Every finding on record at Embassy of Hearthside

Based on closed clinical record review and staff interview, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission for one of two residents reviewed (Residents CR2).Findings include: Closed clinical record review for Resident CR2 revealed the resident was admitted to the facility on [DATE], with a diagnosis list which included, UTI (urinary tract infection), dysphagia (difficulty swallowing), communication deficit, muscle weakness, difficulty walking, diabetes (blood glucose problem), sleep apnea (loss of breath), depression, back pain, anxiety disorder, absence of right toes, heart failure, reflux disease, elevated lipids, hypertension (high blood pressure), osteoarthrosis (joint disease), chronic kidney disease, and muscle spasms. Resident CR1 was transferred to the hospital at the family's request on July 13, 2026, and did not return to the facility. Further record review for Resident CR2 revealed a nursing admission Evaluation with Baseline Care Plan was created in the electronic record on July 8, 2026, the date the resident was admitted . The sections of the evaluation consisting of the assessment of demographics (social history)/orientation to the facility, skin integrity, oral/nutritional, neurological, respiratory, cardiovascular (heart/lungs), gastrointestinal, bladder/bowel, pain, mobility/safety, sensory, discharge planning/psychosocial wellbeing, and medications/physician's orders and specialized services assessment did not show any entries were completed until July 13, 2026, five days after the resident's admission. At the time of the onsite survey on July 23, 2026, the same evaluation still showed in progress in the resident's closed clinical record. Review of Resident CR1's plan of care revealed no evidence any baseline care plan was created for the resident until July 13, 2026, five days after admission, and the day the resident was transferred to the hospital and subsequently discharged from the facility. There was no evidence the resident/responsible party were provided with a copy of a baseline care plan within 48 hours of admission. The facility failed to implement a baseline care plan within 48 hours of admission for Resident CR1 and provided a written copy to the resident/responsible party. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on July 23, 2026, at 4:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to obtain diagnostic services to meet the needs of its residents and ensure those services are obtained promptly for one of one resident reviewed for a change in condition (Resident 4).Findings Include: Clinical record review for Resident 4 revealed a nursing progress note dated May 26, 2026, at 9:34 PM which noted the facility staff were alerted to the resident complaining of a swollen middle finger on the left hand. The note indicated upon assessment the finger was purple in color, swollen, and bruised. The note also indicated the resident had stated a family member took her out front outside the building and while opening the door her wheelchair had started to roll downhill and the resident tried to stop her wheelchair with her left hand and got her finger stuck and that is how it got swollen/bruised. The note further noted vital signs were obtained and medication was provided for pain management, and ice was offered for the middle finger, but the resident refused. The resident's medical provided was notified and verbally ordered and Xray. An order administration note dated May 27, 2026, at 7:17 AM noted the resident was administered hydrocodone-acetaminophen (pain reliever) for pain at a level of nine out of ten, for the left middle finger, bruising/swollen. Further review of Resident 4's clinical record revealed the following: A nursing note dated May 27, 2026, at 8:10 AM noted the resident's left third finger was assessed, and it is swollen and bruised. The note stated yesterday when doing wound rounding with the wound care provider the resident mentioned her toe was bleeding and stated she had bumped it and it was assessed and noted for wound care and being treated. Resident at that time did not mention her finger being injured. Will be ordering an Xray for the finger if it has not been ordered yet. A late entry provider note documented on May 30, 2026, for May 27, 2026, at 11:13 AM noted the resident was presenting with left middle finger swelling and bruising after her wheelchair rolled forward and her finger was caught on May 26, 2026. The provider noted that the resident reports pain at a level of nine out of ten with limited range of motion of the finger with no other complaints. The plan was noted as Xray of the left middle finger ordered to evaluate for fracture. Buddy tape applied to left index and middle fingers for stabilization PRN (as needed) pain management continued. Will follow up on imaging results and adjust plan accordingly. A nursing note May 28, 2026, at 1:41 AM noting left middle finger continues with swelling/bruising. A nursing note dated May 28, 2026, at 4:36 AM noted new orders from the doctor on rounds, ordered to buddy tape left pointer finger to middle finger, and Xray to be scheduled. A nursing note dated May 28, 2026, at 2:08 PM noted left index finger taped to left middle finger post injury, Xray scheduled. Review of physician orders for the resident revealed an order dated May 28, 2026 (two days after the injury was identified), for an Xray of the left hand, finger series re: left middle finger bruised and swollen. A nursing note dated June 9, 2026 (14 days after the first assessment of the resident's finger), at 1:10 PM which noted a left hand/finger Xray was ordered through Trident care with the claim number noted. A nursing note dated June 10, 2026, at 1:28 PM the noted the Xray was obtained on that shift. shift (15 days after the injury was identified). Review of an Xray report for Resident 4 dated with a service date of June 10, 2026, revealed an Xray was completed of the resident's left hand and fingers on that date. The results noted degenerative (gradual decline) changes to the resident's hand and fingers with no fracture or dislocation identified. In an interview with Resident 4 on July 23, 2026, at 1:31 PM the resident stated she got her finger stuck in the spoke of her wheelchair. The resident stated she still could not bend it all the way as she could her other fingers. Concurrent observation revealed the left middle finger did not bend as far as the other fingers on the hand but was free of swelling and bruising. The resident stated she had an Xray of the finger about three weeks after it happened, they taped it for little while, she stated. The resident stated she was not aware of the Xray results. The resident stated that the finger is still sore from the top knuckle to the tip of the finger. Resident 4 did not receive an Xray of the finger as noted to be completed beginning on May 26, 2026, until June 10, 2026, 15 days after the resident sustained the injury, and it was indicated an Xray would be ordered and completed. There was no evidence the Xray results were reviewed with the resident. The above information was reviewed with the NHA and Director of Nursing on July 23, 2026, at 4:00 PM. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observation and staff interviews, it was determined that the facility failed to ensure a safe and functional environment on two of two nursing units observed ([NAME] and University) and for one of five residents reviewed (Resident 1). Findings include: During an interview with Resident 1, on July 1, 2026, at 11:12 AM he stated that the faucet in his room was broken. Concurrent observation revealed that the hot water handle had been replaced with an alternate knob that seemed to be secured on the previous hardware. The alternate knob, which wiggled and flopped up and down when attempting to turn the water on and off, also did not function normally to turn water on and off, sometimes functioning and sometimes required spinning the handle around multiple times. Observation of the [NAME] unit shower room on July 1, 2026, at 11:27 AM revealed that the shower faucet handle was installed incorrectly, with hot water indicator supplying cold water, and the cold indicator supplying hot water. Concurrent interview with Employee 4, nurse aide, confirmed that the faucet handle was installed with the temperature indicators reversed. Observation of the University shower room on July 1, 2026, at 11:39 AM, revealed that there was no drain cover over the shower drain. Concurrent interview with Employee 1, nurse aide, confirmed there was no drain cover present. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on July 1, 2026, at 2:30 PM. 28 Pa. Code 201.18 (b) (3) Management.

