Upon stopping the vehicle, Employee 3 observed bleeding from the resident's head and called 911. Employee 3 used items from the first aid kit to hold pressure on the resident's wound. Emergency medical services responded and took the resident to the emergency department. Employee 3 described that she didn't have Resident 117's lap seat belt restraints on the resident during transport. A review of the community emergency department trauma note dated July 11, 2025, at 11:25 AM, revealed documentation that Resident 117's wheelchair had been improperly secured. When the transport van began moving forward, the wheelchair rolled backward, causing the resident's head to strike the van door/wall. The note indicated the resident did not fall out of the wheelchair. The resident reported having a headache but denied syncope (loss of consciousness) or vomiting. The resident stated he reached out with his right hand to brace himself, injuring the hand and reporting pain around the knuckles. The note documented no other injuries or complaints, and no pain involving the neck, chest, abdomen, or long bones (the major bones of the arms and legs). Examination findings included a 1.0 cm occipital scalp laceration (a cut at the back of the head) without active bleeding, with small, localized swelling in the area. The cervical spine (the vertebrae in the neck that supports the head) was examined and cleared using advanced imaging (diagnostic tests such as CT scans or X-rays), showing no cervical spine tenderness. The cervical spine collar (a medical device used to support and stabilize the neck and upper spine to limit movement after injury or surgery) was removed. The scalp laceration measuring 1.0 cm was closed with two staples. The note documented that the resident tolerated the procedure well without immediate complications. Upon return to the facility at 3:30 PM the same day, via stretcher with two emergency medical service personnel. The resident was noted to have a 1.0 cm x 0.1 cm scalp laceration with two staples and an abrasion (scrape or superficial skin injury) to the left scapula (shoulder blade) measuring 2.5 cm x 1.5 cm. No other skin alterations were noted. The resident had complaints of pain at the base of his head at a level of three out of ten (pain scale rating with 0 being no pain and 10 being the worst pain). A new order was noted for Bacitracin (an antibiotic ointment) twice daily for five days and leaving the area open to air. The physician was notified and in agreement. A physician's order for Resident 117 to cleanse the area with staples on the back of the head with soap and water, pat dry, and apply Bacitracin (an antibiotic ointment) and open to air twice a day was initiated on July 12, 2025, at 7:00 AM. A review of Resident 117's medication administration record (MAR) dated July 2025 revealed he received acetaminophen 650 mg on July 12, 2025, at 6:49 AM for pain level three out of ten. The MAR dated July 2025 also indicated the resident's wound was cleansed and treated with bacitracin as ordered by the physician. A progress note dated July 12, 2025, at 2:50 PM documented that Resident 117's neurological status checks (assessments of brain and nerve function, such as alertness, orientation, and movement) were within normal limits. The resident was able to move all extremities without difficulty. Acetaminophen (a pain-relieving medication) was administered for mild pain, with positive effects noted. The resident continued to report a mild headache. On August 7, 2025, the surveyor attempted to interview Resident 117 regarding the July 11, 2025 transportation incident. The resident was not available for interview on this date, as he was hospitalized at the time of the attempted interview. During an interview on August 7, 2025, at approximately 9:00 AM, Employee 3, Vehicle Transport Driver, explained that on July 11, 2025, Resident 117's wheelchair tipped over because she forgot to utilize the lap seat belt when securing him for transport. She recalled calling 911 and holding pressure to the back of Resident 117's head to stop the bleeding while she waited for emergency services to arrive. She explained the resident was taken by emergency services to the community emergency department. Employee 3 stated she had received training on securing wheelchairs for transport, was familiar with the procedure, and had prior experience transporting residents in wheelchair vans, but failed to ensure the lap belt was properly secured for this trip. During an interview on August 7, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) confirmed that the facility's investigation identified that Employee 3, Vehicle Transport Driver, failed to ensure required vehicle safety devices were in place prior to transporting the resident, resulting in the resident sustaining a scalp laceration that required closure with staples. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. The driver called 911; the resident was assessed and sent to the emergency department for evaluation. Resident family and physician updated. The driver returned to the facility and was suspended pending investigation, and a vehicle accident report was completed. 2. All resident transports were outsourced to external transportation providers or rescheduled. Facility transport vehicles were removed from service. 3. The transportation policy was reviewed and revised to include an additional laminated checklist verifying seat belts, wheelchair restraints, and shoulder harnesses before each trip. Future transport drivers will complete new competencies before transporting residents. 4. The Director of Maintenance or designee will audit to ensure that facility-owned vans remain out of service and only outsourced transportation is used. The facility's compliance date for this deficient practice was July 11, 2025. 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 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on observation, a review of select facility policy and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications in two of three medication storage rooms (second and third floor medication rooms). Findings include: A review of the facility policy titled Medication Storage, last reviewed by the facility June 19, 2025, indicated the purpose is to ensure medications and biologicals are stored in a safe, secure storage area and ensure safe handling. Multi-use vials must be dated upon opening and discarded within 30 days unless otherwise specified by manufacturer. An observation of the medication room on the second floor on August 7, 2025, at 8:30 AM of medications stored in the medication refrigerator revealed a multi-dose bottle of Tuberculin (solution used for screening for tuberculosis) that had been opened, available for use, and dated July 2, 2025. Review of the manufacturer dosage and administration for Tuberculin revealed that vials in use for more than 30 days should be discarded. The current vial was 36 days beyond the manufacturer's recommended discard date. Interview with Employee 2 (Registered Nurse, Unit Manager) at the time of the observation on August 7, 2025, at 8:30 AM confirmed the Tuberculin vial was dated when opened on July 2, 2025, and was beyond the manufacturer recommended use by date (30 days) and had not been discarded within 30 days of opening. An observation of the medication room on the third floor on August 7, 2025, at 8:45 AM of medications stored in the medication refrigerator revealed a multi-dose bottle of Tuberculin that had been opened, available for use, and not dated when opened. Interview with Employee 1(licensed practical nurse) at the time of the observation on August 7, 2025, at 8:45 AM confirmed the Tuberculin vial was opened and not dated. Interview with the Nursing Home Administrator and Director of Nursing on August 7, 2025, at approximately 1:00 PM confirmed that medications are to be dated upon opening and expiration/use by dates were to be checked prior to administration and removed from the medication refrigerator upon expiration. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services. 28 Pa. Code 211.10 (d) Nursing care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, facility investigative documentation, and staff interviews, it was determined the facility failed to implement necessary safety interventions to prevent a fall and maintain the physical health of one resident (Resident 73) out of 28 residents reviewed.Findings include: A review of the facility policy titled Fall Reduction Policy last reviewed by the facility on June 19, 2025, revealed it is the facility's policy to provide an environment that remains free of accident hazards as possible, to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries, and to promote a systemic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk. A clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (group of conditions affecting movement and posture caused by damage that occurs to the developing brain, usually before birth), quadriplegia (paralysis of both arms and legs), abnormalities of gait and mobility, and need for assistance with personal care. A falls risk assessment dated [DATE], identified the resident as moderate risk for falls. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 6, 2025, revealed that Resident 73 was moderately cognitively impaired with a BIMS score of 10 (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 8-12 indicates moderate cognitive impairment), had an impairment on both sides of his upper extremity (arm) and lower extremity (leg), required total assistance to roll left and right in bed. A review of the resident's care plan dated May 14, 2025, identified deficits in Activities of Daily Living (ADLs) related to musculoskeletal impairments. Interventions included: use of high back wheelchair with pressure relieving cushion and bilateral leg rests, dependent assistance for bathing/showering with one staff member, dependent assistance for dressing and eating, assistance of two staff members for repositioning and turning in bed, and the use of a mechanical lift for transfers. The Registered Nurse (RN) Supervisor assessed the resident. Vital signs were stable (blood pressure 140/88 mmHg, pulse 74 beats per minute, temperature 97.1 F, respirations 18 per minute, oxygen saturation 98% on room air). The resident denied hitting his head or experiencing pain, and a staff member confirmed no head impact occurred. The resident stated, I rolled out of bed. The resident was returned to bed using a Hoyer lift (a mechanical lift used to transfer residents who cannot bear weight), and safety measures were put in place. The physician and responsible party were notified. Review of nursing documentation dated July 1, 2025, at 10:56 AM indicated the resident was complaining of pain in his left shoulder, left elbow, left ribs, and left hip. Tylenol was administered. The physician was made aware and ordered and x-ray of the left upper extremity (arm), rib and hip. Review of the x-ray report dated July 1, 2025, revealed no acute (new) fractures or dislocations. Soft tissue swelling of the left forearm was noted. A review of a facility provided documentation dated July 2, 2025, at 3:15 PM revealed that Employee 4, nurse aide, failed to follow the resident's plan of care, requiring assistance of two staff members for bed mobility/rolling left or right. In a written witness statement dated June 30, 2025, at 9:30 PM, Employee 4 described the incident: while providing care, Employee 4 rolled the resident away from her, briefly removing a hand to reach for a brief on the bedside table. During this moment, the resident rolled off the bed despite Employee 4's attempt to prevent the fall and protect the resident's head. Continued review of the witness statement revealed Employee 4 was asked three follow-up questions: 1. How many staff should be with the resident with transfers? Employee 4 answered Two. 2. How many staff should be with the resident with bed mobility? Employee 4 answered One.3. Which way was the resident rolled in bed? Employee 4 answered rolled him (the resident) away from me. He has two spots between his butt and thigh that needs skin protectant cream applied. If I would have had that second person, it would've been easier to apply the cream. Employee 4 continued to add I was doing what I was told when I was on 1st floor hired two years ago. I would do his bed cares with one person; I would also have a second person there for all transfers. During an interview with the Nursing Home Administrator (NHA) on August 7, 2025, at 1:30 PM, the NHA stated that nurse aides use the Kardex (a nursing information system used to obtain up-to-date specific care information for each resident) to determine the level of assistance required for resident care tasks. During an interview with Employee 4 on August 7, 2025, at 11:40 AM, she confirmed that staff rely on the Kardex for this information but that Resident 73's Kardex did not specify the number of staff needed for bed mobility at the time of the incident. During an interview with the Nursing Home Administrator (NHA) on August 7, 2025, at 1:30 PM, the NHA stated that nurse aides utilize the Kardex system (a nursing information system used to obtain up-to-date specific care information for each resident) to be informed of resident care directives and level of assistance required to perform tasks. During an interview with Employee 4 on August 7, 2025, at 11:40 AM, Employee 4 acknowledged that staff rely on the Kardex for resident care details but indicated that Resident 73's Kardex did not specify the level of assistance needed for bed mobility at the time of the fall. A review of the Kardex dated June 29, 2025, confirmed it lacked any entry identifying the resident's bed mobility status or the required number of staff for safe bed mobility. During a follow-up interview on August 8, 2025, at 9:30 AM, the NHA confirmed the absence of Resident 73's bed mobility information on the Kardex at the time of his fall and acknowledged the facility did not ensure necessary services were provided to prevent a fall during bed mobility. 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 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on clinical record review, select facility policy, and staff interviews, it was determined that the facility failed to provide person-centered care for diabetes management and professional standards of practice for one resident out of 28 sampled (Resident 81). Findings include:A review of Resident 81's clinical record revealed the resident 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 diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin (a hormone that helps regulate blood sugar levels) or when the body cannot effectively use the insulin it produces). A quarterly Minimum Data Set Assessment (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 81 dated July 31, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 02 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A review of facility policy entitled Care of the Diabetic Resident, last reviewed on June 19, 2025, revealed that if an Accu-Chek (a brand of blood glucose monitoring device used to measure the amount of glucose in the blood, reported in milligrams per deciliter [mg/dL]) reveals a blood glucose level below 70 mg/dL, or a level identified per individual physician's orders, then hypoglycemia should be suspected, and the resident's individual hypoglycemic protocol should be followed if ordered by a physician, and if no individual protocol is ordered, then the physician should be updated based on clinical assessment and current blood sugar. Further review indicated that hypoglycemia should be treated promptly with 15 to 20 grams of fast-acting carbohydrates if blood glucose levels are less than 70 mg/dL. A clinical record review for Resident 81 revealed physician orders, dated January 28, 2025, for insulin aspart (fast acting) with sliding scale parameters for subcutaneous (injection under the skin) injection dependent on the resident's blood glucose levels, to be administered four times daily with meals and at bedtime. Orders specified:70-149 mg/dL: 0 units of insulin< (less than)70 mg/dL: Call physician and notify the RN supervisor150-199 mg/dL: 2 units200-249 mg/dL: 4 units250-299 mg/dL: 6 units300-349 mg/dL: 8 units350-400 mg/dL: 10 units400 mg/dL: Contact the physician A clinical record review for Resident 81 revealed physician orders, dated May 22, 2025, for Novolog Insulin mix 70/30 subcutaneously for 10 units in the afternoon and to hold if blood glucose is less than 90 mg/dL. A review of a nursing note dated July 22, 2025, at 4:05 PM, revealed that Resident 81's Humalog 70/30 10 units was held due to a blood glucose level of 54 mg/dL (normal 70mg/dL to 110 mg/dL). A nursing progress note dated July 22, 2025, at 4:43 PM, revealed the resident had a fall out of their wheelchair, was lethargic but responsive, and that vital signs (blood pressure and heart rate) were normal, but the blood glucose was 57 mg/dL. Further review of the nurse's note revealed they were given orange juice per the hypoglycemic protocol. However, there was no documented evidence that Resident 81 received orange juice or any other carbohydrate in a timely manner after the initial hypoglycemic reading of 54 mg/dL at 4:05 PM. There was also no documented evidence that the RN supervisor was notified immediately of the low blood glucose level as required by physician orders; the RN supervisor was only notified after the fall occurred. Likewise, there was no documented evidence that the physician was notified of the hypoglycemia before being informed of the fall. During an interview with the Nursing Home Administrator on August 8, 2025, at approximately 1:00 PM, it was confirmed there was no documented evidence that Resident 81 received carbohydrates per hypoglycemic protocol in a timely manner during a hypoglycemic event and that no documented evidence that the physician and RN supervisor were notified of a low blood glucose until after a fall for Resident 81. