Every finding on record at Ellen Memorial Rehabilitation and Healthcare Cente

Based on select facility policy, observations, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications on two of five medication carts (Gold unit fourth and fifth carts). Findings include: A review of the facility policy titled Medication Storage, last reviewed by the facility on June 22, 2026, revealed that it is the policy of the facility to ensure nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation of the Gold unit's fifth medication cart on August 12, 2026, at 9:20 AM, in the presence of Employee 3 (Licensed Practical Nurse), revealed one multi-dose insulin pen of Lantus Insulin (a long-acting insulin medication used to lower blood sugar) that had been opened and was available for resident use but not dated when initially opened. Continued observation of the same cart on August 12, 2026, at 9:21 AM, revealed one multi-dose insulin pen of Novolog (fast-acting insulin medication used to lower blood sugar) that had been opened on June 30, 2026. According to manufacturer guidance, insulin pens are for single-patient use and should be discarded within 28 days after first use, even if insulin remains in the pen. When the date of opening is not documented, the facility cannot ensure insulin is being administered within the manufacturer's recommended timeframe for potency and sterility, posing a risk of decreased medication effectiveness and possible infection from compromised medication. An interview with Employee 3 (LPN) on August 12, 2026, at 9:22 AM, confirmed that a Lantus insulin pen was open, available for resident use, and not dated when initially opened, and a Novolog insulin pen was beyond the manufacturer's recommended 28-day discard date, and the medications should have been removed from the medication cart and discarded. Observation of the Gold unit's fourth medication cart on August 12, 2026, at 9:30 AM, in the presence of Employee 4 (Licensed Practical Nurse), revealed one multi-dose insulin pen of Lantus Insulin that had been opened and was available for resident use but not dated when initially opened. Continued observation of the same cart on August 12, 2026, at 9:31 AM, revealed one multi-dose insulin pen of Lantus Insulin that had been opened on July 8, 2026. An interview with Employee 4 (LPN) on August 12, 2026, at 9:32 AM, confirmed that a Lantus insulin pen was open, available for resident use, and not dated when initially opened, and a Lantus insulin pen was beyond the manufacturer's recommended 28-day discard date, and the medications should have been removed from the medication cart and discarded. An interview with the Director of Nursing on August 12, 2026, at 12:45 PM confirmed that the facility failed to ensure acceptable storage and adherence to use-by dates for multi-dose medications, as required by facility policy and manufacturer recommendations. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of facility policy, facility documentation, observations, and staff interview, it was determined the facility failed to maintain the privacy and confidentiality of residents' paper and electronic health protected information on one of three clinical environments observed (Blue Hall).Findings include: Review of facility policy HIPAA Privacy and Confidentiality Policy, (Health Insurance Portability and Accountability Act, a federal law enacted to protect the privacy and security of individuals' health information) last reviewed June 22, 2026, indicated the facility is committed to protecting the privacy, dignity, confidentiality, and rights of every resident. Review of the document titled Attachment 4: Statement of Residents' Rights revealed residents have the right to personal privacy and confidentiality of one's care and records. This document was provided to all residents as part of the facility's admission information. An observation on August 12, 2026, at 08:50 AM in the Blue Hall hallway revealed a computer screen containing visible health information. The screen displayed protected health information for Resident 38's wound, including the wound location and procedure details. The consultant wound care provider and wound care assistant were observed walking away from the computer and into the resident's room, leaving the screen and its information visible and readily accessible to unauthorized individuals in the hallway. The wound care provider was notified of the screen visibility and the exposed health information. An observation on August 13, 2026, at 10:40 AM revealed an open-faced binder with resident names and confidential resident information to include bathing, weighing, transfer status, and feeding assistance on top of a desk in the blue nursing unit. A second observation on August 13, 2026, at 1:30 PM, revealed the binder remained open with the confidential resident information still visible to unauthorized individuals. During an interview with the Nursing Home Administrator on August 13, 2026, at 1:35 PM, these observations were brought to the facility's attention. An interview on August 14, 2026, with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) acknowledged that the facility failed to maintain the confidentiality and privacy of residents' protected health information. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on a review of the facility's abuse prohibition policies and procedures, clinical records, investigative documents provided by the facility, and staff and resident interviews, it was determined that the facility failed to ensure one resident (Resident 106) was free from sexual abuse perpetrated by Resident 56 out of 23 residents reviewed. This deficiency is cited as past non-compliance.Findings include: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on June 22, 2026, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse, means the individual must have intended to inflict injury of harm. Sexual abuse is defined as, but not limited to, non-consensual sexual harassment, sexual coercion, or contact or sexual assault. Anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse. Additionally, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse. Additionally, the facility policy indicated that abuse prevention included assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. The facility will strive to maintain adequate staffing on all shifts to ensure the needs of each resident are met. A clinical record revealed that Resident 106 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and the ability to do simple daily tasks), cognitive communication deficits (trouble with communication that happens because of problems with thinking skills), dysphagia (difficulty swallowing), and contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) left wrist. A review of the resident's quarterly Minimum Data Set (MDS is a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 29, 2026, revealed a Brief Interview for Mental Status (BIMS is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 3, which indicated severe cognitive impairment. Additionally, Resident 106's plan of care indicated the resident was dependent on staff to have needs met, non-ambulatory and required a full-body lift assist of two. A clinical record review revealed that Resident 56 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 56's care plan initiated on September 29, 2025, identified a behavior problem related to seeking females with goals to have no evidence of behavior problems related to seeking females. Planned interventions included: for caregivers to provided opportunity for positive interaction and attention, discuss behavior and explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner to divert attention and remove from situation and take to alternate location as needed, and monitor and document behavior episodes and attempt to determine underlying cause. A clinical record review of Resident 56's nursing progress notes revealed inappropriate behaviors towards females documented on the following dates: January 1, 2026, at 11:00 PM, nursing staff noted that the resident had inappropriate comments towards a female staff member. Resident redirected but continued to make comments. February 5, 2026, at 10:10 AM, an activities aid observed Resident 56 reaching for another resident's private area and intervened before the action occurred and resident was redirected. February 13, 2026, at 9:51 PM, Resident 56 was attempting to enter a female resident's room several times and approached a female resident in the blue dinette and was redirected to room. While nurse aides were assisting to get Resident 56 into bed, the resident asked one aide, several times, to go out to dinner. A review of a psychiatric consult completed with Resident 56 on February 17, 2026, indicated the resident has a history of depression and has been having behaviors of hypersexuality and poor impulse control with inappropriately touching female residents. It was stated the resident's room was moved twice as a result of these behaviors. The resident stated, it would have been fine if this weren't a medical facility. At that time appropriate boundaries and expectations regarding inappropriate physical touch was discussed with the resident and the resident would be monitor for behaviors. A review of resident 56's clinical record revealed the resident continued to demonstrate sexually inappropriate behaviors towards females as documented on the following dates: May 8, 2026, at 7:25 AM, Resident 56 was sexually inappropriate towards nursing staff during night shift and staff explained to resident that this behavior was inappropriate and behaviors stopped after conversation. May 10, 2026, at 10:42 PM, staff reported to nurse that Resident 56 kissed her face and grabbed her buttocks while pulling up the resident's brief. May 12, 2026, at 10:37 PM, the resident was observed by nursing staff attempting to enter a female resident's room. Female resident was yelling at Resident 56 not to enter room and was redirected to dinette by staff. Next, Resident 56 tried to approach another female resident and was redirected by staff. The resident stated that he had the right to go into other people's rooms and staff seated the resident in the blue dinette with staff supervision. May 19, 2026, at 9:51PM, Resident 56 approached a female peer, who was in a recliner chair in dayroom, and placed his hand on her forearm. Staff immediately removed the female resident from the situation. Resident 56 attempted to return to peer, actively resisting staff's redirection and did not respond to staff explaining that peer did not want an interaction with him and was inappropriate. Resident was removed from area to room with no further interactions. Female peer was asleep and showed no sign of acknowledging resident's touch, nor did she show any signs of distress with interaction. June 19, 2026, at 10:39 PM, staff observed Resident 56 wheeling up to a female resident in the dinette and started reaching out to touch her blanket. Staff immediately intervened and directed the resident away from the dinette. No further incidents were observed after the redirection. No further behaviors noted. Resident 56's clinical record revealed a nurses note completed by Employee 5, a Registered Nurse (RN), dated July 17, 2026, at 8:12 PM, noting staff reported that resident was observed with his hand on another resident's lap while in the dinette on unit at 7:55 PM and immediately removed from area. Resident re-educated on appropriate verse inappropriate interaction with other residents. Resident 56 denied touching any other residents and stated, I was just saying hi to a friend. Resident 56 placed on one-to-one direct supervision by staff AAT (at all times) immediately following incident. Primary care physician (PCP), power of attorney (POA)/friend, and state police notified of incident per policy as well as the director of nursing (DON), nursing home administrator (NHA), and social service were made aware of incident. A review of investigative documentation provided by the facility dated July 17, 2026, at 7:55 PM and completed by Employee 5, RN, indicated staff observed a male resident, Resident 56 (perpetrator), with hand inside the front of a female resident's brief, Resident 106 (victim). Resident 106 could not recall the incident due to poor cognition (BIMS of 3). Resident 106 was immediately assessed with no injury or skin alteration and to be monitored for seventy-two hours for latent injury or changes in mood/behavior. A review of a witness statement completed by Employee 6, an agency nurse aide (NA), dated July 17, 2026, 3 PM - 11 PM shift, noted while passing the blue dining area the employee saw Resident 56 in the corner in his wheelchair sitting next to Resident 106 with his hands inside the front of her brief. The employee indicated she immediately acted and removed Resident 56 from the area away from Resident 106 and explained that actions were not appropriate and incident was reported. A review of a witness statement completed by Employee 7, an agency NA, dated July 17, 2026, 3 PM - 11 PM shift, noted while passing by the dining area the employee saw Resident 56 in the corner in his wheelchair sitting very close to Resident 106 with his hands inside the front of her brief. the employee indicated they helped removed Resident 56 from the area away from Resident 106 and explained that actions were not appropriate and incident was reported. The facility failed to protect and ensure that Resident 106 was free from sexual abuse perpetrated by Resident 56 who had a known documented history of sexual inappropriate behaviors. Additionally, the facility failed to ensure that a resident with known sexually inappropriate behaviors had sufficient supervision to prevent sexual abuse. During an interview with the Nursing Home Administrator (NHA) on August 14, 2026, at 10:15 AM, it was confirmed that the facility failed to protect Resident 106 from Resident 56, a resident with known sexually inappropriate behaviors, from sexual abuse. Additionally, the NHA confirmed that the facility failed to protect residents from sexual abuse by failure to provide consistent supervision by staff to protect other residents from sexual abuse. This deficiency is cited as past non-compliance. Immediately after the incident, Resident 56, male perpetrator, was removed from the dining area and placed on one-to-one supervision until primary care, nursing, and psychiatric evaluation completed. Resident 106, female victim, was assessed by the RN and displayed no sign of sexual abuse. The attending physician completed an examination of Resident 106 on July 20, 2026. All residents in B-Hall (where the alleged perpetrator resides) were interviewed to determine if they felt safe in the facility and with other residents. No concerns were identified. To prevent occurrence/recurrence, the facility re-educated all staff on the facility's abuse policies including allegation of sexual abuse, abuse prevention, and abuse reporting. All licensed nursing staff received re-education on documenting behaviors. Behavior documentation will be monitored by the Social Services Director of designee, and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form. In the event of any future resident-to-resident sexual abuse, the perpetrating resident will immediately be placed on one-to-one supervision until primary care, nursing, and psychiatric evaluation can be completed. Outcomes of these evaluations will result in continued one-to-one supervision or the initiation of discharge planning to a facility with a focus on behavior management. To monitor and maintain on-going compliance, the DON/designee will audit residents with socially inappropriate/sexually inappropriate behaviors weekly for four weeks and monthly for two months. The NHA/designee will review facility allegations of abuse to ensure the facility's abuse policies are being followed. The QAA committee will review all abuse investigations to determine if further follow up as needed. The facility's immediate corrective action plan was completed July 21, 2026. 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 211.10 (a)(d) Resident care policies.

Based on select facility policies, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to evaluate the resident's need for and use of physical restraints, including assessment of the least restrictive measure necessary to address the resident's medical symptoms for one of 23 residents reviewed (Resident 13).Findings include: A review of the facility policy titled Use of Restraints, last reviewed by the facility on June 22, 2026, revealed that it is the policy of the facility to ensure if restraints are used, the facility shall use the least restrictive method for the least amount of time to respond to individual resident needs safely and adequately in accordance with the resident's comprehensive assessment and comprehensive care plan. When a restraint is ordered, the facility shall document the need for the restraint per the facility protocol and document the type of restraint each time a restraint is used or removed. In determining the least restrictive method for the least amount of time, physical restraints shall be removed at least ten minutes out of two hours during normal waking hours to allow the resident an opportunity to move and exercise. An order from a physician or physician's delegate authorized shall be required for a restraint, and if the order is to be continued, the order shall be renewed by the physician in accordance with the resident's total program of care, and quarterly assessments will be completed for continued use. A clinical record review revealed Resident 13 was admitted to the facility on [DATE], with diagnoses that included Lewy Body Dementia (a progressive brain disorder caused by abnormal protein clumps called Lewy bodies that build up inside nerve cells and affect thinking, movement, mood, and behavior). A review of Resident 13's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated July 16, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 06 (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 through 7 indicates severe cognitive impairment). A review of the care plan initiated on January 18, 2025, and last revised on July 20, 2026, revealed Resident 13 used a physical restraint of a soft lap tray (a cushion attached across a chair or wheelchair that stops a person from standing up or leaving their seat) to their Broda chair (a specialized medical positioning wheelchair ) at all times, with interventions to include to ensure the resident is positioned correctly with proper body alignment while restrained, and to monitor, document and report any changes regarding the effectiveness of the restraint, less restrictive device if appropriate, and any negative or adverse side effects noted. A review of Resident 13's physician orders revealed an order dated April 10, 2025, for a soft lap tray to the Broda chair at all times and to remove every two hours for at least fifteen minutes. There was no clinical indication as to why a soft lap restraint was being used for Resident 13 in the physicians order. A clinical record review of a consent for a soft lap tray restraint dated January 13, 2026, revealed the resident was unable to sign, and verbal consent was obtained from the resident's representative over the telephone and was witnessed by two nurse signatures. The consent listed the benefit of the restraint as the prevention of injury to self or others and identified best practice to limit the use of any physical restraint to circumstances in which the resident has medical symptoms that warrant the use of restraints and that interventions, including less restrictive alternatives, were attempted to treat the medical symptom but were ineffective. The facility was unable to provide documented consent for when the soft lap restraint was first initiated and ordered on April 10, 2025. A clinical record review of an occupational therapy Discharge summary dated [DATE], revealed the resident demonstrated safe and appropriate positioning while out of bed to their current seating system with discharge recommendations to include out of bed to the Broda chair with gel cushion, dycem (a non-slip rubber like material that grips to surfaces and it used in fall prevention), bilateral lateral support attachments with pillow, and bilateral leg rests. There was no mention of the use of the soft lap restraint for Resident 13. A clinical record review of an occupational therapy Discharge summary dated [DATE], revealed the resident required a re-assessment for the least restrictive seating system and was out of bed to the Broda chair with a gel cushion, dycem, bilateral lateral support attachments with a pillow, bilateral leg rests for transport, and a soft lap tray to the Broda chair at all times and to remove every two hours for at least fifteen minutes. Resident 13 was assessed and demonstrated safe and proper positioning for five hours with a lap tray in place for safety, bilateral lateral supports, and a cervical support pillow. There was no documented evidence that an assessment was made to ensure Resident 13 was able to remove the soft lap tray. Discharge recommendations included out of bed to Broda chair with gel cushion, dycem, bilateral lateral support attachments with pillow, and bilateral leg rests. An observation conducted on August 12, at 11:00 AM, revealed Resident 13 was seated in their Broda wheelchair at the nurses' station with a soft lap tray secured across the waist attached to the wheelchair and appeared calm. An observation conducted on August 13, at 9:15 AM, revealed Resident 13 was seated in their Broda wheelchair in their room with a soft lap tray secured across the waist attached to the wheelchair and was sleeping. An observation conducted on August 13, at 10:30 AM, with the presence of Employee 9, Nurse Aide, revealed Resident 13 was seated in their Broda wheelchair in their room with a soft lap tray secured across the waist attached to the wheelchair and appeared calm. Resident 13 was unable to verbalize the purpose of the soft lap tray and was unable to remove the soft lap tray. Employee 9 stated the resident had the soft lap tray restraint to help with safety and reduce falls. An observation conducted on August 13, at 10:45 AM, with the presence of the director of rehab, revealed Resident 13 was seated in their Broda wheelchair in their room with a soft lap tray secured across the waist attached to the wheelchair and appeared calm. Resident 13 was unable to verbalize the purpose of the soft lap tray and was unable to remove the soft lap tray. The director of rehab attempted to remove the soft lap tray from Resident 13's Broda chair and was unable to do so because the arm rests were low and holding the soft lap restraint in place. The director of rehab then adjusted the armrests of the Broda chair twice before the correct positioning of the soft lap tray was achieved. Resident 13 again was unable to remove the soft lap tray after adjustment and correct positioning. A clinical record review of an occupational therapy evaluation dated August 13, 2026, revealed the resident was being evaluated for the least restrictive device for positioning, wheelchair positioning, and functional decline. The assessment summary revealed the resident presented with a fall history, a soft lap tray in place on the Broda wheelchair for positioning safety, and a safety aide, and presented with deficits in coordination, grip strength, balance, endurance, bilateral upper strength, and general safety awareness. Further review revealed Resident 13 attempted to remove the soft lap tray when prompted but displayed strength deficits impacting her ability to remove the tray, and the resident was to continue with occupational therapy for bilateral upper extremity strengthening and trial a less restrictive device. Despite long-term use of the soft lap tray, the clinical record lacked documentation demonstrating the interdisciplinary team (a group of healthcare professionals such as nursing, therapy, and medical providers who collaborate to plan and evaluate care) evaluated whether the device was clinically necessary to treat a medical symptom (a physical or clinical condition that requires treatment) or whether the soft lap tray represented the least restrictive intervention for positioning. The clinical record lacked documentation demonstrating periodic reassessment of the continued need for the device, attempts to reduce the use of the device, or evaluation of alternative positioning interventions. During an interview conducted on August 13, 2026, at 11:35 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged Resident 13 was unable to remove the device independently and confirmed the soft lap tray restricted Resident 13's movement. A device the resident cannot remove that restricts freedom of movement meets the definition of a physical restraint. The stated purpose of fall prevention does not represent a medical symptom that justifies restraint use without evidence that less restrictive interventions were attempted and determined ineffective. The clinical record lacked documentation demonstrating the interdisciplinary team evaluated whether the soft lap tray was necessary for positioning, whether less restrictive positioning interventions were attempted, or whether the use of the soft lap tray was clinically justified based on an assessed medical symptom for continued use. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing service. 28 Pa. Code 211.8(c.1)(1)(3)(e)(f) Use of Restraints.