Based on staff interview, it was determined the facility failed to employee a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. Findings include: In an interview with Employee 6, certified dietary manager, on May 6, 2026, at 12:17 PM, Employee 6 indicated they were only working at the facility one day a week over the past one to two months to help out until the facility obtained a new food and nutrition services director, and that they were employed by another facility owned by the same company. Interview with the Nursing Home Administrator on May 6, 2026, at 1:19 PM indicated the facility's registered dietitian was only employed on an as needed basis and the facility did not employe a full-time registered dietitian. The facility did not employee a full-time registered dietitian or a full-time qualified director of nutrition services. Cross Refer 805, 810, and 812 483.60(a)(1) Qualified Dietary StaffPreviously cited 2/20/26 28 Pa. Code 201.18(b)(1)(3) Management

Based on observation and staff interview, it was determined that the facility failed to maintain adequate housekeeping and maintenance services to ensure a clean, comfortable, orderly, and homelike environment on three of four nursing units, (Heirloom, [NAME] & University) and in an outdoor access area (breezeway) that leads to the central supply room. Findings Include:Observations of the Heirloom nursing unit main shower room on May 6, 2026, at 12:20 PM revealed that the bathroom has a strong, musty smelling odor. A dark, black substance was observed lining the white wall grout where the floor meets the wall under the shower head. The black buildup extended five feet from under the showerhead, to the corner, and three feet along the adjoining wall of the shower area, spreading into the grout of the floor tiles of the corner. Concurrent interview with Employee 3, nurse aide, revealed that the bathroom always had this odor, and the black substance had been present for a long time. Observation on May 6, 2026, at 12:35 PM of the outdoor breezeway that connects the main building to the laundry and central supply room revealed a drainage pipe on the ground measuring eight inches round with a metal cover that was broken in three pieces and resting inside the hole of the drain. Observation of the University nursing unit main shower room on May 6, 2026, at 11:51 AM revealed a bathtub located in the room. The white tub contained black dirt/debris throughout the interior of the tub. In a concurrent interview with Employee 4, nurse aide, Employee 4 indicated staff did not utilize the tub to bath residents but confirmed it was not in clean condition for resident use if they wished to do so. Continued observation of the University nursing unit main shower room revealed the following: A privacy curtain hanging in the shower room was stained and contained spots of a brown substance on the curtain. A plastic shower curtain on the shower stall was dirty and ripped/cracked in multiple places. The shower room was unkempt with pieces of equipment/bins staggered throughout the room, multiple bottles of shampoo, conditioner, creams, and used hairbrushes were scattered around unlabeled, on shelves, shower litter (bed for transport), and on stands and bins throughout the room. The toilet and flooring surrounding the toilet area was blackened and dirty. Multiple open cracks were observed in the seat cushion of a shower chair sitting beside the shower. Observation of the [NAME] nursing unit main shower room on May 6, 2026, at 11:56 AM revealed the shower stall was surrounded in a black substance covering the white grout where the flooring meets the wall. This extended in some areas up the wall and onto the flooring area. Further observation of the [NAME] unit main shower room revealed the following: A bathtub in the room contained a large yellow caution - wet floor sign, two disposable briefs, a stack of pink plastic basins, an electric razor, a piece of plastic piping, and an empty shampoo bottle in the interior of the tub. A toilet riser sitting directly on the floor unbagged under a bedside commode beside the bathtub. A small stand containing a used hairbrush covered in hair with shampoo and conditioner bottles unlabeled in the shower stall. Blackened floor tiles surrounding the toilet area and black buildup along the wall edges in the toilet/sink area. The exit doors to the hallway were significantly marred. A roof access door (piece of hard ceiling) located directly over the toilet was dirty and significantly marred. The above environment concerns related to the shower rooms and the outdoor breezeway were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on May 6, 2026, at 3:00 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 2/20/2026 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: An observation in the facility's main kitchen on May 6, 2026, at 12:17 PM revealed the following: A foot pedal garbage can was overflowing with trash to the point where the lid was completely held open vertically by empty food cans and trash. The flooring in the food delivery receiving area was covered in debris, dirt, and black marks. Employee 6, certified dietary manager, indicated the mess was from a delivery early in the day due to rain outside, although, much of the dirt/debris was collected up along the wall edges and dried throughout the flooring. The flooring in the dry storage area was significantly dirty upon observation with black dirt as well as debris including lids, wrappers, packs of crackers, and other debris throughout the flooring and under food storage shelving units. The flooring throughout was sticky to walk on. A commercial ice dispenser was observed in the dry storage room with dust/debris, and parts to the machine lying on top of it. The machine bin did not contain any ice. Employee 6 indicated she was not aware when the machine was last in use, or if it was under repair, and that the facility purchased ice from the store if needed. Multiple open wire rack shelving units were observed with various food items stored on them in the dry storage room. The lower shelves of the unit were observed with food stored on them six to eight inches from the floor. There was no solid barrier observed between the floor and the food items stored on the lower shelves to prevent the potential contamination from mop water splash or sweeping debris. The interior compartments of the steam table (areas of a steam table that holds water that is heated to maintain hot serving temperatures of pans of food that sit in the wells), observed as staff were removing pans of food upon completion of the lunch service line revealed the compartments were coated in thick brown buildup and multiple particles of food were floating in the water. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 6, 2026, at 3:00 PM. Cross Refer 801 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 2/20/26 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on staff and resident interviews, the facility failed to inform residents, in advance, of the care to be furnished for one of six residents reviewed (Resident 3).Findings include: Clinical record review for Resident 3 revealed a care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the focus, goal, and interventions) initiated on December 14, 2023, with a focus that they have impaired communication related to hearing loss. Resident 3 has an intervention to utilize a dry erase board for communication, initiated on December 30, 2023. During an interview with Resident 3 on May 6, 2026, at 12:45 PM, it was observed that even with a hearing aide in place, the resident had difficulty hearing the surveyor, and questions needed to be repeated slowly and loudly for the resident to understand fully. The resident stated they were very upset about what the DON (Director of Nursing) did to them. The resident stated that a few weeks ago, the DON told them that the staff would take them to the shower room (also a bathroom area) to use the bathroom. Resident 3 stated that they understood this to mean that they would be taken to the bathroom to use the toilet. Instead, the resident was placed in a shower chair with a bucket underneath them and wheeled to the shower room in a chair to try and have a bowel movement into the bucket. The resident stated that they protested this multiple times and stated they did not want to be in a chair with a bucket underneath them. The resident indicated that they did not understand what was going to happen, and the DON did not write anything down during their conversation. The resident also stated that they wanted to speak with the DON regarding this event, but that the DON never came to speak with them. Interview with Employee 1, nurse aide, on May 6, 2025, at 12:50PM, revealed that she was directed by the DON to transfer Resident 3 to the bathroom in the shower chair because the resident needed to have a bowel movement. Employee 1 stated that the resident usually gets transported in a trolly (a shower cart where the resident is laying down) when they have a shower, and that they usually use a bedpan when they need to have a bowel movement. Employee 1 stated that the resident was very upset when she realized what was happening. Employee 1 stated they informed the DON that the resident wished to speak with them. Interview with Employee 2, nurse aide, on May 6, 2026, at 12:57 PM, stated that the DON came down to the unit and stated that Resident 3 needed to have a bowel movement, and that she should be placed into the shower chair. Employee 2 stated that the when the resident was returned to her room, she was very angry and was yelling and crying. The above information was reviewed with the Nursing Home Administrator and the Director of nursing on May 6, 2026, at 3:00 PM. The DON indicated they recalled the event. 201.14.(a) Responsibility of licensee 201.18.(b)(1) Management

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to prepare food in a form to meet physician ordered diets for one of one resident reviewed (Resident 5).Findings include: Clinical record review for Resident 5 revealed an active physician's order dated November 5, 2025, to provide a pureed texture diet with nectar thick liquids. Observation of the lunch meal on May 6, 2026, at 12:40 PM revealed Resident 5's meal tray included an entree that presented as ground up meat, large pieces of sweet potatoes, and peas and diced carrots in their regular form, as well as a container of strawberry ice cream. Review of Resident 5's meal tray ticket on the tray confirmed the resident was to receive a puree texture diet with nectar thick consistency liquids. Employee 5, nurse aide, confirmed the meat was ground in texture as she observed on other resident trays with a ground consistency and not pureed, and the potatoes and peas and carrots were not pureed. Employee 5 also confirmed due to the resident being ordered nectar thick consistency liquids that the resident should not have received regular ice cream. The surveyor reviewed the above dietary concerns for Resident 5 during an interview with the Nursing Home Administrator and the Director of Nursing on May 6, 2026, at 3:00 PM. Cross Refer 801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide an assistive device for one of one resident reviewed (Resident 5).Findings Include: Review of Resident 5's care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the focus, goal, and interventions), revealed the resident required assistance with activities of daily living (ADLs - things such as eating, drinking, dressing, bathing, hygiene). A spouted sippy cup (adaptive feeding cup with a lid and spout to assist in drinking) and red foam built up handles on spoons were listed as an intervention to aid the resident in eating/drinking. Observation of Resident 5 on May 6, 2026, at 12:40 PM revealed the resident in bed with a lunch meal tray in front of her. There was no sippy cup observed for the resident's liquid which was served in a regular cup on the meal tray. Further review of Resident 5's meal ticket on the tray revealed the resident was also to receive the food in separate bowls and the entree (protein and sides) were all served on one plate. Concurrent interview with Employee 5, nurse aide, confirmed the resident did not receive the appropriate adaptive feeding cup or food served in separate bowls as indicated on the resident's plan of care and meal tray ticket. The above information regarding Resident 5 was reviewed with the Nursing Home Administrator and Director of Nursing on May 6, 2026, at 3:00 PM. Cross Refer 801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on staff interview, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian.Findings include: During an Interview with Employee 9, dietary aide, on February 17, 2026, at 9:25 AM, she revealed that the facility currently did not have a dietary supervisor or a certified dietary manager (CDM) employed. Interview with the Nursing Home Administrator on February 18, 2026, at 2:15 PM confirmed the facility did not employ a full-time registered dietitian or qualified director of food and nutrition services. Cross Refer 801 and 804 S483.60(a)(1) Qualified dietary staffPreviously cited 3/14/25 28 Pa. Code 201.18(b)(1)(3) Management