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to fully develop, revise, and implement a person-centered comprehensive care plan to meet the individualized needs of two residents out of 28 sampled (Resident 81 and 73).Finding include: A review of Resident 81's clinical record revealed the resident 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 diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin which is a hormone that helps regulate blood sugar levels or when the body cannot effectively use the insulin it produces). A quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 81 dated July 31, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 02 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). Observation of Resident 81 on August 5, 2025, at 1:00 PM, revealed the resident was Spanish speaking. During an interview at 1:15 PM on the same day, Employee 8, Licensed Practical Nurse, stated that Resident 81 required Spanish-speaking staff, family, or an interpreter to translate the care being rendered, but understood some basic English words. A review of the resident's comprehensive plan of care, last revised on August 1, 2025, failed to include interventions required to effectively communicate with the resident. Further review of the clinical record revealed the resident was at high risk for falls and had sustained a fall on July 22, 2025; however, the August 1, 2025, plan of care did not reflect updated medical treatment goals or interventions for fall prevention. An elopement risk assessment dated [DATE], identified the resident as being at risk for wandering, yet the same plan of care failed to include updated treatment goals and interventions for elopement and wandering risk. During an interview on August 7, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed the facility failed to ensure that the comprehensive care plan was fully developed for Resident 81. A clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (group of conditions affecting movement and posture caused by damage that occurs to the developing brain, usually before birth), quadriplegia (paralysis of both arms and legs), abnormalities of gait and mobility, and need for assistance with personal care. A falls risk assessment dated [DATE], identified the resident as moderate risk for falls. A review of the resident's comprehensive care plan, dated May 14, 2025, identified deficits in Activities of Daily Living (ADLs) related to musculoskeletal impairments. Interventions included: use of high back wheelchair with pressure relieving cushion and bilateral leg rests, dependent with bathing/showering with assistance of one staff member, dependent with dressing and eating, assistance of 2 staff members for repositioning and turning in bed, and use of a mechanical lift for transfers. During an interview with the Nursing Home Administrator (NHA) on August 7, 2025, at 1:30 PM, the NHA stated that nurse aides utilize the Kardex system (a nursing information system used to obtain up-to-date specific care information for each resident) to be informed of resident care directives and level of assistance required to perform tasks. A review of the resident's Kardex, dated June 29, 2025, did not reflect the resident's bed mobility status or indicate that two staff members were required to safely reposition the resident in bed, as outlined in the care plan. In a follow-up interview on August 8, 2025, at approximately 9:30 AM, the NHA was unable to provide documented evidence that the bed mobility interventions developed in the resident's care plan had been incorporated into the Kardex or otherwise communicated to direct care staff. Specifically, there was no documentation to support that staff were informed that two caregivers were required for safe repositioning and turning the resident in bed for personal care and hygiene. Refer F689 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on a review of clinical records and staff interviews, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions for a Preadmission Screening and Resident Review (PASRR) level II resident review for one out of 28 residents (Resident 99).Findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have serious mental illness before admission. This is called a PASRR Level I screen. Those individuals who test positive for PASRR Level I are then evaluated in-depth; this is called PASRR Level II. The results of this evaluation result in a determination of need, a determination of an appropriate setting, and a set of recommendations for services for the individual's plan of care. A review of the Pennsylvania Department of Human Services Office of Long-Term Living Bulletin titled Revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level 1 Identification Form (MA 376), effective July 1, 2024, revealed if the individual has a change in condition that affects program office criteria as found on the PASRR Level I form, a PASRR Level II evaluation form will need to be completed. Nursing facilities will communicate the need to have a PASRR Level II form done by notifying the department's Office of Long-Term Living, Division of Nursing Facility Field Operations Team. A clinical record review revealed Resident 99 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mood disorder characterized by persistent feelings of sadness and loss of interest in activities that impact daily life). Further clinical record review revealed Resident 99 was transferred to a community emergency department after a suicide attempt on April 2, 2025. Resident 99 was subsequently involuntarily committed to a community psychiatric hospital for evaluation and stabilization. Resident 99 was readmitted to the facility on [DATE]. A clinical record review revealed no documented evidence that the facility referred Resident 99 for a pre-admission screening and Resident Review level II through the state mental health authority following the emergence of his newly evident and serious maladaptive behaviors and readmission to the facility on April 15, 2025. During an interview on August 8, 2025, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed the facility failed to refer Resident 99 for a PASRR level II resident review after his suicide attempt on April 2, 2025, psychiatric hospitalization, and subsequent readmission to the facility on April 15, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of clinical records, facility-initiated transfer notices, and staff interviews, it was determined the facility failed to notify the resident and the resident's representative(s) of a facility initiated transfer in writing and in a language and manner they understand for five out of 28 residents reviewed (Residents 3, 5, 81, 99, and 117). Findings include: A clinical record review revealed Resident 99 was admitted to the facility on [DATE]. Further review showed Resident 99 was transferred to a community hospital on April 2, 2025, and readmitted on [DATE]. A review of the facility-initiated transfer notification form dated April 2, 2025, revealed the facility did not notify the resident or resident representative of the specific reason for the transfer in writing.A clinical record review revealed Resident 3 was admitted on [DATE]. The resident was transferred to a community hospital on April 26, 2025, and readmitted on [DATE]. The transfer notification form dated April 26, 2025, did not indicate the specific reason for the transfer, nor did it provide written information in a manner the resident or representative could understand. A clinical record review revealed Resident 5 was admitted on [DATE]. The resident was transferred to a community hospital on May 1, 2025, and readmitted on [DATE]. The transfer notification form dated May 1, 2025, did not include a written statement of the specific reason for transfer. A clinical record review revealed Resident 81 was admitted on [DATE]. The resident was transferred to a community hospital on July 22, 2025, and readmitted on [DATE]. A review of the facility-initiated transfer notification form dated July 22, 2025, revealed the specific reason for transfer was not documented in writing for the resident or representative. A clinical record review revealed Resident 117 was admitted on [DATE]. The resident was transferred to a community hospital on May 29, 2025, and readmitted on [DATE]. A review of the transfer notification form dated May 29, 2025, revealed the facility did not provide the specific reason for the transfer in writing. During an interview on August 7, 2025, at approximately 1:30 PM, the nursing home administrator was unable to provide documented evidence that residents 3, 5, 81, 99, and 117, or their representatives, had received written notification of the specific reason for their transfers on the aforementioned dates. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on a review of clinical records, select facility policy, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by seven residents out of 18 residents sampled (Residents 3, 4, 6, 7, 8, 9, and 11). Findings include: A review of the facility policy titled Call Light Use and Response, last reviewed by the facility on September 26, 2024, revealed it is the facility's policy that facility staff will respond promptly to the residents' calls for assistance and ensure the call system is functioning. The policy indicates facility personnel will be aware of all call lights, answer call lights promptly, and answer call lights in a calm and courteous manner. A review of clinical records revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that include heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 7, 2025, revealed that Resident 3 is 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 13-15 indicates cognition is intact). During an interview conducted on April 3, 2025, at 10:10 AM, Resident 3 stated that he often waits 30 minutes or longer for staff to respond after activating his call light for assistance. He further explained that staff frequently sit in the nurses ' station and do not respond when residents request help. Resident 3 reported that, on one occasion last week, he waited over four hours for staff assistance. He stated that he often uses his call light to request pain medication and becomes upset when staff fail to respond in a timely manner. A review of clinical records revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that include major depressive disorder (a mood disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts) and agoraphobia (an anxiety disorder characterized by intense fear and anxiety of situations where escape might be difficult or help unavailable, often leading to avoidance of public places or situations). A review of an admission MDS assessment dated [DATE], revealed that Resident 4 is cognitively intact with a BIMS score of 13 (a score of 13-15 indicates cognition is intact). During an interview conducted on April 4, 2025, at 10:20 AM, Resident 4 stated that on many occasions, he has waited up to an hour for staff to respond to his call light. He explained that, on average, he typically waits about 30 minutes for assistance. Resident 4 further reported that when he uses his call light to request medications or fresh water, he often experiences delays of approximately 30 minutes, which he attributed to a lack of available staff A review of clinical records revealed Resident 6 was admitted to the facility on [DATE], with diagnoses that include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and morbid obesity (a chronic disease that's characterized by a body mass index of 40 or higher, or a body mass index of 35 or higher with obesity-related health issues). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 6 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). During an interview on April 4, 2025, at 10:25 AM, Resident 6 stated that she sometimes waits between 30 minutes to an hour and a half for staff assistance. She explained that she is dependent on staff to help her to the bathroom and to provide care if she soils herself. Resident 6 reported that a few weeks ago she filed a grievance after staff left her sitting on the toilet for over an hour. She stated that waiting so long for assistance is painful and uncomfortable. A review of grievances filed with the facility revealed a grievance form dated March 4, 2025, submitted by Resident 6. The grievance indicated that she rang her call bell before breakfast to request assistance to use the toilet. Resident 6 reported that staff told her she would not receive help until after breakfast. She stated she rang her call bell again, and although three different staff members responded, none provided care. The grievance indicated that Resident 6 waited two hours before staff assisted her. The grievance form documented that staff were provided education on care and responding to call bells for resident assistance. A review of clinical records revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it difficult to breathe). A review of an admission MDS assessment dated [DATE], revealed that Resident 7 is moderately cognitively impaired with a BIMS score of 12 (a score of 8-12 indicates moderate cognitive impairment). During an interview on April 4, 2025, at 10:30 AM, Resident 7 stated that he shares a room with his wife, Resident 6. He reported that many times she waits over 30 minutes for assistance after activating her call bell, and he becomes frustrated because he is unable to help her. Resident 7 explained that after waiting 15 to 20 minutes, he often goes into the hallway to look for staff, but there is frequently limited staff available to provide care. A review of clinical records revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that include acute respiratory failure (a condition where the lungs fail to oxygenate the blood adequately or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs). A review of an annual MDS assessment dated [DATE], revealed that Resident 8 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). During an interview on April 4, 2025, at 10:35 AM, Resident 8 stated that while the facility has improved somewhat with care, she usually waits about 30 minutes for staff to respond after activating her call bell. She reported that, many times during the night shift, staff do not provide incontinence care, and she wakes up saturated in urine. Resident 8 stated that the longest wait times for care typically occur during the night shift. A review of clinical records revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that include peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). A review of an annual MDS assessment dated [DATE], revealed that Resident 9 is moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicates moderate cognitive impairment). During an interview on April 3, 2025, at 10:40 AM, Resident 9 stated that she often waits a long time for staff assistance. She explained that she needs help to get to the bathroom but frequently waits one to two hours for assistance. Resident 9 reported that, as a result, she often soils herself while waiting. She stated that the delays occur on all shifts. Resident 9 explained that she has discussed this concern with staff in the past, but nothing seems to have changed. A review of clinical records revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it difficult to breathe). A review of an admission MDS assessment dated [DATE], revealed that Resident 11 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). During an interview on April 3, 2025, at 10:55 AM, Resident 11 stated that she typically waits 20 to 30 minutes for staff assistance. She explained that she knows this is unsafe, but she often transfers herself to the toilet because she would rather not soil herself while waiting for help. Resident 11 reported that she has only been at the facility for about a month but has already waited over an hour for assistance to the toilet on several occasions. During an interview on April 3, 2025, at approximately 1:00 PM, the Nursing Home Administrator (NHA) confirmed that all residents at the facility should be treated with dignity and respect and provided care in a manner that promotes each resident's quality of life. The NHA was unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports and interviews with staff and residents it was determined the facility failed to ensure that one resident (Resident 1) was free from sexual abuse perpetrated by a facility staff member out of 6 residents sampled. This failure to prevent, identify, and respond appropriately to sexual abuse placed Resident 1 and all other residents in the facility at risk for further harm, resulting in Immediate Jeopardy. Findings include: A review of a facility policy entitled Abuse and Neglect Prevention revealed it is 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. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. Further it is indicated every resident has the right to be free from verbal, sexual, physical, and mental abuse. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD a group of lung diseases that cause ongoing breathing problems), type 2 diabetes (high blood sugar), and muscle wasting. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 7, 2024, revealed the resident was cognitively intact with 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). A review of a facility investigation report dated February 9, 2025, at 7:45 PM revealed Employee 1 NA (nurse aide) approached Employee 2 RN (registered nurse) in regard to an inappropriate encounter between Resident 1 and Employee 3 NA. The resident was assessed at the time and no injuries were identified. Further it was indicated Employee 3 was escorted from the building and the resident refused to be transferred and evaluated in the hospital. A review of a witness statement from Employee 1 NA dated February 9, 2025, revealed the employee was passing snacks out to the residents. The employee stated she knocked on Resident 1's closed door and observed the resident's bed was raised to Employee 3's waist height. The resident was lying on her left side. Employee 1, NA reported witnessing Employee 3 receiving oral sex from Resident 1. Employee 1 NA observed that Employee 3 NA was holding the resident's head and shoulders while engaging in thrusting motions. Employee 1 indicated Employee 3 was startled when he saw Employee 1 and moved away from the resident quickly. A review of a statement from Employee 3 NA provided to facility staff via telephone dated February 10, 2025, revealed the employee was done with his work and was doing a walk throughout the hallways. He indicated Resident 1's dinner tray was still in her room and went to get it. The employee stated the resident looked uncomfortable, so he turned her on to her side and put a pillow behind her back. Further he indicated Employee 1 NA was quiet and he did not hear her come into the room. The employee stated Employee 1 NA walked by and put a sherbet on the foot of the resident's bed. The employee then indicated he got the resident situated and fed her the sherbet. When he exited the room, he was told he had to leave the facility. A review of a statement dated February 10, 2025, revealed the resident was questioned about the incident that occurred. Resident 1 was asked what had occurred the night before and asked if she was in a relationship with Employee 3. The resident stated he was married but she did give him oral sex the night before. The resident indicated that it was not the first time she had seen his genitals. The resident stated in the past Employee 3 had touched her genitals and oral sex was preformed once before. An interview with Resident 1 on February 13, 2025, at 9:50 AM revealed the resident denied that any incident occurred with Employee 3. The resident stated Employee 3 NA did come in her room, but they were just talking. During the interview the resident appeared to be uncomfortable and evasive when asked why the Employee would have come into her room and closed the door and pulled the curtain shut just to talk with her. The resident stated he didn't force me to do anything, and she stated she was fine. A second interview was completed with Resident 1 on February 13, 2025, at 11:45 AM. The surveyors explained to the resident they read her witness statement she provided to the facility on [DATE], about an alleged sexual encounter that occurred and asked if she would like to talk about the incident. Resident 1 stated she was afraid she and Employee 3 was going to get in trouble. The surveyors explained to the resident she was not in trouble for anything. The resident then indicated Employee 3 had initiated sexual contact with her on February 9, 2025. The resident stated he approached her in her room was talking to her about sexual things. The resident stated one thing led to another and she performed oral sex on the employee. She indicated the oral sex stopped when Employee 3 pulled away from her when another staff member came into the room and saw what was happening. The resident stated this was not the first time she had a sexual encounter with Employee 3. The resident indicated that for at least a month her and Employee 3 would have sexual conversations, and she performed oral sex on Employee 3 one other time while he touched her bare genitals and penetrated her with his fingers. When asked if she ever had sexual intercourse with Employee 3 the resident stated no. A telephone interview was conducted by the surveyor with Employee 1 on February 13, 2025, at 12:23 PM. Employee 1 stated that on the evening of February 9, 2025, between 7:45 PM and 7:50 PM, she began passing out nighttime snacks to residents. When she arrived at Resident 1's room, she noticed that the door was closed, which she found unusual since neither Resident 1 nor her roommate typically closed their door. Employee 1 explained that she knocked lightly and slowly opened the door to avoid hitting anyone who might be walking to the bathroom. Upon entering the room, she observed that the privacy curtain was completely drawn around Resident 1's bed. She first approached Resident 