Based on clinical record review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement appropriate nursing practices for the administration of an intravenous (IV) flushes for two residents via peripheral inserted central venous catheter (PICC) (Resident 84) and via a midline catheter (Resident 8) of 23 residents reviewed.Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145 b. IV therapy curriculum requirements:(f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1).(1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as aCRNP, physician, physician assistant, podiatrist or dentist).(g) An LPN who has met the education and training requirements of S 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145 and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. According to the policy Peripheral and Midline IV Catheter Flushing and Locking reviewed June 22, 2026, its purpose is to maintain catheter patency, ensure proper catheter function, and confirm that the full dose of medication or solution enters the venous system. The policy stated the facility will consult the State Nurse Practice Act to verify the scope of practice for RNs and LPNs related to IV catheter care, including flushing and locking. The policy Central Venous Catheter Care and Dressing Changes reviewed June 22, 2026 directed staff to follow the State Nurse Practice Act regarding the scope of practice for LPNs for central venous catheter care and dressing changes. Clinical record review revealed that Resident 84 was admitted to the facility on [DATE], with diagnosis to include Non-Rheumatic Aortic Valve Disorder (abnormalities in a valve of the heart), and Diabetes Mellitus, (a metabolic disorder where a person has high sugar levels for a prolonged period). A review of the clinical record revealed Resident 84 was admitted to the facility with a PICC line in the left arm (a peripherally inserted central catheter, a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). A review of physician orders dated July 17, 2026, revealed the resident was to receive a 10 milliliters (ML) of normal saline flush solution (a saltwater solution through the IV every shift to keep it working properly), intravenously every shift for IV patency, a 10 ML flush of normal saline flush solution intravenously four times a day before antibiotics, and a 10 ML flush of normal saline flush solution intravenously after antibiotics. Review of the electronic Medication Administration Record (eMAR) revealed between July 17 2026, and August 13, 2026, Employee 1 license practical nurse (LPN) and Employee 8 LPN documented administration of normal saline flush through the PICC line catheter. The facility could not produce any documentation verifying that Employee 1 LPN and Employee 8 LPN had completed the IV therapy education and training required . There was no evidence of current competency validation, supervision documentation, or internal training specific to administration of IV medications, specifically saline flushes. A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection (occurs when bacteria enter the urinary tract and cause an infection). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 13, 2026, revealed that Resident 8 had moderate cognitive impairment 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, suggesting a noticeable but not severe difficulty remembering things or staying oriented). A review of a clinical record dated February 10, 2026 from the acute care setting revealed Resident 8 had a midline catheter, single lumen inserted into the right arm using ultrasound guidance (special type of catheter placed in a vein in his right arm, using an ultrasound machine to help guide where it should go). The length of the catheter was 15 centimeters (cm), the external catheter length was 0 cm (catheter length visible outside of the arm), and the size around Resident 8's right arm (circumference) at the spot where the catheter was placed was 34 cm. A review of physician orders dated February 12, 2026, revealed the resident was to receive 10 ML of normal saline flush solution intravenously every shift for IV patency for seven days. Review of the eMAR revealed between February 12, 2026, and February 19, 2026, Employee 1 LPN and Employee 2 LPN documented administration of normal saline flush through the midline catheter . The facility could not produce any documentation verifying that Employee 1 and Employee 2 had completed the IV therapy education and training required. There was no evidence of current competency validation, supervision documentation, or internal training specific to administration of IV medications, specifically saline flushes. During an interview conducted on August 13, 2026, at 12:15 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility had no documentation of required IV therapy education or competency for LPNs regarding administration of intravenous flushes. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on observation, review of clinical records, and staff interviews, it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol to promote normal bowel activity to the extent practicable for one resident (Resident 66) out of 23 residents reviewed.Findings include: According to the American Academy of Family Physicians (The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine) the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week. A review of the clinical record revealed that Resident 66 had physician orders dated February 11, 2025, for the following bowel regimen: Milk of Magnesia (a laxative used to stimulate bowel activity) 30 milliliters (ml) by mouth as needed give in the evening of the third day if no bowel movement. Bisacodyl suppository (a rectal stimulant laxative used to promote bowel evacuation) insert rectally as needed in morning of fourth day if no bowel movement and milk of magnesia was ineffective Fleet enema 7-19GM/118ML (a rectal solution containing sodium phosphate used to stimulate evacuation of stool) insert one unit rectally as needed in the evening of the fourth day if bisacodyl suppository is ineffective A review of Resident 66's bowel monitoring documentation for July 2026 revealed no documented bowel movements on July 28,29,30,31, 2026, during all three shifts. A review of Resident 66's Medication Administration Records for July 2026 revealed no documented evidence that nursing staff administered the physician-ordered bowel protocol during the periods when the resident had no documented bowel activity. A review of Resident 66's bowel monitoring documentation for August 2026 revealed no documented bowel movements on August 2,3,4, and 5,2026. A review if Resident 66's Medication Administration Records for August 2026 revealed Resident 66 was administered Bisacodyl suppository August 5, 2026. There was no documented evidence the facility staff attempted to administer Milk of Magnesia prior to the suppository as ordered by the physician. An interview with the Director of Nursing and the Nursing Home Administrator on August 14, 2026, at 9:15 AM revealed the facility was unable to provide evidence that staff implemented the physician-ordered bowel protocol for Resident 66 during the periods in which the resident had no documented bowel movement. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(ix) Medical records.

Based on select facility policy, clinical record review, investigative documentation provided by the facility, and staff interviews it was determined the facility failed to provide adequate staff supervision and effective safety measures to prevent a resident's elopement for one out of 23 residents reviewed (Resident 23). This deficiency is cited as past non-compliance.Findings include: A review of the facility policy titled Elopement, last reviewed by the facility on June 22, 2026, revealed it is the policy of the facility to evaluate and identify residents that are at risk of elopement and develop individualized interventions. Elopement occurs when a patient leaves the premises without authorization and/or unnecessary supervision to do so. A review of the facility policy titled Facility Non-Smoking Policy for Residents, last reviewed by the facility on June 22, 2026, revealed it is the policy of the facility to provide a safe and healthy environment for all residents, visitors, and employees and that resident smoking and the use of tobacco and nicotine products are prohibited. A review of the clinical record revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of Resident 23's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10, 2026, revealed that the resident had moderately impaired cognition with a BIMS score of 12 (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). A review of the resident's care plan initiated June 19, 2023, and last revised July 21, 2026, revealed Resident 23 was identified as being at risk for elopement and wandering related to wandering on units and asking to go outside and sit alone and being non-complaint with the smoking policy. A review of a wandering risk assessment dated [DATE], identified the resident as being at low risk for wandering. A review of a nursing progress note documented by Employee 12, Registered Nurse, dated July 4, 2026, at 1:58 PM, revealed that Resident 23 had requested to Employee 10 receptionist to go onto the patio. The receptionist had left to ask the nurse if the resident could go outside. When the receptionist returned to their desk, Resident 23 was no longer in the lobby. Employee 11, Registered Nurse, left the facility and found Resident 23 sitting in their wheelchair on the front patio smoking a cigar. Staff requested that the resident come back into the facility, and the resident was brought back inside and handed over five cigars and a lighter. A skin assessment was completed, no injuries noted. A wander guard bracelet was placed onto Resident 23's wheelchair. Resident 23 was educated on the non-smoking policy at the facility and that he needs a staff member with him when he is outside. A review of a nurse progress note from Employee 13, Registered Nurse, dated July 4, 2026, at 2:09 PM, revealed Resident 23 was educated on the importance of safety at the facility and the resident had stated that he did not care and that he should be able to go outside when he pleases and that no one should worry about him smoking cigars and burning his fingers because he used to be in the wars shooting guns. A review of a physician order dated July 4, 2026, at 2:12 PM, revealed an order was obtained for the application of a wander guard bracelet to the wheelchair and for staff to check placement each shift. A review of a form titled 'education documentation' dated July 4, 2026, for Employee 10, receptionist, revealed that Employee 10 was educated that the front desk needs to be always supervised and to use the phone or pager system if you need to get staff assistance. Employee 10 was also educated on residents asking to go outside and that they need a staff member present when doing so and to ensure coverage for breaks and whenever the desk needs to be unattended. A review of a written witness statement dated July 4, 2026, from Employee 11, Registered Nurse, revealed that she arrived at the facility on July 4, 2026, at 12:30 PM, and witnessed Resident 23 sitting outside near the bench smoking a cigar in front of the building and alerted the supervisor. A review of a written witness statement dated July 7, 2026, from Employee 10, receptionist, revealed the resident came to the receptionist desk on July 4, 2026, at 12:20 PM, and said he could go outside. Employee 10 then went to go ask a supervisor, and when Employee 10 returned to the desk, Resident 23 was gone. A review of a written witness statement dated July 9, 2026, from Employee 12, Regeristered Nurse, revealed that on July 4, 2026, on the dayshift, Resident 23 was found out on the front patio smoking a cigar and then came inside with assistance and handed over a bag with five cigars and a lighter in it and was reminded that this was a non-smoking facility. A review of a wandering risk assessment dated [DATE], revealed Resident 23 was reassessed and identified as being at risk for wandering. A review of a no smoking policy assessment dated [DATE], revealed Resident 23 had currently smoked cigars and attempted to leave the facility to smoke. During an interview conducted on August 11, 2026, at 12:20 PM, Resident 23 confirmed he had left the facility unattended on July 4, 2026, and was smoking a cigar. Resident 23 stated in the past he had gone out with his son and smoked cigars and felt like he should have been able to go smoke a cigar in front of the building by himself. Resident 23 acknowledged that he no longer had possession of any cigars or a lighter and that his family had taken them home. During an interview conducted on August 12, 2026, at 1:20 PM, Employee 10, receptionist, acknowledged that Resident 23 came up to the front desk lobby and stated he was able to go outside, and then he left the desk unattended to find the nursing supervisor to ask if Resident 23 could go outside. Employee 10 stated the nursing supervisor told him that Resident 23 was not allowed to go outside by himself and stated when he returned to the desk that Resident 23 was no longer in the lobby, and he thought Resident 23 had gone back to his room. Employee 10 acknowledged that he was educated after the resident was found outside to not leave the desk unattended and to always find coverage when leaving the desk and to utilize the phone or pager system if he needs to reach another facility staff member. During an interview conducted August 13, 2026, at 11:30AM, Employee 11, Registered Nurse, acknowledged that she came to work on her day off to drop something off and witnessed Resident 23 outside on the front patio smoking a cigar and alerted staff members who then assisted Resident 23 back into the facility. These findings demonstrated the facility failed to ensure effective supervision and implement adequate environmental and monitoring safeguards for a resident with impaired cognition and impaired safety awareness, resulting in an unsupervised exit from the facility. This deficiency is cited as past noncompliance. The facility's corrective action plan was to immediately educate staff members on the protocol of not leaving the desk unattended, and Employee 10 received a disciplinary action. Resident 23 was educated on the non-smoking policy of the facility and educated on not leaving the facility unattended for safety reasons and was placed on fifteen-minute checks for three days. Elopement/wander assessments were initiated and completed on all residents. Any newly identified residents with high scores for risk of wandering had their plans of care reviewed to ensure accuracy and appropriate interventions. All residents had received a smoking assessment with care plans updated, and education was completed for all residents and their representatives on the non-smoking policy of the facility. Elopement books were reviewed and updated for all nursing units, the front desk ,and with the social service department per the facility elopement policy. To prevent this from recurring, the NHA and Interdisciplinary Team (IDT) provided re-education to all facility staff regarding the facility's elopement policy and non-smoking policy, including procedures and protocols, initiated on July 4, 2026, with completion on July 10, 2026. To monitor and maintain ongoing compliance, the facility completed audits daily for five days, three times weekly for three weeks, and planned monthly for two months to ensure residents had a completed and updated smoking and wandering assessment completed with care plans updated. The facility completed random audits of the front desk to ensure it was not left unattended and completed random education questionnaires for facility staff related to the elopement and non-smoking facility policy. The findings of the plan of correction were submitted to QAPI for review. The facility's immediate corrective action plan was completed on July 10, 2026. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa Code 201.18(b)(1) (e)(1) Management. 28 Pa Code 211.10 (c) Resident care policies. 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 ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for one resident of 23 residents reviewed (Residents 8).Findings include: According to the Infusion Nurses Society (INS) (2024), Infusion Therapy Standards of Practice, the baseline circumference of an extremity with a midline catheter is measured upon insertion, noting location for future measurements to ensure consistent measurement. Facilities should assess circumference when edema or signs and symptoms of deep vein thrombosis (DVT) present, noting the location and characteristics of edema. A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection (occurs when bacteria enter the urinary tract and cause an infection). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 13, 2026, revealed that Resident 8 had moderate cognitive impairment 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 means moderate cognitive impairment, suggesting a noticeable but not severe difficulty remembering things or staying oriented). A review of hospital documentation revealed written communication dated February 10, 2026, to the facility confirming Resident 8 had a single lumen, midline, 4.5 Fr, 18-gauge catheter placed into the right arm (small, flexible tube was gently put into the person's right arm so medicines or fluids can be given, stays in the arm for a longer time than a regular intravenous insertion site). The catheter length (inside the arm) was 15 centimeters (cm) (length) and the external catheter length (length of the catheter outside the arm) was 0 cm. The arm circumference was 34 cm. A review of the documentation titled Nursing Assessment V-2 dated February 12, 2026, revealed Resident 8 was admitted with a midline catheter in his right upper extremity. No additional information including circumference of the arm was noted upon admission, or length of catheter was documented upon admission. A physician's order dated February 12, 2026, indicated staff were to measure the exposed length of midline line catheter with dressing change, and to measure upper arm circumference weekly with dressing change. A review of the medication administration record (MAR) revealed no documentation of midline line measurements or arm circumference for Resident 8 from his entry into the facility on February 12, 2026. Failure to measure the midline length and arm circumference as ordered limited the facility's ability to identify potential catheter displacement (movement out of proper position) in a timely manner, placing residents at risk for complications. During an interview on August 13, 2026 at 12:15 PM, Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility did not consistently monitor and maintain midline catheters in accordance with physician orders, and professional standards of practice for Resident 8. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on select facility policy, review of clinical records, controlled substance records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled drugs for two out of the 23 residents sampled (Residents 10and 40).Findings include: A facility policy titled Controlled Substances last reviewed by the facility on June 22, 2026, revealed that the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications. A review of facility documentation revealed the facility utilizes a Controlled Substance Record to track, monitor, and reconcile each controlled medication. The facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication. A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses that include Diabetes Mellitus, (a metabolic disorder where a person has high sugar levels for a prolonged period of time) and Alcoholic Myopathy (a muscle disease caused by the toxic effects of alcohol on the skeletal muscle). A review of the physician's order-initiated February 2, 2026, revealed the resident was to receive Tramadol HCL oral tablet 50 mg (pain medication) one tablet every six hours as needed for moderate pain for 4-6(a scale used to measure pain and intensity) related to difficulty in walking. A comparison of Resident 10's Controlled Substance Record with Resident 10's Medication Administration Record (MAR) from May 18,2026, through August 11, 2026, revealed four entries indicating Tramadol was utilized according to Resident 10's Controlled Substance Record. However, there was no documented evidence in Resident 10's MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 10's Controlled Substance Record and MAR:June 7, 2026, at 4:00 PM July 18, 2026, at 12:50 AMAugust 1,2026, at 12:16 AMAugust 3, 2026, at 12:15 AM Comparison of the Controlled Substance Record with the MAR for May 18,2026, through August 11, 2026, revealed one entries indicating Tramadol was documented as administered on the MAR; however, there was no corresponding documentation in the Controlled Substance Record indicating the medication was removed from inventory on the following dates:August 2,2026, at 12:27 AM A review of a physician's order initiated on February 3,2026, revealed the resident was to receive Oxycodone Acetaminophen oral tablet 10-325 (opiate pain medication) was one tablet every six hours as needed for severe pain rated 7-10. A comparison of Resident 10's Controlled Substance Record with Resident 10's Medication Administration Record (MAR) from June 23,2026, through August 10, 2026, revealed seven entries indicating Oxycodone Acetaminophen was utilized according to Resident 10's Controlled Substance Record. However, there was no documented evidence in Resident 10's MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 10's Controlled Substance Record and MAR:June 27,2026 at 1:00 PMJune 29, 2026, at 2:33 PMJuly 2, 2026, at 7:00 AMJuly 3, 2026, at 10:00 PMJuly 31, 2026, at 12:00 AMAugust 1, 2026, at 2:14 PMAugust 4, 2026, at 12:42 PM A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that include Diabetes Mellitus, (a metabolic disorder where a person has high sugar levels for a prolonged period of time) and Unspecified Fracture of the Third Lumbar Vertebrae (a break in the lower back that causes severe pain and limited movement). A review of a physician's order initiated on April 7, 2026, revealed the resident was to receive Tramadol HCL oral tablet 50 mg one tablet every eight hours as needed for Moderate pain (score 4-6). A comparison of Resident 40's Controlled Substance Record with Resident 40's Medication Administration Record (MAR) from April 8, 2026, through July 27, 2026, revealed five entries indicating Tramadol was utilized according to Resident 40's Controlled Substance Record. However, there was no documented evidence in Resident 40's MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 40's Controlled Substance Record and MAR:April 16, 2026, at 1:20 AMMay 7, 2026, at 9:27 AMMay 13, 2026, at 8:30 PMMay 17, 202610:30 AMJune 25, 2026, at 10:50 AM Comparison of the Controlled Substance Record with the MAR for April 8,2026, through July 27, 2026, revealed three entries indicating Tramadol HCL oral tablet 50 mg was documented as administered on the MAR; however, there was no corresponding documentation in the Controlled Substance Record indicating the medication was removed from inventory on the following dates:April 7, 2026, at 1:34 AMMay 13, 2026, at 5:28 PMJune 30, 2026, at 2:13 AM A review of a physician's order April 7, 2026, revealed the resident was to receive Oxycodone HCL oral capsule 5 mg one tablet every six hours as needed for severe pain (score 7-10). A comparison of Resident 40's Controlled Substance Record with Resident 40's Medication Administration Record (MAR) from May 14, 2026, through July 25, 2026, revealed seven entries indicating Oxycodone was utilized according to Resident 40's Controlled Substance Record. However, there was no documented evidence in Resident 40's MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 40's Controlled Substance Record and MAR:May 18, 2026, at 11:00 AMMay 21, 2026, at 10:50 AMMay 27, 2026, at 10:00 AMMay 28, 2026, at 8:19 AMJune 1, 2026, at 10:50 AMJune 5, 2026, at 10:00 AMJune 7,2026 at 4:30 PM Comparison of the Controlled Substance Record with the MAR for May14,2026, through July 25, 2026, revealed 1 entry indicating Oxycodone was documented as administered on the MAR; however, there was no corresponding documentation in the Controlled Substance Record indicating the medication was removed from inventory on the following dates:June 8, 2026, at 7:22 PM An interview was conducted on August14, 2026, at 9:15AM, with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) to review the above findings related to the facility's failure to implement effective procedures to reconcile Resident 10 and 40's controlled substance medications. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 Resident care policies.

Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members and the use of a mechanical lift as planned to ensure safety and prevent major injuries. As a result, the resident sustained a fracture of the ankle with actual harm for one out of five residents reviewed (Resident CR1). This deficiency is cited as past noncompliance.Findings include: A review of a facility policy titled Abuse, adopted by the facility on December 1, 2025, revealed the residents at the facility have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when a facility is aware of or should have been aware of goods and services that a resident requires but the facility fails to provide them to the resident that has resulted in or may result in physical harm, pain, mental anguish or emotional distress including failure of staff to implement resident interventions identified on the care plan. A review of the closed clinical record revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses, including, right sided hemiplegia/hemiparesis (paralysis or weakness affecting one side of the body) following a cerebral infarct (stroke, a condition in which blood flow to part of the brain is interrupted causing brain cell damage). A review of Resident CR1's quarterly Minimum Data Set Assessment, (MDS, a federally mandated standardized assessment process completed periodically to plan resident care) dated December 9, 2025, revealed the resident was independent with activities of daily living to include transfers, ambulation and toileting. The MDS revealed the resident was cognitively intact as evidence by a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). Review of the individualized care plan-initiated January 8, 2025, revealed Resident CR1 had a self-care deficit related to hemiplegia, imbalance, limited mobility, and limited range of motion (the extent to which a joint can move in different directions, including bending and straightening, which reflects flexibility and functional movement ability). Interventions at that time indicated the resident was independent with a roller walker (a wheeled walking device used for stability) for transfers and ambulation. Review of therapy documentation dated March 11, 2026, revealed Resident CR1 was reevaluated March 6, 2026, following a decline in functional mobility (ability to move safely and independently) and complaints of increased left hip pain. Documentation indicated the resident had recently refused attempts to stand and requested use of a standing lift for transfers. A therapy progress note dated March 9, 2026, indicated the resident remained in bed and declined to attempt standing. The therapist documented education provided to the resident regarding the importance of mobility and determined the resident's assistance level required a downgrade from independence with rollator walker to a standing lift (sit-to-stand lift, a mechanical assistive device used to help a person who can bear some weight safely move from a sitting position to a standing position with staff support, reducing the risk of injury to the individual and caregiver) due to inability to assess safe ambulation and transfers. Resident CR1 was not concerned with being changed to a stand-up lift despite previously being independent. Review of Resident CR1's care plan dated March 9, 2026, revealed updated interventions requiring use of a stand-up lift for transfers with assistance of two staff members and ambulation with a roller walker and gait belt (a safety belt placed around the waist to assist with balance support during walking) with assistance of two staff members. There was no Kardex report (a report that indicates the date when interventions were added to the Kardex, which is a quick reference for staff that includes a summary of resident required care information) regarding the resident's care needs at the time of the incident available to the survey team for review at the time of the survey. A nursing progress note dated March 13, 2026, at 4:00 PM documented Resident CR1 experienced a witnessed fall in the bathroom while ambulating with one nurse aide and using a roller walker. Documentation indicated the resident fell while turning to sit on the toilet and was found sitting on the floor with the left foot twisted backward at the ankle. The resident complained of ankle and foot pain. The physician was notified and ordered transfer to the hospital for evaluation and treatment. Hospital documentation dated March 13, 2026, indicated the resident was evaluated and underwent X-ray imaging (a diagnostic test using radiation to visualize bone structures). Imaging revealed a comminuted fracture (a break in which the bone is splintered into multiple pieces) of the medial malleolus (inner bony prominence of the ankle) and a laterally displaced oblique fracture (a diagonal break in the bone that has moved out of normal alignment) of the lateral malleolus (outer bony prominence of the ankle). The impression was medial and lateral malleolar fractures of the left ankle. Hospital documentation indicated that the resident received narcotic pain medication (strong prescription medication used to treat severe pain) and a splint (rigid support used to immobilize an injured body part) and wrap were applied. The resident returned to the facility on March 13, 2026, at 7:38 PM with a diagnosis of closed bimalleolar fracture (fracture involving both sides of the ankle joint without an open wound). Physician orders included splinting the left ankle at all times, non-weight bearing, total mechanical lift with assistance of two staff members for transfers and follow-up with an orthopedic surgeon (a physician specializing in treatment of bone and joint conditions), and administration of pain medication as needed.A review of a nurse's notes dated March 17, 2026, at 12:27 PM revealed that Resident CR1 left the facility for an appointment with the Orthopedic Surgeon at 10:30 AM. The resident was transferred into the wheelchair via a total mechanical lift with her left leg splint in place. A review of the consultation report and corresponding physician orders dated March 17, 2026, revealed that Resident CR1 had a closed, displaced fracture of the lateral malleolus of the left tibia (left ankle fracture). The note indicated that surgical intervention was required for this resident. The note also stated that medical clearance was required prior to surgery. A nurse's note dated March 19, 2026, at 8:13 PM revealed Resident CR1 was medically cleared for surgery. Surgery was scheduled for March 27, 2026. The resident had an additional orthopedic presurgical visit on March 25, 2026, at 1:04 PM. A review of the consultation report dated March 25, 2026, revealed that the reason for the consultation was a left bimalleolar ankle fracture. A review of an orthopedic consultation report dated March 25, 2026, revealed that the resident was examined and her history reviewed. Surgical and nonsurgical treatments were discussed with the resident. The note stated, Given the unstable nature of the bimalleolar ankle fracture, discussed and recommended surgical intervention to include, left lower extremity ORIF (open reduction internal fixation, surgical intervention to repair the fracture) of the left ankle. The resident agreed to surgery at that time. According to nursing progress documentation Resident CR1 was transferred to the hospital on March 27, 2026, at 6:15 AM for surgical repair and returned to the facility on March 27, 2026, at 5:37 PM following ORIF surgery of the left ankle. Review of a facility-provided investigative document dated March 13, 2026, included a written statement from Employee 1, Nurse Aide. In the written statement, Employee 1 documented she responded to Resident CR1's call bell requesting assistance to the bathroom. Employee 1 documented that another nurse aide (Employee 2, Nurse Aide) told the resident to prove herself (demonstrate her ability) by using the walker. Employee 1 documented that she told the resident, That is not the way you transfer anymore; however, the resident insisted on using the walker. Employee 1 documented that the resident was ambulating with the walker until the resident turned to sit on the toilet and began to fall. Employee 1 documented that as the resident was actively falling, she leaned against the resident's body in an attempt to guide her safely to the floor. Employee 1 documented that the resident landed sitting on her left foot and that she was unable to move from under the resident, at which time she called out for assistance. Review of a facility-provided witness statement dated March 13, 2026, from Employee 2, Nurse Aide documented that at the beginning of her shift she received report from nursing staff and began responding to call bells. Employee 2 documented that she entered Resident CR1's room and asked the resident, Hey do we plan on using the toilet today? I would like you to try since you were incontinent yesterday. Employee 2 documented that the resident responded, I will, but I don't feel like going right now. Employee 2 documented she responded, ok, let us know, and then continued answering call bells and performing assigned duties. During a telephone interview conducted by the surveyor on March 31, 2026, at 12:11 PM Employee 1, Nurse Aide, confirmed she was aware of Resident CR1's transfer and ambulation status at the time of the fall. Employee 1 stated that Resident CR1 told her that Employee 2, Nurse Aide, instructed the resident that she had to prove herself by ambulating to the bathroom. Employee 1 stated that she knew the resident's transfer status required assistance of two staff members with use of a stand-up lift for transfers and ambulation with a roller walker and assistance of two staff members. Employee 1 stated the resident was transferred and ambulated without the required level of assistance, resulting in a fall with injury requiring surgical intervention. Employee 1 stated she was suspended and sent home immediately following the incident and her employment was terminated on March 16, 2026. During a telephone interview conducted by the surveyor on March 31, 2026, at 12:30 PM Employee 2, Nurse Aide, stated that on March 13, 2026, at 4:00 PM, she entered Resident CR1's room at the start of her shift to encourage the resident to request staff assistance when ready to use the bathroom. Employee 2 denied pressuring the resident or encouraging the resident to ambulate or toilet independently. Employee 2 stated she was suspended and sent home at the time of the incident. Employee 2 stated that following completion of the facility's investigation, she returned to work on March 16, 2026. Review of Employee 1's personnel file revealed the employee completed training, including abuse and neglect prevention, safe bed mobility procedures, safe transfer and lift techniques, and documentation requirements within the electronic health record, with attestation signed March 11, 2026. During an interview on March 31, 2026, at 1:00 PM, the Nursing Home Administrator confirmed the facility investigation determined Employee 1 did not follow Resident CR1's care plan requiring assistance of two staff members for ambulation and transfers. The Nursing Home Administrator confirmed Employee 1 was removed from the schedule pending investigation and employment was terminated March 16, 2026. The facility implemented corrective actions immediately following the incident. The resident was assessed and transferred for medical evaluation. Employees 1 and 2, Nurse Aides, were suspended pending investigation. The facility reviewed all resident records to verify transfer and ambulation requirements were accurately reflected in care plans and Kardex reports. Nursing staff received re-education regarding adherence to individualized care plans and neglect prevention requirements. To sustain compliance, nursing administration implemented observational audits to ensure staff compliance with transfer requirements. Audits were conducted three times weekly for four weeks, weekly for four weeks, and monthly thereafter. Audit results were reviewed through the Quality Assurance Performance Improvement (QAPI, a program that monitors and improves quality of care and services) committee to determine ongoing compliance needs. The facility achieved substantial compliance on March 16, 2026. This deficiency is cited as past noncompliance. 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)(5) Nursing services.