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of four nursing units (Nittany and University).Findings include: An observation in the facility's main kitchen on February 17, 2026, at 9:25 AM with Employee 9, dietary aide, revealed the following: The dishwasher room ceiling tiles above the clean dish line have yellow water damage and are buckled, broken, and hanging down revealing broken drywall beneath the ceiling tiles. A dirty vent in the same area is uncovered and dust and cobwebs are visible inside. The drain in the center of the dishwasher room has water pooling around it and white 2 half inch sized pieces of grout from the floor are in the water around the drain. The three-compartment sink has a continual drip of water from the handle of the hot water faucet. The knobs of the stove have large amounts of dust and debris collected behind and between the knobs. Both ovens are noted to have brown residue built up inside the glass doors and inside the ovens. Expired apple cider vinegar on the spice shelf was noted to have a best before date of August 5, 2025. The refrigerator was noted to have multiple containers of food dated February 16, 2026, that were leftovers from the previous day, however no cool down temperature logs were available. Employee 9 confirmed that there was no binder that contained any cool down log information in the kitchen. A storage shelving unit of clean kitchen equipment had a plastic cover on the shelf that was broken and left a two-inch exposed area in the middle of the bottom shelf. There is a half inch deep triangular shaped hole in the floor in front of the tray line caused by a broken floor tile. The refrigerator was noted to have four quarts of expired Lactaid milk, dated February 15, 2026. Observation of the nourishment room on Nittany unit revealed a zip lock bag filled with condiments including mayonnaise, ketchup, and mustard. There was no date on the bag to indicate when the bag was delivered or a best before date, and no items within the bag were noted with any expiration or best before dates. Employee 11, licensed practical nurse, confirmed that these items are delivered from dietary. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Chapter 8 of the 2018 International Plumbing Code, 802.3.1 Air gap, stipulates that the air gap between the indirect waste pipe and the flood level rim of the waste receptor shall not be less than twice the effective opening of the indirect waste pipe. Chapter 8 of the 2018 International Plumbing Code, 802.3.2 Air break, stipulates that an air break shall be provided between the indirect waste pipe and the trap seal of the waste receptor. Observation of the University nursing unit ice machine, with Employee 6 (licensed practical nurse), on February 18, 2026, at 10:56 AM revealed that the white drainage pipe from the back of the machine had no visible air gap between the indirect waste pipe and the floor drain. Employee 6 stated that this ice machine is the only ice supply for all residents on the second floor of the facility. The surveyor reviewed the above ice machine concerns during an interview with the Nursing Home Administrator and the Director of Nursing on February 18, 2026, at 2:00 PM. Cross Refer 801 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 3/14/25, 5/6/25, and 8/25/25 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on observation, and resident and staff interview, it was determined that the facility failed to serve food at palatable temperatures on three of four nursing units (Heirloom, University, and Nittany; Residents 3, 13, 17, 89, and 93). Findings: Review of the mealtime documentation provided by the facility revealed the Heirloom food carts are scheduled to arrive on the nursing unit at 12:00 PM. Observation of the Heirloom nursing unit meal cart revealed it was observed outside the kitchen on February 19, 2026, at 11:55 AM. Observation of the lunch meal service on February 19, 2026, on the Heirloom nursing unit revealed that food trays arrived on the meal cart at 12:29 PM. Staff immediately began passing the food trays until the last tray was passed at 12:42 PM. The surveyor began testing the food temperatures of Resident 3's tray at this time with the following results: Puree ham was cold at 90.4 degrees FahrenheitPuree mixed vegetables were cold at 92.2 degrees FahrenheitPuree mac and cheese was cold at 91.4 degrees FahrenheitContainer of sherbert was melted Interview with Resident 17 on February 18, 2026, at 8:53 AM revealed that her food is delivered cold. Observation of the lunch meal on the University nursing unit on February 18, 2026, at 12:15 PM revealed that food trays arrived via the meal cart. Staff immediately began passing the food trays, and the surveyor began testing the food temperature of Resident 17's tray on February 18, 2026, at 12:18 PM with Employee 6 (licensed practical nurse). The chicken served on Resident 17's meal tray was cold at 107.2 degrees Fahrenheit. The surveyor reviewed the above dietary concerns on the Heirloom and University nursing units in a meeting with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 2:04 PM. Interview with Resident 93 on February 17, 2026, at 3:00 PM revealed that her food is always cold. She said it happens every day at every meal. Observation of the lunch meal on February 20, 2026, on the Nittany unit revealed the lunch trays were delivered at 12:30 PM on the food carts. The staff immediately began passing the trays and the surveyor began testing the temperature of the food on Resident 93's food tray at 12:35 PM with Employee 12 (nursing aide). The ham served on Resident 93's meal tray was cold at 94.5 degrees Fahrenheit. The surveyor discussed the dietary concerns noted on Nittany unit related to Resident 93's tray with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 3:00 PM. During an interview with Employee 11, licensed practical nurse, on February 17, 2026, at 12:38 PM, they stated that the food often arrives cold. During an interview with Resident 13 on February 17, 2026, at 1:15 PM they stated that the food temperatures are not good. Interview with Resident 89 on February 17, 2026, at 2:05 PM revealed that food often comes cold and when she asks for a substitution, such as grilled cheese, it often comes cold or very hard and difficult to eat. The concerns regarding food temperatures for Residents 13 and 89 were discussed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Cross Refer 801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(a) Dietary services

Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain informed consent prior to the installation of bedrails for two of eight residents reviewed (Residents 8 and 11), and failed to assess all potential risks for entrapment for five of eight residents reviewed for bedrail use (Residents 4, 8, 9, 11, and 93). Findings include: The facility policy entitled, Bed Rail Procedure, last reviewed without changes on January 21, 2026, revealed that if a resident is appropriate for a bed rail, nursing and/or designee will complete a Bed Rail Education/Consent with the resident and/or responsible party. Note, consent must be completed prior to bed rail(s) being placed on the resident's bed. Nursing will place a request for bed rails in TELS (maintenance communication system). Maintenance will confirm that consent/education was completed before placing bed rails to the bed, will install bed rails as requested, will ensure that manufacturer's recommendations and specifications are followed for bed rails being placed, and will conduct quarterly inspection of all beds with bed rails as part of a regular maintenance program to identify areas of possible entrapment. Housekeeping will notify maintenance of the discharge or transfer of a resident to remove bed rails. Ambassadors are to look for empty beds with bed rails to request removal via TELS. The Maintenance Bed Rail Evaluation noted seven zones evaluated for entrapment risk; and noted to refer to facility policy. A diagram identified seven potential entrapment zone locations on a bed equipped with bed rails. Zone six was defined as between the end of the rail and the side of the head or foot board. The Dimensional Guidelines for Entrapment Zones noted specific measurements for zones one through five; however, had no measurements noted for zones six or seven. Observation of Resident 11's room on February 18, 2026, at 11:17 AM revealed that her bed was equipped with a headboard, footboard, and bilateral assist bed rail devices. Interview with Resident 11 on the date and time of the observation revealed that she recently moved rooms although she was unsure of the exact date or reason for the move. Clinical record review for Resident 11 revealed no documented assessment for the need for, consent for the use of, or entrapment risk assessment regarding the bed rails. Interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM revealed that staff who facilitated Resident 11's room change (on February 8, 2026) did not exchange Resident 11's bed; and allowed her to use the bed that was in the room she transferred to. Staff submitted a maintenance request to have enabler bars removed on February 11, 2026 (three days after Resident 11 moved to a new room), however, this was not done as of the time of the onsite survey. The facility failed to assess Resident 11 for the risk of entrapment from bed rails prior to her use of her bed, failed to review the risks and benefits of bed rails to obtain informed consent prior to her use of her bed, and failed to assess that her new bed's dimensions were appropriate for her size and weight. Observation of Resident 8's room on February 18, 2026, at 10:52 AM revealed him in his bed that was equipped with bed rail assist devices bilaterally at the head of his bed, a headboard, and a footboard. Clinical record review for Resident 8 revealed an active physician's order dated January 5, 2026, for bilateral enabler bars on his bed for bed positioning and bed mobility. A Bed Rails Informed Consent for Use was not dated; and did not include an acknowledgement or signature to attest that Resident 11 and/or his responsible party consented to the use of the devices. A Maintenance Bed Rail Evaluation dated January 5, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM confirmed that the facility had no signed consent for Resident 8's use of bed rails. Observation of Resident 4's room on February 18, 2026, at 11:10 AM revealed her to be in her bed that was equipped with bed rail assist devices bilaterally at the head of her bed, a headboard, and a footboard. Clinical record review for Resident 4 revealed an active physician order dated June 14, 2024, for bilateral enabler bars to aide with turning and repositioning. A Maintenance Bed Rail Evaluation dated January 5, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Observation