1's roommate, who was on the other side of the room, and handed them a snack. As Employee 1 walked back toward the doorway, she noticed a small opening in the privacy curtain. Looking through the gap, she saw Employee 3 standing near the head of Resident 1's bed. She noted that the bed had been raised to the level of Employee 3's waist and that Resident 1 was lying on her side, propped up with pillows. Employee 1 observed that Employee 3 was holding the blankets up to Resident 1's head, had his hands on the resident's head, and was making thrusting motions toward the resident's face. Employee 1 stated that Employee 3 appeared focused on what he was doing and did not immediately realize she was in the room witnessing the interaction. When Employee 3 finally noticed her, he quickly pulled away and moved down from the resident's face. Employee 1, feeling scared and shocked by what she had just witnessed, immediately threw the snack she was holding onto the resident's bed, exited the room, and sought out Employee 2 RN for assistance. Employee 1 further stated that after she reported the incident, Employee 2 RN promptly removed Employee 3 NA from the building, and law enforcement was contacted. On February 13, 2025, at approximately 2:00 PM, a surveyor conducted an in-person interview with Employee 4 (NA). During the interview, Employee 4 stated that on February 9, 2025, she was working on the nursing unit alongside Employee 1. While charting at the time, Employee 1, who was visibly shaken, pale, and teary-eyed, approached her and asked for assistance in finding a supervisor. Employee 4 recalled that while riding the elevator, Employee 1 explained that when she entered Resident 1's room to distribute nighttime snacks, she witnessed a disturbing incident. According to Employee 1, upon entering the room, she saw that Employee 3 had propped up Resident 1 with pillows. Employee 1 described that Employee 3 was making thrusting motions at Resident 1's face while as he was receiving oral sex. After hearing this, Employee 4 NA and Employee 1 NA located Employee 2 RN on the second floor and informed him of what had occurred. Employee 4 NA reported that Employee 2 RN then went downstairs to investigate while she and Employee 1 NA stayed upstairs to document witness statements. When asked if she had ever observed any interactions between Resident 1 and Employee 3 NA before, Employee 4 NA indicated that she had seen Resident 1 make sexual and inappropriate comments to Employee 3 NA on prior occasions. Although she found these interactions unusual, she mentioned that she would correct Resident 1 by telling her it was inappropriate to talk to men that way. Additionally, Employee 4 NA noted that Employee 3 NA was not assigned to Resident 1 on the night of the incident, and there was no reason for him to be in her room. A telephone interview was also attempted with Employee 3 on February 13, 2025, at 2:22 PM. However, after calling his number twice, the line indicated the number was no longer in service. A telephone interview was completed on February 13, 2025, at 2:24 PM by the surveyor, Employee 5, a licensed practical nurse (LPN), stated that on February 9, 2025, she was working as the unit nurse while the Superbowl was airing, with residents gathered in the dining room under her supervision. She reported that she did not witness any sexual encounter that night. However, upon leaving the dining room, she noticed Employee 1, who appeared extremely distraught. When she asked Employee 1 NA what had happened, Employee 1 explained that Resident 1 had told her she witnessed Employee 3 NA receiving oral sex from Resident 1. Employee 5 LPN added that she and Employee 2 RN then went to speak with Resident 1. During that conversation, Resident 1's account was inconsistent-at times stating she was merely touching Employee 3's head and neck, and at other times claiming she had not touched him at all. Employee 5 also observed that Resident 1 kept wiping her mouth, which she found suspicious. Additionally, Employee 5 reported witnessing Employee 3 being escorted out of the building; he did not speak or ask any questions during his removal. In an interview conducted on February 13, 2025, at 2:57 PM, Employee 2 stated that on February 9, 2025, she was on the second floor when a visibly upset Employee 1-crying and shaking-approached her. Employee 1 informed her that while passing out snacks, she had seen Resident 1's bed raised to the level of Employee 3's waist, with Resident 1's face positioned near Employee 3's genitals as he moved back and forth over her face. Employee 1 noted that Employee 3 became startled when he saw her and quickly moved back. Employee 2 then went downstairs and observed Employee 3 pacing with a red face. She confronted him, told him he had to leave, and escorted him out of the building. When she asked him what had happened in the foyer, Employee 3 claimed that nothing had occurred, and that the interaction was consensual before leaving. Employee 2 further stated that she later discussed the incident with Resident 1 who was evasive and maintained that nothing had happened. Witness testimony and investigative reports confirmed that Employee 3 had engaged in prior sexual encounters with Resident 1, including inappropriate touching and penetration, which were undiscovered by facility staff. Despite initial denials, Resident 1 later confirmed that Employee 3 initiated sexual interactions and had been engaging in sexual contact with her for approximately one month. Interviews with multiple employees confirmed that Employee 1 was visibly distressed after witnessing the abuse and immediately reported the incident. Employee 3 was removed from the building that night but was able to engage in sexual activity with a resident without detection prior to this incident. The facility failed to ensure that residents were protected from sexual abuse by facility staff. Employee 3 was in a position of power and engaged in repeated sexual abuse of a resident, violating the resident's rights, dignity, and safety. The facility did not prevent or detect the abuse, placing all residents at risk for further harm. The failure to recognize, report, and intervene in a timely manner led to Immediate Jeopardy, which was identified on February 13, 2025, at 1:45 PM due to the facility's failure to prevent abuse and protect the residents beginning on February 9, 2025, at 7:45 PM when Resident 1 and Employee 3 were observed in a sexual act. The facility's immediate action plan dated February 13, 2025, indicated that the following actions would be taken: 1. An internal investigation was immediately initiated on February 9, 2025. 2.The employee who left the resident with the perpetrator was suspended on February 10, 2025. 3.The accused perpetrator was removed in the facility on February 9, 2025. 4. The nursing agency was notified of the alleged accusation towards their employee on February 10, 2025. 5. The abuse policy will be reviewed and revised which was completed on February 13, 2025. 6. The facility staff will be educated on the abuse policy and procedure, protecting resident safety which includes remaining with the resident, and guidelines on preserving an investigative scene prior to the start of their shift in person or via telephone beginning on February 12, 2025. Further no staff will be permitted to work until this education has been completed. 7. The facility immediately completed resident interviews with those residents with BIMS of 12 and above to determine if any other residents were affected on February 10, 2025. 18.The facility assessed residents with BIMS under 12 for signs of abuse on February 13, 2025. 9. The QAPI Committee will reconvene on February 14, 2025, to review the root cause of the noncompliance. 10. The NHA or designee we'll take a random sampling of residents an interview them to determine if any abuse has occurred and if appropriate steps were followed. Audits will occur daily until further direction beginning on February 14, 2025. Further a random sampling of employee interviews will be completed to ensure they know how to identify and respond to abuse. These audits will occur daily until further direction beginning on February 14, 2025. Following verification of the implementation of the corrective action plan the Immediate Jeopardy was lifted at on February 13, 2024, at 5:15 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to prevent the sexual abuse of one resident (Resident 1) out of 6 sampled residents. Findings included: A review of the job description for the nursing home administrator (NHA) signed and dated on February 1, 2025, revealed the administrator manages all business-related activity to achieve the facility's vision and supporting strategies and assures that the company's image as an ethical and high-quality provider of healthcare services is maintained. The essential job functions include the following: Know and respect patient rights. Ensure resident concerns and complaints are responded to with tact and urgency. Reports allegations of resident abuse, neglect, and or misappropriation of resident property. Follows established safety policies and procedures. Ensures potential safety and health hazards are eliminated. Direct the location of staff to provide high quality in daily care which meets and exceeds all standards within budget parameters. Intervenes as appropriate with potentially threatening situations and follows up with staff after the crisis has been resolved. Organizes the functions of the nursing home throughout appropriate departmentalization and the delegations of duties. Establishes formal means of accountability. Manages safety according to procedures and guidelines and ensures that potential safety health hazards are eliminated or controlled through regular reviews of work activities and materials. A review of the job description for the director of nursing (DON) signed and dated on February 1, 2025, revealed the director of nursing works with the administrator and directs the nursing department to maintain quality standards of care in accordance with current federal, state, and the facility standards guidelines and regulations. In the absence of the administrator, the director of nursing assumes the responsibility for center operations. The position conducts the nursing process, assessment, planning, implementation, and evaluation under the scope of the states nurse practice act of registered nurse licensure. The essential job functions include the following: Reports complaints made by the resident to the supervisor. Reports allegations of patient abuse, neglect, and or misappropriation of resident property. Follows established safety policies and procedures. Observed safety needs of patients as indicated in their care plan. Participates in and promotes resident rights and customer service programs. Understands and promotes the federal, state, and company position on abuse and neglect prevention. Ensures ethical care delivery with adherence to corporate compliance and safe business practices. Freedom from Abuse, Neglect, and Exploitation revealed that the administrator and director of nursing failed to fulfill the essential job duties for ensuring the safety of the residents and adherence to regulatory guidelines. Deficiencies cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F600 F607 F610) 483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation, 483.12(b) The facility must develop and implement written policies and procedures that 483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, 483.12(b)(2) Establish policies and procedures to investigate any such allegations, and 483.12(b)(3) Include training as required and 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. 483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken, revealed the NHA and DON failed to fulfill the essential job duties for ensuring the safety of the residents and adherence to regulatory guidelines. Cross refer F600, F607, F610 28 Pa. Code: 201.14 (a) Responsibility of licensee 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code 211.12 (c) Nursing services

Based on a review of select facility policy, facility investigative reports, clinical records and staff interviews it was determined the facility failed to ensure a complete and accurate investigation into sexual abuse was completed for one resident out of 6 sampled (Resident 1). Findings included: A review of a facility policy entitled Abuse and Neglect Prevention revealed it is 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. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. Further it is indicated every resident has the right to be free from verbal, sexual, physical, and mental abuse. Further review of the facility abuse policy revealed under the area of investigation when the facility receives a complaint of alleged maltreatment, the administrator must be notified immediately and they, the director of nursing, or assigned designee will coordinate an investigation which will include completion of witness statements. All parties involved including staff residents or visitors who were potentially involved or observed the alleged incident are to be interviewed by the director of nursing, director of social services, or their designees. When a specific staff member is implicated in an alleged event, the person will be removed from the resident care area immediately interviewed by the supervisor assigned and ask to provide a written statement. Under the area of protection of residents during an investigation the facility should remove the resident from the situation and examine and interview the resident immediately to ensure there is no injury. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD a group of lung diseases that cause ongoing breathing problems), type 2 diabetes (high blood sugar), and muscle wasting. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 7, 2024, revealed that the resident was cognitively intact with 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). A review of the facility's investigation report dated February 9, 2025, at 7:45 PM revealed that Employee 1 (Nurse Aide) reported to Employee 2 (Registered Nurse) an inappropriate sexual encounter between Resident 1 and Employee 3 (Nurse Aide). The report indicated that Resident 1 was assessed, and no injuries were found. Employee 3 was escorted from the facility, and Resident 1 declined transfer to a hospital for evaluation. A witness statement from Employee 1 dated February 9, 2025, described the following: Employee 1 was passing out snacks when she knocked on Resident 1's closed door. Upon entering, she observed Employee 3 receiving oral sex from Resident 1. Resident 1's bed was raised to Employee 3's waist height, with the resident lying on her left side. Employee 3 was holding the resident's head and shoulders while moving back and forth. Employee 3 appeared startled when he noticed Employee 1 and quickly moved away from the resident. A statement from Employee 3, obtained via telephone on February 10, 2025, provided a conflicting account: Employee 3 claimed he was performing a routine walk-through on the unit and noticed Resident 1's dinner tray still in the room. He stated that the resident appeared uncomfortable, so he turned her onto her side and placed a pillow behind her back. He reported that Employee 1 quietly entered the room, placed a sherbet on the bed, and then left. Employee 3 stated that after adjusting Resident 1, he fed her the sherbet and then exited the room, at which point he was told he needed to leave the facility. A review of a statement dated February 10, 2025, revealed the resident was questioned about the incident that occurred. Resident 1 was asked what had occurred the night before and asked if she was in a relationship with Employee 3. The resident stated he was married but she did give him oral sex the night before. The resident indicated it was not the first time she had seen his genitals. The resident stated in the past Employee 3 had touched her genitals and oral sex occurred once before. A statement from Employee 4 (Nurse Aide) dated February 9, 2025, indicated that she did not witness the incident but last saw Resident 1 in bed at 6:30 PM. The facility failed to conduct a thorough and complete investigation by neglecting to interview and obtain statements from all staff members present in the unit during the incident. This includes: Employee 5 (Licensed Practical Nurse - LPN) Employee 2 (RN Supervisor) Both individuals were potentially involved or could have been witnesses to the events that transpired. Their accounts could have provided crucial information regarding the timeline of events and staff awareness of Resident 1's interactions with Employee 3. An interview conducted with the Nursing Home Administrator and Director of Nursing on February 13, 2025, at approximately 5:30 PM confirmed that the facility's investigation into the sexual abuse of Resident 1 was incomplete 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on select facility policy and staff interview it was determined the facility failed to fully develop and implement an abuse prohibition policy that includes specific procedures to fulfill the requirement of fully identifying and investigating abuse. Findings include: A review of a facility policy entitled Abuse and Neglect Prevention revealed it is 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. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. Further it is indicated every resident has the right to be free from verbal, sexual, physical, and mental abuse. The facility policy includes components addressing: Screening Training Prevention Identification Investigation Protection Reporting/Response. Under the area of identification, the policy indicates in the event of a suspected maltreatment, the needs of the resident will be immediately assessed, and the safety of the resident will be insured. The safety and health of the resident will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment, including medical intervention as needed. However, the facility's policy failed to include written procedures to assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. Specifically, the policy does not provide guidance on recognizing different types of abuse, such as: Mental/verbal abuse Sexual abuse Physical abuse Deprivation of goods and services Under the area of investigation, the policy indicates upon receiving a complaint of alleged maltreatment, the administrator must be notified immediately and they, the director of nursing, or assigned designee will coordinate an investigation which will include completion of witness statements. When a specific staff member is implicated in the alleged event, the person will be removed from the resident care area immediately, interviewed by the supervisor assigned, asked to provide a written statement, and suspended until the investigation is completed. However, the facility's policy failed to include procedures specific to the handling of evidence in cases of sexual abuse. The policy does not state that the facility must conduct its investigation without tampering with evidence, which could interfere with a thorough investigation by the facility and external authorities. Examples of tampering include, but are not limited to: Washing linens or clothing Destroying documentation Bathing or cleaning the resident before a forensic examination (including a rape kit, if appropriate) Otherwise impeding a law enforcement investigation An interview with the Nursing Home Administrator on February 13, 2025, at approximately 11:00 AM confirmed the facility failed to fully develop and implement an abuse policy that ensures proper identification and investigation of abuse allegations. Failure to include these provisions in the facility's abuse prohibition policy increases the risk of incomplete investigations and failure to protect residents from further harm. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services 28 Pa. Code 201.29 (a)(c)Resident Rights 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on observation, clinical record review, calendar of activities programming, and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs, interests, preferences, and functional and cognitive abilities of two of the 25 residents reviewed (Residents 31, 95) and experiences expressed by residents during a group interview (Residents 9, 84, 97, & 104). Findings include: During a resident group interview on October 30, 2024, at 10:00 AM, alert and oriented residents expressed dissatisfaction with the facility's activity offerings, particularly noting the lack of options in the evenings. Resident 9 reported that Bible study appears to be the only evening activity, and he expressed his interest in more engaging options, such as games, stating he would be willing to participate in almost any evening activity offered. Resident 84 expressed similar concerns, stating that she enjoys bingo and would like to see it offered more frequently, especially in the evenings. She also emphasized a desire for a broader variety of activities. Resident 97 shared that, aside from bingo, she finds the current activity schedule unsatisfactory and would like to see more arts and crafts activities as well as outdoor options. Similarly, Resident 104 noted that although bingo is available a few times a week, she is dissatisfied with the limited activity variety and would like to see more evening activities scheduled. A review of the October 2024 activity calendar revealed evening activities were offered on Tuesdays and Thursdays at 6:30 PM. A review of the upcoming activity calendar revealed that evening activities would be reduced to three days out of 30 in the month of November. Review of the clinical record revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses that included diabetes and paraplegia (paralysis of the legs and lower body). An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 2, 2024, indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13-15, indicates cognitively intact), activity preferences very important included music, animals, keeping up with the news, and going out for fresh air, and activity preferences somewhat important included doing things with a group of people. Interview with Resident 31 on October 30, 2024, at 10:00 AM revealed the resident does mostly prefer independent activities in his room, such as watching television, but that he does like to be made aware of activities being offered in the facility. Resident 31 also stated that he enjoys Word Find Puzzle books but does not currently have any to complete. Observation at this time revealed the current activity calendar on the resident's bulletin board was for September 2024. Resident 31 stated that he does not recall any recent visits from the activities department. Resident 31 stated that he did not have a current activity calendar. A review of Resident 31's current care plan, initially dated August 31, 2022, indicated the resident prefers independent/self-driven activities, likes watching the news and current events, being outdoors, playing cards, and cooking. Interventions included for staff to invite, make arrangements, offer materials, or provide assistance to facilitate participation in interests and for staff to meet with the resident to see if enjoyment is gained from activities or a self-directed routine. Further review of the clinical record revealed no documented evidence of the resident's participation in activities. There was no documented evidence that room visits were being completed to ensure the resident was being provided with an ongoing program of activities to meet his needs. Review of the clinical record revealed that Resident 95 was admitted to the facility on [DATE], with diagnoses that included intellectual disability (below average intelligence and set of life skills present before age 18) and cerebral palsy (congenital disorder or movement, muscle tone, or posture). An admission Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired, and activity preferences included being around animals and pets and going outside for fresh air. Further review of the clinical record revealed no evidence that an activity assessment and care plan specific to meeting the resident's activity needs were completed. There was no documented evidence of Resident 95's participation in activities or visits being provided to ensure the resident was being provided with an ongoing program of activities to meet her needs. Interview with the Nursing Home Administrator (NHA) on November 1, 2024, at 10:30 AM failed to provide documented evidence that Resident 95 and Resident 31 were being provided an ongoing program of activities designed to meet their interests and support their physical, mental, and psychosocial well-being. The NHA confirmed that Residents 9, 84, 97, and 104 should have access to group, individual, and independent activities developed based on their interests and designed to support their physical, mental, and psychosocial well-being. 28 Pa. Code 201.18 (e)(1)(6) Management. 28 Pa. Code 201.29 (a) Resident rights

Based on review of clinical records, select incident reports and information submitted by the facility and staff interview it was determined that the facility failed to develop and implement a resident's person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific transfer needs to meet the objective of safe transfers, to prevent a fall with a serious injury, a left hip fracture, for one resident out of four sampled (Resident 70). Findings included: A review of Resident 70's clinical record revealed that the resident had diagnoses of a left leg above the knee amputation, cerebral infarction (stroke), muscle weakness, lack of coordination, abnormalities of gait and mobility, abnormal posture, and left femur (leg) fracture. The resident had an above the knee amputation. The resident's care plan, dated August 31, 2022, identified that the resident had activities of daily living (ADL) self-care performance deficit related to weakness, recent surgery, decrease mobility, cerebral infarction, absence of left leg above the knee and required the assistance of 1 staff to reposition in bed, but was independent with rolling. The resident's care plan also noted that the resident had an acquired absence of left leg above knee with interventions to use a draw sheet or lifting device to move resident, initiated September 01, 2022. Resident 70's care plan, dated September 15, 2023, indicated that the resident required restorative programs related to an unsteady gait with interventions noted as transfer - minimum assist of 1 for transfer with prosthetic on, and moderate assist of 1 without prosthetic. The care plan did not define moderate assistance of one staff and how it differed from minimum assistance of one staff. A review of the resident care Kardex (a quick reference guide used to inform staff of the resident's care needs and staff tasks) dated December 4, 2023, revealed Resident Care; use a draw sheet or lifting device to move resident, Bed mobility; the resident requires assistance of 1 staff to reposition in bed; independent with rolling, Nursing Rehab / Restorative; Restorative - transfer, minimum assist of 1 for transfer with prosthetic on, and moderate assist of 1 without prosthetic, Transferring; the resident requires assist of 1 for bed/wheelchair modified transfer when wearing prosthetic. A nurse's note dated December 4, 2023, at 2:20 PM revealed that staff found the resident sitting on his buttocks facing the bed on the floor of his room. The resident was wearing a non-skid sock to his right lower extremity (RLE). At the time of the fall, one nurse aide was assisting the resident with a transfer. The resident denied hitting his head. The resident was holding his left hip with discomfort and he stated, I was transferring to weight chair and lost my balance. Nursing assessed the resident for injuries and no injuries were noted. The resident voiced complaints of left hip pain and Tylenol was administered. According to information dated December 4, 2023, submitted by the facility indicated that the resident was not wearing his prosthetic at the time of the above fall. A nurses note dated December 4, 2023, at 3:53 PM indicated that the physician assistant was in the facility to see the resident. The resident was complaining of left hip pain. A new order was noted for an x-ray of the left hip. Nursing documentation dated December 5, 2023, at 3:49 AM noted the results of the x-ray as a left hip fracture. Ortho consult in the AM, and non-weight bearing at all times. The resident was educated on non-weight bearing. Nursing noted on December 5, 2023, at 9:46 PM, that the resident was admitted to hospital with left femoral head fracture with impaction. Nursing noted on December 8, 2023, at 10:45 PM that the resident was readmitted to facility after left hip surgery related to fracture. The incident report (IR) entitled fall, dated December 4, 2023, noted the predisposing factor was gait imbalance during transfer. The root cause was identified that he lost his balance transferring to chair for weight. The intervention was to ensure caution by staff with assists during transfer to and from weight chair. The facility failed to identify the level of staff assistance required with transfers to prevent recurrence. A review of information dated December 4, 2023, submitted by the facility indicated the resident fell to the floor during a transfer from bed to a chair to be weighed with a nursing assistant present. The resident was admitted with a left femoral head impacted fracture. The care plan was being followed regarding transfer status and restorative nursing program. His transfer status was minimum assist of 1 staff when his prosthetic is on, and moderate assist of 2 when he does not have his prosthetic is on. During the transfer, the resident did not have his prosthetic on, he refused and wanted to transfer with the assist of 1 staff member. The facility indicated in this report that the resident's care plan was being followed, and indicated that his transfer status was minimum assist of 1 staff when his prosthetic is on, and moderate assist of 2 when he does not have his prosthetic is on, however the resident was being transferred with the assist of 1 staff member and was not wearing his prosthetic. The resident's care plan, in effect at the time of this fall, did not specify the moderate assist of two when he does not have his prosthetic on. The resident's care plan and care Kardex in effect at the time of the fall indicated both noted minimum assist of 1 for transfer with prosthetic on, and moderate assist of 1 without prosthetic. A review of Employee 3, a nurse aide, witness statement dated December 4, 2023, revealed the aide brought the chair into the resident's room in order to weigh him. The resident was in bed, stood, pivoted, and lost his balance falling to the floor onto his left hip. During an interview with Employee 3, on January 18, 2024, at approximately 2:10 PM, she confirmed that she was alone in the resident's room without other staff members to assist with Resident 70's transfer. Employee 3 further stated she was unaware of the resident's transfer status and had looked at his care plan or Kardex, but other staff members told her that he was independent (no help required). Employee 3 stated that the resident did not refuse additional staff assistance (2nd staff member) and Employee 3, did not ask for additional assistance because he was independent. A review of facility provided document entitled Employee Education/Counseling Form date of incident December 4, 2023, indicated that Employee 3's transfer of Resident 70 from bed to scale was improperly performed, and to check the transfer status of the residents prior to transferring which is found in the Kardex. Date signed January 18, 2024, during the survey ending January 18, 2024. The facility failed to accurately identify the resident's transfer status and needs on the resident's care plan and care Kardex to ensure staff awareness of the level of assistance the resident required, both while wearing the prosthetic device on his lower leg and when not wearing the prosthesis. During an interview on January 18, 2024, at approximately 3:00 PM, the DON confirmed facility failed to fully develop and implement person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific transfer needs under varied situations to meet the individualized safety needs to prevent this fall with serious injury to the resident. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of select facility policy, clinical records and select facility reports and interviews with staff, it was determined that the facility failed to ensure that one out of seven residents reviewed was free from physical abuse (Resident 1) perpetrated by another resident (Resident 2), which resulted in actual harm of a fractured wrist to Resident 1. Findings include: A review of the current facility policy titled Abuse Policy reviewed by the facility December 2022, revealed that residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion, noting that No abuse or harm of any type will be tolerated. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included alzheimer's disease (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 3. According to the MDS Section E. Behavior, Resident 2 displayed verbal behaviors such as threatening others, screaming at others, cursing at others on 1-3 days during the assessment look back period and had physical behaviors of kicking, biting, scratching at others, etc., 1-3 days of the assessment look back period. The clinical record revealed that due to previous incidents of resident to resident abuse, perpetrated by Resident 2 in the past recent months, Resident 2 was receiving 1-1 staff supervision while awake and 15-minute checks while sleeping at the time of the incident on February 14, 2023. A review of a facility investigation report dated February 14, 2023, at 2:30 p.m., revealed that Employee 1 (LPN) heard a resident yelling let go of my hand. When Employee 1 entered the dining room she observed Resident 2 standing next to Resident 1 with his hand around Resident 1's left hand. Resident 2 was asked what happened and he stated, I don't know, that was my seat. Both residents were assessed. A review of Resident 1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included Alzheimer's disease (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 1's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired, with a BIMS score of 3. A review of information submitted by the facility and a facility incident investigation dated February 14, 2023, at 2:30 p.m., revealed that Employee 1 heard Resident 1 yell for help. Employee 1 was behind the nurses' station at that time, Employee 1, saw Resident 2 with his hand around Resident 1's left hand in the dining room. Resident 2 wanted Resident 1's seat and was squeezing Resident 1's hand. The residents were separated. Resident 1's hand swelled over the evening of February 14, 2023, and her physician ordered an x-ray. Results of an x-ray of Resident 1's left hand indicted a potential occult fracture of the distal cortical margin of the radius (wrist fracture). Resident 1 required a cast for two weeks. The facility reported that prior to the incident on February 14, 2023, Resident 2 was last seen sleeping and was not due to be checked on for another 5 minutes because the plan was to check the resident every 15 minutes while sleeping. A review of staffing for the day, February 14, 2023, of the incident revealed two LPNs and two CNAs were assigned to the resident's unit at time of the incident. Review of the facility incident report, including employee witness statements, revealed only two staff members were on the unit at the time of the incident as the other two employees were on lunch breaks, Employee 1 and Employee 2 (CNA). Employee 1 was behind the nurses station at the time of the incident. According to Employee 2's witness statement she was toileting another resident. There was no staff present in the dining room where there were multiple residents with dementia, left unsupervised according to the report. Resident 2's room is located at the end of the hallway farthest away from the dining room where the incident occurred. The facility failed to ensure that Resident 1 was free from physical abuse perpetrated by Resident 2, resulting in serious injury to Resident 1. An interview with the DON (director of nursing) and NHA (nursing home administrator) on March 29 2023, at approximately 2:00 p.m., confirmed that the facility substantiated physical abuse of Resident 1 by Resident 2. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 201.29(c)(d) Resident Rights 28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services

Based on a review of clinical records and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to accurately assess skin impairment and to prevent the development and/or worsening of pressure sores, which included complications of infection and pain, for two of three residents reviewed with pressure sores (Resident 59 and 77). Findings: 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 the areas of risk. The American College of Physicians (ACP) 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 clinical record revealed Resident 77 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated March 21, 2020, revealed that the resident required extensive assistance of staff with activities of daily living, bed mobility and transfers, and was identified at risk for pressure ulcers. A review of a, Braden Scale (a tool used to determine/predict pressure sore development) dated March 17, 2020, revealed that the resident received a score of 14.0, indicating that the resident was at moderate risk for pressure sore development. Review of the Resident 77's plan of care, initiated September 8, 2017, identified Resident 77 as at risk for alteration in skin integrity related to: impaired mobility, obesity, [CONDITION(S)], and diabetes mellitus. Interventions planned to prevent the development of a pressure area at the time of the finding include barrier cream to peri area/ buttocks as needed, encourage repositioning with care and comfort, and pressure reducing device to bed/chair. Additionally, review of the clinical record revealed that Resident 77 was positive for COVID-19 on May 22, 2020. Review of a, Pressure Ulcer assessment completed by Employee 10 (RN) dated May 24, 2020, revealed that Resident 77 presented an area on her right buttock. The description of the area was as follows: non-blanchable purple and redness to area the size of 17 long and 9 wide. Skin intact, painful to touch, area cleaned dried and ZGard cream (skin protectant) applied. Review of the clinical record and care plan revealed no documented evidence related to the circumstances surrounding the development of the pressure area. There was no documented evidence that the physician and responsible party were made aware of the significant change in the resident's skin condition. There were no new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator on March 19, 2021, at approximately 10:00 AM confirmed that the facility was unable to provide with any further information related to the development and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A, General Progress Note entered as a late entry on May 30, 2020, at 1:48 PM with an effective date of May 28, 2020 at 1:41 PM, by Employee 5 (RN) indicating that Resident 77 was seen for wound rounds. The area continued with deep red-purple area on right buttock consistent with a Deep Tissue Injury (DTI) 17.0 x 9.0 x UTD (Unable to Determine). Additionally, the documentation indicated the care plan was reviewed and current, treatment per physician orders, and the physician and responsible party were made aware. Review of Resident 77's May 2020, treatment administration record (TAR) and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, no new interventions were noted to be implemented at this time. Review of the resident's June 2020, TAR revealed