Based on review of clinical records, laboratory reports, intake documentation, facility records, and staff interviews, it was determined that the facility failed to provide the necessary care and services to ensure one resident (Resident 1) out of six residents reviewed, received timely assessment, monitoring, and intervention following a significant change in condition, including failure to ensure timely follow up of ordered diagnostic testing and failure to identify and address inadequate fluid intake. Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included cerebral vascular disease (a condition affecting blood flow in the brain), anxiety, and hypertension (high blood pressure). A review of Resident 1's quarterly minimum data set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 16, 2025 revealed a BIMS score of 14 (BIMS, brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 14 to 15 equates to cognitively intact resident).A review of nursing documentation dated November 7, 2025, revealed Resident 1 experienced a significant change in condition, including an elevated temperature of 103.2 degrees Fahrenheit and dysuria (pain with urination). Acetaminophen (Tylenol, a medication used to reduce fever) 650 mg by mouth was administered. At 5:41 AM, the resident's temperature remained elevated at 102.2 degrees Fahrenheit. The physician was notified and ordered a urinalysis (U/A, a test used to detect abnormalities in urine) and a urine culture and sensitivity (C&S, a test used to identify bacteria and determine appropriate antibiotic treatment). The specimen was collected and sent to the laboratory. There was no evidence that the facility ensured the results of the urinalysis collected on November 7, 2025, were received, reviewed, or acted upon Nursing documentation dated November 10, 2025, revealed the laboratory notified the facility that two urine specimens with the resident's identification were processed with conflicting results and that an additional specimen was required. The physician reordered the U/A and C&S, and another specimen was collected and sent to the laboratory. There was no evidence that the facility ensured timely completion of the reordered testing. A review of urinalysis results dated November 11, 2025, revealed yellow, cloudy urine with 3+ protein, 3+ leukocyte esterase (an enzyme produced by white blood cells that typically indicate infection), greater than 50 red blood cells per high power field, bacteria, and mucus, findings consistent with a urinary tract infection.Despite abnormal findings and persistent fevers, there was no evidence the facility ensured timely receipt of the culture and sensitivity results needed to guide treatment.Resident 1's temperature dated November 17, 2025, at 3:17 AM was documented as 101.6 degrees Fahrenheit, and the resident was administered acetaminophen 650 mg by mouth for the increased temperature.Nursing documentation dated November 17, 2025, at 3:58 PM revealed the laboratory had not completed the culture and sensitivity ordered on November 10, 2025, seven days after the order was placed. At that time, the physician was notified and reordered a urinalysis and culture and sensitivity. The documented nursing assessment indicated the resident's cheeks were pink, the resident reported she did not feel well, and her temperature was documented as 104 degrees Fahrenheit. Nursing documentation dated November 18, 2025, at 9:13 AM revealed the physician was again notified regarding the resident's condition. Additional orders were obtained for a urinalysis and culture and sensitivity, as well as laboratory studies including a complete blood count (CBC, a blood test that measures infection and inflammation markers) and a comprehensive metabolic panel (CMP, a blood test that measures kidney function and electrolyte balance). The urinalysis and culture and sensitivity were collected and sent to the laboratory, representing the third urine specimen collected for processing. A review of laboratory results received at the facility on November 18, 2025, at 4:15 PM revealed abnormal findings, including a blood urea nitrogen (BUN, a measure of kidney function) level of 41 mg/dL (normal range 9 to 23 mg/dL), a creatinine level of 2.03 mg/dL (normal range 0.55 to 1.30 mg/dL), and a white blood cell count of 25.8 x103/uL (normal range 3.2 to 10.6 x103/uL), indicating a significant infection and impaired kidney function. A urine culture and sensitivity dated November 18, 2025, revealed greater than 100,000 colony forming units per milliliter of Escherichia coli ESBL (a resistant strain of bacteria commonly associated with urinary tract infections).In response to these findings, the physician ordered an antibiotic, Bactrim DS one tablet by mouth every 12 hours for three days, and intravenous fluids, one half normal saline at 70 cubic centimeters (cc) per hour. The resident was then transferred to the hospital for evaluation and treatment, where the resident remained hospitalized for seven days with a diagnosis of acute kidney injury. A review of a nutritional assessment dated [DATE], revealed Resident 1's estimated daily fluid requirement was 1443 cubic centimeters (ccs), an amount necessary to maintain hydration and support kidney function. A review of daily intake records revealed the following documented fluid intake amounts:November 7, 2025, 480 ccsNovember 8, 2025, 660ccsNovember 8, 2025, 630 ccsNovember 9, 2025, 630 ccs November 10, 2025, 720 ccsNovember 11, 2025, 720 ccsNovember 12, 2025, 960 ccsNovember 13, 2025, 660 ccsNovember 14, 2025, 790 ccsNovember 15, 2025, 840 ccsNovember 16, 2025, 840 ccsNovember 17, 2025, 840 ccsNovember 18, 2025, 620 ccsNovember 19, 2025, 960 ccsNovember 20, 2025, 780 ccsA review of intake documentation revealed that from November 7, 2025, through November 20, 2025, Resident 1 consistently failed to meet her estimated daily fluid needs. There was no evidence that the facility identified the inadequate fluid intake, reassessed hydration status, implemented interventions to increase fluid consumption, or notified the physician of the resident's failure to meet fluid needs during a period of infection and persistent fever. A review of hospital emergency department documentation dated November 21, 2025, revealed the resident required intravenous hydration and was admitted for treatment of acute kidney injury. Resident 1 was readmitted to the facility on [DATE]. During an interview conducted December 10, 2025, at approximately 12:00 PM, the Nursing Home Administrator and Director of Nursing were informed of the survey findings related to Resident 1's change in condition, follow up of ordered diagnostic testing, and monitoring of fluid intake. The Nursing Home Administrator and Director of Nursing reviewed the findings presented at that time.28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of clinical records, laboratory reports, physician orders, and staff interviews, it was determined that the facility failed to ensure laboratory services were provided in a timely manner and failed to ensure appropriate follow up of ordered laboratory testing for one resident (Resident 1) out of the six residents sampled (Resident 1). Findings included: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include cerebral vascular disease (conditions affecting blood flow and bleeding in the brain), anxiety and high blood pressure. A review of Resident 1's quarterly minimum data set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 16, 2025 revealed a BIMS score of 14 (BIMS, brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 14 to 15 equates to cognitively intact resident). A review of nursing documentation dated November 7, 2025, at 7:19 AM, revealed Resident 1 had an elevated temperature of 102.2 degrees Fahrenheit and dysuria (pain with urination). The physician was notified and ordered a urinalysis (U/A, a test used to detect abnormalities in urine) and a urine culture and sensitivity (C&S, a test used to identify bacteria and determine appropriate antibiotic treatment). The specimen was collected and sent to the laboratory. The specimen was collected and sent to the laboratory. There was no evidence at the time of the survey that results of the urinalysis were received or reported to the facility.Nursing documentation dated November 10, 2025, at 6:45 AM revealed facility staff received a telephone call from the laboratory indicating two urine specimen tubes bearing the resident's identification had been processed with conflicting results. The laboratory advised that an additional specimen was required to obtain accurate results.The physician was notified and reordered the urinalysis and culture and sensitivity. The specimen was collected and sent to the laboratory on November 10, 2025.Nursing documentation dated November 17, 2025, at 3:58 PM revealed the culture and sensitivity ordered on November 10, 2025, had not been completed seven days later. At that time, the physician was notified and ordered another urinalysis and culture and sensitivity. The nursing assessment documented the resident's cheeks were pink, the resident reported she did not feel well, and her temperature was noted to be 104 degrees Fahrenheit.Nursing documentation dated November 18, 2025, at 9:13 AM revealed the physician was again notified regarding the resident's condition. Additional laboratory testing was ordered, including a urinalysis, culture and sensitivity, a complete blood count (CBC, a blood test that measures components of the blood such as white blood cells to identify infection), and a comprehensive metabolic panel (CMP, a blood test that evaluates kidney function and electrolyte balance). The urinalysis and culture and sensitivity were collected and sent to the laboratory, representing the third urine specimen collected for processing.A review of laboratory results received at the facility on November 18, 2025, at 4:15 PM revealed abnormal findings, including a blood urea nitrogen (BUN, a blood test that measures the amount of urea nitrogen in the blood and is commonly used to assess how well the kidneys are functioning) level of 41 mg/dL (normal range 9 to 23 mg/dL), a creatinine level of 2.03 mg/dL (creatinine is a waste product filtered by the kidneys, and elevated levels indicate reduced kidney function; normal range 0.55 to 1.30 mg/dL), and a white blood cell count of 25.8 x103/uL (normal range 3.2 to 10.6 x103/uL), indicating significant infection and impaired kidney function.The resident was started on intravenous fluids, one half normal saline at 70 cubic centimeters per hour, and transferred to the hospital for evaluation and treatment, where she remained hospitalized for seven days with a diagnosis of acute kidney injury.There was no evidence at the time of the survey that the culture and sensitivity specimen submitted on November 10, 2025, was completed or that results were reported to the facility in a timely manner. There was also no evidence the facility ensured follow up with the laboratory when the ordered culture and sensitivity results were not received.During an interview conducted December 10, 2025, at approximately 2:00 PM, the Director of Nursing was informed of the survey findings related to laboratory services. The Director of Nursing reviewed the findings presented and was unable to provide documentation demonstrating timely follow up with the laboratory regarding the delayed culture and sensitivity results. 28 Pa. Code 211.12 (3)(5) Nursing services.

Based on review of clinical records, select facility policy and staff interview, it was determined the facility failed to timely notify the resident's responsible party of a change in condition for one resident out of 6 residents sampled (Resident 1). Findings include:A review of a facility policy for Change in condition last reviewed December 9, 2025, revealed, the purpose of the policy is to insure that the facility promptly informs the resident, consults the resident's Physician and notifies, consistent with his or her authority, the resident's representation when there is change requiring notification. Circumstances requiring notification to include, a transfer or discharge of the resident from the facility. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include cerebral vascular disease (conditions affecting blood flow and bleeding in the brain), anxiety and high blood pressure. A review of Resident 1's quarterly minimum data set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 16, 2025 revealed a BIMS score of 14 (BIMS, brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 14 to 15 equates to a cognitively intact resident). A review of Resident 1's clinical record, nursing documentation revealed that on November 21, 2025, at 9:06 PM, the resident was transferred to the hospital for evaluation and treatment. There was no evidence at the time of the survey that the residents responsible party was notified of the transfer to the hospital. An interview with the Director of Nursing and Nursing Home Administrator on December 10, 2025, at approximately 12:00 PM confirmed the facility failed to notify the resident's responsible party of the hospital transfer. Cross refer F 684, F770 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of clinical records and select facility policy. facility investigative reports, and staff interviews, it was determined the facility failed to thoroughly investigate an incident of unknown origin to rule out abuse, neglect or mistreatment as the potential cause, for one out of 5 sampled residents (Resident 1). Findings include: A review of the facility's Abuse Policy, last reviewed by the facility in January 2025, indicated that incidents of unknown origin will be investigated as abuse until root cause can be identified. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. A review of clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes and severe protein/calorie malnutrition. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) dated January 21, 2025, revealed the resident was cognitively intact with a BIMS score of 13 (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) and requires staff assistance with activities of daily living (ADLs). A review of physician orders dated February 21, 2025, revealed an order for potassium chloride extended release, 10 MEQ tablets, four tablets by mouth, three times daily. A review of a February 2025 Medication Administration Record (MAR) revealed that nursing staff documented administration of all prescribed medications, including the potassium chloride, from February 21 through February 28, 2025 when he was transferred out to the hospital. Nursing documentation dated February 28, 2025, at 11:52 AM indicated the resident's son requested hospital evaluation due to the resident feeling unwell, with symptoms of nausea and loose stools. The resident was noted to be incontinent of a small, pasty, tarry stool. He refused breakfast and morning medications. The abdomen was soft, non-tender, with positive bowel sounds. The physician evaluated the resident and ordered hospital transfer at approximately 11:40 AM. A review of hospital emergency room documentation dated February 28, 2025, indicated a CT scan (medical imaging procedure that uses X-rays to create detailed images of cross-sections of the body) of the abdomen and pelvis revealed innumerable circular foreign bodies. A rectal examination resulted in the expulsion of a copious amount of light brown, [NAME]/gritty liquid stool and 20-30 circular-shaped tablets, some with KC scoring, suspected to be potassium chloride. The emergency room physician documented a call with the attending physician, who stated uncertainty about whether nursing staff observed the resident swallow his oral medications. Nursing documentation dated February 28, 2025, at 8:02 PM revealed, Resident 1 was readmitted to the facility from the hospital with a diagnosis of foreign body in rectum. The hospital report included disimpaction (procedure to remove feces from the rectum) of more than 30 pills (multiple clusters). The resident denied inserting the medications into his rectum. Education was provided to the resident. There was no documented evidence the facility initiated an investigation upon the resident's return to identify the root cause of the unknown incident, including: interviews or witness statements from all staff members who had administered medications to Resident 1 during the period in question, an interview or written statement from the resident himself to assess potential mistreatment and a root cause determination to evaluate if abuse, neglect, or mistreatment may have occurred. On March 1, 2025, at 6:51 AM, nursing documentation revealed that staff entered the resident's room and observed multiple pills on the floor. The nursing supervisor was notified. A facility investigation report dated March 3, 2025, regarding the March 1, 2025, incident, documented that pills were found on the floor at the resident's bedside. The report stated the resident was known to have medications come out of his bowels. Witness statements from three employees dated March 3, 2025, (no time indicated) regarding the March 1 incident included: Employee 1 (LPN): Resident 1 always took his meds by mouth when I was the nurse. Employee 2 (LPN): Indicated the resident took his medications and was never observed attempting to insert them rectally. Employee 3 (RN): Noted the resident frequently refused medications; however, she waited bedside to ensure administration and never witnessed him placing medications in his rectum. There was no further documentation that staff responsible for medication administration from February 21-28 were interviewed or that any attempt was made to determine how the resident became impacted with more than 30 pills. Additionally, there was no documented evidence that the facility interviewed Resident 1 regarding the incident to determine whether any staff had harmed him or administered medication inappropriately. An interview conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on April 9, 2025, at 1:00 PM, confirmed that the facility failed to initiate a timely and comprehensive investigation into the February 28, 2025, incident to rule out abuse, neglect, or mistreatment. The facility failed to implement its own Abuse Policy requiring that incidents of unknown origin be investigated as potential abuse 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management

