Every finding on record at Embassy of East Mountain

Based on review of clinical records, select facility policy, payor source data, and resident and staff interview, it was determined the facility failed to ensure timely and necessary dental services for one resident who is a Medicaid recipient (Resident 1) out of 10 residents reviewed. Findings include: Review of the facility Ancillary Services policy last reviewed January 1, 2026, indicated it is the policy of the facility to assist residents in obtaining routine and emergency ancillary services as needed. The policy defined emergency dental services as the need to treat an episode of pain in teeth, gums, or broken, damaged teeth, or any other problem that requires immediate attention by a dentist. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid in the brain's cavities) and weakness. A review of Resident 1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 30, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). During an interview on Wednesday 27, 2026, at 10:30 AM the resident stated she was complaining of mouth pain to the staff for months and did not see the dentist until the tooth was extracted on April 30, 2026, despite the resident expressing pain in the beginning of March. The resident revealed that she currently had no pain but was telling nursing staff and administration for months that she was in pain. A review of an email chain between the facility social services director (SSD) and the dental services care coordinator, revealed an email sent by the facility SSD on March 17, 2026, revealed a request for the resident to be seen by the dentist because of a complaint made to nursing staff for pain in Resident 1's teeth. The email response from the dental services coordinator dated March 16, 2026, confirmed that Resident 1 would be seen by the dentist on March 26, 2026, 10 days after the initial complaint of pain was made. A review of the dental visit on March 26, 2026, revealed the dentist note summary detailed the resident requested two different teeth to be extracted due to plus 2 mobility (Plus 2 mobility in teeth is an abnormal finding caused by advanced gum disease, trauma, or teeth grinding). The visit summary then revealed the dentist would extract the two teeth at the next visit. A review of the continued email communication with the SSD and the dental care coordinator revealed the dental care coordinator emailed the SSD on April 6, 2026, at 8:55AM, requesting the attached consent form be signed by Resident 1 for the planned teeth extraction. The email detailed that the form would need to be completed and signed prior to scheduling the extraction. The SSD responded on April 7, 2026, at 4:50PM, asking how the resident consent would be signed if the resident was unable to physically sign her name due to her physical condition. The Dental care coordinator responded on April 8, 2026, at 8:26AM, confirming that verbal consent was acceptable, and whoever takes the verbal consent would need to sign the form indicating it was a verbal consent, and return to the care coordinator so the resident can be scheduled. A review of the dental care visits provided in the facility revealed the dentist conducted a visit on April 17, 2026, but Resident 1 was not on the schedule due to no consent being obtained. A review of the continued email chain revealed an email sent by the dental care coordinator on April 22, 2026, revealed the resident was scheduled for her teeth extraction on April 30, 2026. An interview with the Nursing Home Administrator (NHA) on May 27, 2026, at 11:30AM, revealed the consent was sent to the dental care coordinator on April 21, 2026, 15 days after the initial request for the consent from the Dental services coordinator. The NHA revealed the SSD was out sick from April 8, 2026, to April 13, 2026, and the reason for the delay in the consent being obtained was because the SSD was out sick. A interview with the NHA on May 27, 2026, at 1:15PM reviewed the above findings of the facility's failure to obtain verbal consent from Resident 1 to ensure prompt extraction of the teeth that were causing Resident 1 pain. The facility failed to provide prompt dental services, as indicated in their facility policy. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 28 Pa Code 211.10 (c) Resident care policies

Based on observations, review of clinical records, review of select facility policies and information submitted by the facility, and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident to monitor the resident's whereabouts and timely identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy for one out of 19 residents sampled (Resident 26). Following this elopement the facility further failed to promptly identify the resident's absence as well as identify supervisory and safety needs to prevent unsupervised exits from the facility, which placed residents in immediate jeopardy of unsupervised exits from the facility and the potential for serious bodily injury or death. Findings include: A review of the facility policy entitled Elopement and Wandering Residents, last reviewed January 16, 2025, revealed it was the policy of the facility to ensure that residents who exhibit wandering behavior or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their plan of care. The policy further required residents to be assessed for risk of wandering and elopement upon admission and throughout their stay by the interdisciplinary team. Clinical record review revealed that Resident 26 was admitted to the facility on [DATE], with diagnosis to include Mild Intellectual Disability (a developmental condition characterized by below-average cognitive functioning and adaptive skills, allowing individuals to learn practical life skills with minimal support). The resident's functional status was independent with ambulation. Review of a quarterly Minimum Data Set assessment (MDS, federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 22, 2025, revealed the resident had a BIMS score of 11 (Brief Interview for Mental status, a tool to assess the resident's cognition, orientation, and ability to register and recall new information). A score of 8-12 indicates moderate cognitive impairment. Review of information provided by the facility revealed they eliminated the receptionist position, resulting in no staff assigned to monitor the front lobby or main entrance. The receptionist's last day was December 9, 2025. A request was made on January 6, 2026, at 10:30 AM for Resident 26's initial elopement risk assessment. The assessment was not provided to the surveyor and was not located in the electronic medical record. Concurrent interview with the Director of Nursing revealed that the resident was not considered an elopement risk. Review of the resident's care plan, initiated April 4, 2025, did not identify the resident as an elopement risk, despite documentation noting difficulty adjusting to placement in the facility. Review of facility investigative documentation dated December 22, 2025, at 12:35 PM revealed the facility was notified by Resident 26's legal guardian that she was at her private residence. Documentation indicated Resident 26 was last seen at 10:30 AM in the main lobby of the facility requesting staff assistance to make telephone calls to her guardian. Review of facility surveillance video revealed Resident 26 exited the facility through the lobby door at 11:03 AM without staff awareness. The resident returned to the facility at 1:06 PM via a neighbor's private vehicle. Upon return, nursing documentation indicated Resident 26 was wearing a coat, hoodie, pants, and sneakers. A body audit and temperature assessment were completed, revealing a temperature of 97.2 degrees Fahrenheit. Resident 26 had an open area on her left great toe measuring 2 cm (centimeter) by 2 cm by 0.1 cm, with a small amount of serous (clear) drainage and an epithelialized base (new skin growth). Review of the investigative documentation and staff interviews revealed Resident 26 walked to her home, located two to three miles from the facility, during winter weather conditions (the temperature was 30 degrees Fahrenheit) in an area of heavy vehicular traffic, exposing her to environmental hazards and risk of serious injury. During a telephone interview conducted on January 6, 2026, at 12:27 PM, Resident 26's legal guardian stated she received a phone call from the resident at 10:32 AM on December 22, 2025. Resident 26 stated she wanted to leave the facility and go home. The guardian stated she sent a maintenance worker to check on the condition of the resident's home. At 12:35 PM, the guardian received a text message confirming Resident 26 was present at the home. The guardian contacted the facility and informed the Director of Nursing that Resident 26 was found at her home. At that time, licensed nursing staff were unaware the resident was not at the facility. Resident 26's absence from the facility was a little over two hours. Review of the Director of Social Service witness statement dated December 22, 2025, indicated Resident 26 was observed in the lobby at 10:30 AM talking on the telephone. Review of Employee 5's, Licensed Practical Nurse, witness statement dated December 22, 2025, indicated Resident 26 was last seen around 10:30 AM on the west wing walking toward the dining room with her father, who is also a resident of the facility. Licensed nursing staff failed to identify Resident 26's absence until notified by the legal guardian. The facility permitted access to an unlocked and unmonitored exit, lacked a system to account for resident whereabouts in common areas such as the lobby, and failed to ensure adequate staff supervision. These failures resulted in the resident leaving the facility unsupervised and placed her at Immediate Jeopardy, with ongoing risk to other residents for elopement, and serious bodily injury, or death. Following the incident, the facility relocated Resident 26 to a secure unit, despite the resident not having a diagnosis of dementia. The Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) and provided the IJ Template on January 6, 2026, at 2:30 PM. In response, the facility submitted a written Immediate Jeopardy action plan at 5:15 PM on January 6, 2026. The plan included the following corrective actions: The resident is currently accounted for and had no ill effects from the incident. A skin assessment was initially completed on December 22, 2025, at 2:55 PM and another assessment on December 23, 2025, with no new findings. Elopement assessment completed on Resident 26, which indicated resident is at high risk for elopement and was moved to secure ACU (advanced cognitive unit) unit. Guardian and MD (physician) Notified. Care plan updated. Director of Nursing (DON) completed elopement assessments on all residents with a BIMS of 11 or less Residents identified as high risk had care plans updated, and appropriate intervention were reviewed and updated. Elopement binders updated in facility. Education was provided to all staff on the elopement policy. Policy reviewed and no changes noted. Random weekly audits to be completed by DON to identify any elopement concerns. Residents with wander guard were checked for function and placements on December 22, 2025. New elopement assessments were completed. Doors will be checked every shift by maintenance/designee daily for 4 weeks. Elopement drills will be completed on January 6, 2026, with day shift staff. Elopement drills will continue monthly. Audits weekly x 4 weeks, then monthly x 4 months. Results will be reviewed during QAPI meeting. On January 6, 2026, all doors will be locked at all times. New doorbell installed in foyer. Signage posted through facility, main lobby, reception and all nursing stations. All staff educated regarding all doors locked at all times on January 6, 2026. Date of compliance will be January 7, 2026. Verification of implementation of the Immediate Jeopardy action plan was completed, and the Immediate Jeopardy was determined to have been removed on January 7, 2026, at 10:15 AM after it was verified that the corrective actions had been fully implemented and were effective in removing the immediate threat to resident health and safety. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (e)(1) (2.1) (3) Management.28 Pa. Code 211.10 (d) Resident care policies.

Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by five of five residents attending a resident group meeting (Residents 51, 58, 63, 73, and 99) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.Findings include: A review of the facility's Grievance Policy last reviewed on January 16, 2025, indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official will keep the resident apprised of progress of resolution of grievance. A review of the Minutes from a Resident Council meeting, which included a food committee review, dated June 4, 2025, revealed concerns from residents that snacks were not being provided in the evening. Review of grievances revealed no documented evidence of a grievance regarding this concern and no evidence of any corrective actions taken to address this issue. A review of the grievance list of any grievances for the month of December 2025, provided by the facility on January 7, 2026, showed only one grievance for the month of December regarding missing clothing. A group meeting conducted on January 7, 2026, at 10:00 a.m. with five residents (Residents 51, 58, 63, 73, and 99) revealed multiple concerns regarding potential new ownership and significant changes that the facility has been implementing since December 2025, including (of significant concern to all the residents in attendance) the lack of activities. All residents in attendance also had concerns regarding shower temperatures in both the east and west halls, lack of snacks and inability to get snacks after dinner. During this meeting surveyor asked residents if they were aware of the grievance process, all residents in attendance stated that they had filed grievances after the last resident council meeting on December 17, 2025. Further stating there had been no follow up in regard to these grievances. These grievances were not part of the grievance list from December provided to surveyors by the facility. Upon further inquiry after the resident council meeting on January 7. 2026, the Director of Social Services provided these grievances to surveyor. These grievances had been modified, the bottom part of the paper which would generally indicate resolution to grievance had been cut off, thus leaving only the concern with no documented resolution. These grievances all stated the same thing, that the residents were concerned and upset about the lack of services being provided by the facility specifically Activities. When the Director of Social Services was further interviewed on January 8, 2026, at 11:00 a.m., she indicated she had been advised by former Nursing Home Administrator to cut off the bottom of the grievance form which would document resolution and was unable to provide evidence that these grievances had been addressed. The facility was unable to provide documented evidence that efforts had been made to resolve resident complaints concerning activities as of the survey ending January 9, 2026, that had been brought up during resident council meeting. During an interview on January 8, 2026 at 11:10 a.m., the Director of Nursing (DON) confirmed the absence of documented actions addressing grievances raised during Resident Council meetings or verbal complaints. 28 Pa. Code 201.18 (e)(1)(4) Management.28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 211.10 (d) Resident care policies

Based on observations and resident and staff interviews, it was determined the facility failed to maintain a safe, sanitary, and homelike environment in two out of three resident shower rooms (East and West). Findings include: During a resident council meeting on January 7, 2026, at 10:10 AM, interviews with five cognitively intact residents, Residents 73, 51, 58, 63, and 99, it was reported during the month of December through present, the temperatures inside the East shower room was frequently cold and uncomfortable and the [NAME] shower room's hot water intermittently went cold during showers and was uncomfortable. All residents reported nursing staff were aware, but nothing was addressed. During an observation of the [NAME] shower room with facility's maintenance director on January 7, 2026, at 10:55 AM, observed contractors and the regional maintenance director investigating issues with the water heating system. An interview with Employee 2, a nurse aide, January 7, 2026, at 11:02 AM, revealed staff were able to complete some resident showers in the [NAME] shower room but the water temperature got colder with increased use. Additionally, it was reported that when the water temperature was not a comfortable temperature, nursing staff used the East shower room. A review of facility provided daily water temperature logs for East and [NAME] shower rooms dated December 2025, through survey ending January 9, 2026, revealed no recorded temperature monitoring on the following dates: December 1, 2025, through December 5, 2025, December 6, 2025, through December 7, 2025, December 13, 2025, through December 14, 2025, December 20, 2025, through December 21, 2025, December 27, 2025, through December 28, 2025, and January 3, 2026, through January 4, 2026, or forty-two (42) missed recordings/observations. Observations of the East resident shower room in the presence of the facility's maintenance director present on January 7, 2026, at 11:04 AM, revealed the environmental temperature was only 65 degrees Fahrenheit and felt uncomfortably cold. Additionally, inside the shower room observed a strong urine smell, missing/loose tiles along the baseboard, and a buildup of a black substance in the corners and crevices around drains and baseboard. A review of a work order (6693) submitted by nursing dated December 5, 2025, at 6:15 AM, indicated the East shower room's environmental temperature was 68 degrees Fahrenheit. During an interview with the facility's maintenance director on January 7, 2026, at 11:05 AM, it was reported that he worked at a sister facility and starting work at the building as the maintenance director on October 20, 2025, and identified some maintenance issues throughout the facility that included the heating system that heated the East shower room but didn't get to repair it yet. The above findings were reviewed with the facility's interim Nursing Home Administrator (NHA) on January 8, 2026, at 12:30 PM, and confirmed the resident's shower rooms should be maintained to assure comfortable temperatures and a clean area for a homelike environment. 28 Pa Code 207.2(a) Administrator's responsibility.

Based on a review of scheduled activities and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents including experiences expressed by five out of five residents during a resident group interview (Residents 51, 58, 63, 73, and 99).Findings include: During a resident group interview conducted on January 7, 2026, at 10:00 AM, five out of five residents interviewed (Residents 51, 58, 63, 73, and 99) expressed concerns regarding the lack of available activities within the facility. Residents stated there were no meaningful activities being offered that aligned with their interests. Resident 51, identified as the Resident Council President, reported that all activity staff had either resigned or were no longer employed by the facility. Resident 51 further stated that the most recent activity offered was BINGO on Monday, January 5, 2026, which was facilitated by a nurse aide due to the absence of activity department staff. All residents present verbalized frustration and disappointment regarding the lack of activities and expressed sadness over the departure of the former Activity Director, whom they described as kind and effective in providing enjoyable activities. The residents interviewed consistently reported no alternative or substitute activities were provided following the departure of activity staff. A review of the facility's January 2026 activity calendar revealed scheduled activities that did not occur. Specifically, the calendar listed a coffee social scheduled for January 6, 2026, at 10:00 AM and puzzles scheduled for January 6, 2026, at 2:00 PM. Documentation and resident interviews confirmed these activities did not take place. Additionally, the calendar listed a coffee social scheduled for January 7, 2026, at 10:00 AM, which also did not occur. No documentation was provided to indicate alternative activities were offered in place of those scheduled. During an interview conducted on January 7, 2026, at 11:00 AM, the Director of Nursing (DON) stated the facility previously employed four activity staff members, consisting of one Activity Director, two part-time activity aides, and one per diem (as needed) activity aide. The DON explained that a recent administrative decision resulted in the allocation of only one activity staff position for the facility. The DON confirmed the Activity Director resigned, with her last day of employment being December 31, 2025. The DON further stated the last remaining activity aide's final day of employment was January 2, 2026. According to the DON, a new Activity Director was expected to begin employment on or about January 8 or January 9, 2026. The DON confirmed that no activities had been conducted by activity staff from January 2, 2026, through the date of the interview. During a separate interview conducted on January 7, 2026, at 9:15 AM, the DON acknowledged the facility was not currently offering a structured activities program for residents. The DON confirmed there were no scheduled or implemented activities at that time, including the absence of evening activities. 28 Pa. Code 201.18 (b)(3)(e)(6) Management.201.14(a) Responsibility of licensee.

Based on review of facility documentation and staff interviews it was determined the facility failed to employ and maintain a qualified activities director.Findings include: Review of facility documentation: job description Activity Director: The primary purpose of the job position is to plan, organize, develop, direct and implement the overall operation of the Activity Department in accordance with current, federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. During an interview on January 7, 2026, at 1:00 PM with the Director of Nursing and Regional Nurse Consultant, it was reported the Activities Director left employment on December 31, 2025. The DON and Regional Nurse Consultant confirmed that since December 31, 2025, there has been no activities director. An individual has been hired as an activities director and is expected to begin employment on January 8, 2025. A review of the newly hired activities director's application for employment date August 13, 2025 reveled no experience or qualification as an activity director. Interview with the NHA on January 8, 2026, at 9:38 AM confirmed the newly hired activities director does not possess the minimal qualifications. The newly hired activities director is not licensed, registered or eligible for certification as a therapeutic recreation specialist, is not an activities professional recognized by an accrediting body, and does not possess two years of experience in a social or recreational program within the last five years. Since December 31, 2025, the facility does not have a qualified professional to direct the provision of activities to the residents. 28 Pa. Code 201.18 (e)(6) Management.28 Pa. Code 201.9(3) Personnel policies and procedures.