of Resident 9's room on February 18, 2026, at 11:20 AM revealed her sitting in a chair beside her bed. Her bed was noted to be equipped with bedrail assist devices bilaterally. Concurrent interview with Resident 9 revealed that she utilized the bedrail assist devices to help her move in bed. Clinical record review for Resident 9 revealed an active physician's order dated February 11, 2026, for bilateral enabler bars to aid with turning and repositioning. A Maintenance Bed Rail Evaluation dated February 11, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Observation of Resident 93's room on February 17, 2026, at 3:12 PM revealed her in her bed with bedrail assist devices bilaterally. Concurrent interview with Resident 93 revealed that she used the bedrails to help move herself in bed. Clinical record review for Resident 93 revealed that there was no current physician's order for her bilateral bedrail assist devices until February 19, 2026, after the surveyor discussed Resident 93's bilateral assist devices with the facility during a meeting on February 18, 2026, at 2:45 PM. A Maintenance Bed Rail Evaluation for Resident 93 dated January 10, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Interview with Employee 10 (maintenance director) on February 20, 2026, at 11:26 AM confirmed that although he was documenting that zones six and seven posed no entrapment risk, he had no parameter or expectation of a measurement or finding that would meet a criterion to determine that there was no entrapment risk (e.g., a range of measurements or angle degrees) for zones six or seven. Employee 10 confirmed that neither zone had an established range or measurement within the facility policies or procedures. Employee 10 stated that he would expect no gaps (e.g., measurement of zero) when he assessed zone seven, however, he had no parameter for zone six. The surveyor reviewed the above concerns regarding the facility's policy and procedure for bed rail/assist bar assessments during an interview with the Nursing Home Administrator and the Director of Nursing on February 20, 2026, at 11:45 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 17 and 100).Findings include: The facility's medication error rate was eight percent based on 25 medication opportunities with two medication errors. Observation of a medication administration pass on February 18, 2026, at 12:36 PM revealed Employee 4 (licensed practical nurse) administer Carafate (anti-ulcer medication, adheres to the stomach lining to protect it from acids and enzymes) 1 gm (gram) to Resident 17. The packaging of the Carafate medication included instructions to administer the medication on an empty stomach. Resident 17 had her lunch tray in front of her on her overbed table and was beginning to eat her lunch at the time of the medication administration. Employee 4 stated, normally trays are not this early, as she administered the medication to Resident 17, to which Resident 17 responded, I didn't eat a lot. Interview with Employee 4 on February 18, 2026, at 12:54 PM verified that the labeling on the Carafate medication noted to give the medication on an empty stomach, however, Resident 17 was in the process of eating her lunch at the time she took the medication. The medication reference Drugs.com instructions regarding the administration of Carafate noted, The usual dosage for ulcer treatment is four times daily on an empty stomach (at least an hour before food and at bedtime). Continued observation of a medication administration pass on February 18, 2026, at 12:32 PM revealed Employee 4 administered Diclofenac Sodium external gel (a nonsteroidal anti-inflammatory topical medication, works by reducing substances in the body that cause pain and inflammation) to Resident 100's bilateral knees. Employee 4 dispensed a small dollop of the gel on her gloved fingers before massaging the gel over Resident 100's knees. Clinical record review for Resident 100 revealed an active physician's order for staff to apply four grams of Diclofenac Sodium external gel topically to Resident 100's bilateral knees three times a day, not to exceed 32 grams in 24 hours. The medication reference Drugs.com instructions regarding the administration of Diclofenac Sodium gel noted that this medicine comes with a dosing card. Be sure you know how to use it. Interview with Employee 4 on February 18, 2026, at 12:54 PM indicated that she was not aware of the process of utilizing a dosing card to measure the amount of Diclofenac Sodium gel for an accurate dose of four grams. Observation of the medication packing revealed a plastic dosing card that permitted the user to dispense different amounts for either a two-gram or a four-gram dose. Observation of the medication's box also included a diagram of the approximate length of gel used to administer a two-gram dose or a four-gram dose. The surveyor reviewed the above two medication error concerns during an interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide menu items as indicated for the dining room and two of four nursing units (Heirloom and Nittany, Residents 51 and 89).Findings include: In an interview with Resident 51 on February 17, 2026, at 1:05 PM they stated that they often do not receive what they are supposed to on their meal tray. Review of the menu for lunch on February 19, 2026, included maple glazed ham, macaroni and cheese, Prince [NAME] vegetable blend, wheat dinner roll, and rainbow sherbet. During an observation of the tray line service on February 19, 2026, at 11:40 AM the plating of the meals for the dining room and Heirloom unit were observed. No wheat dinner rolls or bread was plated with the meal. Observation on February 19, 2026, at 12:18 PM on the Nittany unit of Resident 89's tray revealed that no bread was present. Observation of lunch meal service on the Heirloom unit on February 19, 2026, from 12:29 to 12:58 PM revealed there were no dinner rolls, or bread present on any of the meal trays. Observation of the kitchen supply room on February 19, 2026, at 1:30 PM, revealed three and a half racks of sliced bread, one rack of bread buns, and one rack of hoagie buns. Concurrent interview with Employee 13, dietary aide, revealed that bread was not served with the lunch meal today. Employee 13 also stated that no dietary supervisor was present today, and the bread item was not seen when checking the menu for the day. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Cross Refer 801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of the facility's arbitration agreements and resident and staff interview, it was determined that the facility's arbitration agreements failed to ensure the selection of a neutral arbitrator for two of three residents reviewed with a signed arbitration agreement (Residents 93 and 118); and failed to include required regulatory language for one of three residents reviewed with a signed arbitration agreement (Resident 49).Findings include: Review of an Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 93 on December 13, 2023, revealed that the document stipulated that, The arbitration shall be conducted by the National Arbitration Forum (NAF). If the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties. The agreement afforded the facility the initial selection of the arbitrator (third-party decision-maker contracted to resolve a dispute). Review of an Arbitration Agreement signed by Resident 118's responsible party (daughter) on November 22, 2023, revealed that the document stipulated that, The arbitration shall be conducted by the National Arbitration Forum (NAF). If the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties. The agreement afforded the facility the initial selection of the arbitrator. Interview with Resident 49 on February 19, 2026, at 11:40 AM revealed that he did not remember signing an arbitration agreement. Review of Voluntary Arbitration Agreement, signed by Resident 49 on April 12, 2025, revealed that Resident 49 electronically initialed all paragraphs of the provided document, however, the document did not contain an acknowledgement to stipulate that Resident 49 understood the agreement. The document did not explicitly grant Resident 49 the right to rescind the agreement within 30 calendar days of signing it. The document did not explicitly inform Resident 49 of his right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation and resident and staff interview it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean, safe, and functional environment for three of four nursing units (University, Heirloom, and Nittany; Residents 7, 49, 53, 84, 109, and 121) and the facility's laundry department. Findings include: Observation of the University nursing unit nurses' station on February 18, 2026, from 9:05 AM to 9:15 AM revealed an intermittent audible sound that resonated from a wall-mounted call bell device. Interview with Employee 6 (licensed practical nurse) on the date and time of the observation confirmed that there were no resident room call bell lights visible on the University nursing unit hallways. There was no room number indicated on the screen of the wall-mounted call bell device. Employee 6 described the ongoing intermittent noise as, a phantom call bell. Employee 6 indicated that the malfunctioning device has been an issue for approximately a year, that maintenance staff were aware through the facility's system of reporting building maintenance needs, and that staff were told by the maintenance representative that, the wiring is old. Observation of the University nursing unit nurses' station on February 18, 2026, from 9:41 AM to 10:15 AM revealed the intermittent audible sound continued from the wall-mounted call bell device without a resident room identification. Observation of the University nursing unit nurses' station on February 19, 2026, at 12:09 PM revealed the intermittent audible sound continued from the wall-mounted call bell device without a resident room identification. Interview with Employee 6, on February 19, 2026, at 12:10 PM indicated that, it's that phantom one again. Interview with Employee 7 (nurse aide) on February 19, 2026, at 12:30 PM indicated that the audible signal (not indicative of a resident room call bell activation) signals throughout the night. The audible noise does not stop at any time. The surveyor reviewed the above concern regarding the continuous audible noise on the University nursing unit during an interview with the Director of Nursing and the Nursing Home Administrator on February 18, 2026, at 2:00 PM. Observation of Resident 7's room on the University nursing unit on February 18, 2026, at 10:30 AM revealed a gray floor fall mat on the left side of his bed with a large amount of various colored debris and spillage. Observation of Resident 7's room on February 19, 2026, at 12:15 PM revealed his floor fall mat continued to be soiled with various colored debris and spillage. The surveyor confirmed the observation with Employee 8 (registered nurse) on February 19, 2026, at 12:17 PM. Observation on February 17, 2026, at 12:16 PM of the hallway on the Nittany unit outside the main kitchen revealed the flooring to be in disrepair. A missing floor tile was observed adjacent to a carpeted area with two chairs and a table near the exterior exit. Further review reveals multiple tiles running the entire length of the hallway are raised and peeling away from the floor. A four-foot span of tiles are noted to be held down around the edges with duct tape and masking tape, which has peeled away in places and left behind an adhesive residue. Interview with Employee 11, licensed practical nurse, on February 17, 2026, at 12:38, revealed that the facility often runs out of washcloths and instead towels, which have been cut to the size of a washcloth, are utilized. Concurrent observation of the laundry room on the Nittany nursing unit revealed a stack of 25 washcloths, more than two thirds of which were noted to have fraying edged as though they were cut up towels. Observation of the