Based on review of clinical records and staff interview it was determined the facility failed to fully develop and revise a person-centered comprehensive care plan to meet the individualized needs of one resident out of 20 sampled (Resident 67). Findings included: A review of Resident 67's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and muscle weakness. A review of Resident 67's POLST (Pennsylvania Orders for Life Sustaining Treatment, a process that helps an individual receive the medical treatment they want, and avoid the medical treatments they do not want, when they are seriously ill or frail) initiated by the facility's Social Worker (SW) and completed with Resident 67's RP (responsible party) dated [DATE], indicated the resident's code status was changed to do-not-resuscitate (DNR a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if breathing stops or if the heart stops beating and comfort care (a specialized patient care approach focused on managing symptoms, relieving pain, and enhancing quality of life. It is typically offered to residents who have experienced multiple hospitalization s, where further medical interventions are unlikely to change the outcome), elected medical interventions for comfort measures, antibiotic use to be determined when infection occurs or with comfort as the goal, and no hydration or nutrition by means of a feeding tube. The POLST form dated [DATE], and a progress note by the Social Worker indicated that the resident's responsible party (RP) had elected a care plan that included do-not-resuscitate (DNR), comfort care, antibiotics for comfort, and no artificial hydration or nutrition by tube. Physician's orders dated [DATE], at 1:15 PM, revealed that the Resident 67's code status was DNR. A review of the resident's comprehensive plan of care, last revised on [DATE], failed to reflect these updated medical treatment goals and interventions. Despite updated physician orders and documentation in progress notes, the care plan did not address the resident's goals for comfort measures only, the selective use of antibiotics, or the decision to forego artificial hydration and nutrition. On [DATE], the Social Worker confirmed that the resident's RP elected comfort measures due to the resident's progressive weight loss and variable meal intake. The Director of Nursing (DON) confirmed that the facility failed to revise the resident's care plan to include the specific medical treatment goals outlined by the POLST form and RP's instructions. The facility failed to incorporate the resident's medical treatment goals for comfort measures only, antibiotics use for comfort, and no hydration or artificial nutrition by tube 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records, and staff interview, it was determined the facility failed to implement individualized approaches to prevent declines in bowel continency and restore normal bowel function to the extent possible for one resident (Resident 65) out of 20 residents sampled. Findings include: Review of facility policy entitled Bladder and Continence, last reviewed on January 2, 2025, indicated residents who are identified as having the potential to improve continence, place on a retraining program. According to the policy, upon admission, re-admission, with any significant change, and after urinary catheter removal, a bowel and bladder diary will be completed for a minimum of three days to gather information about the resident's current continence status. Upon review of the data gathered from the diary, a continence evaluation will be completed, and an appropriate toileting program implemented. A review of Resident 65's clinical record revealed admission to the facility on [DATE], with diagnoses which included hypertension (high blood pressure), anxiety, and recurrent urinary tract infections. A review of Resident 65's admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 1, 2024, section H, bowel, and bladder, indicated the resident was frequently incontinent of bladder and frequently incontinent of bowel and was not on a toileting program to manage the resident's incontinence. The resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with activities of daily living which included toilet transfer and toileting hygiene. A review of Resident 65's care plan-initiated February 26, 2024, revealed that the resident has an ADL self-care performance deficit related to weakness and need for assist with personal care. There was no evidence the facility had evaluated the resident's bowel and/or bladder habits and status to develop an individualized toileting retraining program to decrease episodes of incontinence. A Continence Evaluation completed on April 9, 2024, indicated that Resident 65 experienced occasional incontinence of both bowel and bladder. Recommendations included routine toileting before and after meals, at bedtime, and as requested, with checks and changes every three hours during the night. Despite this evaluation, there was no evidence that the recommended program was implemented. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of clinical records and staff interview, it was determined the facility failed to ensure coordination of care and services between the facility and the Hospice Agency for two residents (Residents 69 and 7). Findings include: A review of Resident 69's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of physician's order dated December 4, 2024, revealed the resident was admitted into hospice services for a diagnosis of end stage Alzheimer's disease. A review of the resident's care plan initially dated October 30, 2024, and last revised November 25, 2024, revealed the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis. A review of Resident 7's clinical record revealed she was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of physician's order dated September 19, 2024, revealed the resident was admitted into hospice services for a diagnosis of end stage dementia. A review of the resident's care plan initially dated September 19, 2024, and last revised December 10, 2024, revealed the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis. An interview with the director of nursing on January 8, 2025, at approximately 12:30 pm, confirmed the resident's care plan was not coordinated with hospice services. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.21(c) Use of outside resources

Based on a review of select facility policy, clinical records and select investigative reports, and resident and staff interviews, it was determined that the facility failed to ensure that three residents out of the five sampled for abuse (Residents 65, 73, and 89) were free from physical abuse. Findings include: A review of facility policy entitled Abuse, Neglect, and Exploitation, last revised by the facility on January 16, 2024, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defines physical abuse as including, but not limited to, hitting, slapping, punching, biting, and kicking. Review of the clinical record revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses of alcohol-induced persisting 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 related to the consumption of alcohol). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 14, 2023, revealed that Resident 73 was severely cognitively impaired. Clinical record review revealed that Resident 74 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). The resident's quarterly MDS assessment dated [DATE], revealed that Resident 74 was severely cognitively impaired. Resident 74's care plan noted that the resident displayed socially inappropriate behaviors that included hitting, punching, and swinging at staff initiated on April 11, 2023, with planned interventions to encourage the resident to interact with others and participate in activities of interest and encouraging the resident to express any feelings, fears, needs, or concerns as able. The resident's care plan also noted that Resident 74 has the potential to be verbally and physically aggressive toward staff related to dementia initiated October 18, 2022, with planned interventions to anticipate the resident's needs, provide physical and verbal cues, and providing the resident with as many choices as possible about care and activities. A record review revealed a Documentation Survey Report dated April 2023, indicating that Resident 74 displayed physical aggression towards others on April 2, 11, 15, and 16, 2023. The report indicated that Resident 74 threatened others on April 2, 9, 11, 15, and 16, 2023. The report also indicated that the resident hit and kicked others on April 2, 15, and 16, 2023. A review of clinical records and investigative reports, and staff interviews revealed that Resident 74 grabbed and scratched Resident 73's left forearm on May 10, 2024. A facility witness statement dated May 10, 2023 revealed that Employee A1, Nurse Aide witnessed Resident 74 attempting to push Resident 73's wheelchair. Employee A1 indicated that Resident 74 grabbed and scratched Resident 73 before staff could intervene. A progress note dated May 10, 2023, at 13:51 PM indicated that Resident 74 scratched another resident {Resident 73}. The entry indicated that Resident 74 sustained no injuries during the incident. However, a progress note dated May 11, 2023, at 14:26 (2:26 PM)revealed that Resident 73 sustained a scratch to her left forearm with linear scabbed areas and ecchymosis (bruising) measuring 6.0 cm x 0.5 cm. There was no redness, swelling, or drainage noted. The note indicated that Resident 73 had no complaints of pain in the area. During an interview on March 15, 2024, at approximately 10:15 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the Resident 73 was not free from physical abuse perpetrated by Resident 74 resulting in a scratch and bruising on her left forearm. A clinical record review revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses to 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). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 65 was severely cognitively impaired. A facility Report of Resident Aggression form dated February 15, 2024, revealed that Employee A2, a nurse aide, witnessed Residents 65 and 74 talking in the hallway. Employee A2, indicated that Resident 74 slapped Resident 65's face. Resident 65 grabbed Resident 74's hands and yelled out in response. Employee A2 explained that the residents were separated and calmed down. A progress note dated February 15, 2024, at 4:00 PM in Resident 65's clinical record, revealed that staff observed another resident, Resident 74, slap Resident 65 on the left side of her face. Resident 65 had no complaints of pain or discomfort and was assessed without redness, edema, or bruising to the left side of her face. A progress note dated February 15, 2024, at 9:06 PM in Resident 74's clinical record revealed that a nurse aide reported Resident 74 had smacked another resident {Resident 65} in the face. The note indicated that the residents were immediately separated, and Resident 74 had no complaints of pain or distress. The entry indicated that Resident 74 continued to display increased poor impulse control with behaviors such as wandering into resident rooms and pushing residents in wheelchairs. The progress note explained that distraction activities were provided and effective for brief periods of time. During an interview on March 15, 2024, at approximately 10:15 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to protect Resident 65 from physical abuse. A clinical record review revealed that Resident 89 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A quarterly MDS assessment indicated that Resident 89 was moderately cognitively impaired. A clinical record review revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses that included dementia. A significant change in status MDS assessment dated [DATE], revealed that Resident 80 was severely cognitively impaired. A review of Resident 80's current care plan revealed that he has a problem with impaired cognitive functions, impaired thought processes, and impulse control related to his diagnosis of dementia, initiated on September 3, 2023. Care plan interventions planned were cueing, reorienting, and supervising as needed; engaging the resident in simple, structured activities; and providing a program of activities that accommodates the resident's abilities. The resident's Documentation Survey Report dated January 2024, indicated that Resident 80 displayed agitation on January 1 and 3, 2024. The resident was cursing at others, frustration directed at others, displayed aggression towards others on January 1, 3, and 4, 2024, and the resident was entering other resident rooms on January 3, 2024. A review of clinical records and investigative reports revealed that Resident 80 pushed and hit Resident 89 with a reaching-assistance device on January 10, 2024. A witness statement dated January 10, 2024, provided by Employee 2, Licensed Practical Nurse, indicated that Resident 89 was at his bedroom door, yelling to get this man {Resident 80} out of his room. Resident 80 was found in Resident 89's bathroom. Resident 80 was agitated and putting his fist up. Employee 2 indicated that she was able to redirect Resident 80 out of Resident 89's room. Employee 2 reported that Resident 89 informed her that Resident 80 went through his belongings, shoved him, and then hit him with a grabber {reaching-assist device}. A progress note dated January 10, 2024, at 10:30 PM indicated that Resident 89 was on the phone with his family member when Resident 80 entered Resident 89's bedroom. Resident 89's family member called the facility to report the incident, at which time Employee 2, LPN, responded to Resident 89's room. The note indicated that Resident 80 went through Resident 89's personal belongings, shoved him in the left shoulder, and hit him on the left hand with a grabber bar {reaching-assist device}. The note indicated that Resident 89 had no complaints of pain or injuries noted. A progress note dated January 10, 2024, at 10:28 PM indicated that Resident 80 was wandering into rooms and agitated with another male resident. The note indicated that Resident 80 had no symptoms of pain or discomfort, care was provided, and the resident appeared pleasant and cooperative. A physician note dated January 11, 2024, at 9:53 PM indicated that Resident 89 was seen today due to being accosted yesterday by another resident with a long shoehorn {reaching-assist device} and a tissue box. Resident 89 complained of left shoulder pain after being hit there with the long shoehorn. During an interview on March 12, 2024, at 10:10 AM, Resident 89 indicated that a while back, a gentleman entered his room. He explained that he told the resident to leave, but he wouldn't listen. Resident 89 stated that the resident pushed him and hit him on the shoulder. He explained that he had some pain in the shoulder the next day, but it has healed since the incident. During the interview, Resident 89 explained that the incident doesn't bother him, because he believes that the other resident didn't know what he was doing. During an interview on March 15, 2024, at approximately 10:15 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to protect Resident 89 from physical abuse. Refer to F744 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

Based on observation, a review of clinical records and schedule of activities programming and resident activities participation records, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents, including three residents out of 21 sampled (Residents 77, 74, and 80). Findings include: A clinical record review revealed that Resident 74 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2024, revealed that Resident 74 is severely cognitively impaired. Resident 74's care plan, included the problem of socially inappropriate behaviors that included hitting, punching, and swinging at staff initiated April 11, 2023. Planned interventions were to encourage the resident to interact with others, participate in activities of interest, encourage the resident to express any feelings, fears, needs, or concerns as able. Resident 74's care plan also identified that the resident had the potential to be verbally and physically aggressive towards staff related to dementia dated October 18, 2022. Planned interventions were to anticipate the resident's needs, providing physical and verbal cues, and providing the resident with as many choices as possible about care and activities. Resident 74's care plan identified that the resident had a preference for activities that include gardening, time outdoors, watching Jeopardy, Hallmark Channel movies, and Classic movies, listening to others reading, hymns, and crafting. A review of Resident 74's activities participation revealed no documented evidence that the facility had provided, or the resident had participated in the preferred activities. Resident 74's activities participation records for December 2023, January 2024, and February 2024 revealed that she participated in only three reading activities. There was no indication of how many reading activities were offered to the resident. It was not identified if the resident was reading or other were reading to the resident. There was no indication that Resident 74 was provided an opportunity to watch Hallmark Channel movies, classic movies, or the Jeopardy television game show. There was no indication that Resident 74 was provided the opportunity to participate in a crafts program in February 2024. Resident 74's activities participation records for December 2023, January 2024, and February 2024, revealed that the resident was wandering during 10 activities opportunities and in bed during 22 activities opportunities. There was no evidence that Resident 74 was encouraged, prompted, or directed to the available activities programming on those dates. A review of Resident 74's activities participation records for December 2023, January 2024, and February 2024, revealed no evidence of the resident's level of participation, duration of participation in the activities and the resident's response to any programming provided to evaluate the adequacy and appropriateness of the activities programming provided to this resident. A review of Resident 77's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, dysphagia, aphagia (inability to speak), anxiety disorder and was severely cognitively impaired. The resident's care plan, dated January 18, 2022, and revised December 19, 2023, identified that the resident displayed socially inappropriate behaviors, of rummaging through other resident's belongings, disrobing in public, voiding/defecating in inappropriate areas, physical and verbal aggression, calling anyone near her [NAME]/[NAME] and looking for husband [NAME] and pushing other residents. Resident 77's goal was to not exhibit socially inappropriate behaviors with planned interventions to encourage the resident to interact with others as able, enjoy small groups such as sing-a-longs and Rosary. Resident 77's plan of care indicated that the resident was at risk for wandering and had the potential to become physically/verbally aggressive towards staff and others related to dementia. Planned interventions to manage these behaviors were to distract the resident from wandering by offering pleasant diversions such as structured activities (not specified), food, conversation (topic not identified), television (viewing preference not identified), warm tea, reminiscing (topic not identified), looking through old pictures (location of these photographs), and memory boxes. Planned interventions to manage the resident's dementia related behaviors also included providing independent activities such as folding and organizing clothes and sensory activities such as light shows with music. A review of Resident 77's activity participation logs dated October 2023, November 2023, December 2023, January 2024, February 2024, through survey ending March 15, 2024, revealed that the resident had limited periodic participation in activities such as coffee cart, small group activities (program not identified) in the AM and PM, arts and crafts, and outside. Observation of the facility's activities calendar posted on the wall in the Gold Unit on March 14, 2024, at 10:45 a.m., revealed the scheduled activities for the day included: Coffee Clutch at 9:00 a.m., One-to-Ones at 10:00 a.m., Sensory Time at 11:00 a.m., Chip 'N' Dips at 3:00 p.m., Balloon Battle from 4-6:00 p.m., and Music Time from 7-8:00 p.m. During an observation of the Gold Unit, the facility's dedicated dementia unit, on March 14, 2024, at approximately 10:45 a.m., revealed the doors to the activity room were closed. Upon entering the activity room, four residents were observed seated in their wheelchairs there was no activities program occurring at that time. The television was on, but the residents did not appear to be engaged in watching the television. At this time, Resident 77 was observed in another resident's room, room [ROOM NUMBER], laying on the other resident's bed near the door. Observation of the Gold Unit revealed that upon exiting the resident activity room, at approximately 11:04 a.m., nursing staff discovered that Resident 77 was in an another's resident's room and escorted her out. Resident 77 then entered the activity room, but not begin watching the television and instead began to wander about the unit. During an interview with Employee 8, an activity staff member, on March 14, 2024, at 11:07 a.m., revealed that lunch would be coming shortly and that they were getting ready to set up the activity area. Employee 8 stated that staff were going to put a sing-along video that showed the words for the residents to follow along while they set up the room for lunch. The planned activity noted on the activity calendar for the Gold Unit at that time was, Sensory Time, but the source of the sensory stimulation was not identified A review of the