Based on observations and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by five out of five residents during a group interview (Residents 73, 51, 58, 63, and 99).Findings included: During a resident group interview with cognitively intact residents, Residents 73, 51, 58, 63, and 99, on January 7, 2026, at 10:10 AM, reported since a decrease in the facility's activity department staffing, no evening/bedtime snacks were being passed to residents and would like to receive an evening/bedtime snack. The residents reported after dinner activities staff would obtain snacks from the dietary department and come around to each unit to pass snacks as per resident preference. However, this process had not been occurring for about three weeks. Observations of the [NAME] resident pantry on January 7, 2026, at 11:15 AM, revealed inside the cupboards only two open boxes of oatmeal cream pies and cookies available for residents and not enough for all residing on the unit. The resident refrigerator/freezer contained items brought in from outside the facility for specific residents, pitchers of fruit punch and lemonade, and applesauce for medication passes. During an interview with the Direcor of Nursing (DON) on January 9, 2026, at 12:25 PM, the above was reviewed. The DON reported the activities staff were responsible for distributing evening/bedtime snacks to residents. However, since a decrease in the facility's activities department staff, a new process for the evening/bedtime snack pass had not been established or tasked to alternative staff/departments. Further interview with the DON confirmed that residents were not consistently receiving snacks as desired and confirmed residents should receive a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis.28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on observations, review of clinical records, review of select facility policies and job descriptions, information submitted by the facility, and staff interviews, it was determined that the facility failed to ensure effective administrative oversight to maintain systems necessary to provide a safe environment and adequate supervision to prevent resident elopement. This failure resulted in Immediate Jeopardy to the health and safety of one resident (Resident 26) out of 19 residents sampled and placed other residents at risk for serious bodily injury or death.Findings included: A review of the job description for the Nursing Home Administrator (NHA) signed and dated July 7, 2025 revealed the NHA must be knowledgeable of and demonstrate the ability to provide quality care by fostering a safe environment for residents and staff; provide emotional and psychological support for the residents within the facility, direct and oversee the day to day operation of the facility to ensure the highest degree of quality of care is maintained at all times in accordance with current state and federal standards, and implement and enforce company policies and procedures to that end. The job description further identified responsibilities that include planning, developing, organizing, implementing, and directing programs and activities; assisting departments in the use of departmental policies and procedures; fostering interdepartmental rapport and teamwork with an emphasis on safety; and assuring that all employees, residents, and visitors follow established policies and procedures. A review of the Director of Nursing Services (DON) job description, signed and dated June 1, 2024, outlined responsibilities that included planning, organizing, developing and directing the overall operation of the resident care department in accordance with all current regulatory standards to ensure the highest degree of quality care, knowledge of professional nursing theory and practice to provide first class resident care, expert knowledge of policies, regulations and procedures governing resident care, expert knowledge of medical equipment and instruments to administer resident care. The ability to apply the principles, methods, and techniques of professional nursing associated with long term resident care; preparing and maintaining detailed records, writing reports, and responding to correspondence; cultivate and manage effective working relationships with residents, medical staff, and the community; effectively manage regulatory and company compliant quality control standards and demonstrate effective verbal and written English communication. The position responsibilities included the DON would evaluate effects of care delivered and assign special treatments when indicated, assure resident safety through nursing staff, integrate and coordinate care with other disciplines, determine and schedule the staffing needs to meet the total care needs of the residents, develop, implement, and maintain an effective staff orientation plan, ensure that personnel follow established departmental policies and procedures and provide discipline as necessary. Despite these clearly defined administrative and nursing leadership responsibilities, the facility failed to ensure that effective systems were in place to monitor resident whereabouts, supervise common areas, and promptly identify and respond to a missing resident. As a result, Resident 26 exited the facility through an unlocked and unmonitored lobby door without staff awareness and remained absent from the facility for more than two hours. Licensed nursing staff were unaware the resident was missing until notified by the resident's legal guardian. The investigation further revealed that the facility had eliminated the receptionist position and failed to implement alternative systems to monitor the front lobby and main entrance. This administrative decision resulted in an unmonitored point of exit and directly contributed to the facility's inability to detect Resident 26's unsupervised exit and to promptly identify the resident's absence. The Administration failed to provide adequate monitoring and failed to implement effective nursing interventions to prevent Resident 26's elopement. In addition, there was insufficient coordination and direction of staff to ensure the safety of other residents identified as at risk for elopement. Following the elopement, the facility failed to demonstrate that effective supervisory systems had been implemented to identify and mitigate elopement risks for other residents. The facility's inability to implement and enforce policies and oversight systems to monitor residents and address elopement risks resulted in Immediate Jeopardy to the health and safety of eight residents, reflecting a systemic failure in administrative oversight, leadership accountability, and resource allocation necessary to ensure a safe environment. Immediate Jeopardy was identified on January 6, 2026, at 2:30 PM, as the facility's actions and inactions caused, or were likely to cause, serious injury, harm, impairment, or death. Refer F689 28 Pa. Code: 201.14 (a) Responsibility of licensee 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(1) Nursing services

Based on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician orders consistent with the professional standard of practice for one resident out of 18 sampled (Resident 40).Findings include: A review of the facility policy titled Oxygen Administration, last reviewed by the facility on January 16, 2025, revealed it is the facility's policy to provide oxygen therapy to residents who need it, consistent with professional standards of practice that are comprehensive person-centered care plans, and the resident's goals and preferences. The policy indicates oxygen is administered under orders of a physician, except in the case of an emergency. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists according to the policy. A clinical record review revealed Resident 40 was admitted to the facility April 15, 2024, with diagnoses that include peripheral vascular disease (a disorder of the blood vessels outside the heart that affects blood flow to the limbs). Further clinical record review revealed Resident 40 providers orders included administration of Oxygen at 2 liters per minute via nasal cannula (a medical device used to deliver supplemental oxygen to a patient through their nostrils) as needed for shortness of breath. The order was dated December 22, 2025, at 7:00 AM. An observation on January 6, 2025, at 11:24 AM, at 12:10 PM revealed Resident 40 was awake in bed, the head of bed was elevated, with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 0.5 liters per minute. Tubing connected the oxygen concentrator to her via a nasal cannula. Resident 40 was in no distress, breathing easily and able to speak without demonstrating shortness of breath. During an interview on January 6, 2025, at 12:05 PM, Employee 1, Licensed Practical Nurse (LPN), confirmed Resident 40 should be receiving continuous oxygen via a nasal cannula at 2 liters per minute. During an interview on January 7, 2025, at 1:00 PM, the Director of Nursing (DON) and Regional Nurse Consultant confirmed it is the facility's responsibility to ensure oxygen therapy is administered by provider orders and consistent with professional standards of practice. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of facility documents, clinical records, and staff and resident interviews, it was determined that the facility failed to ensure physician review and oversight of recommendations provided by a consulting medical specialist for one of 19 residents reviewed (Resident 11).Findings include:Review of the policy titled 'Suprapubic Catheter Placement' last reviewed January 16, 2025, indicated it is the policy of the facility to reinsert a suprapubic catheter when there appears to be a drainage problem and or when directed by a physician.A clinical record review reveals Resident 11 was admitted to the facility on [DATE], with a diagnosis of permanent atrial fibrillation (irregular heart rhythm). From February 13, 2025, to February 22, 2025, Resident 11 was hospitalized for sepsis (a potentially life-threatening condition that occurs when the body's response to infection causes injury to its own tissues and organs).Review of a document from the acute care facility, titled Consult - Urology dated February 17, 2025, revealed a suprapubic catheter (a medical device that helps drain urine from the bladder and enters the body through a small incision in the abdomen) was recommended for Resident 11 due to urethral pathology (a condition affecting the tube that carries urine from the bladder to the outside of the body). The suprapubic tube was inserted while Resident 11 was hospitalized . Clinical record review revealed Resident 11 returned to the facility on February 22, 2025, with the suprapubic catheter in place. Review of the facility care plan initiated February 23, 2025, identified that Resident 11 had a suprapubic catheter with a goal for the resident to remain free from catheter-related trauma (injury or damage to tissue at or near the catheter site). Review of the clinical record revealed Resident 11 attended a urology (doctor who specializes in disorders of the urinary system) appointment on May 9, 2025. Documentation from that visit indicated the suprapubic catheter was replaced. The written urology consult from May 9, 2025, included the recommendation that the skilled nursing facility change the suprapubic catheter monthly. The consult further documented that the resident would require monthly clinic visits if the facility was unable to safely remove and reinsert the catheter.Review of the facility medical record failed to demonstrate that the recommendations contained in the May 9, 2025, urology consult were reviewed, acknowledged, or verified by the facility physician. The medical record lacked evidence of a physician progress note, order, or other documentation indicating provider review of the recommended suprapubic catheter change schedule. Further review of facility nursing documentation revealed Resident 11 experienced episodes of suprapubic catheter blockage on November 11, 2025; November 30, 2025; December 16, 2025; December 23, 2025; January 2, 2026; and January 6, 2026. On each of these dates, the suprapubic catheter was documented as not draining urine as intended. Nursing documentation indicated flushing attempts were unsuccessful, and the suprapubic catheter was removed and reinserted.During an interview conducted on January 9, 2026, at 8:10 AM, the Director of Nursing was unable to provide evidence that the facility medical provider reviewed or acted upon the urology consult dated May 9, 2025, including the recommendation for a scheduled suprapubic catheter change. 28 Pa. Code 211.2(d)(3)(9) Medical Director.28 Pa. Code: 211.5 (f)(vii) Medical records.28 Pa. Code; 211.10 (d) Resident care policies.28 Pa. Code; 211.12(a)(c)(d)(1)(3)(5) Nursing Services.