that an order was initiated on June 3, 2020, for Hydraguard to bilateral buttocks DTI every shift for DTI bilateral buttocks. This treatment was discontinued on June 7, 2020. Further review of June 2020's TAR revealed that there was no indication a treatment was provided, or that the area on the right buttocks had been assessed, on June 7, 2020 or June 8, 2020. However, on June 9, 2020, a new order for the right buttock wound was to apply [MEDICATION(S)] (skin prep) to the peri wound and to pack loosely with ¼ inch strength Dakin's solution and cover with an ABD every day and evening shift for unstageable right buttock wound. The pressure sore measured 6.3 centimeters (cm) x 4 cm x 3.75 cm. The stage of the pressure sore was not identified in wound documentation. Review of facility weekly wound documentation revealed an entry on June 11, 2020, at 1:13 PM indicated at this time the right buttock wound was unstageable and currently measures 6 cm x 5 cm x 4 cm, Stage not identified. The wound was noted to have 80% yellow slough and 20 % black eschar, bloody drainage mixed with yellow drainage was noted along with mild odor. Peri wound was described as reddened, but blanchable. Interventions put into place at this time were to reposition resident from side to side and to place resident on her back only during meals. Additionally, it was noted they are currently awaiting wound cultures. Review of Resident 77's general progress notes revealed an entry on June 14, 2020, at 7:17 AM noting that the lab called the facility and indicated that Resident 77's wound was positive for [CONDITION(S)]- Resistant Staphylococcus aureus (MRSA). According to the Centers for Disease Control and Prevention: Staphylococcus aureus (staph) is a type of bacteria found on people's skin. Staph bacteria are usually harmless, but they can cause serious infections that can lead to [CONDITION(S)] and death, [CONDITION(S)]-resistant Staphylococcus aureus [MRSA] is a cause of staph infection that is difficult to treat because of resistance to some antibiotics). A general progress note dated June 14, 2020, at 9:56 AM indicated that the physician was aware of the culture results and to initiate an antibiotic [MEDICATION(S)] 100 milligrams (mg) by mouth (PO) every twelve (12) hours for ten (10) days for MRSA right buttocks wound. Review of Resident 77's weekly wound round documentation dated June 18, 2020, at 9:17 AM revealed that the resident's right buttock wound, had significantly increased in depth, and now measured 6 cm x 5 cm x 6 cm. Tunneling present 7.5 cm between 11 o'clock and 1 o'clock and 2 cm at 2 o'clock. Wound is 90% red granulation tissue and 10% yellow slough. Mild odor was noted. Resident denies pain during the assessment and the antibiotic for MRSA continues. Weekly wound rounds documentation revealed that the resident was denying pain from May 24, 2020, through July 9, 2020, with the exception of June 7, 2020, at which time she complained of 10/10 (scale from 1-10) pain and June 11, 2020, the weekly wound round skin note indicated that the resident had, mild pain. However, a review of the resident's clinical record revealed that the resident received as needed oxycodone- APA 10/325 mg (Combination medication used to help relieve moderate to severe pain. It contains and opioid [oxycodone] and a non-opioid (acetaminophen [APAP]) when the resident was provided a dosage. A general progress note entered July 10, 2020, revealed that the physician visited Resident 77 on this day and new orders were received in which [MEDICATION(S)] 30 mg was to be given by mouth (PO) every 8 hours from every 12 hours and to change oxycodone-APAP 10/325 mg one tablet by mouth every 6 hours as needed (PRN) from every 8 hours for breakthrough pain related to a, stage 4 sacral ulcer indicating an adjustment was made to increase the use of the narcotic medication to help relieve pain. Review of facility documentation related to the area first found on May 24, 2020, revealed the area persisted until December 17, 2020, at which time the area was identified as healed per facility documentation. Observation of Resident 77's buttock on March 19, 2021, at approximately 10:30 AM revealed an area on her sacrum which the facility reportedly had identified on March 18, 2021, which measured 1.3 cm x 0.5 cm x 0.1 cm. Interview with the Nursing Home Administrator (NHA) on March 19, 2020 at approximately 10:00 a.m. confirmed that effective measures were not implemented to prevent the development of pressure sores, planned interventions were not revised upon pressure sore development to ensure adequacy and ongoing appropriateness and the facility failed to promptly treat and consistently assess the pressure sore to prevent worsening. A review of Resident 59's clinical record revealed the resident's most recent admission to the facility was on January 13, 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Resident 59's Significant change Minimum Data Set (MDS) assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene (brushing teeth, washing face, combing hair etc.) and was identified as being at risk for developing pressure areas. A review of Resident 59's current care plan (a tool used by staff to direct the care needed for the specific resident) revealed interventions planned to prevent pressure sore development that included use pillows/positioning devices as needed, preventative skin care, elevate heels as able, encourage to reposition as needed, and pressure redistributing device on bed or chair. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that staff were checking the skin integrity at this site and surrounding area when completing this daily treatment. A review of a facility provided incident report dated January 27, 2021, at 10:50 a.m. revealed that the resident presented a newly acquired abrasion with a bruise was identified on the left posterior knee. Employee 2 (LPN), evaluated this newly acquired abrasion with a bruise that measured 10.8 cm (l), x 2.5 cm (w), intact dark blue - purple, without drainage. The physician and resident representative were notified. The intervention included to discontinue the ace wrap and apply [MEDICATION(S)] (a skin protectant) to left posterior knee every shift. However, further review of Resident 59's clinical record, including wound tracking documentation the following day, dated January 28, 2021, at 5:00 p.m., revealed that the area Employee 2 had identified as a new abrasion with a bruise located behind the left knee was now assessed as a newly acquired pressure ulcer. The left posterior knee skin impairment, had also increased in size, with new measurements as 11.5 cm x 4 cm, in total, the inner aspect of the wound was now open, unstageable and measures 2 cm x 4 cm. The wound bed was now 100% slough, edges are reddened, and the surrounding tissue of the wound is a deep tissue injury (DTI) with no drainage and no odor. New physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound tracking documentation dated February 4, 2021, at 10:06 p.m., indicated that the measurements of the pressure sore was 11.5 cm x 4 cm, in total, the inner aspect of the wound was now dry, closed, and scabbed. The edges remain reddened, the surrounding wound area is now a light purple and has the appearance of fading. No drainage, no odor. No new orders were obtained. Wound tracking documentation dated February 17, 2021, at 10:28 a.m., indicated the measurements were now 1 cm x 1 cm and the depth was undetermined. Area is intact with a hard - black eschar (dry, dark scab). Light purple skin staining around the wound that blanches with no drainage. On February 24, 2021 at 9:01 p.m., the clinical record indicated the wound had resolved and the physician and resident representative were aware. Interview with the NHA on March 19, 2021, at approximately 10:00 a.m. revealed that the NHA stated that Resident 59's skin impairment did not significantly decline from January 27, 2021 to January 28, 2021, as reflected in the wound tracking. The NHA confirmed that the assessment conducted by Employee 2 was not accurate when the LPN identified the area as an abrasion and bruise A facility investigation determined that Employee 2 did not record an accurate assessment of the resident's skin impairment. The facility determined that the resident had developed a pressure area as the result of the use of the Ace wrap. 483.25(b)(1)(i)(ii) Treatment/Services to prevent/heal pressure ulcers 28 Pa. Code 211.5(f) Clinical records. Previously cited 5/10/19, 6/14/19, 10/31/19, 11/15/19 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 5/10/19, 11/15/19 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services. Previously cited 5/10/19, 6/14/19, 10/1/19, 11/15/19 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/10/19, 6/14/19, 11/15/19

Based on a review of clinical records, the facility Diet Manual and select facility investigative reports and staff interview, it was determined the facility failed to ensure that food was served in a form to meet the individual needs of one of 19 residents sampled that resulted in actual harm to that resident (Resident 89) who expired as a result of the choking episode. Findings include: Review of the facility, Diet and Nutrition Care Manual last reviewed by the facility February 2021, for a Pureed diet revealed that the diet consists of foods that are easy to swallow because they are blended, whipped, or mashed until they are a pudding-like, cohesive texture. All foods on the diet are smooth and free of lumps. Everything is pudding-like. Nothing that requires chewing is allowed. A review of the clinical record revealed that Resident 89 had diagnoses, which included cerebral infarction (stroke), oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat), and [CONDITION(S)] (paralysis on one side of the body). The physician prescribed diet order dated [DATE], was for an enhanced diet pureed texture, mildly thick consistency (nectar thick fluids). Review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify specific resident care needs) dated [DATE], indicated that the resident had a BIMS (brief screener that aids in detecting cognitive impairment) score of 15 (score of ,d+[DATE] is indicative of cognitively intact), required extensive assistance of two staff for bed mobility, had no signs and symptoms of possible swallowing disorder, was independent in eating with set-up help for meals (includes cutting food to appropriate bite sizes), and was receiving a mechanically altered diet (require change in texture or liquids such as pureed foods or thickened liquids). Review of a facility, Incident Report Timeline of Critical Events: dated [DATE], revealed that on that date at 5:55 PM Employee 4 (LPN) was in the hallway when Resident 53 (Resident 89's roommate) came out into the hall and said help, help there is something wrong with her (Resident 89). Employee 3 (RN) was standing by the nurses desk. Employee 4 (LPN) and Employee 3 (RN) ran into Resident 89's room. Resident 89 was struggling to breathe and pointing at her meal tray. Employee 3 (RN) knew Resident 89 was telling Employee 3 (RN) she was choking. Employees 4 (LPN) and Employee 3 (RN) sat the resident straight up in bed. Employee 4 (LPN) climbed into bed and started doing the [MEDICATION(S)] maneuver (first-aid technique for someone who is choking because food or another swallowed object is obstructing his or her airway. Using an upward abdominal thrust, the [MEDICATION(S)] maneuver compresses the lungs and forces air up into the windpipe {trachea} until the object causing the choking is ejected from the throat). Resident 89 was laid on her side for a finger sweep. No food was found. Resident 89 was sat back up and the [MEDICATION(S)] maneuver was resumed. Oxygen was initiated. Code Blue was initiated and 911 was called. The [MEDICATION(S)] maneuver continued. At 6:10 PM EMS arrived and asked Employee 4 (LPN) if Resident 89 was in [CONDITION(S)]. Employee 4 (LPN) stated no she is breathing and responsive. Resident 89 then became unresponsive. EMS instructed Employee 4 (LPN) to start chest compressions until equipment prepared. EMS placed leads and could not find a rhythm (heartbeat). CPR (cardiopulmonary resuscitation- a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [CONDITION(S)]) was resumed. EMS turned Resident 89's head for another finger sweep and a whole green grape was in her mouth. EMS intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) the resident and another whole green grape came out. Rhythm checked and EMS shocked times one and rhythm resumed. Employee 4 (LPN) was manually ventilating Resident 89 with Ambu bag (a handheld device commonly used to provide positive pressure ventilation when not breathing or not breathing adequately) and as manually ventilating Resident 89 pureed food was coming up in the tube. Resident 89 was suctioned. Resident 89 was transferred to EMS litter (stretcher). Resident left the facility with a pulse while being manually ventilated. Review of Resident 53's statement related to the incident revealed that Resident 53 confirmed that fruit cocktail was provided as the dessert for supper on that date and that Resident 89 received it on her meal tray. Resident 53 confirmed that no one else had given Resident 89 the fruit cocktail and came on the resident' tray. Further review of the Investigation Report noted the probable root cause was the labeling of the pureed dessert was omitted in the dietary department. Desserts (for all diet textures) may have been in the same location as they were in identical disposable containers with lids. Immediate dietary education was completed. Labeling of altered diet textures and highlighting diet texture modified and/or thickened liquid tickets will be monitored by the dietary manager or designee and initialed for confirmation of accuracy. The trayline calls out the highlighted ticket to be checked and verified. The staff member at the end of the trayline will be responsible to ensure the accuracy of all trays as they are going into the cart. Nursing initiated a dining observation checklist on all floors- comparing the tray ticket to the items on the tray. A late entry general progress note dated [DATE], at 7:45 PM noted that a call was received from the emergency room informing the facility that Resident 89 was pronounced deceased following [CONDITION(S)] that did not respond to ACLS (advanced cardiovascular life support) efforts. Interview with the Director of Nursing (DON) on [DATE], at approximately 10:00 AM confirmed Resident 89's received food (fruit cocktail) that was not in a form to meet the resident's needs for safe swallowing to prevent the resident from choking. 483.60 (d)(3) Food in form individual needs 28 Pa. Code 211.6 (c) Dietary Services. Previously cited [DATE] 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records, facility event summary reports and information submitted by the facility and staff interview, it was determined that the facility failed to implement sufficient supervisory measures to prevent falls with serious injuries ([MEDICAL CONDITION] and head injury) for two of five residents reviewed with falls (Resident 45 and Resident 65). Findings include: A review of the clinical record review revealed that Resident 45 was admitted from the hospital to the facility on (MONTH) 15, (YEAR), with diagnoses, which include pneumonia (infection that inflames the air sacs in one or both lungs) [MEDICAL CONDITION] (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). The resident resided in a personal care home prior to the resident's hospitalization on (MONTH) 6, (YEAR). A review of a hospital history and physical report dated (MONTH) 6, (YEAR), revealed that the resident had a past medical history of [REDACTED]. The pressure on the brain causes a subdural hematoma's symptoms) but unsure of the date of occurrence. An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific intervals to identify resident care needs) dated (MONTH) 22, (YEAR), indicated that the resident was severely cognitively impaired and required extensive assistance with two persons for transfers between surfaces and for toileting. The resident was identified at risk for falls due to weakness and difficulty walking as per his care plan dated (MONTH) 15, (YEAR), with planned approaches that included to encourage the resident to transfer and change positions slowly, have commonly used articles within easy reach and reinforce need to call for assistance. Nursing documentation dated (MONTH) 20, (YEAR), at 6:56 PM indicated that the resident was found on the foot of his wheelchair with a lump noted to the right side of his head. The resident's pupils were unequal, but reactive. The resident was sent to emergency room at that time. A CT scan (computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CT scan images provide more detailed information than plain X-rays do) was performed and was negative. Following this fall, there was no documented evidence that the facility had evaluated the adequacy of the existing care plan addressing the resident's fall risk and/or had developed and implemented additional interventions to prevent future falls. Nursing documentation dated (MONTH) 23, (YEAR), at 9:17 PM indicated that the resident was very restless and was attempting to self-transfer and walk with poor ambulatory skills at this time. It was noted that he required 1:1 supervision (one staff member assigned to resident for supervision) for four hours for his safety. On (MONTH) 26, (YEAR), at 4:53 PM nursing documentation indicated that the resident slipped out of his chair and sustained a 5 cm hematoma (collection of blood under the skin caused by an injury) to the right side of his forehead. As the result of this fall, the facility revised the resident's care plan on (MONTH) 27, (YEAR), noting that the resident would wear non-skid footwear when he allowed it and physical therapy was to evaluate the resident. Nursing documentation dated (MONTH) 2, (YEAR), at 2:10 PM indicated that the resident attempted, three times, to self ambulate and get up out of his Broda chair (a chair used for positioning and mobility), but the staff was able to ambulate him. A review of nursing documentation dated (MONTH) 5, (YEAR), at 2:29 PM revealed that the resident's family requested a CT Scan of the resident's head due to his history of a subdural hematoma and falls in the past. A CT scan was completed on (MONTH) 10, (YEAR), which revealed a thin subdural collection of blood along the right parietal convexity (right area of the brain surface) measuring 3 mm (millimeter) in thickness. According to the CT scan report, there was a prior right frontoparietal (frontoparietal region is the portion of the left frontal and parietal lobes that overlap) craniotomy (a surgical operation in which a bone flap is temporarily removed from the skull to access the brain) with burr hole (hole surgically created to remove collection of blood). The report revealed no evidence of a new hemorrhage examination since study of (MONTH) 12, (YEAR) (performed prior to the resident's admission to the facility). Nursing documentation dated (MONTH) 14, (YEAR), indicated that the resident was very restless and frequently attempted to get out of his Broda chair, which continued on (MONTH) 15, (YEAR). Nursing documentation dated (MONTH) 19, (YEAR), at 2:24 PM indicated that the resident was attempting to ambulate on his own while staff assisted him. He attempted to sit back down on the Broda chair legs, which were extended. The resident flipped the Broda chair and the resident fell to the floor, hitting the right side of his head off another resident's chair. The resident sustained [REDACTED]. In response to this fall, an immediate intervention was to trial a rock and go wheelchair (a wheelchair that features a rocking motion designed to comfort the resident) and increase restorative ambulation. The resident's care plan was updated on (MONTH) 19, (YEAR), to trial the rock and go wheelchair, which has a design feature that has been shown to ease agitation in dementia. The resident's care plan