schedule of the activities department staff for the months of January 2024, February 2024, and through survey ending March 15, 2024, revealed that the employees assigned to the Gold Unit worked the day shifts 9:00 a.m. to 5:00 p.m. and one employee that worked 2:00 p.m. to 7:00 p.m. once per month. During an interview with the facility's activities consultant on March 15, 2024, at 10:05 a.m., the employee stated that that the Gold Unit (dementia care unit) that the facility currently has a job openings on the evening shift and confirmed that the facility does not consistently have activities staff working during the evening shifts on the Gold Unit to provide diversional activities to manage escalating dementia behaviors that frequently occur during periods of sundowning in the late afternoon and early evening hours. The facility was unable to provide evidence that the facility had developed and implemented an individualized activities program to meet the resident's cognitive and functional abilities. The facility failed to accurately monitor the resident's activities participation and the resident's response to any activities programming provided to design an appropriate individualized program of activities to meet the resident's current needs and abilities. A clinical record review revealed that Resident 80 was admitted to the facility on [DATE], with a diagnosis of dementia. A significant change in status MDS assessment dated [DATE], revealed that Resident 80 is severely cognitively impaired. Resident 80's current care plan revealed that he has a problem with impaired cognitive functions, impaired thought processes, and impulse control related to his diagnosis of dementia, initiated on September 3, 2023. The planned interventions were to cue, reorient, and supervise the resident as needed, engaging the resident in simple, structured activities (not identified) and providing a program of activities that accommodates the resident's abilities. The resident's care plan revealed that he enjoys 50's and 60's music, word search, reading the newspaper, car magazines, spending time outdoors, socials, animals, kids, and assisting with bingo. A review of Resident 80's activities participation records for the months of December 2023, January 2024, and February 2024, revealed no evidence that the facility had participated in the resident's preferred activities or was provided materials/resources for self-directed activities he preferred. Resident 80's activity participation records for December 2023, January 2024, and February 2024 revealed that he participated in one bingo activity. There was no indication of how many bingo opportunities were offered to Resident 80. The resident's participation records for December 2023, January 2024, and February 2024 revealed that the resident was wandering during three activity opportunities, napping during 35 activity opportunities, and refused 16 activities (not identified which were refused). The resident's activities participation records from December 2023 through the time of the survey ending March 15, 2024, revealed no evidence of the resident's level of participation, duration of participation in the activities and the resident's response to any programming provided to evaluate the adequacy and appropriateness of the activities programming provided to this resident. During an interview on March 15, 2024, at approximately 10:30 AM, the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences, and functional abilities of residents, including Residents 77, 74, and 80. 28 Pa. Code 201.29 (a) Resident rights

Based on clinical record and select policy review and staff interview, it was determined that the facility failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for two residents out of 21 sampled. (Resident 35 and 43) Findings include: A review of a facility policy entitled Fluid Restrictions that was last reviewed by the facility on January 16, 2024, indicated that the facility would ensure that fluid restrictions would follow in accordance with physician's orders. Nursing will obtain and verify physician's orders for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24-hours to be distributed between the food and nutrition department and the nursing department and will be recorded on the medication record or other format as per facility policy. A review of Resident 35's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included heart failure [is a progressive heart disease that affects pumping action of the heart muscles that causes fatigue, shortness of breath] and hyponatremia [(low sodium lab value) is a condition where sodium levels in the blood are lower than normal and caused by too much water present in the body dilutes sodium levels and caused symptoms of confusion, muscle spasms, convulsions]. A physician orders dated February 1, 2024, was dated for the resident to maintain a 1500 ml per day fluid restriction due to hyponatremia. The resident's nutritional plan of care revised by the registered dietitian (RD) on February 2, 2024, at 10:27 a.m., indicated that Resident 35 was nutritionally at risk due to hyponatremia with an intervention to maintain a 1500 ml per day fluid restriction. Planned interventions were for the dietary department to provide the following fluids at breakfast: decaf hot tea 6 oz- 180 cc, orange Juice- 4 oz- 120 cc, and milk- 8 oz- 240 cc for a total of 18 oz/540 cc at breakfast; lunch: decaf hot tea 6 oz- 180 cc, orange juice- 4 oz- 120 cc for a total of 12 oz/300 cc at lunch, and dinner decaf hot tea 6 oz- 180 cc, orange juice- 4 oz- 120 cc for a total 12 oz/300 cc at dinner. Total fluids from dietary on trays 1140 cc/day and allotted 360 cc of fluids to be provided by nursing staff to total 1500 cc per the MD orders. A review of Resident 35's clinical record Medication Administration Record [(MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional and is a part of a patient's permanent record on their medical chart] dated February 2024 and March through survey ending March 15, 2024, failed to reveal documented evidence that nursing staff recorded the amount of fluids nursing staff provided to the resident daily. A review of the resident's Documentation Survey Reports dated February 2024 and through survey ending March 15, 2024, failed revealed inconsistent documentation to demonstrate that the facility accurately recorded and/or accounted for the amount of fluids the resident consumed each day to assess compliance with physician ordered fluid restriction to treat the resident's clinical diagnosis of hyponatremia and heart failure and meet the resident's hydration needs. During an interview with the Director of Nursing (DON) and in the presence of the Nursing Home Administrator (NHA) on March 15, 2024, at 10:15 a.m., confirmed that the facility was unable to provide documented evidence that nursing staff documented the amount of fluids provided to Resident 35 daily and confirmed that the facility failed to ensure that staff consistently documented and monitored the resident's fluid intakes as required for maintenance of the physician ordered 1500 ml per day fluid to manage Resident 35's chronic conditions. A physician's order dated February 20, 2024, was noted for the resident to be maintained on a 2000 cc fluid restriction related to a diagnosis of congestive heart failure. Resident 43's care plan, initiated July 17, 2023, revealed that the resident has the potential for fluid overload or potential fluid volume overload related to disease process congestive heart failure. Interventions planned October 30, 2023, included that 1410 ml fluid provided by dietary on meal trays, and nursing staff provide at total of 410 ml fluids daily. The registered dietitian recommended 7 AM - 3 PM nursing staff offer/give 180 ml daily, 3 PM to 11 PM nursing staff offer/give 120 ml daily, and 11 PM to 7 AM nursing staff offer/give 110 ml daily. The care planned interventions were to monitor/document/report as needed any signs/symptoms of fluid overload: anorexia, mood/behavior changes, confusion, edema, nausea/vomiting, shortness of breath, difficulty breathing, increased respirations, difficulty breathing when lying flat, congestion, cough, fatigue, jugular venous distention, or sudden weight gain. The resident was to be weighed daily in the morning and ensure that all the resident's snacks and beverages offered at activities comply with diet and fluid restrictions. A review of the resident's February 2024 and March 2024 Documentation Survey Reports failed to provide evidence of an accurate recording and accounting of the amount of fluids the resident consumed each day to assess compliance with physician ordered fluid restriction and hydration needs. Review of clinical documentation completed by Registered Dietitian February 20, 2024 through March 7, 2024, failed to provide evidence that Resident 43's physician ordered fluid restriction was monitored for compliance with the prescribed 2000 ml restriction and that the resident's fluid intake was adequate to maintain hydration. An interview with the Director of Nursing on March 15, 2024, at 1:15 p.m., confirmed that the facility failed to total and calculate resident's daily fluid intake to confirm the amount of fluid consumed by the residents' daily, compliance with the physician prescribed fluid restriction and adequacy for hydration needs. 28 Pa. Code: 211.12 (c)(d)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on a review of select facility policy, clinical records, and facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and timely assistance with activities of daily living for residents at risk for falls and known unsafe behaviors and failed to implement planned and effective safety measures based on individual resident needs to promote resident safety and prevent repeated falls, which resulted in major injuries for two residents, a [CONDITION(S)] and thigh bone, (Resident 64 and 4) and minor injuries for one resident (Resident 52) out of 18 residents sampled. Findings include: Review of facility policy entitled Fall Prevention, dated April 20, 2021, revealed that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood to fall. According to the policy, a fall risk assessment will be completed on each resident upon admission to determine the resident's level of fall risk. The nurse will then initiate interventions on the resident's care plan in accordance with the resident's level of fall risk. A list of universal environment interventions that decrease the risk of resident falling included a clear path to the bathroom, bed locked and in lowered position when the resident is in bed, call light and frequently used items are to be within the resident's reach, adequate lighting, implement routine rounding schedule, monitor for changes in the resident's condition, encourage the resident to wear shoes or slippers with non-skid soles when ambulating, and provide eyeglasses that are clean, if applicable. Fall Prevention policy indicated that those residents identified to be at a higher risk for falls would have additional interventions implemented to prevent falls. These interventions included that are individualized to the resident's needs (e.g. increased frequency of rounds, medication regimen review, alternate call system access, scheduled ambulation or toileting assistance, therapy services referral, resident or care-giver education, floor mats, safety alarms, diversional activities, pain assessments and treatment for pain as needed, offer a nap, and soothing music/environment). When any resident experiences a fall, the facility will assess the resident, including neurological checks for 72 hours, complete a post fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, provide a new intervention based on circumstances to prevent further falls, document all interventions and actions, and obtain witness statements for staff witnesses on duty. According to the facility's Morse Fall Scale Assessment (a rapid and simple method of assessing a patient's likelihood of falling), fall risk is based upon fall risk factors and it is more than a total score. Determine fall risk factors and target interventions to reduce risks. Complete on admission, quarterly, at change of condition, and after a fall. Review of the clinical record revealed that Resident 64 was admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)], symptomatic [CONDITION(S)] (the seizures are a symptom of some type of brain malfunction or injury) and epileptic syndrome with complex partial seizures (person is not usually aware of their surroundings while [CONDITION(S)] happens, they will not respond to others or their environment, and they typically don't remember what occurs during the episode), and dementia. A review of Resident 64's Admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 11, 2021, revealed that the resident was severely cognitively impaired, required extensive assistance from staff with activities of daily living to include bed mobility, transfers, dressing, eating, and toilet use. Review of Resident 64's fall risk assessment completed on November 8, 2021, indicated that the resident was at high risk for falls. The assessment indicated that the resident had a history of falls, had an impaired gait, and overestimates or forgets limits. Review of Resident 64's care plan initiated November 8, 2021, indicated that the resident was at risk for falls related to confusion, deconditioning, and unaware of safety needs. The planned interventions included toileting schedule of ambulation to bathroom daily by 7:30 AM, offer resident 7:30 PM bedtime daily, ensure that resident wearing appropriate footwear, resident to be wearing non-skid socks when shoes not in place when ambulating or mobilizing in wheelchair, pad alarm to bed and chair, anticipate and meet the resident's needs, encourage the resident to participate in activities that promote exercise, physical activity for strength and improved mobility, therapy evaluation and treat as ordered or as needed. A review of facility incident report of a fall dated December 3, 2021, at 10:40 AM revealed that Resident 64 was lowered to the floor by the therapist while being transferred into bed. According to the investigation, the resident was wearing old non-slip socks and that the socks were worn out, which caused the resident's feet to slip out from under her. The interventions planned to prevent future falls was that the resident must wear non-slip socks or wear tennis shoes. There was no evidence that the facility had completed a Morse Fall Scale Assessment after this fall of December 3, 2021, according to the facility's fall prevention policy. A review of the facility incident report of a fall dated December 5, 2021, at 8:00 PM indicated that Resident 64 was found on the left side of her bed between the bed and her broda chair. According to the report, the resident stated that she was tired of waiting for help into bed and didn't want to bother the girls. Review of a witness statement indicated that Resident 64 had been seen 5 minutes prior to the fall when staff asked the resident to wait until after they put another resident to bed. According to the witness statement, Resident 64 agreed to wait for staff. The intervention implemented to prevent future falls was to offer daily bedtimes at 7:30 PM and pad alarms were applied to the resident's bed and chair. There was no evidence that the facility had completed a Morse Fall Scale Assessment after this fall of December 5, 2021, according to the facility's fall prevention policy. A review of the facility report for fall dated December 10, 2021, at 8:00 AM indicated that the resident was found in a sitting position on the floor by the bathroom in the resident's room. According to the report, the resident stated that she was in the toilet and I called for help. I used the call light in the bathroom, and no one came to help me, so I tried to get myself back to bed. The resident received an abrasion to her left elbow. The investigation indicated that the bed alarm did not sound and that the call bell was on in the resident's bathroom. Review of a witness statement indicated that staff had responded to the resident's alarm, just prior to the reported fall (no time noted) At that time, staff observed the resident attempting to take herself to the bathroom. Staff assisted the resident to the bathroom, then back to bed. Interventions implemented to prevent future falls was to initiate a toilet schedule and to change the alarm box for the bed alarm. It had been determined that the resident disengaged the bed alarm box and that is why it did not sound upon the resident's self-transfer from the bed and self-ambulation to the bathroom. According to the nurse aide tasks report dated December 13, 2021, there was no documented evidence that a toileting schedule had been implemented after the resident's fall of December 10, 2021, as planned as an intervention to prevent future falls related to toileting. A review of the facility incident report of a fall dated December 25, 2021, at 2:49 AM indicated that staff responded to an alarm sounding and observed Resident 64 enter the bathroom of the resident's room, lose her balance, and fall backwards. The resident hit her left hip on the door jamb, then fell to the floor. The resident complained of severe left hip pain during the nurse's assessment and was sent to the emergency room for an evaluation and was admitted with a left hip fracture. According to the report, the resident was last seen sleeping in her bed at 2:30 AM. At the time of the fall at 2:49 AM, the resident was not wearing shoes or non-slip socks, the bed alarm was sounding and the resident's call bell was sounding. Review of staff witness statement dated December 25, 2021, indicated that earlier that night prior to the resident's fall at 2:30 AM, staff had responded to the resident's bed alarm sounding at 12:45 AM. Staff had found the resident out of bed and halfway to the bathroom in the resident's room. According to the witness statement, staff assisted the resident to the bathroom then walked her back to bed after toileting needs were met. The task of to toilet resident as per times in tasks (instructions for resident care for nurse aides) was initiated on the resident's care plan February 18, 2022. Review of Resident 64's tasks report on May 5, 2022, revealed that the resident was to be offered toileting for fall prevention at 7:30 AM, 10 AM, 1 PM, 4 PM, 7 PM, 9 PM, 11:30 PM, 2:30 AM, and 5 AM. Review of Resident 64's Documentation Survey Report for December 2022, revealed no documented evidence that the resident was offered toileting according to the schedule noted on the task report. The facility failed to consistently implement the scheduled toileting plan to reduce the resident's attempts at self transfers and ambulation. The facility also failed to demonstrate that staff had timely responded to the resident's requests for assistance and call bells to prevent the resident from self-rising, self-transferring and self-ambulation, which resulted in multiple falls. The resident was identified at risk for falls and the facility failed to provide timely and necessary staff supervision and assistance with activities of daily living and meet the resident's toileting needs in a timely manner to prevent a fall with serious injury. A review of the clinical record of Resident 4 admission to the facility on [DATE], with diagnoses to include dementia and unsteadiness on her feet. A review of an admission Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired, required staff assistance with all activities of daily living to include toileting. The resident's balance during transitions and walking, was not steady, and the resident was only able to stabilize with staff assistance according to the MDS assessment. A review of the resident's admission fall risk assessment, dated September 28, 2021, indicated that the resident was at high risk for falls. A review of a facility investigation report dated January 19, 2022, at 12:30 PM, revealed an alarm was sounding and staff found Resident 4 on the floor in the bathroom of the resident's room. According to a staff statement, the resident self transfers on