Based on review of the facility policy, observations, and staff interviews, it was determined the facility failed to ensure medications and biologicals were stored and labeled in accordance with professional standards and manufacturer recommendations. Specifically, the facility failed to ensure that multi-dose medication vials were labeled with an open date on two of two nursing areas (East Hall Medication Room and [NAME] Hall Medication Room).Findings include:A review of the facility policy titled Medication Administration and Medication Storage, last reviewed [DATE], indicated that medications and biologicals (medications derived from living organisms) are to be stored safely, securely, and in accordance with manufacturer or supplier instructions. The policy further indicated that multi-dose vials (containers intended for multiple uses after initial entry) must be dated when first opened or accessed (for example, punctured by a needle) and discarded within 28 days unless the manufacturer specifies a shorter or longer time frame.During an observation of the medication refrigerator located at the [NAME] Hall Medication Room on [DATE], at 8:50 AM, in the presence of Employee 3, a Licensed Practical Nurse (LPN), one vial of Tuberculin Purified Protein Derivative (a solution used in the Mantoux skin test to detect exposure to tuberculosis) was observed stored in the refrigerator and available for resident use. The vial did not have a label indicating the date it was opened.At the time of the observation, an interview with Employee 3, LPN, confirmed that the Tuberculin Purified Protein Derivative vial had been opened and was in use but was not dated to identify when it was first accessed.A review of the manufacturer's storage instructions indicated that Tuberculin Purified Protein Derivative must be stored under refrigeration and discarded 30 days after opening, or sooner if the solution becomes expired, cloudy, or discolored. Without an open date, staff were unable to determine whether the vial remained safe and appropriate for use. A second observation was conducted in the East Hall Medication Room on [DATE], at 9:05 AM, in the presence of Employee 4, a Registered Nurse (RN). One vial of Lantus Insulin Glargine (a long-acting insulin used to control elevated blood glucose levels) was observed stored in the medication refrigerator and available for resident use. The vial was not labeled with an open date. At the time of the observation, an interview with Employee 4, RN, confirmed that the vial of Lantus Insulin Glargine had been opened and was in use but was not dated. An interview was conducted with the Director of Nursing on [DATE], at 12:00 PM, to review the above findings. The Director of Nursing confirmed the facility failed to ensure that multi-dose medication vials stored in both the East and [NAME] Hall Medication Rooms were labeled with the date opened, preventing staff from determining whether the medications were within the manufacturer's recommended time frame for safe use. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services.28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.28 Pa. Code 211.10 (c) Resident care policies.

Based on a review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to notify the resident and the resident's representative(s) of the transfer in writing and in a language and manner they understand and to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for two out of 19 residents reviewed (Resident 11 & Resident 41). Findings include: A clinical record review revealed Resident 11 was admitted to the facility on [DATE]. Further clinical record review revealed Resident 11 was transferred to a community hospital on August 29, 2025, and was readmitted to the facility on [DATE]. A clinical record review revealed Resident 41 was admitted to the facility on [DATE]. Further clinical record review revealed Resident 41 was transferred to a community hospital on December 16, 2026, and was readmitted to the facility on [DATE]. The facility was unable to provide documented evidence that the resident and resident representative were notified of the reasons for the transfer in writing or provide documented evidence the facility sent copies of written notices of these transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the Nursing Home Administrator (NHA) on January 8, 2026, at approximately 10:11 AM confirmed there was no documented evidence that copies of transfer notices for Resident 11 and Resident 41 were sent to a representative of the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on a review of clinical records, facility policy, resident representative and staff interviews, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrates that is not possible for one out of four residents sampled (Resident CR1).Findings include: A facility policy titled Weight Monitoring, dated October 1, 2024, revealed it is the facility's policy that based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. A significant change in weight is defined as a 5.0% change in weight in 1 month (30 days), a 7.5% change in weight in 3 months (90 days), or a 10.0% change in weight in 6 months (180 days). A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and chronic kidney disease (gradual loss of kidney function). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 6, 2025, revealed that Resident CR1 was severely cognitively impaired with a BIMS score of 03 (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 00-07 indicates severe cognitive impairment). A review of Resident CR1's care plan revealed Resident CR1 has potential for malnutrition initiated on November 4, 2024. Interventions implemented to ensure resident intake of nutrients will meet metabolic needs included consulting a dietician, monitoring the eating environment, and monitoring weight closely for weight gain or loss. Further review of the care plan revealed Resident CR1 had a nutritional problem or potential nutritional problem related to the need for a mechanically altered diet related to dysphagia (difficulty swallowing) initiated on November 2, 2024. Interventions implemented to maintain adequate nutritional status included individual bowls to be utilized at all meals initiated on February 5, 2025; the Kennedy cup (an assistance device with a screw-on lid and an easy-grip handle, designed for people with difficulty drinking from standard cups) with a straw to be utilized with all meals initiated on January 22, 2025; a scoop dish to be utilized with all meals initiated on November 6, 2024; and a registered dietician (RD) to evaluate and make diet change recommendations as needed. A nutrition note dated January 13, 2025, at 9:20 AM indicated the resident weighed 161.8 pounds, required a scoop dish at all meals, had good intake by mouth, and had a stable weight since admission. The note also indicated Resident CR1 eats with help for setup, has no pressure injuries, and nutrition/dietary will continue to monitor monthly. A progress note dated January 14, 2025, at 12:22 PM, revealed Resident CR1 was evaluated by a physician assistant for a cough, congestion, fatigue, aches, decreased appetite, and fever that started two days prior. Chest x-ray results were interpreted as likely acute pneumonitis (inflammation of the lung's air sacs). Due to these findings and the resident's symptoms, a new order was placed for cefepime, 1 gram (antibiotic medication), to be administered intravenously twice a day for seven days. The resident's representative was informed about the new treatment. Also, an order was noted for prednisone 40 mg by mouth for five days and albuterol sulfate inhalation nebulization solution. 63 mg/3 ml (a bronchodilator medication primarily prescribed to manage and prevent breathing difficulties related to respiratory conditions) oral inhalation three times a day for one week. A review of progress notes from January 12, 2025, through February 5, 2025, revealed the resident was diagnosed and treated for pneumonia and COVID-19. During this time period, a speech-language pathology evaluation dated January 20, 2025, included recommendations to change Resident CR1's diet to pureed meals and moderately thickened liquids.Resident CR1 weighed 161.8 pounds on January 12, 2025, and 146.4 pounds on February 5, 2025, representing a 9.5 percent loss in thirty days, which met the facility's definition of significant weight loss. A nutrition/dietary note dated February 5, 2025, at 3:14 PM, revealed Resident CR1's weight was 146.4 pounds. This triggered a weight warning due to significant weight loss, including a 9.9% loss over the last 30 days and a 9.9% loss over the last 90 days. The note indicated the resident's weight loss is not considered planned or beneficial and was likely related to their recent clinical status, including receiving IV antibiotics for pneumonia. The note indicated a decrease in the resident's oral intake (0-50% of most meals); CR1's diet was changed from pureed and honey-thickened to a moderately thickened, liquidized consistency. Recommendations made by Employee 1, Registered Dietitian (RD), included implementing a Magic Cup (a nutritional frozen dessert utilized to add calories and protein to a diet) twice a day with lunch and dinner, as Resident CR1 requested sweet and cold options; weekly weights will be taken for four weeks, and staff will encourage adequate intake, honor food preferences, and offer alternatives if less than 50% of a meal is consumed. The clinical record revealed the frozen nutritional treat supplement was not implemented until February 20, 2025, fifteen days after it was recommended. There was no documented evidence that alternatives were offered when the resident consumed less than fifty percent of a meal. A documentation survey report dated March 2025 revealed Resident CR1 ate 50% or less of his meals for 46 out of 93 meals from March 1, 2025, through March 31, 2025. A documentation survey report dated April 2025 revealed Resident CR1 ate 50% or less of his meals for 18 out of 90 meals from April 1, 2025, through April 30, 2025. A review of the clinical record revealed no documented evidence that facility staff were offering the resident alternative meals when he consumed 50% or less of his meal.Further clinical record review revealed Resident CR1's weight loss trend continued, and he weighed 143.0 pounds on March 16, 2025 (11.6% loss over three months), and 135.0 pounds on June 1, 2025 (16.6% loss over 6 months). Resident CR1 was transferred from the facility on July 19, 2025, and not available for interview. During an interview on August 21, 2025, at approximately 11:30 AM, Employee 1, Registered Dietician (RD), indicated that her recommendation for Resident CR1 to receive the Frozen Nutritional treat supplement should have been implemented when recommended on February 5, 2025. Employee 1, RD, explained that she could not access data logs to determine when the Frozen Nutritional Treat supplement intervention was implemented. Employee 1, RD, confirmed that the Medication Administration Record dated February 2025 indicated that Resident CR1 did not receive the frozen nutritional treat supplement until February 20, 2025. Employee 1, RD, also confirmed that there was no documented evidence that staff were documenting that alternatives were offered to Resident CR1 when he consumed less than 50% of his meals.During an interview on August 21, 2025, at approximately 12:15 PM, Resident CR1's resident representative indicated that the facility did not discuss or inquire about resident-specific interventions that may be utilized to maintain Resident CR1's nutritional status. Resident CR1's representative indicated that she recalled only one contact from the facility about Resident CR1's weight when his diet restrictions changed to puree. During a follow-up interview on August 21, 2025, at approximately 12:30 PM, Employee 1, Registered Dietician (RD), confirmed she could not provide documented evidence that the facility discussed resident-specific interventions with Resident CR1's representative that may be utilized to maintain Resident CR1's nutritional status. During an interview on August 21, 2025, at 12:45 PM, the nursing home administrator (NHA) and director of nursing (DON) confirmed there was no documented evidence explaining the implementation delay, the absence of alternative meal offerings, or the facility's efforts to involve the resident's representative in developing interventions to maintain the resident's nutritional status. 28 Pa Code 211.5 (f)(ii)(iii)(x) Medical records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records and residents' financial account records and staff interview, it was determined the facility failed to return the personal funds of one discharged resident (Resident CR1) within 30 days of discharge, for one of 12 residents reviewed. Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], and discharged on January 2, 2025. A review of the resident's financial account statement, provided by the facility and dated June 1, 2025, revealed a credit balance of $12,743.00 remained on the account, indicating funds belonging to Resident CR1 had not been disbursed within 30 days of the resident's discharge. Further review included an email, provided to the surveyor, from the Regional Business Office Manager (RBOM) dated May 29, 2025, which stated the facility's Business Office Manager was terminated on March 4, 2025, due to poor performance. The RBOM subsequently assumed responsibility for financial operations at this facility and two others. The RBOM acknowledged that the resident's refund had not been processed in a timely manner and that the refund was now scheduled to be issued on June 5, 2025. During an interview with the Director of Nursing on May 29, 2025, at 10:45 AM, it was confirmed that Resident CR1's personal funds were not returned within the required 30-day period following discharge from the facility. 28 Pa. Code: 201.18 (b)(2)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights

Based on a review of clinical records and resident and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for two of 21 residents reviewed (Residents 252 and 81) to reflect the residents' discharge goals. Findings Include: Clinical record review revealed that Resident 251 was admitted to the facility on [DATE], with diagnoses to include alcoholic cirrhosis of the liver (a degenerative disease of the liver resulting in scarring and liver failure). Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated December 17, 2024, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating he was cognitively intact. A review of Resident 251's social service notes, revealed a note dated December 11, 2024, indicating the resident would like to be discharged home when able. This note further stated the resident's wife did not want him to be discharged home. There was no documented evidence the facility addressed the desire of the cognitively intact resident to go home and his wife's desire for him to stay in the facility. Further review of Resident 251's clinical record revealed there was no further documentation regarding discharge to home until the resident decided to discharge home AMA (Against Medical Advice) on February 1, 2025. A review of the resident's comprehensive care plan, reviewed during the survey ending March 7, 2025, revealed no documented evidence that an individualized discharge plan was revised, as needed to reflect the resident's current desire for discharge or long-term placement at the facility. During an interview with the Nursing Home Administrator on March 7, 2025, at 12:00 PM confirmed there was no documented evidence of a current discharge goal and plan for this resident. Clinical record review revealed that Resident 81 was admitted to the facility on [DATE], with diagnoses to include depression and anxiety. Review of a quarterly MDS assessment dated [DATE], indicated the resident was cognitively intact with a BIMS score of 15. Interview with Resident 81 on March 5, 2025, at 9:15 AM revealed the resident had a desire to return home with waiver services (an alternative to nursing home placement, allowing individuals to receive long-term care services in their home or community, including assistance with daily activities). The resident stated the facility was aware of his desire to return home. A review of the resident's comprehensive care plan initially dated November 15, 2023, and reviewed during the survey ending March 7, 2025, revealed the resident will remain at the facility for long-term placement with interventions to review and update the discharge plan quarterly and as needed. There was no documented evidence that Resident 81's discharge plan was updated at least quarterly, and the resident agreed with long-term placement in the facility. Interview with the director of nursing on March 5, 2025, at approximately 1:00 PM failed to provide documented evidence the facility implemented a discharge plan that focused on the resident's discharge goal. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29 (a) Resident rights.

Based on observations and interview, it was determined the facility failed to maintain an environment free of accident hazards to the extent possible in three of three resident hallways Findings include: During an observation conducted on March 4, 2025, at 10:00 AM, the following environmental hazards were identified: In the 200 hallway, three linen carts were positioned at the end of the hallway on the same side, obstructing access to the handrails. Additionally, four linen carts were lined up against the wall in the hallway connecting the 100 and 200 hallways, further occluding the handrails. A floor cleaning machine was also present in this hallway, on the same side, blocking access to the handrails. This hallway included access to the resident dining room, an area of frequent resident traffic. In the 100 resident hallway, plastic storage bins with three drawers, containing Personal Protective Equipment (PPE) such as face masks, gloves, and gowns, were observed in front of resident rooms [ROOM NUMBERS]. A mechanical lift was positioned between rooms [ROOM NUMBERS], all on the same side of the hallway, further restricting access to the handrails. In the 200 resident hallway, additional plastic storage bins containing PPE were observed in front of rooms 200, 207, 213, 215, 217, and 223. Additionally, two wheelchairs were placed outside of room [ROOM NUMBER], further obstructing the resident handrails. In the 300 resident hallway, a plastic storage bin with three drawers containing PPE was observed in front of room [ROOM NUMBER], as well as in front of the 300 hallway mechanical room, impeding access to handrails in these areas. During an interview on March 7, 2025, at 10:00 AM, the Nursing Home Administrator confirmed the above observations and acknowledged that the placement of these items created obstructions in the hallways. The facility failed to ensure that hallways were free from obstructions to allow safe passage for residents, staff, and visitors. 28 Pa. Code 211.12 (d)(4)(5)Nursing Services. 28 Pa Code 201.18 (b)(1) Management

Based on observation, review of select facility policy and staff interview, the facility failed to store Oxygen in a safe and secure manner. Findings include: A review of a select facility policy for Oxygen safety, last reviewed January 1, 2025, revealed it is the policy of the facility to provide a safe environment for residents, staff and the public. This policy addresses the use and storage of oxygen equipment. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of non-combustible or limited combustible construction, with doors or gates that can be secured against unauthorized entry. Precautionary signs readable from 5 feet shall be maintained on the door or gate where oxygen is used or stored. (Example: OXYGEN STORED WITHIN-NO SMOKING) On March 4, 2025, at 9:00 A.M., seven full oxygen cylinders were observed in a multi-tank rack on wheels (not secured to the wall or floor) positioned on the right side of the hallway. Five empty oxygen tanks were stored in a similar multi-tank rack on wheels (not secured to the wall or floor) on the left side of the hallway at the end of the west resident hallway near the exit door. Signs posted above the oxygen tanks designated areas for full and empty cylinders. The sign above the full tanks read: Full cylinders only. This area is designated for full O2 (oxygen) cylinders only. If cylinders are used, please place empty cylinders in the carrier to the far left. The sign above the empty tanks read: Empty cylinders only. This area is designated for empty O2 cylinders. If the cylinders are used, please place empty cylinders here. On March 4, 2025, at 2:26 P.M., Employee 1 (Maintenance Assistant) was observed refilling the oxygen storage rack with full tanks, resulting in a total of 12 full oxygen tanks stored in the unsecured hallway location. During an interview on March 4, 2025, at 2:30 P.M., Employee 1 (Maintenance Assistant) stated that an enclosed, locked oxygen storage area is located outside the west hallway exit door. He reported that he removes empty oxygen tanks and replaces them with full tanks inside the hallway every afternoon, stating he has been performing this task forever and that it is just easier for nursing staff to retrieve oxygen from inside rather than going outside to the designated storage area. During an interview March 5, 2025, at 1 P.M., the Nursing Home Administrator confirmed that Oxygen stored in the hallway is not in accordance with the facility policy. 28 Pa. Code 201.18 (b)(3)(e)(1)(2) Management. 28 Pa code 211.12 (d)(1)(2) Nursing services