facility laundry room on February 19 ,2026, at 1:02 PM with Employee 14 (laundry supervisor) revealed there was a stack of cut of towels in the area of clean linen to be folded. Employee 14 stated the staff frequently run out of washcloths and cut up towels to use as a washcloth. Observation of Resident 84's bathroom on February 17, 2026, at 12:19 PM revealed drywall damage to the right of the mirror. Two inches of brown drywall paper is visible on either side of a soap dispenser mount. Observation of Resident 109's bedroom on February 17, 2026, at 1:10 PM revealed a heating and cooling unit was installed inside the metal casing of the previous unit. There are sharp metal edges noted to be protruding from around this casing. The new unit was smaller than the previous unit, and there were four towels rolled up filling the gap inside the unit. Additionally, multiple towels were noted to be lying across the top of the old unit casing and along the windowsill above the unit. A cold draft could be felt when standing near the window. Concurrent observations of resident 109's bedroom revealed the bedside stand had a large area of peeling varnish to the front locking drawer, measuring four by six inches. Observation of Resident 49's bathroom on February 18, 2026, at 9:56 AM revealed drywall damage to the right of the mirror. The area behind the soap dispenser was noted with brown drywall paper on either side and the damage measured two and three inches wide to the right and left sides respectively. The right corner of the bathroom above the soap dispenser was noted to have an eight-inch squared area of repaired drywall with brown water spots around the corners of the repair. The corner below the repair is noted to have paint on wall that has bubbled. The paint damage at the ceiling is six inches across, gradually narrowing to one inch and extending down three feet of the wall. Concurrent observations of Resident 49's room revealed a heating and cooling unit was installed inside the metal casing of the previous unit. There are sharp metal edges noted to be protruding from around this casing. There are multiple towels lying across the windowsill above the heating and cooling unit and around the old metal casing. Concurrent interview with Resident 49 revealed the towels are there because of a draft. The above noted concerns related the Nittany unit and Residents 84, 49, and 109, were reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Observation of the Heirloom unit on February 17, 2026, at 12:49 PM revealed there was a large sticky spot on the floor in the hallway upon entering the unit from the facility's main dining room. Observations made on February 18, 2026, at 10:41 AM and February 19, 2026, at 12:26 PM revealed the same sticky spot remained in the hallway on the floor. Observation of the Heirloom unit on February 18, 2026, at 10:28 AM revealed Resident 53's wall was marred next to the doorframe, and the wallpaper was peeling off the wall. Observation of the Heirloom unit on February 18, 2026, at 10:28 AM revealed Resident 121's wall was marred next to the doorframe, and the wallpaper was peeling off the wall. The above noted concerns related to Heirloom unit and Residents 53 and 121 were reviewed with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 2:12 PM 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited 5/6/25 and 3/14/25 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to a resident prior to a facility-initiated room change for one of one resident reviewed for concerns related to resident choice (Resident 11).Findings include: Interview with Resident 11 on February 18, 2026, at 11:15 AM revealed that she, .got room moved and do not know why, staff just came in and started taking stuff out of closets and drawers and was moved that day. Resident 11 further stated, I'm not cattle, they could have talked to me about it. I speak English and understand what they say. Clinical record review for Resident 11 revealed census information that she did reside in the same room from November 18, 2024, to February 8, 2026, when she moved to her current room. Nursing documentation by the registered nurse dated February 8, 2026, at 12:17 PM noted, We spoke with resident about moving rooms and she agreed she is okay with moving rooms, I also called and left a message for her daughter so she would know we moved her room. Resident 11's clinical record contained no evidence that written documentation was given to Resident 11 and/or her responsible party of why the room move was required. The facility also could provide no documentation to evidence that Resident 11 was given the opportunity to see the new location or meet her new roommate. The surveyor reviewed the above concerns regarding Resident 11's room and roommate change during an interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM. The interview confirmed that there was no written documentation given to Resident 11 and/or her responsible party of why the room move was required. The facility also could provide no documentation to evidence that Resident 11 was given the opportunity to see the new location or meet her new roommate. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review, facility documentation review, and resident and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of two residents reviewed for personal funds concerns (Resident 12).Findings include: Interview with Resident 12 on February 18, 2026, at 9:23 AM revealed that the business office in the facility held money for him, that a cousin deposited a check in that account for him, but that he did not receive a statement or had knowledge of how much money was in the account. Clinical record review for Resident 12 revealed a Resident Personal Funds agreement dated November 7, 2022, that Resident 12 signed to elect to manage his own funds (declined to have the facility manage his funds). A Resident Fund Management Service (RFMS) Authorization and Agreement to Handle Resident Funds form signed by Resident 12 on November 8, 2022, declined an RFMS account. A Resident Personal Funds agreement dated November 5, 2024, signed by Resident 12, again documented his election to manage his own funds (declined to have the facility manage his funds). An RFMS Authorization and Agreement to Handle Resident Funds form signed by Resident 12 on November 5, 2024, again documented his declination to establish an RFMS account. An Authorization Agreement for pre-authorized payments signed by Resident 12 on January 22, 2025, permitted the facility to automatically withdraw a monthly amount not to exceed $2000.00 from his bank's checking account. Review of an RFMS statement dated from December 15, 2025, to February 17, 2026, indicated that Resident 12's monthly payments, care cost debits, interest payment, and a credit adjustment resulted in a $191.88 credit balance in the account. The surveyor requested the written authorization completed by Resident 12 to establish a personal fund during an interview with the Nursing Home Administrator and the Director of Nursing on February 18, 2026, at 2:00 PM. An interview with Employee 2 (business office manager), the Director of Nursing, and the Nursing Home Administrator, on February 20, 2026, at 11:45 AM confirmed that Resident 12 authorized the facility to withdraw his personal liability payment from his personal checking account monthly, however, there was no evidence that he provided written authorization to establish an RFMS account. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to establish clear end of life directives for one of six residents reviewed (Resident 13).Findings include: A review of Resident 13's clinical record revealed an active physician's order dated [DATE], that indicated the resident was a DNR (do not resuscitate, do not attempt CPR (cardiopulmonary resuscitation) when the person has no pulse and is not breathing) and stated, DNR (Do Not Resuscitate)-LIMITED: NO INTUBATION, use medical treatment, IVF, ABX Discussed with daughter, new POLST completed. Resident 13's POLST (Pennsylvania Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) dated on [DATE], was noted to be signed by the resident's daughter due to confusion at that time. Clinical record review for Resident 13 revealed a quarterly MDS (Minimum Data Set, an assessment completed at periodic intervals of time to assess resident care needs), dated [DATE], in which facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status, used to evaluate aspects of cognition such as attention, orientation, and memory recall) score of 15, the highest possible score, indicating a normal level of cognition. The resident was noted to have a previous POLST dated [DATE], signed by the resident which indicated a desire for CPR and full medical treatment. No evidence was found that the facility discussed the change of code status with Resident 13 to confirm the resident's wishes for the change in end-of-life care. This was confirmed with the Nursing Home Administrator and the Director of Nursing during a meeting on February 20, 2026, at 11:20 AM. Resident was unavailable for further interview due to a medical procedure. 483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Treatment; Formulate Adv DirPreviously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.29(a) Resident rights

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse by staff that resulted in bruises to the resident's left arm, and medications administered against the resident's will, for one of five residents reviewed resulting in actual harm (Resident 1) Findings include: Observation and interview with Resident 1 on October 7, 2025, at 11:30 AM revealed she was in bed in her room. The surveyor asked Resident 1 if something happened to her arm and she immediately told the surveyor to leave the room, not to worry about it, and to shut the door. Clinical record review for Resident 1 revealed a nursing progress note dated October 3, 2025, at 4:20 PM that indicated Resident 1's son reported to Employee 1, Licensed Practical Nurse (LPN), that Resident 1 had multiple bruises on her left arm. The note indicated that Employee 1 was able to observe the bruises on Resident 1's left arm but the resident would not allow her to measure them. The note indicated that there were three oddly shaped bruises noted on Resident 1's outer and inner left arm. Employee 1 asked Resident 1 what happened to her arm, she made an arm movement to her own arm as if to twist it. Employee 1 contacted the Nursing Home Administrator (NHA), Director of Nursing (DON), and Certified Registered Nurse Practitioner (CRNP) at this time regarding the bruises, and an investigation was initiated. Review of the facility's investigation into the bruises on Resident 1's left upper arm determined that the incident occurred on October 1, 2025, between 6:00 PM and 7:00 PM. Further review of the facility's investigation into the bruises on Resident 1's left upper arm revealed that she had multiple bruises on her left upper arm. The facility investigation notes dated October 3, 2025, indicated that Employee 2, registered nurse (RN), was interviewed by the NHA and DON by telephone on October 3, 2025. Employee 2 revealed that she went into administer medication to Resident 1, but the resident struck her hand and the medication (Ativan, a medication used to treat anxiety, 0.5 mgs two tablets) fell from her hand. She indicated the medications were found in Resident 1's bed. Employee 2 then indicated that Employee 3, nurse aide (NA), placed the pills in Resident 1's mouth. Employee 2 said that Employee 3 held the resident's legs down and was rubbing them to calm the resident down and Employee 4, NA, was holding the resident's left hand during the medication administration. She said that Resident 1 was wild during the medication administration and kept saying you are going to jail. Employee 2 also indicated that she directed Employee 3 to stop when she was being aggressive with Resident 1, but she did not respond to her direction. The facility investigation