a daily basis and had self-transferred to the bathroom. The resident sustained a skin tear on her left elbow. The new intervention was to install a bathroom door alarm and offer to toilet the resident between 11:30 AM and 11:45 AM. Review of the quarterly MDS of January 6, 2022, the resident was not currently on a toileting program. There was no documented evidence that a Morse Scale Fall Risk Assessment was completed after this fall of January 19, 2022. A review of a facility investigation report dated February 3, 2022, at 8:05 PM, revealed that the resident was found in the bathroom of the resident's room, lying on her right side with her head near the sink and her feet near the toilet. The investigation indicated the resident's chair alarm or the bathroom door alarm did not sound to alert staff of the resident's self transfer and unassisted ambulation. The resident was last seen by the activity staff at 7:00 PM, when the resident was placed in her room in her wheelchair. The report did not state if the alarms activated and in place when staff had returned the resident to the resident's room. There was no documented evidence that the facility had obtained a statement from the activity staff member who returned the resident to her room after the activity to ascertain the placemnt and activation of the resident's alarms. According to an interview with the Assistant Nursing Home Administrator (ANHA) on May 5, 2022, at 11:30 AM, the facility did not obtain a statement from the activity staff member who returned the resident in her room after the 8:00 PM activity to ascertain placement and activation of the resident's chair and bathroom door alarm A review of a facility investigation report dated February 27, 2022, at 4:50 PM, revealed that the resident was in the day room when her chair pad alarm sounded. A staff member heard the alarm and tried to reach the resident, but she was unable to reach the resident before the resident fell backwards and hit her head on the floor The resident sustained a small laceration to the left occipital area with small amount of bleeding. The physician was notified and ordered the resident be sent to the hospital for evaluation. The investigation included staff statements that indicated that the resident was self rising and self transfering throughout that day. The investigation also indicated that the resident had made multiple attempts to stand up from her chair unassisted. There was no documented evidence that a Morse Scale Fall Risk Assessment was completed after this fall of February 27, 2022. A review of a facility investigation report dated April 5, 2022, at 11:45 AM, revealed that the resident was found on the floor on her right side, in front of her roommate's recliner chair. The resident complained of right hip pain and was unable to lift her right leg. The physician was notified and ordered that the resident be sent to the hospital. The hospital x-ray report indicated that the resident sustained a nondisplaced subcaptial fracture of the right femur (thigh bone). There was no documented evidence that a Morse Scale Fall Risk Assessment was completed after this fall of April 5, 2022. During an interview with the Director of Nursing (DON), on May 5, 2022 at 12:37 PM, the DON stated that the facility is responsible to review residents with a history of falls to increase activities, address toileting and increase supervision in an attempt to minimize falls. The facility failed to demonstrate Resident 4 was consistently provided with timely and necessary staff supervision, an increase in diversional activities or individualized toileting plan in response to address the resident's known unsafe behaviors and prevent repeated repeated falls and a serious injury. During an interview May 5, 2022 at 12:37 PM, the Nursing Home Administrator (NHA) ANHA and (DON) it was confirmed that the facility was unable to provide evidence that the facility had conducted Morse fall risk assessments after each occurrence as noted in facility policy. The NHA verified that the facility was unable to show that the facility had consistently provided sufficient staff supervision of these residents identified at risk for falls. The residents sustained serious injuries during falls. Staff were aware of the residents' repeated displays of unsafe behaviors of self-transfers and unassisted ambulation. Review of Resident 52's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included dementia without behavioral disturbances, abnormal gait (deviation in the pattern of walking), and a history of falls. Review of Resident 52's quarterly Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status [(BIMS) section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information], revealed that the resident had severe cognitive impairment. The MDS also indicated that the resident had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred four to six days and exhibited verbal behavioral symptoms directed toward others four to six days during the assessment period. The resident required extensive assistance with support of two plus persons physical assistance with transfers (from bed, chair, wheelchair, standing position) and toileting. A review of a quarterly Morse Fall Risk assessment dated [DATE], at 5:27 PM, revealed that Resident 52 was at high risk for falls. Review of Resident 52's care plan for falls, initiated October 1, 2020, indicated that the resident was at risk for falls related to unawareness of safety needs. Interventions planned were to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed, respond to the resident's requests for assistance promptly response, anti-skid strips on floor in front of dresser, and a bed pad alarm to her bed, and review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible. Resident 52's care plan for falls did not address the resident's bowel and bladder incontinence and toileting needs as they relate to the resident's fall risk. Review of a facility incident report dated October 20, 2021, at 7:45 AM, revealed that Resident 52 was found lying on the floor of her room, on her stomach in from of her dresser, with her head towards the window and feet towards the door. The resident was unable to state what happened and the cause of the incident was unknown. The resident was assessed and had complaints of severe right hip pain, an abrasion above her right eyebrow, and ecchymosis and laceration to the right hip. According to the report, a safety alarm was present, but not sounding. An employee witness statement given by Employee 3, a LPN, noted that she was unsure of what caused the resident's fall, but noted that Resident 52 had been incontinent of bowel. An employee witness statement revealed that Employee 4, nurse aide, indicated that the resident was last toileted at 4:30 AM. Interventions planned to prevent future falls were to offer toileting at 7:00 AM. The resident was sent to the emergency room for an evaluation, which was negative for fractures. A therapy referral to evaluate ambulation status was to be made and staff were to replace the resident's bed alarm to prevent others falls. There was no documented evidence that a Morse Fall Risk Assessment was conducted after this fall per policy. There was also no documented evidence that 72-hour bowel and bladder screener was completed to assess the resident's potential for a bowel and bladder program or check and change program as a fall prevention measure. Interview with the Director of Nursing (DON) on May 5, 2022, confirmed that the facility was to ensure that the resident's bed alarm was in place and functioning properly and that the resident was provided timely staff assistance with toileting needs to prevent falls. The facility failed to develop and implement a care plan that addressed the resident's toileting needs and required staff assistance to deter falls as noted in facility policy. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services 28 Pa. Code 211.11(d) Resident care plan

Based on a review of clinical records and select incident/accident reports and interviews with staff, residents and family, it was determined that the facility failed to implement planned interventions to prevent an accident with serious injuries (fractures) to one out of 19 residents sampled (Resident 41) and failed to assess the individual safety needs and implement necessary measures to maintain the safety of three out of three residents who smoke. (Residents 2, 47 and 92). Findings include: A review of the clinical record revealed that Resident 41 was admitted to the facility on (MONTH) 10, 2011, with current [DIAGNOSES REDACTED]. The resident's Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify resident needs) dated (MONTH) 22, (YEAR), indicated that the resident required limited assistance of one staff for transfers, ambulation, dressing, and toileting and was moderately cognitively impaired. A review of the resident's Functional Mobility for Nursing completed by the therapy department on (MONTH) 17, (YEAR) indicated that the resident's transfer status was contact guard assist (contact with patient due to unsteadiness) with a rollator walker. A review of Resident 41's current Evaluation of Unsupported Sitting For Toileting, revealed that the resident's awareness of safety needs was poor and that it was determined that the resident could not be left alone on the toilet for short periods of time. A review of an Incident Report for Falls dated (MONTH) 22, (YEAR), and timed at 7:30 AM revealed that the resident was found on the floor in the bathroom of the resident's room complaining of left knee pain. The resident had sustained a hematoma (raised, localized collection of blood usually clotted in the tissue following an injury) to her left forehead and abrasions (brush burns) to her bilateral (both) knees. The resident stated that I slipped. The floor was found to wet underneath the resident's buttocks; her pull up (incontinence brief) was dry and the origin of the wetness was unknown. A review of a Witness Statement, dated (MONTH) 22, (YEAR) and completed by Employee 1 (Nurse Aide) revealed that she walked the resident with the walker from the bed to the bathroom door (in the resident's room). The resident told Employee 1 to let her go, so I did. Employee 1 noted I left the bathroom door opened while the resident walked with her walker to the toilet. I looked away for a second. By the time I ran to the resident the resident was already on the floor. Resident was dry. Resident had black non-skid slippers on the whole time of transfer. A nursing note dated (MONTH) 22, (YEAR), and timed for 8:00 AM revealed that the resident sustained [REDACTED]. The physician was notified and 911 (phone number used to obtain emergency help) was called for transportation to the hospital. The resident was admitted to the hospital with [REDACTED]. An interview with the Director of Therapy on (MONTH) 15, (YEAR), at 8:30 AM indicated that contact guard means that while ambulating the resident, the staff was to have hands on contact with the resident at all times. During an interview with Employee 1 on (MONTH) 16, (YEAR), at 12:32 PM the nurse aide relayed that the resident was to be assisted with ambulation and that she had maintained contact with the resident until the resident said to let her go. An interview with the Nursing Home Administrator on (MONTH) 16, (YEAR), at 8:25 AM confirmed that that Employee 1 should have maintained contact at all times while ambulating the resident to the bathroom and verified that the facility failed to implement planned interventions for the resident to prevent a fall resulting in fractures. Review of the information provided by the facility revealed that Residents 2, 47 and 92, are smokers. However, there was no documented evidence that the facility assessed each of these residents for their individual safety needs while smoking. Interview with Resident 92 on (MONTH) 13, (YEAR), at 11:00 AM, confirmed that she is a smoker. The resident stated that the facility provides smoking times for the residents to go out of the facility to smoke supervised by the facility staff. Resident 92 also stated that her daughter visits her daily and also takes her out of the facility to smoke. The resident stated that the facility holds her cigarettes and lighter, but they do not provide a smoking apron ( intended for individuals who smoke and require a protective cover to shield against hot ashes and dropped cigarettes; aprons can be used to protect wheelchair or geri-chair users from accidental [MEDICAL CONDITION] smoking). Interview with Resident 92's daughter on (MONTH) 14, (YEAR), at 1:25 PM, revealed that the facility does not provide the resident with a smoking apron and she was not aware if the facility had conducted a smoking assessment of the resident's safety needs while smoking. The resident's daughter stated that her mother's left side mobility is limited, due to a stroke ([MEDICAL CONDITION] - the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain). The resident's daughter also stated that there have been times when she took the resident outside for a cigarette and had noticed cigarette ashes had fallen onto the resident. Clinical record review revealed Resident 47 was admitted to the facility on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. During an interview (MONTH) 13, (YEAR), at approximately 11 am, Resident 47 stated that she goes out three times a day to smoke. She further stated that nursing staff keeps her smoking materials and gives them to her prior to going to the smoking area. She stated that she lights her own cigarette and does not wear any protective clothing while she smokes. Clinical record review revealed Resident 2 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Resident 2 also stated that she was not assessed by nursing for safe smoking. She stated that she is accompanied by nursing three times a day outside to the front area of the nursing home to smoke. She stated that she lights and holds her own cigarettes and does not wear any protective clothing while smoking. During an interview on (MONTH) 14, (YEAR), at approximately 11:30 AM Employee 4 (LPN) confirmed that safe smoking assessments are not completed on residents. The Nursing Home Administrator and Director of Nursing, confirmed during interview on on (MONTH) 16, (YEAR) at 11:00 AM, that there is no documented evidence of smoking assessments or safety equipment provided for those residents who may require it while smoking. 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/devices Previously cited 2/24/17 28 Pa. Code 209.3(b) Smoking 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 2/24/17, 3/31/16

Based on clinical record review, observation and staff interview, it was determined that the facility failed to timely identify and address potential factors contributing to one resident's weight loss (Resident 92) and failed to consistently monitor and assess the adequacy of two residents nutritional parameters (Resident 65, 97) and implement interventions to improve the residents' nutritional status out of 21 sampled residents. Findings include: A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's activities of daily living sheets for the month of November 2015 and December 2015 revealed that the resident required limited assistance of one staff member for eating. A review of the weight flow sheet revealed that the resident was initially weighed on November 17, 2015, upon admission, which staff recorded as 137 pounds. The dietitian noted on November 23, 2015, that Resident 65's current intake was falling short of the resident's calculated needs and the resident's meal intake was variable at times. Hi Pro, a nutritional supplement, was recommended for the resident, twice daily, with medication administration pass to aid in maximizing the resident's intake. A dietary note dated December 4, 2015, indicated that the resident's current meal intake from trays was averaging 37% and her consumption of the Hi Pro twice a day was averaging 85%. The entry noted that the combined intake fell slightly short of the resident's assessed needs. Hi Pro was increased to three times a day with medication administration pass to manage the resident's intake. The dietitian also noted that Resident 65's progress would be followed and (nutritional) therapy would be adjusted further as indicated. A dietary note dated December 15, 2015, revealed that the dietitian received a referral related to the resident's meal refusals, especially breakfast. The resident's meal intake was averaging only 25% and consumption of Hi Pro supplement three times a day was averaging around 50-75%. The progress note further indicated that the resident would be followed for further food intake decrease and change in weight patterns. The dietitian made no recommendations any additional forms of nutritional support or adjustment to the resident's nutritional regimen to maintain adequate nutritional status. The resident had been displaying decreased oral intake, which the dietitian noted did not meet the resident's assessed needs, but there was no evidence that the facility had monitored the resident's weight or other nutritional parameters more frequently to timely identify declines and intervene accordingly. The dietitian noted, on December 4, 2015, that the resident would be followed for further food intake decrease and change in weight patterns, but did not identify the frequency for evaluating the resident's nutritional parameters to assess the effectiveness of the planned nutritional interventions. The resident's weight recorded December 17, 2015, revealed that the resident weighed 121 pounds. A reweight on December 18, 2015, indicated that the resident weighed 122 pounds, indicating a loss of 15 pounds in the last month, since admission on November 17, 2015. A nursing progress note dated December 18, 2015, and timed for 2:25 p.m. revealed that the resident had a 15 pound weight loss and a referral was sent to the dietitian. Resident 65 was admitted to the hospital on December 20, 2015, due to a change in mental status. The dietitian did not acknowledge the 15 pound weight loss and referral made on December 18, 2015, until December 21, 2015, a day after the resident was admitted to the hospital. Review of the resident's weight flow sheet revealed that upon return from the hospital on December 28, 2015, the resident's weight was 124 pounds. A dietary note dated December 30, 2015, revealed that the resident was averaging 25% for meal intake from her trays and 60% for Hi Pro three times a day, which was providing 75% of the resident's assessed caloric needs. A chocolate magic cup (nutritional supplement) was added to the resident's diet twice a day in an attempt to maximize the resident's dietary intake. Interview with the Dietitian on March 31, 2016, at approximately 10:30 a.m., confirmed that between November 17, 2015 and December 18, 2015, the resident's oral intake was poor, despite the increase in dietary supplements and that the resident had not been weighed more frequently to to determine if the interventions in place were effective in maintaining adequate nutritional parameters. The dietitian also verified that a monthly weight was insufficient to determine significant fluctuations in weight patterns. A review of the clinical record revealed that Resident 92 had [DIAGNOSES REDACTED]. A review of the resident's activities of daily living sheets for the month of January 2016, February 2016 and March 2016 revealed that the resident required total assistance of one staff member for eating. Current physician's orders [REDACTED]. Magic cup was ordered February 18, 2015, one daily and staff were to record the resident's percentage of intake. The resident's care plan regarding the potential for weight loss dated October 5, 2015, revealed interventions to prevent weight loss included the two noted supplements, Magic cup and Hi-Pro, and to monitor food intake. A review of a dietary interview on admission for resident food preferences dated January 18, 2013, revealed multiple food item likes with no noted dislikes. A review of the weight flow sheet revealed that the resident was weighed on August 26, 2015, upon admission