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure the provision of pharmacy services to assure the timely receipt and administration of physician-prescribed medications for three (3) of twenty-one (21) residents reviewed (Residents 90, 64, and 201). The facility also failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and failed to maintain oversight of the facility's medication dispensing system. Findings include: Review of clinical record revealed that Resident 90, was admitted to the facility on [DATE], at 10:45 AM with diagnoses to include chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing), depression, and anxiety. A physician order dated February 4, 2025, documented an order for Clonazepam (an antianxiety medication) 1 mg by mouth twice daily for a diagnosis of anxiety. A review of the February 2025 Medication Administration Record (MAR) revealed that Clonazepam was not administered to Resident 90 as prescribed on February 4, 2025, due to awaiting pharmacy delivery. An interview with the Director of Nursing (DON) on March 5, 2025, at approximately 11:00 AM confirmed that the medication was not available in the facility due to a delay in pharmacy delivery. Review of the clinical record revealed Resident 64 was admitted to the facility on [DATE] with diagnosis 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 congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues). The resident sustained a fall on February 23, 2025, at 9:30 PM and was hospitalized with fractures of the right hip and right pubic ramus. Upon readmission to the facility on [DATE], at 3:00 PM the resident had physician orders for Oxycodone HCL 5 mg every 4 hours (a narcotic opioid pain medication) for moderate pain as needed, hospital documentation, The resident received 2 doses of oxycodone in the hospital, one at 5:57 AM and another at 10:19 AM. A review of the facility physician orders dated February 24, 2025, at 9:00 PM revealed an order for Oxycodone HCL 5 mg by mouth every 4 hours as needed for pain rated 6-10 on the pain scale. However, this order was discontinued on February 25, 2025, at 7:00 AM. A new order for Oxycodone HCL 5 mg every 4 hours as needed for pain was re-entered on February 25, 2025, at 7:00 AM, with the addition of non-pharmacological interventions. A review of Resident 64's February 2025 Medication Administration Record (MAR) indicated that the resident did not receive Oxycodone on February 24, 2025, February 25, 2025, February 26, 2025, or February 27, 2025. The first recorded administration of Oxycodone was at 7:09 AM on February 27, 2025. Nursing documentation dated February 27, 2025, at 6:09 AM noted that the resident exhibited increased confusion throughout the night, reporting visual hallucinations of children in her room. She remained awake all night and was unable to be redirected or oriented to time and place. The documentation further stated that she complained of pain and was given Tylenol instead of Oxycodone. A note was placed on the provider's communication board requesting a signed prescription for Oxycodone HCL 5 mg. The documentation also indicated that the medication had not been available in the facility since the resident's hospital discharge. A review of the clinical record confirmed that the medication was not administered due to a delay in delivery from the pharmacy. An interview with the Director of Nursing (DON) on March 5, 2025, at 2:15 PM revealed that the facility's procedure when a medication is unavailable from the pharmacy is to check the emergency supply to determine if the medication is available. If the medication is not available, the physician should be consulted for further instruction. A review of the facility's emergency medication supply confirmed that Oxycodone HCL 5 mg was not available in the emergency cart. Clinical record review revealed that Resident 201 was admitted to the facility on [DATE], with diagnoses to include aftercare and therapy after hospitalization , muscle weakness and atrial fibrillation (an irregular heartbeat reducing the heart's ability to pump blood through the body reducing oxygen supply). Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 17, 2024, indicated the resident had a 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 13-15 equates to being cognitively intact) score of 15 indicating he was cognitively intact. Review of Resident 201's January 2025 Medication Administration Record revealed Physician orders to include: Diltiazem HCl ER 300 mg daily for hypertension Oxycodone-Acetaminophen 5-325 mg every 6 hours as needed for moderate pain Levothyroxine Sodium 88 mcg daily for thyroid management. A review of the January 2025 MAR (medication administration record) revealed that Diltiazem HCl ER, Oxycodone-Acetaminophen, and Levothyroxine Sodium were not administered on January 15, 2025, due to pharmacy delays, and were not available until January 16, 2025. The DON confirmed on March 5, 2025, that the medications were unavailable and not stocked in the emergency supply A review of facility pharmacy policy reviewed January 16, 2025, entitled, Emergency Medication System: Removal of Outdated Medications revealed, the contract pharmacy staff shall perform routine audits of the system to ensure the integrity of contents and outdated or soon to be outdated contents are removed. Procedures to include, Audits shall be performed routinely to ensure the OOS (Pyxis like system, an automated, medication system, located in the facility) do not contain outdated medications. Medications should be removed at least 90 days prior to expiration. Non-controlled medications may be returned outdated/excess medications to the pharmacy. Non-controlled medications may be returned to the pharmacy by courier during the daily medication delivery return process. A list of medications removed shall be created and signed by both the pharmacy staff and the nursing staff. A list of each item and quantity shall be provided to the facility. A review of the facility's emergency medication supply and observation of the automated medication dispensing system on March 7, 2025, at 12:00 PM, revealed discrepancies between the recorded medication inventory and the actual stock. The noted medication's expiration dates in the system did not match the actual expiration dates on the unit dose packs of the meds contained in the machine and medications listed as available were not physically present. The facility failed to provide documentation of pharmacy oversight, including routine monthly audits for expired medications and medication availability. A review of the facility's Medication Ordering and Receipt, After-Hours Pharmacy Service policy revealed that emergency pharmaceutical services are available 24 hours a day, 365 days a year. According to the policy, emergency medication needs should be met using onsite supplies provided by the pharmacy, including an emergency box, interim box, starter kit, controlled substance interim box, and an electronic cabinet, as permitted by regulations. The policy further states that STAT (immediate) medication requests can be made to the pharmacy and that a corporate pharmacist is available 24/7 to either dispense medications from the pharmacy or arrange for dispensing from a backup pharmacy to meet the facility's medication needs. However, during an interview on March 7, 2025, at 11:00 AM the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility did not have a backup emergency pharmacy, despite the policy stating that one should be available. They stated the facility relied solely on an out of state-based pharmacy with daily courier deliveries. Additionally, they acknowledged that facility nursing staff, rather than trained pharmacy personnel, were responsible for restocking the automated medication dispensing system. The DON further confirmed that facility staff had not received training from a pharmacist on proper restocking procedures and that no documentation of pharmacy oversight or staff training was provided during the survey. The facility failed to provide timely access to physician-prescribed medications for multiple residents, resulting in delays in the administration of essential medications, including pain management and critical daily prescriptions. Additionally, the facility lacked a process to ensure emergency medication availability and failed to maintain proper oversight of the medication dispensing system. 28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services.