notes dated October 3, 2025, for Employee 4, NA, revealed that she was interviewed by the NHA and DON on October 3, 2025, in person. Employee 4 indicated that Employee 2 attempted to administer Resident 1's medication when the resident knocked them out of her hand. Employee 4 indicated that she witnessed Employee 3 put two Ativan in Resident 1's mouth and hold her mouth closed so the medication would dissolve. Employee 4 said that Resident 1 was initially very aggressive and yelled at Employee 3. Employee 4 said that Resident 1 told Employee 3, I will get you, you will get yours and then winked at Employee 4. Employee 4 also indicated that after Resident 1 calmed down Employee 3 asked her to assist with trimming the resident's nails. She said Employee 3 held Resident 1's wrist while she trimmed her nails. Employee 4 also said that she heard Employee 3 at the nurse's station verbalizing that she made Resident 1 take the pills and held her mouth shut. The facility investigation notes revealed that they interviewed Employee 5, NA, in person on October 3, 2025, and by telephone on October 5, 2025. Employee 5 indicated that Resident 1 struck her on the shoulder with a Swiffer broom. She indicated that Employee 3 entered the room after hearing the resident yelling. Employee 5 said that they were all looking for the Ativan tablets that Resident 1 hit out of Employee 2's hand. Employee 5 said the Ativan pills were found, one was in bed, and the other was on the floor. Employee 5 then said that she witnessed Employee 3, wrestle Resident 1 onto the bed, place the pills in the resident's mouth, and hold the resident's mouth closed until the pills dissolved. Employee 5 said that Resident 1 looked at Employee 3 and said that she would get hers and that she would get her. Employee 5 also indicated that she heard Employee 3 at the nurse's station saying, I made the resident take the pills because she scratched the shit out of me. The facility investigative notes revealed that they interviewed Employee 3 visa text messages on October 5, 2025, regarding the incident that occurred on October 1, 2025. Employee 3 indicated that she heard yelling twice. When she heard it the second time she went into the hallway and noted Employee 5 backing out of Resident 1's room with a Swiffer broom. She said Employee 5 claimed that Resident 1 hit her with the Swiffer. Employee 3 said that Resident 1 was holding her door closed and Employee 2 told Employee 3 that she needed her to get into the room because the resident knocked narcotics out of her hand, and she couldn't leave them in there on the floor. When Employee 3 entered the room Resident 1 was trying to hit her with a shoe. Employee 3 said she grabbed the shoe from Resident 1, and Resident 1 then clawed her face and chest. Employee 3 then indicated that she walked out of the room. Employee 3 said that she knew the pills were found on the floor and that Employee 2 had them, but she was not sure if they were administered. Employee 3 stated she did see Employee 2 go back into the room. Employee 3 also indicated that after the Resident 1 calmed down her and Employee 4 went in and cut her fingernails. Employee 3 said that she held Resident 1's upper hand and used her other hand to hold up her fingers so Employee 4 could cut the nails. Employee 3 denied hurting Resident 1 or grabbing her. Employee 3 indicated that she reported this event to Employee 6, RN. The facility investigative notes revealed that they interviewed Employee 6 on October 5, 2025, regarding the incident that occurred on October 1, 2025, with Resident 1. Employee 6 indicated that no one reported anything to her on October 1, 2025, regarding an incident with Resident 1. Employee 6 indicated that she had no information about the incident. A social service progress note dated September 18, 2025, at 1:00 PM revealed that an interdisciplinary meeting was held with the son in attendance via telephone. The note indicated that the son said she liked chips, sweets and soda, she was big into horseracing, playing cards, and loved animals. He also indicated that he was aware of her continuous behavior of refusing care and gave tips that could possibly work, including showing her the bandage and point to the area prior to a dressing change, use hand signals, talk loudly, allow her to read lips, and write on a board. He also said she was always non-compliant with medications. Review of Resident 1's current care plan revealed that Resident 1 has a history of and potential to exhibit the following behaviors, physical abuse towards staff, verbal abuse towards staff, refuses medications, vitals, x-rays and will refuses to eat initiated on September 17, 2025. The interventions that were suggest by the son at the meeting on September 18, 2025, were not present in the care plan for her behavior interventions. This was confirmed by the DON during an interview on October 7, 2025, at 12:30 PM. Further Interview with the DON on October 7, 2025, at 12:30 PM revealed that she was not made aware of the incident that occurred on October 1, 2025, until the bruises were found on October 3, 2025. She confirmed that the incident was not reported to her timely and in turn she did not report to the proper entities until October 7, 2025. She indicated that as soon as she found out on October 3, 2025, Employee 3 was immediately suspended related to the investigation and was then terminated on October 7, 2025, from her employment with the facility due to the facility substantiating her part in the physical abuse to Resident 1 by using excessive physical force by grabbing her arms and causing bruising, for administering medications to Resident 1 (which is outside of her scope of practice as a nurse aide), and holding her mouth shut until the medications dissolved. Interview with the DON and NHA at 2:30 PM on October 7, 2025, revealed that no disciplinary actions have been initiated on the other perpetrators (Employees 2, 4, and 5) yet and that they were still working their normal schedules. They also indicated that re-education on abuse of all staff was initiated this morning, October 7, 2025, but is not finished yet. The facility failed to implement timely measures related to all perpetrators after Resident 1's incident that occurred October 1, 2025. The facility failed to protect Resident 1's right to be free from physical abuse by staff resulting in bruises to her left upper arm and medication administration against her will. 483.12 Freedom from Abuse, Neglect and ExploitationPreviously cited 3/14/202528 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures28 Pa. Code 201.20(b)(d) Staff development28 Pa. Code 201.29 (a)(c) Resident rights28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on observation, clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm related to a fracture of her right leg on one of two residents reviewed for abuse/neglect (Resident 9). This deficiency is cited as past noncompliance Findings include: Observation and interview with Resident 9 on March 12, 2025, at 10:48 AM revealed the resident was in bed. She stated she was sore on both of her knees and had an injury in her thigh area from an incident with her wheelchair. Clinical record review for Resident 9 revealed a medical provider note dated January 21, 2025, at 9:49 PM that the resident was seen for an acute visit for right knee pain and the knee area was mildly swollen. An x-ray was ordered for the resident due to hitting her knee. There were no further details of any accident/injury. Review of x-ray results for Resident 9 dated January 23, 2025, revealed the resident was positive for a fracture of the right femur (thighbone). Review of a staff interview with Resident 9 dated January 23, 2025, revealed Resident 9 indicated Employee 18, licensed practical nurse, was pushing her in her wheelchair and her leg went under the wheelchair. She stated Employee 18 told her it would be okay. Resident 9 was transferred to the hospital on January 23, 2025, and was admitted for surgical intervention for the fracture. The facility investigation into Resident 9's injury revealed the resident was self-propelling to the dining room area on January 19, 2025, when Employee 18, licensed practical nurse, approached the resident from behind and began pushing her to the dining room and the resident's leg got caught under the wheelchair. Per Employee 18's statement of the incident dated January 23, 2025, Employee 18 indicated he was pushing the resident to lunch on January 19, 2025, when the resident's right foot fell to the ground (there were no leg rests to have caused her leg to fall to the ground) and went slightly back under the wheelchair, noting the resident yelped in pain. Employee 18 noted on the statement that he immediately stopped and carefully moved the resident to a comfortable position and indicated no injury, bruising, or swelling was noted. Employee 18 indicated on the statement the resident complained of pain of 4 on a scale of one to 10, and pain medication was administered. It was noted on the statement the resident ate lunch and did not mention any discomfort until shortly after the evening meal noting he made a follow up assessment and observed mild swelling, but no redness, bruising, or other signs of injury. There was no evidence Employee 18 reported the incident when it occurred on January 19, 2025, to any other staff. Per staff statements, the resident refused to get out of bed on January 20, 2025, due to pain, and did the same on January 21, 2025, when the medical provider was contacted. Resident 9 returned to the facility on [DATE]. Employee 18 pushed Resident 9 in the wheelchair on January 19, 2025, to the dining room without leg rests on the chair causing Resident 9's right foot to get caught under the wheelchair resulting in a fracture. Employee 18 did not report the incident or the resident's change in condition due to the incident until the investigation revealed Employee 18's involvement in the injury on January 23, 2025. Employee 18 was terminated from the facility on January 27, 2025. All staff education was completed January 24-29, 2025, on abuse/neglect, proper notification of a resident change in condition, and utilizing leg rests when a resident requires being pushed in a wheelchair. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on March 14, 2025, at 10:30 AM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined the facility failed to ensure acceptable parameters of nutrition status were maintained for four of 15 residents reviewed for nutrition concerns (Residents 49, 81, 105, and 108) and provide timely assessments and interventions from a qualified nutrition professional to promote acceptable parameters of nutrition status resulting in severe weight loss resulting in harm for one of 15 residents reviewed for nutrition concerns (Resident 81). Findings include: Review of facility policy entitled Nutrition Management, last reviewed on January 1, 2025, revealed the facility is to provide care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance guidelines of the policy indicate a systemic approach is used to optimize each resident's nutritional status including monitoring the effective ness of interventions and revising them as necessary. The policy states a nutritional assessment will be completed by a dietitian within 72 hours of admission , annually, and upon significant change in condition. Monitoring will occur to determine if current interventions are being implemented and effective, and the physician will be notified of any significant weight changes, intake changes, or changes in nutritional status. In an interview with Resident 81 on March 11, 2025, at 1:11 PM the resident stated he has lost weight since his admission to the facility and that he was down to about 180 pounds from 210 pounds. Clinical record review for Resident 81 revealed the resident was admitted to the facility on [DATE]. The resident's weight upon admission was 210 pounds. Review of a nutrition assessment completed by a registered dietitian dated December 29, 2024, greater than 72 hours after the resident's admission, indicated the resident was receiving a mechanical soft diet due to difficulty chewing. It was noted the resident had increased needs due to alcohol abuse and that the resident was asking for shakes as he had been trying to eat better at home with the support of his family. Resident 81 reported he was drinking two to three shakes a day to get better. The dietitian noted the resident's appetite and intakes were good and the resident is above an ideal body weight, although it was noted the resident had indicators of mild protein calorie malnutrition. The dietitian indicated one shake would be added to the resident's lunch meal and noted the resident was identified at nutritional risk. A review of Resident 81's physician orders revealed the resident was ordered a four-ounce shake on December 29, 2024. A review of Resident 81's plan of care revealed a nutrition care plan was added on December 29, 2024, that indicated the resident was at risk for alteration in nutrition and/or hydration status and interventions included monitoring weight on admission, per facility policy, every month and as needed, to notify the physician of any significant weight change, and to monitor acceptance, effectiveness, and ongoing needs. There were no new interventions added since December 29, 2024. Resident 81's weight on January 6, 2025, 13 days after his admission, was 200.6 pounds indicating a 9.4-pound (4.4 percent) weight loss in just under two weeks. There was no evidence the dietitian addressed the weight loss. Resident 81 was weighed again on January 13, 2025, at 198.8 pounds reflecting another 1.8-pound loss and a total of 11.2 pounds since admission, now a significant weight loss at 5.3 percent. There was no evidence the resident was reassessed by the dietitian. The resident then was documented as weighing 189.2 on January 20, 2025, a further decline of 9.6 pounds in a week, and now a 20.8 pound loss since admission, which was a 9.9 percent severe weight loss in less than a month. There was no evidence the resident was reassessed by the dietitian. Resident 81 was weighed again on January 28, 2025, remaining at 189 pounds On February 3, 2025, Resident 81 weighed 180 pounds, reflecting a 30-pound weight loss since admission, which was a 14 percent severe weight loss. There was no evidence that Resident 81 was weighed after February 3, 2025, no evidence of the resident refusing to be weighed, and no further assessments by the dietitian despite the severe weight loss and minimal food intakes. Review of Resident 81's meal intake records for December 2024, January, February, and March 2025, revealed the resident ate well for two meals on the day of admission December 24, 2024, and one meal on December 25, 2024. All other meals for the remainder of the month were only documented as intakes of zero to 50 percent, with an occasional meal that was greater. Review of Resident 81's medication administration record (where staff document acceptance of nutrition supplements) revealed the resident was receptive and accepting the nutritional shake that was ordered on December 24, 2024, one time a day. There was no evidence the resident was offered or had the shakes increased as he had indicated he was drinking two to three a day at home prior to admission. As of March 13, 2025, there was no evidence Resident 81 was seen or further assessed by the dietitian since the resident presented with significant and severe weight loss from week to week from December 24, 2024, to February 3, 2025. There was no evidence Resident 81's physician was aware of the resident's significant weight changes as noted above. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on March 14, 2025, at 9:30 AM and a current weight was requested if Resident 81 would allow. Resident 81's current weight was 178.4 pounds, an additional 1.6-pound loss since the last weight on February 3, 2025, for a total loss of 31.6 pounds (15 percent severe weight loss) since admission on December 24, 2024. At 10:35 AM on March 14, 2025, the Nursing Home Administrator confirmed there was no evidence the dietitian had reviewed or assessed Resident 81 since the initial nutrition assessment was completed on December 29, 2024, or that the resident's medical provider was made aware of the resident's significant weight changes. Clinical record review for Resident 49 revealed the resident experienced a weight loss from September 2, 2024, to October 1, 2024, from 121 pounds to 118.6 pounds. The resident was weighed again on November 1, 2024, at a weight of 107.8 pounds, a significant loss of 10.8 pounds (9.1 percent) in one month, and a severe 13.2-pound (10.9 percent) loss over the prior two months. There was no evidence Resident 49's severe weight loss on November 1, 2024, was addressed by a nutrition professional until February 14, 2025, three months later. There was no evidence Resident 49 had been seen by a nutrition professional since August 2024. There was no evidence Resident 49's provider or responsible party was made aware of Resident 49's significant change in nutrition status in November 2024. Clinical record review for Resident 105 revealed the resident experienced a severe weight loss from October 1, 2024, of 173 pounds to November 1, 2024, weighing 146 pounds, a loss of 26.7 pounds (15.4 percent). A re-weight was completed on November 28, 2024, of 144.2 pounds, a 2.2-pound additional loss. There was no evidence Resident 105 was assessed by the dietitian after the severe weight loss was identified on November 1, 2024, until November 26, 2024. Review of a dietary progress note date November 26, 2024, at 2:11 PM for Resident 105 revealed the dietitian assessed the resident as eating well and weight loss at the rate indicated would not be likely and noted in addition to a nutrition supplement being added to the resident's meals, the resident would be placed on weekly weight monitoring. Further review of Resident 105's weights after the resident was seen by the dietitian on November 26, 2024, revealed the resident was weighed on December 1, 2024, at 130.8 pounds, a further loss of 13.8 pounds from November 18, 2024, and no weekly weights were documented as completed between December 1, and the next weight on December 20, 2024, which did indicate a slight increase. There was no evidence Resident 105 was followed by the dietitian after the November 26, 2024, visit until December 27, 2024. Clinical record review for Resident 108 revealed the resident was documented at a weight of 140 pounds on October 2, 2024. The resident's next weight on November 1, 2024, was 126.8 pounds, a severe weight loss of 13.2 pounds (9.4 percent). A re-weight was not completed until November 18, 2024, at 127.2 pounds. There was no evidence Resident 108's severe weight loss indicated on November 1, 2024, was addressed by a registered dietitian or medical provider until November 26, 2024. Review of a dietary progress note dated November 26, 2024, at 3:36 PM for Resident 108, indicated the resident had been experiencing trending weight loss since June of 2024, and had not been on any nutritional support. The dietitian noted the resident presented with signs of moderate protein calorie malnutrition and was unable to identify factors of weight loss other than the resident's dementia. It was noted the resident would be started on nutrition supplementation of a fortified pudding three meals a day, a nutrition supplement at evening medication pass, and add the resident to the weekly weight list. There was no evidenced Resident 108 received any weekly weights for monitoring as recommended on November 26, 2024, the next weight was documented on December 1, 2024, and then December 23, 2024. Resident 108 did stabilize in weight although there was no further dietary assessment for Resident 108 until January 9, 2025. There was no evidence Resident 108's physician or responsible party was notified of Resident 108's significant change in weight that occurred on November 1, 2024. The above information regarding Residents 49, 105, and 108, was reviewed with the Nursing Home Administrator and Director of Nursing on March 13, 2025, at 10:30 AM. Cross Refer F801 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, staff interviews and select facility policies, it was determined that the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) for one of one residents reviewed who had requested that CPR be administered if they became unresponsive with no pulse resulting in the resident's death (Resident CR8). Findings include: Review of the facility policy entitled, Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure that is administered when breathing or a heartbeat has stopped) last reviewed without changes in (MONTH) 2019, revealed if a resident experienced a [MEDICAL CONDITION] (an abrupt loss of heart function) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services and in accordance with the resident's advance directives. Closed Clinical record review for Resident CR8 revealed a nursing progress note dated (MONTH) 24, 2019, at 4:52 PM stating that Resident CR8 needed time to think about her code status because she is a fighter. A nursing progress note dated (MONTH) 26, 2019, at 7:57 AM revealed that Resident CR 8 wanted to be a full code (interventions initiated to restore breathing or heart functioning) and stated, I want CPR, I want to get better. Review of Resident CR8's physician orders for the month of (MONTH) 2019, revealed an order dated (MONTH) 26, 2019, for Resident CR8 to be a full code. Review of the nurse aide task documentation revealed that Resident CR8 was found incontinent of urine at 10:53 AM on (MONTH) 27, 2019, and changed. Further nurse aide task documentation review revealed that Resident CR8 refused her lunch on (MONTH) 27, 2019. A nursing progress note dated (MONTH) 27, 2019, at 12:52 PM revealed that Resident CR8 was lying in bed comfortable with no signs or symptoms of pain. A nursing progress note dated (MONTH) 27, 2019, at 1:35 PM revealed that a nurse aide called Employee 2, Registered Nurse (RN), to Resident CR8's room because she stopped breathing. The note indicated Resident CR8 was in bed ashen in color, cold to touch, no apical pulse, and no spontaneous respirations. There was no evidence in the clinical record that Employee 2 verified Resident CR8's code status, initiated CPR, or activated emergency medical services. A nursing progress note dated (MONTH) 27, 2019, at 4:18 PM revealed that a call was placed to Resident CR8's doctor to make him aware that Resident CR8 ceased to breathe and an order was received to release the body to the funeral home. Interview with the Assistant Director of Nursing on (MONTH) 13, 2019, at 1:30 PM confirmed that Employee 2 did not verify Resident CR8's code status, initiate CPR, or activate emergency medical services. Employee 1 indicated that Employee 2 did not initiate CPR because she felt Resident CR8 had clear signs of death, despite not documenting any clear sign of death. Interview with the Nursing Home Administrator and Staff Educator, Employee 3, RN, on (MONTH) 13, 2019, at 2:30 PM revealed that Employee 2 was not currently CPR certified but Employee 4, Licensed Practical Nurse, was CPR certified and was on duty and available on (MONTH) 27, 2019. Further clinical record review revealed no documentation in the clinical record that Resident CR8 had irreversible signs of death (Rigor mortis- stiffening of the body, lividity- pooling of blood to an area that is in contact with a hard surface or the lowest points of the body, or decapitation- separation of the head from the body, transection, or decomposition). The facility failed to initiate CPR in accordance with Resident CR8's wishes and professional standards of nursing to a resident who had requested CPR and had a physician's order for CPR, when finding the resident unresponsive, without a pulse or breathing, and without clear irreversible signs of death, causing actual harm to Resident CR8. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(e)(3) Management Previously cited [DATE] 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE]