and staff recorded the resident's weight as 98 pounds. Further weights revealed weight changes: September 23, 2015 - 92 lbs September 24, 2015- 92 lbs (reweigh) October 26, 2015 - 93 lbs November 24, 2015 - 91 lbs December 22, 2015- 88 lbs January 27, 2016 - 82 lbs January 29, 2015 - 83 lbs (reweigh) February 24, 2016 - 77 lbs February 25, 2016 -77 lbs (reweigh) The dietitian completed a progress note dated November 09, 2015, indicating that the resident had zero food intake for three meals, 45% of food from meal trays and 55 % of HI Pro supplement and 75 % Magic cup supplement. The dietitian noted that the combined intake exceeded the resident's requirements. A dietary note dated December 20, 2015, revealed that the resident's current intake from trays averaged 40%, Hi Pro supplement 40% and Magic cup 35%. The dietitian noted that the resident does refuse meals and was described as spitting out food. The entry indicated that the resident had a steady weight decline, which continued despite fairly adequate intake; although consumption of trays as well as supplements has been declining. Dietary notes dated from February 1, 2016, through March 2, 2016 indicated that this resident's meal and supplement intakes continued to decline. Nurses notes dated from September 2015 through March 2016 revealed multiple notations by nursing of Resident 92's poor appitite and meal refusals. There was no evidence at the time of the survey that the facility had developed and implemented additional approaches or measures to deter the resident's progressive weight loss. Interview with the Dietician on March 31, 2016, at approximately 10:45 a.m., confirmed that no additional interventions, to improve the resident's intake and nutritional status, had been implemented for Resident 92 since July 2015. The dietitian stated that Magic cup and Hi-Pro supplements were the supplement she preferred to use for residents and verified that no other interventions or approaches were attempted as the resident's weight steadily declined. A review of the clinical record revealed that Resident 97 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was receiving a regular diet and had a documented admission weight of 169 lbs. A review of the resident's activities of daily living sheets for the month of December 2015 and January 2016 revealed that the resident required limited assistance of one staff member for eating. On September 9, 2015, the resident was placed on a 1500 calorie restricted diet due to a weight gain of 7 lbs (weight recorded as 176) A review of the resident's weight flow sheet revealed that the resident was weighed on December 22, 2015, and staff recorded her weight as 163 pounds. The dietitian completed a dietary note on January 4, 2016, indicating that the Resident 97 was not chewing food due to sores in her mouth and the resident's dentures needed to be checked for proper fit. The resident's current diet was 1500 calorie restricted diet and meal intakes were averaging 31% from trays. The dietitian noted that nutritional supplementation was necessary at this point to maximize nutritional intake. The dietitian noted that Hi pro ( a liquid nutritional supplement ) three times a day will be put into place with plans to monitor further weight and appitite patterns and adjust therapy further as indicated. A review of the resident's clinical record documentation dated January 6, 2016, revealed that Resident 97 saw the dentist and no issues were noted with the resident's dentures. A review of activities of daily living tracking forms dated December 2015 revealed that the resident's meal intakes from December 20, 2015 were 25% to 50% most meals, through January 14, 2016, 25 % to 50 % most meals. A nurses note dated January 5, 2016 (no time indicated) revealed MD notified of 0% food intake at meals for three meals. A nurses note dated January 14, 2016, revealed family requests 1500 calorie diet be discontinued. physician's orders [REDACTED]. The resident's decreased oral intake was noted on January 5, 2016, but the resident's calorie restricted diet was not discontinued and nutritional supplementation added until January 14, 2016, when requested by the resident's family. The dietitian noted on January 4, 2016, and again on January 14, 2016, the resident's continued declining meal intakes, but there was no evidence that the resident had been weighed to evaluate the adequacy of the resident's current intake and planned nutritional regimen in maintaining the resident's nutritional parameters and status. The resident's next monthly weight was obtained on January 25, 2016, and noted as 143 lbs, revealing a 20 pound weight loss since December 22, 2015. A reweight taken on January 26, 2016, noted the resident's weight as 146. The next dietary note was dated January 28, 2016, indicating that the resident had a 17 lbs weight loss and an ongoing decline in food intake. The dietary note referenced the the recently increased calorie diet and nutritional supplementation. Interview with the Dietitian on March 31, 2016, at approximately 10:45 a.m., confirmed that there was a nine (9) day delay in liberalizing the resident's diet and adding nutritional supplementation. The dietitian further verified that the resident had not been weighed between January 4, 2016, and January 14, 2016, although a noted decrease in food intake was identified. 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and interview, it was determined that the facility failed to consistently provide supervision as planned for resident safety and failed to evaluate the adequacy and effectiveness of existing safety measures to prevent falls with injury for one resident out of 24 sampled (Resident CR3). Findings included: A review of the facility policy for Fall Prevention, revised by the facility April 24, 2013, revealed that the facility maintains a process in which residents are evaluated for fall risk, preventative measures which are individualized are put in place and the risk of falls is updated as needed for fall prevention. A review of the clinical record revealed that Resident CR3 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS is a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated October 9, 2013, revealed that the resident was severely cognitively impaired and required assistance for ambulation, transfers and toileting and was at risk for falls. A review of nurses notes and a resident incident/accident report revealed that Resident CR3 had a fall from bed on September 14, 2013. The interventions planned to prevent recurrence were to apply alarms to the resident's bed and wheelchair and to initiate daily 10 minute safety checks (a staff member observes and documents the resident's location and activity). Resident CR3 had subsequent falls on September 24, 2013, October 8, 2013, November 4, 2013, and twice November 9, 2013, with the planned interventions of bed and chair alarms and 10 minute safety checks in place at the time of each fall. The incident/accident report for these falls failed to consistently reveal whether the resident's bed or wheelchair alarm were sounding at the time of the incident to alert staff to the resident's unassisted activities. A review of an interdisciplinary team meeting note dated November 12, 2013, indicated that a meeting was held to review Resident CR3's frequent falls and safety interventions. It was noted that the resident removes the personal safety alarms and planned to continue the 10 minute safety checks. The facility planned to continue to conduct frequent monitoring and to use the host of interventions already in place to mitigate the resident's fall risk. A review of a resident incident report and nursing documentation dated November 16, 2013 at 9:45 PM revealed that a nurse aide found Resident CR3 sitting on the edge of her bed. The resident had sustained a skin tear to her lower right arm and there was blood on the sheets of the resident's bed. Upon entering the resident's room, the nurse noted that she heard the alarm box ringing, but it was very muffled. The alarm was observed under two pillows and a blanket. When removed from the bedding, the alarm was sounding loudly. The nurse noted that the crowns of Resident CR3's upper front teeth were loose and had slipped out of place. The resident stated that she fell ; her feet came out from under her. She was yelling in pain and sent to the hospital where she was diagnosed with [REDACTED]. Corresponding nurses notes dated November 16, 2013 indicated that at 9 PM Employee 15 (RN) was in the resident's room administering eye drops and assisting the resident to the bathroom. The next nurse's note was timed at 9:45 PM. The corresponding safety watch record dated November 16, 2013 indicated that the resident was in the bathroom at 9 PM. There was no entry reflecting a safety check of the resident at 9:10 PM. The safety watch record entries for 9:20 PM, 9:30 PM, 9:40 PM and 9:50 PM all documented that the resident was in her room in bed, although the incident report indicated that the resident was found at 9:45 PM after sustaining a fall. The documented safety watch record entry for 9 PM was changed from "in room in bed" to "in the bathroom" and the 9:20 PM entry was changed from "in the bathroom" to "in room in bed" by Employee 15 (RN). The incident report noted that the resident was toileted at 9:15 PM, however the nursing documentation noted that she was toileted by the licensed nurse at 9 PM. There was no evidence in the resident's records that this resident was toileted at 9:15 PM. Corresponding nursing notes and employee witness statements differ in the times that the resident was last seen by staff. The 10 minute safety check sheet and the nursing documentation failed to accurately and consistently reflect that Resident CR3 was seen by staff between 9 PM and 9:20 PM. Corresponding employee witness statements dated November 16, 2013, revealed that Employee 10 (nurse aide) stated that he last saw Resident CR3 at 9 PM, sleeping. Employee 4 (nurse aide) stated she found Resident CR3 about 9:35 PM siting on her bed. There was no documentation between 9 PM and 9:20 PM as to the whereabouts of this resident. There was no documented evidence that the planned interventions including the 10 minute safety checks and bed alarms were consistently implemented or that these interventions were reassessed for effectiveness in maintaining the resident's safety and preventing falls. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services previously cited 4/19/2013 28 Pa. Code 211.10(a)(d) Resident care policies previously cited 4/19/2013

Based on review of clinical records and resident incident/accident reports and staff interview, it was determined that the facility failed to provide adequate supervision and implement planned safety interventions for a resident at risk for falls to prevent falls and injury for one of five residents reviewed (Resident B3). Findings include: A review of the clinical record revealed that Resident B3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident's current fall risk assessment of January 2013 indicated that the resident was a at high risk for falls. Her quarterly minimum data assessment (standardized assessment completed at specific intervals to identify care needs) dated January 18, 2013, indicated that the resident was severely cognitively impaired and required extensive assistance with two persons for transfers. She also required extensive assistance with activities of daily living. A review of the resident's comprehensive care plan dated May 24, 2012 indicated that the resident will be placed on a 1:1 watch if she becomes agitated. The care plan also indicated she would have bed and chair alarms, along with a low bed as fall prevention approaches. Added to the resident's care plan, dated August 16, 2012, was the intervention that the privacy curtain should be pulled so the resident will think the door is closed to prevent her from getting up and shutting the door in her room. A review of nursing documentation dated January 30, 2013 at 9:00 PM indicated that the resident attempted twice to transfer herself out of bed. Nurses noted that on January 31, 2013 at 11:30 AM the resident had increased agitation and was attempting to climb out of bed and yell at staff. At that time 1:1 observation of the resident was initiated. At 2:00 PM on January 31, 2013, the resident continued to attempt to get out of bed. At 3:00 PM on January 31, 2013, the resident was found on the floor in her room on the left side of her bed complaining of elbow pain upon palpation. A "bump" was noted to her left side of forehead and was slightly red in color. A review of the incident report revealed a statement written by Employee 1, a nurse aide, which read, "I was on 1 on 1 (observation of the resident) at the time of the resident's fall on January 31, 2013. Employee 1 stated that she toileted the resident at 2:15 PM and then the resident was returned to bed and seemed quiet. Employee 1, further noted that she told Employee 2, another nurse aide, that someone had to sit with this resident because Employee 1, had to finish her paperwork. since it was the end of her shift. An interview with Employee 1 on February 27, 2013 at 2:45 PM confirmed that she left the resident alone on January 31, 2013, when the resident fell ; she thought that Employee 2, another nurse aide was coming to sit with the resident, but she never showed up and the resident got out of bed herself and fell . An interview with the director of nursing at 3:00 PM on February 27, 2013, failed to provide evidence that the resident was adequately supervised during periods of unsafe behavior resulting in the fall. The post fall interventions planned by the facility were to have a nurse aide specifically assigned to 1 to 1 for this resident. The resident's comprehensive care plan dated January 31, 2013, indicated that the resident was to be continued on 1 to 1 observation, low bed, floor mats, diversions by talking about football and a toileting schedule. Nursing documentation of February 1, 2013 and February 2, 2013 indicated that the resident was on a 1 to 1 observation and attempted to climb out of bed multiple times. Nursing documentation revealed that on February 2, 2013, at 8:00 PM the resident continued to be agitated and attempted to get out of bed so the 1 to 1 observation continued. Documentation on February 3, 2013 at 7:50 PM indicated that the registered nurse, who was at the nurse's station desk, heard an alarm down the hall and found the resident lying on her back on the floor outside room 321, head towards the dining room, feet toward nurse station. The incident report indicated that the cause of the incident was that the resident transferred self out of bed and that future interventions will be to continue 1 to 1 observation when the resident is agitated. There was no explanation as to why or when the 1 to 1 was discontinued from 8:00 PM on February 2, 2013 until February 3, 2013 at 7:50 PM when the resident was found on the floor. Documentation prior to the fall on February 3, 2013, indicated that the resident was agitated and was frequently attempting to get out of bed, which according to the resident's plan of care warranted 1 to 1 observation. Nursing documentation from February 3, 2013 until February 8, 2013 indicated that the resident was frequently agitated and made multiple attempts to get out of bed unassisted. On February 4, 2013, nursing documentation indicated that the resident was taken to the dining room and at 12:00 PM the resident was observed crawling on her hands and knees across the floor. (She was on a 1 to 1 observation as documented at 10:00 AM on this date). On February 8, 2013, at 6:50 AM nursing documentation indicated that the resident had increased behaviors and was combative. (The last documented indication that the resident was on 1 to 1 observation was at 5:00 PM on February 7, 2013). At 1:45 PM on February 8, 2013, the resident was found in front of the television on the floor with an abrasion to her left knee. There was no documentation regarding why the resident was not sufficiently supervised when nursing noted that the resident was was combative and attempting to get out of bed. Nursing documentation of February 9, 2013, at 1:30 AM indicated that the resident was on 1 to 1 observation due to behaviors and attempts to get out of bed unassisted. At 5:30 AM on February 9, 2013, the resident was observed crawling in the hallway. The incident report for falls contained a written statement by Employee 3, a licensed practical nurse (LPN), which read "Resident B3 was attempting to transfer self at beginning of shift. I had a 1 to 1 with her for over half the shift, which left me one nurse aide to do rounds. I helped as much as possible, but had my work to do also. Resident appeared to be sleeping for a while so I took the 1 to 1 away to help the nurse aide with last rounds." The resident was then found crawling on the floor and a nurse aide was placed on 1 to 1 observation of this resident. In an interview with the DON on February 27, 2013 at 3:00 PM she was unable to confirmed that the 1 on 1 observation of the resident was discontinued because the resident fell asleep. Nursing documentation in the clinical record continued to note that the resident was on 1 to 1 observation for agitation and frequent attempts to get out of bed. The comprehensive care plan (August 12, 2012) also indicated that the resident was to have a low bed and privacy curtain should be pulled so the resident would not attempt to get out of bed to close the door. The last time of documentation, which would indicate the resident was on 1 to 1 observation was on February 10, 2013, due to delusions and increased agitation. However, according to safety watch observation records the resident was on a continuous every 10 minute watch. Nursing documentation dated February 12, 2013, at 2:00 PM revealed that the door to the resident's room was observed to be closed; when a staff member checked on the resident, she was found lying on her back at the foot of her bed. The resident had swelling to her left wrist and the resident stated "I can't move my left arm." When the resident's left wrist was touched she yelled out in pain. The resident's alarm did not sound because it was under the blankets. The resident was transferred to the emergency room and was treated for [REDACTED]. A cast was applied. She was prescribed pain medications four times a day if needed. A review of the incident report for falls revealed a written statement by Employee 4, a nurse aide, which read, "I (Employee 4) took Resident B3's lunch tray at 1:15 PM, as she was asleep. I did not put the bed back down to the lowest position. At 1:30 PM I saw her door closed and she was yelling for help. When I walked in she was on the floor." An interview with Employee 4 at 2:40 PM on February 27, 2013, indicated that this employee was in a rush and she did not put the resident's bed back down to its lowest position on February 12, 2013, prior to the resident's fall. Interview with the DON at 3:00 PM on February 27, 2013, failed to provide evidence that the resident was provided sufficient staff supervision and that care planned interventions (bed in lowest position, privacy curtain pulled) were not implemented. The resident's comprehensive care plan revised after the incident with injury on February 12, 2013, revealed that if elevating the bed for any reason the resident must not be left alone until the bed is lowered. The Event Report submitted to the State Survey Agency regarding this resident's transfer to the hospital because of injury or accident did not indicate that the resident's bed was not in its lowest position as planned. The facility failed to provide planned care for this resident by failing to consistently provide adequate supervision to prevent multiple falls. The nurse aide failed to provide care in a safe and effective manner resulting in the resident's fall with serious injury. 483.25(h) Free of Accident Hazards/Supervision Previously cited 10/26/12 28 Pa. Code 211.10 (a)(d) Resident care policies Previously cited 4/20/12 28 Pa Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 8/14/12,4/20/12