also indicated that restorative ambulation was to be completed by staff, ambulating the resident with a rollator walker to and from the dining room and the bathroom for at least 35 feet twice a day and for periods of restlessness. However, at the time of the survey ending (MONTH) 18, 2019, there was no documentation indicating that this restorative ambulation was provided to the resident as planned. Nursing documentation dated (MONTH) 29, (YEAR), at 1:30 AM indicated Employee 2, LPN (licensed practical nurse) witnessed the resident standing in the hallway in front of his room. Staff went to help resident, but he fell on the carpeted floor in the hallway onto his right side. Staff did not observe the resident hit his head according to nursing documentation. Nursing documentation dated (MONTH) 30, (YEAR), at 6:00 AM indicated that the resident was found in another resident's bed and was verbally abusive to staff. Nursing documentation dated (MONTH) 31, (YEAR), at 1:05 AM revealed that this resident on the floor of his room, lying on his right side. The resident was unresponsive to painful stimuli. The resident was noted to have agonal breathing (irregular gasping breaths can be one breath every five to six seconds) and a lump to the back of his head with nonreactive pupils (no response of the pupil (the round black part of the eye) to constrict when stimulated with light or expand when exposed to a reduction of light). The resident also had a 3 cm laceration to the right temporal area of his head. The resident was sent to the emergency room at that time and admitted at 6:50 AM with a cerebral hemorrhage (bleeding in the brain). A CT scan completed at the hospital at 3:13 AM on (MONTH) 31, (YEAR), revealed a large 23 mm right parietal scalp hematoma with suspected active bleeding, an approximately 7 mm right to left midline shift (midline shift refers to when a person's brain actually shifts beyond the center line of the brain. The shift is normally caused by a traumatic event involving the brain or head) at the level of the septum pellucidum (a thin membrane located at the midline of the brain between the two halves of the brain), bilateral ,[DATE] mm frontal parietal subdural hematoma, right greater than the left, moderate 8 mm subdural hematoma along the posterior clivus (bony part of skull base) and multifocal areas of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). The hospital emergency department report indicated that the resident was critically ill with a poor prognosis and comfort care was recommended. The resident expired at 1:45 PM on (MONTH) 31, (YEAR). Interview with the Director of Nursing (DON) on (MONTH) 17, (YEAR), at approximately 11:15 AM confirmed that the facility had identified this resident to be at risk for falls and a known history of subdural hematoma. The DON verified that there was no evidence that the facility had provided adequate and increased supervision at the frequency and level required and/or effective safety measures to promote this resident's safety and prevent repeated falls and serious head injury. A review of Resident 65's clinical record revealed that the resident was admitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. The resident's admission physician orders [REDACTED]. A review of an admission MDS assessment dated (MONTH) 11, (YEAR), indicated that the resident had a BIMS score of 3 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0 to 7 indicates severe cognitive impairment). The resident required staff assistance with activities of daily living (daily tasks of self-care) and required supervision of one person physical assistance walking in his room and in the corridor on the unit. A physician's orders [REDACTED]. On (MONTH) 13, (YEAR), the resident was involved in a behavioral incident with his roommate, which resulted in Resident 65's admission to a psychiatric hospital from (MONTH) 13, (YEAR), through (MONTH) 27, (YEAR). Upon readmission the resident's readmission to the facility on (MONTH) 27, (YEAR), the physician's orders [REDACTED]. for hallucinations. A physician order [REDACTED]. A review of an incident report dated (MONTH) 1, 2019, at 12:20 PM indicated that Resident 65 was observed lying on the floor next to the resident's bed, with his pillow under his head. His head was at the foot of the bed, the bed sheets were lying on the floor and the mattress was pushed off the bed. The resident was found saturated of urine with no visible injury noted. The intervention planned following this incident, according to the report, was to toilet the resident when he awakes from a nap, but this intervention was not added to the resident's care plan. A review of information dated (MONTH) 1, 2019, at 4:40 PM submitted by the facility, revealed that Resident 65 sustained a fall in the hallway and he complained of pain in his left hip. The resident was transferred to the hospital with a [MEDICAL CONDITION] hip, which required surgery. A review of the resident's significant change MDS assessment dated (MONTH) 21, (YEAR), section G (functional status) revealed that the resident required supervision of two persons physical assist, while walking in the corridor. However, a review of progress notes from (MONTH) 21, (YEAR), through (MONTH) 1, 2019, revealed multiple entries noting that the resident was often walking independently throughout the unit and wandering aimlessly. There was no indication that staff was assisting the resident with ambulation in the hallway when he fell on (MONTH) 1, 2019, at 4:40 PM. A review of progress notes from the resident's admission to the facility on (MONTH) 4, (YEAR) until his fall on (MONTH) 1, 2019, revealed that he wandered about the unit. The resident's care plan, dated (MONTH) 4, (YEAR), indicated that the resident was at risk for falls due to poor mobility and resistance to staff education regarding safety. The interventions planned to minimize the resident's risk for falls included to encourage the resident to transfer and change positions slowly; have commonly used articles within easy reach and reinforce need to call for assistance. The facility did not plan approaches to monitor the resident's whereabouts and activities and to supervise the resident's at the level and frequency required to prevent falls. During interview with the Director of Nursing (DON) on (MONTH) 18, 2019, at 11:10 AM the DON acknowledged that upon the resident's return to the facility from the psychiatric unit, the resident was receiving additional psychoactive medications that may increase the resident's risk for falls and that the facility failed to review and revise the resident's fall prevention plan and implement measures necessary to prevent his fall with serious injury on (MONTH) 1, 2019, at 4:40 PM. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited [DATE] 28 Pa Code 211.12(a) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(c) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(d)(1) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records and staff and family interviews it was revealed that the facility failed to identify one resident's risk (Resident 2) for abusive behavior and timely implement sufficient measures necessary to protect residents from sexual harassment and abuse for two of six residents reviewed (Residents 1 and 6). Findings include: A review of Resident 2's clinical record revealed the resident had a [DIAGNOSES REDACTED].>(overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and depression. A review of the resident's most recent MDS Assessment, a significant change assessment dated (MONTH) 21, (YEAR), (Minimum Data Set - a federally mandated standardized assessment completed a intervals to plan resident care) revealed that the resident was independent with ambulation with supervision. The Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition) revealed that the resident was severely cognitively impaired. Resident 2 resided on the facility's dementia unit. A review of nursing documentation for the months of (MONTH) (YEAR) and (MONTH) (YEAR), revealed that the resident displayed intrusive behaviors (November 17, (YEAR), (MONTH) 27, (YEAR), (MONTH) 28, (YEAR), and (MONTH) 29, (YEAR)) including wandering into other residents' rooms, sleeping in other residents' beds and attempting to get into bed with them. The resident also displayed instances of various socially inappropriate behaviors including urinating in inappropriate and public areas and exposing himself (October 17, (YEAR), (MONTH) 22, (YEAR), (MONTH) 19, (YEAR), and (MONTH) 3, (YEAR)). The resident frequently could not be re-directed when displaying these behaviors according to nursing documentation following these above instances. Further review of the resident's clinical record revealed that the resident began to continually masturbate in public areas on the morning of (MONTH) 10, (YEAR). Nursing documented that the resident was redirected to his room, which he shared with Resident 1, for privacy. Nursing noted that additional interventions of attempting fluids and snacks were attempted, but proved ineffective and Resident 2 continued to leave his room and return to the dining room. At 11:50 a.m. on (MONTH) 10, (YEAR), nursing documented that the resident continued to leave his room to masturbate in the dining room. At 12:45 p.m. on (MONTH) 10, (YEAR), nursing documented that the resident was observed in the dining room rubbing the back and the breasts of female Resident 6 who resided with him on the dementia unit. A review of Resident 6's clinical record revealed that this resident lacked the cognitive ability to consent to sexual contact with Resident 2. A review of Resident 6's most recent MDS (quarterly) assessment dated (MONTH) 18, (YEAR), revealed that the resident was severely cognitively impaired. Nursing noted that Resident 2 was masturbating in the dining room at 1:19 p.m. on (MONTH) 10, (YEAR). The noted staff intervention was to redirect the resident to his room for privacy. At 2:20 p.m. on (MONTH) 10, (YEAR), nursing documented that the resident continued to go into the dining room to masturbate. Nursing continued to redirect the resident to his room for privacy. The staff also offered the resident activities to divert his attention, to which he was not receptive, according to nursing documentation. On (MONTH) 12, (YEAR), nursing documented that the resident was awake all night, masturbating in the corridor despite repeated re-direction. Nursing noted that the resident was immediately placed in his room during these instances. During the 3 p.m. to 11 p.m. shift on (MONTH) 12, (YEAR), nursing documented that the resident was masturbating in the corridor, dining room and other resident rooms. Nursing redirected the resident with limited effect and noted that the resident became agitated when staff attempted to redirect him. A review of the resident's clinical record revealed that on (MONTH) 13, (YEAR), at 8:30 a.m. a staff member passed the resident's room and observed Resident 2 sitting on his bed, with two fingers in the rectum of Resident 1 (his roommate). Resident 1 was observed kneeling next to his bed naked. A review of Resident 1's clinical record and corresponding plan of care initiated on (MONTH) 31, (YEAR), and revised on (MONTH) 20, (YEAR), revealed that the resident had a history of [REDACTED]. A review of Resident 1's most recent MDS assessment dated (MONTH) 11, (YEAR), revealed that the resident was severely cognitively impaired. When interviewed, on (MONTH) 27, (YEAR), at 12:30 p.m. Employee 1, Licensed Practical Nurse (LPN) stated that Resident 1 prefers to sleep in the nude and frequently crawls or squats on the floor, at times, with his head on chairs or the bed. Interview with Resident 1's significant other on (MONTH) 27, (YEAR), at 1:50 p.m. revealed that Resident 2 had been wandering about the facility and in and out of their room exposing himself for a few days prior to the incident of (MONTH) 13, (YEAR). She stated that Resident 1 was not easily redirected and required increased staff supervision. A review of Resident 2's comprehensive plan of care revealed that the facility added the problem of the resident's behaviors of masturbating and inappropriately touching others on (MONTH) 11, (YEAR). The planned interventions were limited to placing the resident in his room when masturbating and separating the resident when he was inappropriately touching them. There was no documented evidence that in response to the resident's recent onset of sexual fixation that the facility had planned to increase supervision of Resident 2 to prevent inappropriate sexual contact with other residents. There was no indication that the facility had evaluated the continued appropriateness of Resident 2's room placement with Resident 1 due to Resident 1's known preference to sleep nude in a kneeling position. The facility planned to re-direct Resident 2 to their shared room for privacy when masturbating. There was no evidence that the facility had implemented additional supervision or appropriate interventions following the onset of new behaviors of a sexual nature, to protect other residents from Resident 2's sexual contact. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management Previously cited 7/14/17 28 Pa. Code 201.29(a) Resident Rights Previously cited 2/9/18, 7/14/17 28 Pa. Code 201.29(c)(d) Resident Rights 28 Pa. Code 211.12(a) Nursing Services Previously cited 8/27/18, 6/25/18, 2/9/18, 11/29/17, 7/14/17 28 Pa. Code 211.12(c) Nursing Services Previously cited 8/27/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 8/27/18, 6/25/18, 5/23/18, 2/9/18, 11/29/17, 7/14/17

Based on a review of clinical records, select facility policy and reports and staff interviews it was determined that the facility failed to provide sufficient staff assistance and utilize safe technique required to safely transfer a resident resulting in a fall with a hip fracture for one resident (Resident 28) and failed to provide sufficient staff supervision and necessary safety measures for a resident at risk for falls to prevent a fall with a hip fracture for one resident out 26 sampled (Resident CR5). Findings include: Review of the facility's policy entitled Mechanical Lift reviewed by the facility January 2017 revealed that the purpose of the lift is to move immobile or obese patients for whom manual transfer poses potential for staff or patient injury. It is advisable to have two staff members present to stabilize and support the patient. Review of the clinical record of Resident 28 revealed that the resident had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 30, 2017, revealed that the resident's BIMS score was 15 (Brief Interview for Mental Status, a tool to assess cognitive function, a score of 13-15 indicates that the resident is cognitively intact) and required the assistance of two staff members for transfer and bed mobility. Review of a facility incident report investigation and information dated May 1, 2017, submitted by the facility revealed that a nurse aide approached the desk at the nurse's station and stated that she needed help; there was an issue with Resident 28. Upon entering the room, a nurse observed the resident on the floor with her left foot under the bed and the resident's right leg resting up on the bed. The resident's body was across the hoyer (mechanical lift used for transfer or transport) and the resident's head was under her roommate's bed. The resident stated that she fell from the lift and hit her head on the floor. The nurse attempted to assess the resident, when the resident began screaming in pain with light touch and slight movement of her right leg and hip. The nurse informed the physician at that time and the resident was sent to the hospital for evaluation and treatment on May 1, 2017. The resident was diagnosed with [REDACTED]. Review of Employee 3's (a nurse aide) statement revealed that Employee 3 placed the sling (a cloth lift pad device placed under the resident and used to support the resident during transport or transfer), made sure the leg straps to the sling were crossed under the resident's legs and hooked the lift pad to the hooks (from which the sling hangs) on the mechanical lift. Employee 3 began raising the resident up from the bed; the resident was over the wheelchair when the sling detached from the hook on the lift and the resident fell . Employee 3 also stated that she pushed the resident over too far over the wheelchair and began adjusting the sling over the chair when the sling came off the hook on the lift. Employee 3 confirmed that she knew that she needed a second staff member to help with the resident's transfer in the lift. A review of the Resident 28's statement revealed that the resident only saw one nurse aide in the room at the time of the fall. The resident also stated she fell out of the (lift) sling and hit her head on the floor. Review of a general orientation (hire) to include utilization of a mechanical lift dated December 28, 2016 revealed that Employee 3 was instructed on the proper use of the mechanical lift to include review of the facility's policy. Employee 3's signature verified the training. Interview with Resident 28 on July 11, 2017, at 2:30 p.m. revealed that the resident stated that the nurse aide was alone during the transfer with the mechanical lift. The resident also stated that the lift pad was not hooked up correctly under her and she fell from the lift while being transferred. Interview with the Director of Nursing on July 12, 2017, at approximately 11:00 a.m. verified that the Employee 3 needed another staff member to safely transfer the resident in the mechanical lift. Review of the clinical record of Resident CR5 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set assessment dated [DATE], revealed that the resident had a BIMS score of 11, (a score of 8-12 indicates moderate cognitive impairment) and required the assistance of two staff members for transfer and bed mobility. A review of an admission nursing assessment dated [DATE], indicated that Resident CR5 was at risk for falls and that the facility should proceed to a fall plan of care. The resident's initial plan of care dated June 28, 2017, included the problem of at risk for falls and interventions that nursing staff would evaluate the resident's medications if the resident demonstrates changes in mental status, to provide assistance to transfer and ambulate the resident as needed and to reinforce with the resident the need to call for assistance. A review of a resident/family concern form dated June 29, 2017, submitted to the facility revealed that Resident CR5's husband's concern was that Resident CR5 had a history of [REDACTED]. The husband was concerned that his wife required a bed alarm, maybe a Wanderguard bracelet (Wanderguard system is a door monitor designed to monitor cognitively impaired individuals with wandering by wearing a bracelet that alarms when an individual approaches the alarmed door) or a move to the locked dementia unit in the facility. According to the concern form, the facility's social services coordinator spoke with the resident's spouse that day (June 29, 2019) on the telephone. The resolution to the family's concerns was to state that it was OK for the resident to have a Wanderguard bracelet and the resident's husband agreed to have the resident remain in her original room. There was no mention of adding any additional interventions to prevent falls for the resident, including a bed alarm, as noted by the resident's husband on the concern form. The resident's family completed a second facility concern form on July 7, 2017. The resident family expressed a concern regarding untimely staff assistance for the resident on the evening of July 5, 2017. The facility social services director again spoke to the resident's family and addressed the staff assistance issues. The facility social services director also informed the resident's husband that it is not the facility policy to use bed and chair alarms or fall risk identification bracelets as fall prevention interventions. During an interview on July 14, 2017, at 9:15 a.m. Employee 7 (assistant business office manager - ABOM) stated that upon admission she met with Resident CR5's husband. She stated that the resident's husband stated that his wife was a fall risk, having several falls at home and was often up wandering at night, prior to admission to the facility. The resident's husband requested at the time of the resident's admission that bed alarms be placed on his wife's bed to prevent falls and that a fall alarm bracelet be placed on his wife. Employee 7 (ABOM) stated that she told the resident's husband that would look into this request. Employee 7 (ABOM) then told Employee 9 (housekeeping personnel) about the request of the resident's husband because she wanted someone in the building to know of the husband's request for fall prevention interventions. Employee 7 (ABOM) then told Employee 8 (RN, MDS coordinator) of the request for fall interventions. Employee 7 then told the resident's spouse to write a concern form and give it to the Nursing Home Administrator to look into the issue. A review of nursing documentation dated July 1, 2017, at 4:32 a.m. revealed that the resident transferred herself to the wheelchair and was yelling out for help to go to the bathroom. The entry indicated that staff educated the resident on the risks vs the benefits of ringing the call bell for staff assistance to the bathroom. Review of a facility incident report and investigation and documentation dated July 11, 2017, submitted by the facility revealed that on July 11, 2017, at approximately 5 p.m. staff found Resident CR5 on the floor next to her bed. The resident was unable to state what had occurred at the time of the incident. She was wearing non-skid socks and was continent of bladder and bowel. The physician and the responsible party were contacted at that time and the resident was sent to the hospital for evaluation on July 11, 2017. She was admitted to the hospital for surgical repair of her right hip. There was no evidence at the time of the survey that the facility had timely acted upon the resident's risk and history of falls and had promptly implemented sufficient safety measures to prevent falls and serious injury to the resident. 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices Previously cited 1/27/17, 7/20/16 28 Pa. Code 211.10(a) Resident care policies. Previously cited 1/27/17, 4/5/17, 9/23/16, 9/8/16, 7/20/16, 2/9/16 28 Pa. Code 211.10(c) Resident care policies. Previously cited 1/27/17, 9/23/16, 9/8/16, 2/9/16 28 Pa. Code 211.10(d) Resident care policies. Previously cited 1/27/17, 4/5/17, 9/23/16, 7/20/16, 2/9/16 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services Previously cited 1/27/17, 4/5/17, 9/23/16, 9/8/16, 7/20/16, 2/9/16