Based on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49. Findings include: A review of Pennsylvania Code title 49, part I, subpart A, chapter 27 - STATE BOARD OF PHARMACY, 49 Pa. Code S 27.204 - Automated medication systems revealed: (a) This section establishes standards applicable to licensed pharmacies that utilize automated medication systems which may be used to store, package, dispense or distribute prescriptions. (b) A pharmacy may use an automated medication system to fill prescriptions or medication orders provided that: (1) The pharmacist manager, or the pharmacist under contract with a long-term care facility responsible for the dispensing of medications if an automated medication system is utilized at a location which does not have a pharmacy onsite, is responsible for the supervision of the operation of the system. (4) The automated medication system must electronically record the activity of each pharmacist, technician or other authorized personnel with the time, date and initials or other identifier so that a clear, readily retrievable audit trail is established. A pharmacist will be held responsible for transactions performed by that pharmacist or under the supervision of that pharmacist. (c) The pharmacist manager or the pharmacist under contract with a long-term care facility responsible for the delivery of medications shall be responsible for the following (2) Ensuring that medications in the automated medication system are inspected, at least monthly, for expiration date, misbranding and physical integrity, and ensuring that the automated medication system is inspected, at least monthly, for security and accountability. (4) Ensuring that the automated medication system is stocked accurately, and an accountability record is maintained in accordance with the written policies and procedures of operation. (5) Ensuring compliance with the applicable provisions of State and Federal law. (6) Set forth methods that ensure that access to the automated medication system for stocking and removal of medications is limited to licensed pharmacists or the pharmacist's designee acting under the supervision of a licensed pharmacist. An accountability record which documents all transactions relative to stocking and removing medications from the automated medication system must be maintained. (g) The pharmacist manager shall be responsible for ensuring that, prior to performing any services in connection with an automated medication system, all licensed practitioners and supportive personnel are trained in the pharmacy's standard operating procedures with regard to automated medication systems set forth in the written policies and procedures. The training shall be documented and available for inspection. Specifically, the facility failed to ensure: The oversight and management of the automated medication system as required by Pennsylvania Code Title 49, Chapter 27, which mandates pharmacist supervision, system inspections, and proper medication accountability. The timely delivery and availability of prescribed medications, leading to multiple instances of missed doses for residents, including Clonazepam for Resident 90, Oxycodone for Resident 64, and Diltiazem, Levothyroxine, and Oxycodone-Acetaminophen for Resident 201. The maintenance of a readily retrievable audit trail and documented oversight of the automated medication system. The Pennsylvania code Title 49 require that automated medication systems be managed under the supervision of a pharmacist and include documentation of oversight activities, system inspections, and accountability for stocking and removing medications. However, the facility failed to provide documentation verifying that the required oversight and management of the automated medication system were conducted. During an interview on March 7, 2025, at 11:00 AM, the Nursing Home Administrator confirmed the facility pharmacy did not adhere to the Pennsylvania code regarding pharmacy services. She further stated that documentation regarding oversight of the system was unavailable, and that pharmacy staff were not actively managing the system. This lack of oversight contributed to medication availability issues, delays in administration, and a failure to maintain regulatory compliance. Cross refer F755 28 Pa. Code 201.18 (b)(3)(e)(1)Management. 28 Pa. Code 211.9 (a)(l)(d)(k)(l)(1)(2)(3) Pharmacy Services. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 21 sampled (Resident 25). Findings included: A review of Resident 25's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (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 oropharyngeal dysphagia (difficulty swallowing). A current physician order initially dated April 30, 2024, noted an order for Nutren 1.5 (liquid nutritional supplement) 45 ml/hour via peg tube (percutaneous endoscopic gastrostomy tube- feeding tube surgically placed through the abdomen into the stomach, allowing direct delivery of nutrition, fluids, and medications) for enteral feeding (method of delivering nutrition directly into the gastrointestinal tract though a tube). A current physician order initially dated September 19, 2024, noted an order for a full liquid nectar/mildly thick consistency diet (consists of liquids that need to be thickened to a consistency similar to fruit nectar, using a thickener to prevent choking) for pleasure feeding only. A review of Resident 25's quarterly MDS assessment dated [DATE], revealed in Section K0520 Nutritional Approaches the resident did not have a feeding tube (flexible tube inserted into the stomach or small intestine to deliver fluids, medications, and liquid nutrition to individuals who cannot safely or adequately eat or drink by mouth). An interview with the director of nursing on March 7, 2025, at 9:00 AM, confirmed that Resident 25's MDS Assessment was inaccurate. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records and select facility reports, and staff interview it was determined that the facility failed to provide sufficient staff supervision and assistance with activities of daily living to prevent a fall for a resident identified at high risk for falls that resulted in a fracture of the right hip and right distal humerus (lower end of the upper arm bone, one of the three bones that come together to form the elbow joint) for one resident (Resident 75) out of nine residents reviewed. Findings include: A review of the clinical record revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)]. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 12, 2022 revealed that the resident had a BIMS (brief mental screener that aids in detecting cognitive impairment) score of 12 (a score of 8 -12 indicates moderately cognitively impaired) and required extensive assistance from two persons for transfer assistance and toileting assistance. The MDS assessment also indicated that the resident was not steady and required staff assistance due to balance problems while moving on and off the toilet, moving from seated to standing position, and while standing. A review of the resident's plan of care, initially dated January 6, 2022, identified that the resident had a potential for falls due to a decline in functional status. Interventions designed to prevent falls were to place the resident's bed in lowest position, call bell within reach/encourage use/answer promptly, and non-skid socks in and out of bed, that was added as an intervention on January 10, 2022, after fall on that date. There was no indication on the resident's care plan that safety alarms were planned for the resident, either in bed or out of bed in a chair. A fall risk assessment dated [DATE], indicated the resident had intermittent confusion and was a high risk for falls. A nurses note dated January 10, 2022 at 3:30 AM indicated that staff responded to an alarm and found Resident 75 sitting upright on the floor in her room on the left side of her bed. The resident was unable to explain what happened. The call bell was in place. The resident was noted to be barefoot. No injuries were noted. A new intervention for slipper socks in and out of bed was noted after this fall. Although this nursing entry indicated that an alarm had alerted staff that the resident had fallen, there were no alarms planned as a safety intervention on the resident's plan of care, in effect at the time of the fall dated January 6, 2022 . Review of an Occupational Therapy Evaluation dated January 31, 2022 indicated Resident 75 required maximum assistance of two staff from a sitting to a standing position and was dependent on staff for toileting. The resident was identified with impairments in balance, mobility, and self-monitoring resulting in limitations and/or participation restrictions in the areas of mobility and self-care. A nurses note dated February 3, 2022, at 7:45 AM indicated that two nurse aides walked the resident, who was wearing non-skid socks, into the bathroom. The nurse aides told the resident, who was moderately cognitively impaired, to ring the call bell when the resident was done using the toilet. The aides went to set up the resident's roommate for breakfast and heard the resident fall in the bathroom. The resident complained of pain to the right hip. An assessment was completed, the responsible party notified and the physician was made aware. An order was received to transfer the resident to the emergency room for evaluation. Review of the registered nurse nursing assessment dated [DATE] completed following the resident's fall in the bathroom on February 3, 2022, revealed that the resident was found in the bathroom lying on her right side. The resident was guarding her right hip and complaining of pain in the right arm and right hip and unable to move both. The physician assistant was made aware and an order was received to transfer the resident to the emergency room for evaluation. The responsible party was notified. Review of the facility report dated February 3, 2022, at 7:30 AM indicated that the resident had a fall in the bathroom of the resident's room. The resident was was a transfer assist of one staff according to the report. The resident was placed on the toilet by Employee 4 (nurse aide). The resident was told to wait for Employee 4 to come back in (to the bathroom) and assist her with morning care. Employee 4 (nurse aide) and Employee 5 (nurse aide) left the resident in the bathroom and went to the resident's roommate to position her for breakfast and within one to two minutes they heard Resident 75 fall in the bathroom. The pull call bell alarm was next to the toilet, but not activated. The facility's report noted that the predisposing physiological factors were gait, balance, visual impairment and decreased strength/ endurance. The resident was readmitted to the facility on [DATE], with diagnoses, that included right hip fracture with ORIF (open reduction with internal fixation performed to repair a complex or severe hip fracture) and fracture of the right distal humerus. Interview with the Director of Nursing on February 16, 2022 at 2:00 PM failed to provide documented evidence that the facility provided necessary staff supervision of a resident with identified balance problems and risk for falls to maintain the resident's safety to prevent a fall, which resulted in a fracture to the resident's right hip and distal humerus. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records and select facility incident investigations and resident and staff interviews, it was determined that the facility failed to provide sufficient staff assistance and utilize safe technique and/or necessary assistance devices during transfers to prevent a fall with serious injury, a fractured femur, for one resident out of five sampled (Resident CR4). Findings include: A review of Resident CR4's clinical record revealed he had diagnoses, which included cerebral infarct (is an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) with [CONDITION(S)] and [CONDITION(S)] of the left side ([CONDITION(S)] means paralysis of one side of the body - [CONDITION(S)] means a slight paralysis or weakness on one side of the body) muscle weakness and [CONDITION(S)] (disorder of the central nervous system that affects movement, often including tremors). The resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 24, 2019, indicated that the resident's cognition was intact with a score of 15/15 of BIMS assessment (Brief interview for mental status - a tool to assess cognitive function). The resident's weight was documented as 255 pounds. A review of the resident's MDS Assessments of transfer status dated March 14, 2019, (quarterly); June 6, 2019, (quarterly); September 24, 2019 (quarterly); November 24, 2019, (annual); and December 24, 2019, (quarterly) revealed that each indicated that the resident required extensive assistance of two person physical assistance for transfers. A review of the resident's clinical record revealed that upon admission to the facility on [DATE], the resident was assessed for the use of a mechanical lift for safe transfers. A review of this assessment dated [DATE], revealed that the resident required the use of a bariatric lift (Heavy-duty patient lifts are especially designed to accommodate users who are of greater than average weight and require assistance in transferring from their beds to their wheelchairs or from wheelchairs to the toilet, bath or back into bed for transfers). There were no further assessments regarding the resident's need for a mechanical lift for transfers upon review of the resident's clinical record conducted at the time of the survey ending January 22, 2020. Interview with the occupational therapist on January 22, 2020, at 2:05 p.m., revealed that lift assessments are conducted upon a resident's admission and if a resident's transfer status changes. Further review of the resident's clinical record revealed that the resident was referred to occupational therapy services on December 11, 2019, related to pain in his left shoulder. The occupational therapy evaluation dated December 11, 2019, revealed that the goal was to have the resident display a decrease in pain with movement to allow for activities of daily living participation and to increase right upper extremity strength to assist with stand up lift transfers. During this evaluation, the resident's past history was obtained and it was determined that prior to his admission to the facility, he had resided in another skilled nursing facility, and required moderate transfer assistance of two persons for transfers and ambulation. Review of the OT assessment summary revealed that the therapist's clinical impression was that the resident required the stand-up lift for bed to wheelchair transfers. The resident additionally had informed the therapist that he utilized the stand-up lift for transfers to the commode. The occupational therapy discharge summary dated January 6, 2019, noted that resident's use and assistance with stand-up lift transfers. An occupational therapy discharge summary dated June 28, 2019, revealed that the resident received occupational therapy services from June 1, 2019, to June 30, 2019, to assist the resident with repositioning himself in the wheelchair without assistance. A review of the OT assessment and summary of skilled services section, revealed that the equipment that was utilized prior to the onset of the current problem requiring therapy, included the use of the stand-up lift. A review of the occupational therapy evaluation and plan of treatment revealed that the functional skills assessment-activities of daily living section, revealed that the resident required assistance in the areas of bathing/transfers. It was further determined that these areas would not be addressed during treatment, as the resident was presenting with no change in function in that area. According to review of a nursing progress note, dated as a late entry by Employee 1, RN, on January 7, 2020, at 15:35 [3:35 PM}, for January 6, 2020, at 13:15 [1:15 PM], revealed that she was called to the resident's room to assess the resident due to a resident fall. Employee 1 documented that Employee 2, nurse aide, stated that he was transferring the resident from the bed to the chair, when the (wheel) chair moved, and he had to lower the resident to the floor. A review of the incident report dated January 6, 2020, revealed that approx 1 hr later resident reported to charge nurse he was experiencing pain in left hip/leg area. Call placed to PA (physician assistant); orders received to obtain x-ray of the left leg and hip. The X-ray was completed and the results received at 8:45 PM on January 6, 2020, revealing a suspected undisplaced fracture of the left femur (thigh bone). The resident was admitted to the hospital on Janaury 7, 2020, with a minimal non-displaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture base of left femoral neck (femoral neck fracture is one type of hip fracture. This injury occurs just below the ball of the ball-and-socket hip joint, the region of the thigh bone called the femoral neck. A femoral neck fracture disconnects the ball from the rest of the thigh bone (femur)). A review of the statement completed by Employee 2 regarding the incident dated January 7, 2020, revealed that he stated that he proceeded to get the resident ready for the morning shift and the resident was then washed up and dressed for the morning. Employee 2 stated I placed the resident's sneakers on his feet as part of the procedure. I then proceeded to get the resident ready for transfer. I pulled the wheelchair next to the bed. The brakes were locked on the chair. I proceeded to transfer. The chair kicked back from the resident. I proceeded to place the resident on the floor. I was in front of the resident and lowered him to the floor. Employee 3, LPN (Licensed Practical Nurse), was called to the resident's room after the incident. He stated that the nurse aide, Employee 2, providing the resident's morning care stated that he was transferring the resident and the wheelchair shifted and the resident was placed on the floor. There was no documented evidence that the facility had interviewed Resident CR4, who was assessed as cognitively intact, to obtain the resident's account of the incident. The Director of Nursing confirmed during interview at 2 PM on Janaury 22, 2020, that the resident had not been interviewed regarding his fall during transfer. A review of the resident's care plan and Kardex (working tool used by direct care staff identifying each resident's specific needs for daily care and assistance level) conducted during the survey ending January 22, 2020, revealed that Employee 1, RN, had revised the resident's comprehensive care plan on January 7, 2020, and Kardex to indicate that the resident was a transfer assist of one person. Prior to that date (January 7, 2020), there was no transfer status identified on the resident's care plan or Kardex. When interviewed on January 22, 2020, at 2:20 p.m., the Director of Nursing Services confirmed that the resident's transfer status was not part of the resident's plan of care or identified on the Kardex prior to the incident on January 7, 2020. The DON stated that transfer status was left up to the resident since he was cognitively intact and it was based on his perception of his strength that day. The DON stated that the nursing staff relied on communicating this information to each other by word of mouth. The facility was unable to provide an assessment of the resident's transfer status at the time of, or prior to the incident of January 6, 2020. The facility was unable to provide documented evidence of what information had been used to update his comprehensive plan of care and Kardex on January 7, 2020, to a transfer assist of one. The resident had consistently triggered during MDS assessments process, as an assist of two. It was documented in therapy notes that the resident consistenly said that he utilized the sit to stand lift and therapy had been working to strengthen his ability to continue to do so. The only lift assessment completed by the facility determined the resident required the use of a bariatric lift. An interview was conducted with Resident CR4 on January 28, 2020, at 3:18 PM following his admission to another skilled nursing facility after his hospital stay for treatment of the fracture. A review of the resident's admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 13. When interviewed at 3:18 PM on Janaury 28 2020, the resident confirmed that he had fallen on January 6, 2020, during morning care. The resident estimated the fall to have occurred at approximately 7:30 a.m. that morning and was able to identify the caregiver (Employee 2) involved. The resident stated that Employee 2 had been assigned to him in the past, and had always used another caregiver for transfers, but on that date had transferred him by himself. The resident wasn't aware of the reason Employee 2 transferred without the assistance of another person on that morning. The resident stated that the only thing I can think of is he was trying to be a hero. He stated that the facility staff consistently used the sit to stand lift or a transfer assistance of two during his stay at the facility. The resident stated that he had been transferred in this manner since admission to the facility and prior to his admission in November 2018. The resident stated it was necessary to use two persons to transfer, due to his left sided weakness, size and lack of strength in his arms and legs. The resident stated that he was recently having pain in his left shoulder, for which he was receiving therapy and which was causing an additional issue with his activities of daily living status at the time of his fall with fracture. The resident confirmed that the use of the sit to stand lift or transfer status of two was not a new intervention. The resident stated that he would never ask staff to transfer him without the assistance of a second person. The resident explained to the surveyor how Employee 2, put his one arm around his right side(the resident demonstrated his chest area) and they walked towards the wheelchair. The resident added that the locks on the wheelchair were not activated. He stated that he was not sure if he or Employee 2, bumped the chair or lost their footing, but they both, went down on the floor. The resident stated that he played many sports in his lifetime, some of them contact sports, but never did he take a fall or a hit that caused so much pain upon impact. The resident stated that he is now in constant pain and has not been able to tolerate getting out of bed. His goal now he stated, is to control his pain to participate in therapy. The resident confirmed that no one at the facility had interviewed him regarding the incident despite the extended time period from the time of incident (approximated 7:20 a.m) up to his transfer to the hospital, which he recalled was about 8:30 p.m. on January 6, 2020. The facility failed to assure that staff used sufficient staff assistance and/or necessary assistance device and safe technique to prevent this fall with serious injury and pain to Resident CR4. 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices Previously cited: 6/21/19. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services. Previously cited: 6/21/19, 2/16/19 28 Pa. Code 211.11(d)(e) Resident care plan