Based on a review of clinical records and resident incident reports and investigations, observations and staff interviews, it was revealed that the facility failed to provide sufficient staff assistance during an activities outing to prevent an accident resulting in a serious head injury to one resident (Resident 35) and failed to utilize safe technique and/or sufficient staff assistance during care to prevent one resident's fall from bed for one resident out of 24 sampled residents (Resident 57). Findings include: A review of the clinical record revealed that Resident 35 had [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment (MDS -a federally mandated standardized assessment process completed periodically to plan resident care) dated December 28, 2016, revealed that the resident required assistance from the staff with the activities of daily living (routine activities that people tend do every day without needing assistance including eating, bathing, dressing, toileting, transferring (walking) and bladder and bowel continence) including transfers, walking and toileting. The resident's BIMS Score (Brief Interview for Mental Status - a tool to assess cognitive function) was a 14 indicating that the resident was cognitively intact. A review of resident incident reports dated February 2016 through December 16, 2016, revealed that the resident had incurred eight falls during that time frame, six of which involved the resident's use of the wheelchair. Following these falls, the resident was referred to therapy and education was provided to the resident regarding the use of the call bell to request staff assistance and not to reach out while seated in the chair. There was no documented evidence, however, that the resident had been evaluated for the continued safety in the use of the wheelchair. An incident report dated December 19, 2016, revealed that Resident 35 was out of the facility attending church with six other residents and one staff member. Three of the residents attending church that day were able to ambulate with the use of a walker without staff assistance, one resident was independent in ambulation and three residents required the use of wheelchairs. According to the report, two of the six residents in attendance were severely, cognitively impaired, one was moderately cognitively impaired and three were cognitively intact. The incident report indicated that Resident 35 attempted to exit the church in her wheelchair via a ramp and her chair fell backwards. The resident was lying on her back with bleeding to the back of her head and her legs tangled in the wheelchair. A witness statement regarding this incident from Employee 11 (the Activity Director) indicated that at approximately 9:00 AM on December 19, 2016, the county transit bus arrived at the church to pick up the residents for their return trip to the facility. Employee 11 asked Resident 35 to wait at the bottom of the ramp while she assisted three ambulatory residents onto the bus. While Employee 11 assisted the other residents onto the bus, she looked out the bus window and saw Resident 35's wheelchair flipped over. The resident was lying on her back holding her head, slight bleeding was observed from her head, and her legs were tangled in the wheelchair. Emergency services was called and Resident 35 was transported to the local hospital. According to the facility's investigation report at the time Resident 35 was subsequently transferred to a trauma center because she required a higher level of care than was available at the local hospital. A review of a hospital history and physical (trauma center H & P report) dated December 19, 2016, at 3:10 PM indicated that, at the time of the fall, the resident had been receiving aspirin and Plavix (a blood thinning medication - both aspirin and Plavix thin the blood, which may increase bleeding and the time it takes for blood to clot). The H & P report noted that while the resident was leaving the church earlier that date, her wheelchair tipped backward, causing her to hit her head on the ground. The resident reported losing consciousness, having pain and had presented with a hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma) on her occipital (the back of the head) and had been first transferred to the local hospital for evaluation. While at that local hospital she had a CT scan (a Computerized Tomography Scan - diagnostic test using computer-processed combinations of many X-ray images taken from different angles to produce cross-sectional images of specific areas) of the head. The resident was found to have a left subarachnoid hemorrhage (SAH is bleeding into the subarachnoid space - the area between two of the membranes that surround the brain - the arachnoid membrane and the pia mater) with a possible subdural hematoma (also known as a subdural hemorrhage - usually associated with traumatic brain injury. Blood gathers between the inner layers of the brain and subdural space and may cause an increase in intracranial pressure, which can cause compression of and damage to delicate brain tissue). The resident was then transferred to the trauma center for a higher level of care. She was noted to have an occipital scalp (the back of her head) hematoma (a collection of blood) with an overlying abrasion. Resident 35 was admitted to the trauma hospital for treatment and was readmitted to the long term care facility on December 29, 2016. During an interview on January 26, 2017, at approximately 12:00 PM the Activities Director (Employee 11) stated that the day of Resident 35's fall was the first time the facility had held that church activity. Employee 11 verified that she was assisting the three ambulatory residents onto the bus and through the bus window saw Resident 35 attempt to go up the ramp in her wheelchair inside the church doors and fall backwards. Resident 35 had a history of [REDACTED]. The additional residents attending the outside activities program required some staff assistance or supervision with mobility. There was no evidence at the time of the survey that the facility had provided sufficient staff during this activity outing to supervise residents and maintain resident safety and prevent this resident's accident and serious injury. A review of the clinical record revealed that Resident 57 had [DIAGNOSES REDACTED]. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances) and difficulty walking. According to the resident's quarterly MDS assessment dated [DATE], the resident required extensive staff assistance of two staff with activities of daily living, including bed mobility. The resident's BIMS Score was 3 indicating that the resident was severely cognitively impaired. According to a resident incident report, Resident 57 incurred a fall from bed on January 6, 2017, at 8:02 AM during which time Employee 1, a Nurse Aide, rolled the resident out of bed during care. Employee 1 rolled the resident away from herself and lost control of the resident. The resident's weight created momentum causing the resident to slide down the right side of the bed. The resident did not sustain injury as a result of the fall. A review of the facility's action plan to address Employee 1's job performance dated January 6, 2017, in response to this incident, revealed that Employee 1 was caring for the resident and during care the resident rolled out of bed because the resident was rolled away from this employee instead of towards Employee 1. The plan was that this employee would ask for assistance since the resident required two staff. An interview with the Director of Nursing (DON) on January 27, 2017, confirmed that Employee 1 did not use proper technique and/or sufficient staff assistance during care to prevent Resident 57's fall from bed. 483.25(d)(1)(2)(n)(1)-(3) Free of Accidents Hazards/Supervision/Devices Previously cited 7/20/16 28 Pa. Code 211.10(a) Resident care policies. Previously cited 9/23/16, 9/8/16, 7/20/16, 2/9/16, 12/11/15 28 Pa. Code 211.10(c) Resident care policies. Previously cited 9/23/16, 9/8/16, 2/9/16, 12/11/15 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/23/16, 7/20/16, 2/9/16, 12/11/15 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services. Previously cited 9/23/16, 9/8/16, 7/20/16, 2/9/16, 12/11/15

Based on review of clinical records and select facility policy, observation and resident and staff interview, it was revealed that the facility failed to timely identify contributing and/or risk factors for the development of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin), failed to develop and consistently implement interventions and treatments to prevent development and worsening of pressure sores and failed to consistently monitor and evaluate the effectiveness of treatments to promote the healing of pressure sores for three of 11 residents reviewed (Residents A9, A10, B5) Findings include: A review of the clinical record of Resident A9 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. system) and hypertension (high blood pressure). A review of the resident's admission nursing assessment revealed that the resident was free of skin breakdown. The resident had physician's orders [REDACTED]. According to review of the resident's initial care plan dated June 26, 2016, the resident was at risk for impairment in skin integrity based on decreased mobility. The facility planned interventions to address this risk, included encouraging the resident to reposition as needed, pressure reducing devices on the resident's chair and bed and preventative skin care was to be provided by the staff routinely and as needed. On July 1, 2016, the resident was further assessed for risk of skin breakdown using the Braden Scale (standardized tool used to predict risk of developing skin breakdown). The results indicated that the resident was at mild risk for the development of pressure sores scoring a 16 (a score of 15 to 18 indicates a mild risk for developing pressure sores) A review of the resident's clinical record revealed documentation by Registered Nurse (RN) Employee 1, on July 2, 2016, indicating that the resident had developed an excoriated (damaged, removed, worn away portion of skin) area to the resident's sacrum (bone near the lower end of the spine) measuring 10 cm (centimeter) x 9 cm and an open area to the lower portion of the sacrum measuring 2 cm x 1 cm. The nurse described the areas to the sacrum as non-blanchable (does not lose color when pressure is applied) and free of odor and drainage. An additional area measuring 7.5 cm x 2.7 cm was described as a reddened pressure sore was identified to the resident's lower spine. This area was described as blanchable (skin loses color with pressure.) A review of the resident's skin alteration record (a facility document/tool used to identify and track, for assessment purposes, areas of modified skin integrity) revealed that this particular tool was intended for use for skin issues not categorized as pressure sores. On July 3, 2016, the facility noted on this form that the type of skin alteration the resident presented was other. There was no further description\identification of the actual categorized type or cause of the skin alteration that Employee 1 had described as pressure related on July 2, 2016. The skin alteration record completed on July 3, 2016, indicated that the impaired area of skin on the resident's lower spine was 7.5 cm in length x 2.7 cm in width. The area was described as dark pink\red tissue free of drainage. The area surrounding the alteration was described as reddened. The type of alteration on the resident's sacrum, was also categorized as other without any identification of the cause. The area was assessed on July 3, 2016, and noted on the skin alteration record to be 10 cm length by 9 cm width. The description of the alteration was noted as dark pink/red tissue. The area was free of drainage, with the skin surrounding the area reddened. Treatment orders were obtained on July 3, 2016, for a Comfy foam dressing (self adherent dressing designed to absorb while creating a moist environment for healing) to the resident's sacrum daily and [MEDICATION NAME] Composite dressing (non-adherent layer, absorbent layer, water-[MEDICATION NAME] layer) to lower spine daily for 10 days and re-evaluate. The facility's current interventions included repositioning the resident side to side every two hours, the resident was not to be out of bed longer than two hours per day and periods of non-compliance with these interventions were to be identified. All previous interventions remained the same. A review of Resident A9's nursing progress notes revealed that on July 6, 2016, the resident's areas of impaired skin were assessed for purpose of the Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care). The areas were described as excoriation with open areas from moisture (skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, perspiration, wound drainage, saliva or mucous.) A review of the resident's turning and repositioning records revealed that the resident was not turned and repositioned every two hours from side to side as planned. There was no documented evidence that the resident was repositioned on July 5, 6, 2016, from 3:00 a.m. to 7:00 a.m., and July 6, 2016, from 5:00 p.m. to 9:00 p.m. On July 9, 2016, there was no documented evidence that the resident was turned and repositioned from 7:00 p.m. to 11:00 p.m. There was no documented evidence that the resident had been turned and repositioned on July 10, 2016, from 3:00 a.m. to 7:00 a.m. The resident was not repositioned after 11:00 p.m. on July 10, 2016, according to the records. On July 10, 2016 through July 11, 2016, there was no evidence that the resident was turned and repositioned after 7:00 a.m., or from 7:00 p.m. to 11:00 p.m. On July 14, 2016, there was no evidence that the resident was turned from 3:00 a.m. to 7:00 a.m. and from 7:00 p.m. to 5:00 a.m., on July 15, 2016. There was no evidence that the resident was repositioned from 9:00 p.m. to 1:00 a.m., on July 16, 2016. On July 17, 2016 there was no evidence the resident had been repositioned from 3:00 a.m. to 7:00 a.m. The staff documented that the resident refused to be repositioned after 11:00 p.m. on July 16, 2016, until 5:00 a.m. on July 17, 2016. This refusal was noted to occur again from 1:00 p.m. to 7:00 p.m., on July 17, 2016, and from 7:00 p.m. to 1:00 a.m. on July 18, 2016. On July 18, 2016, staff noted that the resident refused to be repositioned from 1:00 a.m. to 5:00 a.m. The resident was repositioned at 7 a.m. on July 18, 2016. There was no evidence that the facility had identified these periods of non-compliance with turning and repositioning either due to the staff's failure to perform the turning and repositioning or the resident's refusals. A review of nursing progress notes dated July 11, 2016, revealed that the resident's heel and right outer ankle and right lateral (side) foot were boggy (spongy with a fluid filled feel.) The facility obtained an order on July 11, 2016, for [MEDICATION NAME] barrier cream (a cream that provides protection of the skin from bodily fluids while moisturizing the skin) to the areas. There was no indication that the facility had developed specific interventions to reduce pressure on the resident's heels and feet either prior or subsequent to the development of the skin impairments on the resident's heel and foot on July 11, 2016. Further review of the resident's clinical record revealed no further documentation regarding the condition of these impaired areas of skin on the resident's right heel and foot. A review of the skin alteration record for Resident A9 revealed that the areas to her sacrum and lower spine were re-assessed after the assessment of July 3, 2016. However, the nurse completing this assessment did not date the assessment. A review of this assessment revealed that the impaired areas of skin on the resident's sacrum had not improved. The areas were described as slough (a layer or mass of dead tissue separated from living tissue,) with moist yellow or gray necrotic (dead) tissue with a scant amount of serous (clear) drainage. The skin surrounding the area remained reddened, and was described as macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) skin softening related to fluid A review of the facility's policy related to pressure sore prevention and treatment last reviewed by the facility in 2013, revealed that the facility was to use various interventions to assess, plan, implement and evaluate the risk for skin alteration. It was the facility practice to assess areas of modified skin integrity every seven days to track progression and regression and to assess the appropriateness of treatments and interventions. When interviewed on September 23, 2016, at 2:45 p.m. the Director of Nursing Services and Corporate Nurse confirmed that these procedures were currently utilized by the facility. Resident A9 was discharged from the facility on July 18, 2016, to another facility. According to above facility policy, the resident's pressure areas should have been assessed on two additional occasions after their discovery on July 2, 2016 and the completion of the initial skin alteration sheet on July 3, 2016, (July 10, 2016 and 17, 2016). There was no indication that these areas were assessed per policy. Resident A9 utilized a Foley catheter for urinary output and had developed