Based on a review of clinical records and select facility reports and staff interviews, it was determined that the facility failed to utilize safe technique during resident care and ensure necessary safety measures were in place to prevent an accident resulting in a fractured femur for one resident (Resident 45) out of 20 residents reviewed. Findings include: A review of the clinical record revealed that Resident 45 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 2, 2016, revealed that the resident was severely cognitively impaired and required the assistance of one person for bed mobility (turn and reposition in bed) and for transfers between surfaces. A review of a resident incident/accident report dated October 1, 2016, revealed that at 6:40 p.m. on October 1, 2016, Employee 1, a Nurse Aide, was providing evening care to the resident. According to the report, Employee 1 turned the resident away from herself, towards the opposite side of the bed, to render care when the mattress shifted and the resident rolled out of the bed. There was no siderail up on the opposite side of the bed at this time nor was there another staff member present to assist Employee 1 with the resident's care. The report further noted that the mattress shifted over the edge of the bed frame and the resident rolled over onto the floor. The incident/accident report indicated that the mattress was not properly attached to the bed frame, resulting in shifting of the mattress, which resulted in the resident's fall. The resident rolled off the edge of the bed and landed on her left side, striking her head and body on the floor. The resident was assessed and no serious injuries were confirmed at the time of the incident/accident report. Nurses' notes dated October 1, 2016, at 6:46 p.m. indicated that while Employee 1 was providing care, this Nurse Aide turned the resident and the mattress slipped off the bed. The resident fell to the floor and struck her head on a garbage can causing a 4 x 0.5 (no indication of measurement) laceration above the left eye and first aid was rendered. A physician's orders [REDACTED]. Nursing noted that the resident was transferred to the emergency room at 8:15 p.m. on October 1, 2016. The hospital X-ray report dated October 2, 2016, revealed that the resident had sustained a comminuted (break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) impacted (bone fracture in which one of the fragments is driven into another fragment) fracture deformity (deformed or misshapen) of the distal (situated away from the center of the body or from the point of attachment) left femur (thigh bone). Review of the information dated October 1, 2016, submitted by the facility indicated that the resident utilized an air mattress (the mattress system consists of a foam shell with foam topper serving as a support surface underneath the resident. The foam shell also includes contoured foam bolsters at the sides and ends of the mattress to provide added stability and positioning). This facility documentation of the event indicated that the resident used a pump air mattress and the mattress was properly strapped and secured to the bed at the time of incident. This account of the event differed from the circumstances noted on the facility incident/accident report dated October 1, 2016. The facility documentation submitted regarding the event dated October 1, 2016, also indicated that upon inspection of this bolstered (bolsters are positioning devices to support a resident with the potential to roll out of bed) mattress, it was noted that there is an approximate 3 inch overhang of the mattress edge over the bed frame. The facility reported that it is likely that when the resident was rolled to the left side that the unsupported edge gave momentum for the resident to slip off and cause the mattress to slide in addition to the resident. The facility documentation of the event dated October 1, 2016, also indicated that the base of the mattress was measured to be 36 inches wide and the bed frame was 35 inches wide, which supported the mattress but not the bed bolsters. The facility documentation regarding the event indicated that a bariatric (larger size) bed was ordered for this resident. Nurses' note on October 2, 2016, at 5:28 p.m. indicated that the resident was now using the new bariatric bed. During interview with Employee 1 on June 6, 2017, at 2:45 p.m. the employee stated that she rolled the resident away from her, not towards her, when providing evening care. Employee 1 stated that the mattress slid and the resident fell on her left side on the floor. Employee 1 stated that the mattress was overhanging the bed frame at the time of the fall and the resident hit the area that was overhanging and the momentum caused the resident to fall. Interview with the Administrator (NHA) on June 8, 2017, at 9:45 a.m. revealed that he was unable to explain the inconsistencies between the incident/accident report and the facility documentation regarding the event dated October 1, 2016. The NHA confirmed that Employee 1 turned the resident to the opposite side of the bed, with no siderail up on the opposite side of the bed or any other staff member present on the opposite site of the bed to support the resident, as she was rolled away from Employee 1. The NHA was also unable to explain how the mattress shifted off the bed if it had been properly secured in place as noted in the facility documentation of the event dated October 1, 2016, submitted to the State Survey Agency. The facility failed to demonstrate that the mattress on Resident 45's bed was properly secured and/or properly sized and that Employee 1 used safe technique during care to prevent this avoidable accident, which resulted in Resident 45's fall and fratured femur. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/11/15. 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services. Previously cited 7/22/16, 6/11/15.