skin breakdown on her sacrum and lower spine area from moisture, but the facility failed to evaluate the potential source of this causative factor (moisture) and timely develop and implement measures to promote healing of these pressure areas and prevent worsening. A review of the clinical record revealed that Resident A10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident developed an open area to the left heel measuring 1.8 cm x 1 cm. on August 22, 2016. An order was obtained on August 22, 2016, to cleanse the area with normal saline solution (sterile mixture of salt and water) and cover with a dressing daily. On August 23, 2016, the area was evaluated by Employee 3, a Registered Nurse, who described the area as open with macerated edges. The wound base was beefy red and measured 2 cm x 0.7 cm. The physician treatment order was changed on August 23, 2016, to cleanse the left heel with soap and water, pat dry and apply derma gel (a treatment product that maintains a moist wound environment to prevent scab formation) cut to size and cover with gauze and secure with Kling tape (first aide tape). The treatment was to be completed every five days and as needed for slippage and/or soilage. On September 5, 2016, the resident's treatment was changed to cleanse the resident's left heel with wound cleanser, apply Skin integrity Hydrogel Impregnated Gauze (wound dressing pre-saturated with hydrogel gel, a wound treatment product) cover with ABD dressing wrap (highly absorbent dressing that provides padding and protection for large wounds) with Kling tape and change every three days for 15 days and re-evaluate. Review of the resident's clinical record revealed that, a purple colored area to the top of the resident's left foot measuring 0.3 cm x 0.7 cm was discovered on September 9, 2016, and described as not open and free from drainage. The facility determined that the purple colored area was caused by applying the Kling (tape) too tightly. No treatment was ordered with the plan to leave the area open to air and to discontinue the use of Kling tape. The facility was not tracking this area on a pressure ulcer treatment record or skin alteration record and according to nursing progress notes dated September 22, 2016, the facility's plan remained to refrain from treating the area. The area now measured 0.2 cm by 0.4 cm, but was now described as a scab, although there was no nursing documentation prior to this date indicating that the purple colored area of skin had opened (with this later scab formation covering the open wound). Observation of the resident on September 23, 2016, at 3:25 PM revealed that the resident was seated in the hallway wearing Medix boots (padded cloth boots designed to reduce pressure); underneath these boots the resident was wearing a sock, which was applied only to his forefoot (toes to the ball of his left foot) and the excess material of the sock was observed to be rolled under his toes and the ball of his foot. The sock positioning, half on the resident's foot and half rolled beneath, was observed to elevate the resident's forefoot upwards, placing pressure on the resident's heel. Observation of the resident in his room on September 23, 2016, at 3:45 PM revealed that the area to the top of the resident's left foot remained scabbed. When observed at that time there was no dressing on the resident's heel. Employee 2, a Licensed Practical Nurse (LPN), stated that nursing staff most likely had assessed the resident's foot earlier that day, but did not perform the treatment because she was responsible for completing the resident's foot treatment during the 3 PM to 11 PM shift. A review of the clinical record revealed that the facility assessed Resident B5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility assessed the resident for the risk of the development of pressure ulcers on June 2, 2016, utilizing the Braden scale. The resident's score indicated that the resident was at mild risk for the development of pressure sores. In response to this risk, the physician ordered Cavalon (barrier cream to protect the area from moisture) to the resident's heels daily beginning April 30, 2016, Medix boots as resident allows and float (elevate) the resident's heels when in bed beginning April 18, 2016. According to the resident's comprehensive plan of care initiated on August 14, 2015, staff were to observe the resident's skin condition on a daily basis and report any abnormalities to the licensed nurse. A review of the resident's treatment administration records for July 2016, revealed no documented evidence of the application of the Medix boots or the resident's acceptance of them, according to the physician order. According to review of the resident's last MDS Assessment, a quarterly review, dated July 22, 2016, the resident was an extensive assistance of two staff members for hygiene, bathing and transfers. The resident required extensive assistance of at least one staff member for all other activities of daily living (routine activities that people tend do every day without needing assistance, eating, bathing, dressing, toileting, transferring (walking) and bowel and bladder continence). A review of nursing progress notes dated August 3, 2016, revealed that an area to the resident's left heel was identified. The area measured 5.2 cm. in length x 4.4 cm. in width x 0.1 cm. in depth. Moderate amounts of serosanguineous drainage (pink mix of watery blood mixed with serum separated blood) was observed and the area was described as foul Smelling. The wound base of the area was assessed as having 90% slough(a layer or mass of dead tissue separated from living tissue) and was bright red in color. physician's orders [REDACTED]. Kling tape. The treatment was to be reassessed in 14 days. The Medix boots were to be applied bilaterally at all times and removed for care. A physician order [REDACTED]. decline in skin integrity. On August 10, 2016, Employee 6, a Registered Nurse, completed a treatment on the resident's heel and documented that the area was very red with large areas of yellow exudate (pus-like fluid). The area was assessed as measuring 7 cm x 8 cm with an area to the left side of the wound that measured 6 cm x 4 cm. No odor was noted, but the previous dressing that was removed had several inches of old dark grey drainage. Employee 3, RN who is responsible for monitoring wounds at the facility, assessed the area on August 11, 2016. The area was documented as measuring 7.2 cm x 5.4 cm x 0.1 cm. with a heavy amount of serosanguineous drainage. The wound base was 90% slough and was bright red in color. The wound edges were macerated and the area was described as having a foul odor. The resident was described as having increased pain, but refusing pain medications. There was no indication that the resident's attending physician was notified of the regression of the area or that the interdisciplinary team identified this decline to determine if changes in the resident's treatment regimen were indicated. The only documented approach was the resident's pending appointment at an outside wound care clinic scheduled for August 19, 2016. On August 19, 2016, the resident was evaluated at the wound care clinic. It was confirmed that the area was a Stage III pressure area (full-thickness loss of skin, slough and/or eschar may be visible) to the resident's left calcaneus (bony part of the heel.) Debridement (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of an area described as 9.98 square centimeters was performed at the wound care clinic. Notes from the visit revealed that both viable (capable of surviving or living) and non-viable tissue and material including eschar (thick scabbed dead tissue), callus and subcutaneous (under the skin) required excision. Subsequent to this procedure, the area measured 2.5 cm x 3.5 cm x 0.3 cm. The post (after) debridement stage of the wound was listed as unstageable/unclassified (If slough or eschar obscures the extent of tissue loss this is an unstageable pressure sore). Observation of the resident's left heel on September 23, 2016, at 3:30 PM revealed an irregular shaped open area measuring 2 cm x 5 cm x less than 0.1 cm. The right outer edge was black eschar. The left outer edge was red with blood present that area. The center was pink as well as the outer edges of the area. When interviewed on September 23, 2016, at 2:45 PM the facility's Corporate Nurse and the Director of Nursing Services stated that it is not the facility's practice to formally evaluate areas of modified skin integrity to determine potential causative factors. Both of these individuals were unable to explain why this significant involved area of skin breakdown had not been discovered by facility staff prior to August 3, 2016. 483.25(c) Treatment/services to prevent/heal pressure sores Previously cited 12/11/15, 7/8/15 28 Pa. Code 211.10 (a) Resident care policies Previously cited 9/8/16, 7/20/16, 2/9/16, 12/11/15, 11/4/15, 7/8/15 28 Pa. Code 211.10 (d) Resident care policies Previously cited 7/20/16, 2/9/16, 12/11/15, 11/4/15, 7/8/15 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services Previously cited 9/8/16, 7/20/16, 2/9/16, 12/11/15, 11/4/15, 7/8/15 28 Pa. Code 211.12 (c) Nursing services Previously cited 9/8/16, 7/20/16, 2/9/16, 12/11/15, 7/8/15

Based on a review of clinical records and select facility policy, observation and staff and resident interview, it was determined that the facility failed to timely identify and address declines in skin integrity to prevent worsening of a pressure sore for one resident (Resident 63) out of 25 resident's sampled. Findings include: A review of the facility's skin practice guide, issued January 2013, revealed that a weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown that do not have a pressure ulcer. Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation of skin evaluations is completed on the treatment administration record (TAR). If a skin disruption is found, the type of skin injury will need to be identified by a qualified health professional (physician, certified wound specialist, Advanced Registered Nurse Practitioner(ARNP). If a pressure ulcer is identified, a pressure ulcer scale for healing (PUSH tool) is initiated by a member of the wound team for each site identified. A comprehensive evaluation is completed and documented in the patients clinical record. Skin evaluations are documented in the residents clinical record. A review of the clinical record revealed that Resident 63, a cognitively impaired resident, was admitted to the facility on January, 2015, with [DIAGNOSES REDACTED]. The resident was hospitalized and treated for [REDACTED]. A Significant Change Minimum Data Set assessment ( MDS - a federally mandated standardized assessment process used to plan resident care) dated July 16, 2015, revealed that the resident required assistance with her Activities of Daily Living (ADLs) and was at risk for developing pressure areas. A review of nursing documentation and a physician's orders [REDACTED]. There was no description of the wound on the resident's left outer ankle documented in the clinical record at that time. A nursing care plan developed for the resident's risk for skin impairment dated October 24, 2015, revealed that the resident had developed an area on left outer ankle, with a goal that it will resolve within 9 days. The facility planned interventions included that the resident will wear a Medipex boot (a padded boot used to offload the heals for pressure relief ) at all times, that staff may remove for care and for staff to observe the resident's skin condition with activities of daily living care daily and report abnormalities. Interview with the Director of Nursing on December 11, 2015, revealed that that the application of the Medipex boots was a nursing measure that was initiated on October 24, 2015, after the open area was found on the resident's left outer ankle. A review of the resident's treatment administration record (TAR) for October 2015 revealed that the physician ordered treatment was completed every three days as ordered with the last treatment completed on November 1, 2015. A notation on the TAR indicated that the wound was scabbed with no further description of the impaired area on the resident's left outter ankle in the resident's clinical record. There was no documented evidence at the time of the survey that the resident's left ankle area was reevaluated as ordered by the physician and that daily skin evaluations were conducted during daily ADL care. Weekly skin observation reports for October 2015 were completed on October 1, 15 and 22, and revealed no new skin issues. There was no documented evidence at the time of the survey that the facility had evaluated the left outer ankle wound and had identified the type of wound and any necessary associated surveillance and preventative measures to be implemented. A review of a skin alteration record dated November 22, 2015, revealed that Resident 63 had an open area to her left ankle measuring 1.5 cm x 1.3 cm x 0.1 cm with moist yellow slough in the wound bed and a scant amount of purulent (containing pus) drainage and the surrounding skin was reddened. A nurses note dated November 22, 2015, at 8:35 PM revealed open area to left ankle discovered. A new physician order [REDACTED]. Physicians orders also included obtaining a culture of the left ankle wound. A culture and sensitivity report dated November 27, 2015, revealed staphylococcus aureus and [MEDICATION NAME] (types of bacteria) and an antibiotic was prescribed. A review of nursing documentation dated November 23, 2015, 2:24 PM indicated that Resident 63 had an open area on the left lateral malleolus (the bony protuberance on either side of the ankle) measuring 1.5 cm x 1.3 cm x 0.1 cm. Slough ( dead skin tissue, yellow or white in appearance) was noted in the wound bed with a moderate amount of serosanguineous (bloody) drainage. Nursing documentation dated November 25, 2015, described the wound as 1.5 cm x 1.6 cm x 0.5 cm deep, the wound bed with slough and granulation tissue, surrounding wound area reddened, nonblanchable, area comparable to a Stage III (Stage III pressure sore is Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). At the time of the survey ending December 11, 2015, there was no evidence that staff conducted daily skin evaluations or that the Medipex were removed for daily care and that the condition of the resident's skin was consistently and effectively monitored to promptly identify any impaired areas of skin and to ensure necessary and treatment and services were provided to prevent the development/progression to a Stage III pressure sore. An observation conducted on December 9, 2015, at 12 PM revealed Resident 63 seated in a reclining geri-chair. There was a flat pillow underneath her calves and her heels were directly on the foot rests. An observation conducted on December 11, 2015, at 10 AM, the pressure area on the resident's left outer ankle measured 1 cm x 1.2 cm x 0.5 cm. The wound bed was pink. The outer edge was reddened. There was a small amount of serous drainage observed on the dressing. During an interview conducted on December 10, 2015 at 11 AM, the Director of Nursing confirmed the absence of documented evidence demonstrating that staff consistently monitored the resident's skin integrity and had consistently and effectively provided preventative measures to deter pressure development and prevent worsening of skin impairment. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 11/4/15, 7/8/15 28 Pa. Code 211.10 (a)(c)(d) Resident care policies previously cited 11/4/15, 7/8/15

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a restorative nursing range of motion program for two of 25 sampled residents (Resident 153 and Resident 63), which resulted in one resident's development/worsening of contractures (Resident 63). Findings include: A review of the clinical record revealed that Resident 63, a cognitively impaired resident, was admitted to the facility in January 2015, with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set assessment (MDS - a federally mandated standardized assessment process used to plan resident nursing home care) dated July 16, 2015, revealed that the resident required assistance with activities of daily living (ADLs). A review of a physical therapy summary dated June 5, 2015, revealed that Resident 63 was discharged from Physical therapy on June 5, 2015. The summary stated that the plan was to discontinue skilled physical therapy with patient at her maximum level and an restorative nursing program (RNP) was established. A review of an occupational therapy (OT) summary dated May 28, 2015, revealed that Resident 63 participated in OT from May 21 2015 through May 28, 2015. The summary indicated that the resident was at her maximum level of function and occupational therapy was discontinued. The discharge recommendation was to initiate a restorative nursing program. A review of nursing request to therapy dated September 15, 2015, revealed the that nursing requested a therapy screen due to the development of contractures in the resident's hands and associated pain. The Occupational therapy screen dated September 23, 2015, revealed that Resident screened per nursing requested due to hands getting tighter. OT indicated that the resident requires PROM (passive range of motion) and bilateral palm guards were applied for comfort. Physical Therapy's response to nursing was that Resident's chart and care plan were reviewed. RNP (restorative nursing program) were never implemented when she was discontinued from physical therapy services in April 2015 and June 2015. PT (physical therapy) requests nursing to implement RNP and physical therapy will continue to monitor. There was no documented evidence at the time of the survey that Resident 63 received any restorative nusing services after the discontinuation of skilled occupational and physical therapy services as recommended. During an interview conducted December 10, 2015, at 1 PM the Director of Therapy Services confirmed that Resident 63 was not provided a restorative nursing program as therapy had recommended, which resulted in the development of contractures in her hands. A review of the clinical record revealed that Resident 153 was admitted to the facility on [DATE], and had diagnoses, which included [MEDICAL CONDITION] (stroke) with left sided weakness. A quarterly Minimum Data Set assessment (MDS - standardized assessment completed at periodically to identify resident care needs) dated November 3, 2015, indicated that the resident was cognitively intact and had impaired mobility in one upper and lower extremity. Review of the resident's Therapy Discharge Communication dated November 3, 2015, indicated that nursing staff were to assist the resident to complete three sets of ten repetitions of exercise to the left upper and lower extremity with daily activities of daily living. Further review of Resident 153's clinical record failed to provide evidence that a restorative range of motion program for the left upper and lower extremities had been initiated for this resident. An interview with Employee 3 (Physical Therapist) on December 11, 2015, at 12:45 p.m. revealed that upon being discharged from specialized rehab therapy the Therapy Discharge Communication form is sent to the nursing unit and it is the responsibility of the nursing unit director to implement the resident's restorative nursing program. Employee 3 further stated that no one oversees the Restorative Program in the facility and resident progress is not reviewed routinely to determine its effectiveness and if the resident is improving or declining. Interview with the Director of Nursing on December 11, 2015 at 12:59 p.m., failed to provide evidence that a restorative nursing program was initiated and monitored to for effectiveness to maintain the resident's level of function and prevent decline in range in motion. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 10/8/14 28 Pa Code 211.10 (a)(c)(d) Resident care policies Previously cited 10/8/14