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent resident accidents for one of 12 residents reviewed for falls (Resident 57); and failed to implement interventions to prevent an accident with serious injury for one of 12 residents who sustained a [MEDICAL CONDITION] (Resident 85). Findings include: The facility policy entitled, Fall Prevention Policy, last reviewed without changes on (MONTH) 7, (YEAR), revealed that the purpose of the policy included to identify residents at risk for falls and to identify resident-specific fall prevention interventions for those at risk residents. Following the initial assessment, the Fall Risk Evaluation is completed quarterly and annually by the Registered Nurse supervisor or designee. Each time a resident falls, the current interventions are reviewed with the completion of the incident report. Interventions are revised as indicated following each event. Appropriate preventative measures will be initiated and documented in the care plan. Observation of Resident 85 on (MONTH) 26, 2019, at 9:29 AM revealed her to ambulate with a walker while wearing non-skid socks. Clinical record review for Resident 85 revealed a Fall Risk Evaluation dated (MONTH) 19, (YEAR), that assessed her as moderate risk for falls (score of eight). Factors identified during staff analysis of Resident 85's gait included, Wears poorly fitting shoes. Resident 85's clinical record did not contain evidence that staff implemented measures to correct the identified risk factor that Resident 85 wore poorly fitting shoes (e.g. contacting the responsible party, obtaining a therapy evaluation to determine the appropriateness of shoes, eliminating Resident 85's access to poorly fitting shoes, etc.). A plan of care developed by the facility to address a high risk for falls by Resident 85 (initiated (MONTH) 28, (YEAR)) instructed staff to ensure proper footwear when out of bed since (MONTH) 28, (YEAR). The same plan of care instructed staff to ensure Resident 85 wore non-skid socks at all times since (MONTH) 28, (YEAR). Nursing documentation dated (MONTH) 22, (YEAR), at 10:20 AM revealed that staff noted Resident 85 on the floor at the end of the hall. Resident 85 stated that she hit her head although staff noted no signs or symptoms of head trauma. Resident 85 complained of left hip pain with limited range-of-motion of the left lower extremity. Staff identified that Resident 85's left lower extremity was slightly rotated outward. Resident 85 would not bear weight on the left lower extremity. Nursing documentation dated (MONTH) 22, (YEAR), at 10:42 AM regarding Resident 85's unwitnessed fall, indicated that Resident 85 stated, I was at the door and I went to turn around and these damn shoes slipped out from under me. Get rid of them. Physician documentation dated (MONTH) 22, (YEAR), at 2:57 PM indicated that an x-ray of Resident 85's (left) hip showed a [MEDICAL CONDITION]; and that Resident 85 needed to go to the emergency room . Nursing documentation dated (MONTH) 22, (YEAR), at 9:14 PM indicated that staff received a telephone call from the emergency room that the hospital admitted Resident 85 with the [DIAGNOSES REDACTED]. Review of the facility's investigation of Resident 85's fall on (MONTH) 22, (YEAR), at 10:00 AM revealed that predisposing environmental factors pertinent to the fall included that Resident 85 did not have non-skid socks in place as per her plan of care. Resident 85 wore rubber-soled shoes at the time of the incident. A witness statement by the Licensed Practical Nurse reiterated that Resident 85, Wears poorly fitting shoes. The Post Fall Investigation noted the one action taken to prevent further incidents/injuries of this kind was, Better fitting shoes. Notes entered by the interdisciplinary team dated (MONTH) 24, (YEAR), indicated that the facility would have physical therapy evaluate Resident 85 for the appropriateness of shoes. Interview with the Director of Nursing on (MONTH) 28, 2019, at 1:04 PM and interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 28, 2019, at 2:00 PM confirmed that the facility identified that Resident 85 had poorly fitting shoes during the assessment in (MONTH) (YEAR). The interview indicated that the facility attributed Resident 85's changing levels of [MEDICAL CONDITION] (swelling) as complicating her shoe use; however, the facility was unable to provide what interventions staff utilized to ensure Resident 85 wore appropriate footwear as her condition changed (e.g. non-skid socks only when presented with minimal [MEDICAL CONDITION]). The interview confirmed that the facility allowed Resident 85 to continue to use the poorly fitting shoes. The interview confirmed that Resident 85 has a [DIAGNOSES REDACTED].g. nursing documentation dated (MONTH) 17, (YEAR), at 12:07 AM, noted Resident 85 was exit-seeking; insisting that her brother and husband were coming to open the doors and windows for her). A quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated (MONTH) 21, (YEAR), assessed Resident 85 as severely cognitively impaired (score of seven), and she is widowed. The interview confirmed that the facility had no evidence that staff contacted the resident's responsible party regarding removing all shoes from her room to ensure that she only utilized the non-skid socks while ambulating on the unit. The facility allowed Resident 85 to utilize her shoes that were identified as poorly fitting, which contributed to her fall and resulting [MEDICAL CONDITION] on (MONTH) 22, (YEAR). Observation of Resident 57 on (MONTH) 26, 2019, at 8:30 AM revealed a healing laceration to his forehead covered by several steri-strips (thin strips of adhesive bandage used to pull and keep the edges of a wound together). Nursing documentation dated (MONTH) 6, 2019, at 2:38 PM revealed that staff found Resident 57 sitting on his buttocks in his room on the floor. Review of the facility's investigation of Resident 57's fall on (MONTH) 6, 2019, revealed notes added (MONTH) 8, 2019, indicating that the facility would attempt a perimeter defined mattress (device used to raise the edges of a mattress in an effort to prevent inadvertent rolling out of bed). Review of Resident 57's plan of care developed by the facility to address his moderate risk for falls revealed that staff did not initiate the intervention of the perimeter overlay to Resident 57's mattress until (MONTH) 25, 2019 (almost three weeks after his fall on (MONTH) 6, 2019; and after his repeated fall on (MONTH) 23, 2019). Registered Nursing documentation entered as a late entry on (MONTH) 24, 2019, at 7:58 AM, for (MONTH) 23, 2019, at 7:25 AM, revealed that a housekeeper alerted the nurse that Resident 57 was on the floor in his room. Staff found Resident 57 lying face down on the floor beside his bed, with a large amount of blood noted on the floor, Resident 57's face, and Resident 57's chest, that resulted from a mid-[MEDICAL CONDITION]. Staff also noted several scratches to Resident 57's nose and a small open area above his right eye. Staff documented the assessment of a hematoma (localized raised area of swelling) in the center of Resident 57's forehead that measured 4.0 cm (centimeters) by 3.0 cm with a 2.7 cm by 0.3 cm laceration in the center of the hematoma. Staff also documented that Resident 57 presented with an abrasion to his right scapula (back shoulder blade) that measured 8 cm by 3 cm approximately. Licensed Practical Nurse documentation dated (MONTH) 23, 2019, at 3:26 PM reiterated that staff found Resident 57 face-down on the floor beside his bed with, .an extra large pool of blood under his face. Resident was covered in blood from his head to his mid chest, with, .a gash noted to the middle of his forehead with a hematoma. This writer assessed the area above Resident 57's right eye as measuring 1.5 cm by 1.0 cm. The writer indicated that staff applied steri-strips to the area on Resident 57's forehead. Review of the facility's investigation of Resident 57's fall on (MONTH) 23, 2019, at 7:25 AM indicated that at the time of the incident, Resident 57 was lying in bed. The Post Fall Investigation listed the type of bed used by Resident 57 as pressure reducing. Staff did not identify either perimeter or perimeter overlay in the description of Resident 57's bed. Staff documented current interventions listed as already in place at the time of the fall as: Proper footwear, hipsters (device worn to pad both hips for protection in the event of a fall), bed in low position, clutter free, and lock wheelchair and bed. Staff did not include any perimeter-defining device to Resident 57's mattress. Interdisciplinary notes added (MONTH) 27, 2019, were the first indication that Resident 57 used a perimeter defined mattress. Review of Resident 57's Task History (information in the electronic medical record alerting staff of resident care needs) confirmed that the facility did not add the perimeter overlay intervention to Resident 57's pressure relieving mattress surface until (MONTH) 25, 2019. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 1, 2019, at 10:30 AM confirmed the above findings for Resident 57. 28 Pa. Code 211.11(d) Resident care plan Previously cited 3/2/18, 10/27/17 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 10/3/18, 3/2/18, 1/11/18, 10/27/17 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 3/2/18, 4/24/18, 10/27/17 28 Pa. Code 211.12 (d)(5) Nursing services Previously cited 10/3/18, 4/24/18, 3/2/18, 1/11/18, 10/27/17

Based on review of select policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to prevent skin breakdown resulting in harm for one of 24 residents reviewed (Resident CR3). Findings include: The policy entitled, Pressure Ulcer Prevention and Management Programs Overview and Program Components, last reviewed by the facility without changes on April 28, 2017, revealed that the facility is committed to providing a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers do not develop them unless the individual's clinical condition demonstrates they are unavoidable. Closed clinical record review for Resident CR3 revealed that the facility admitted him on September 1, 2017. The admission nursing assessment indicated there were no skin issues. Review of Resident CR3 physician's orders [REDACTED]. Review of the Braden Scale (a tool used to predict pressure ulcer risk) dated September 2, 2017, revealed that Resident CR3 was at low risk for developing a pressure sore. Review of Resident CR3's plan of care developed on September 3, 2017, indicated that he was at risk for alteration in skin integrity related to fragile skin. One of the interventions to be initiated on September 3, 2017, indicated that staff were to pad the tubing around his ears and check for skin breakdown around his ears and nasal passages when providing care. Nursing documentation dated September 14, 2017, revealed staff requested that the registered nurse come to Resident CR3's room to visualize a wound behind his left ear. It was noted that he had a pressure ulcer. The wound bed had slough (dead tissue) that was yellow and pink. There was thick yellow drainage noted from the wound. Oxy ears (padding) were applied to the right side. Review of the Pressure Ulcer Evaluation, dated September 14, 2017, described the pressure ulcer as a facility acquired Stage III (extends through the second layer of skin) measuring 2.3 cm (centimeters) long, 0.5 cm wide, and 0.5 cm deep behind the left ear. Resident CR3 did not present with any [DIAGNOSES REDACTED]. According to Resident CR3's admission progress notes dated September 1, 2017, he had multiple issues with his lungs and breathing, including Chronic Obstructive [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION], an inflammation of the lungs that obstructs airflow) and a history of [MEDICAL CONDITION] Embolism (PE, a blood clot that occurs in the lungs). He also had mood disorder diagnoses, including Anxiety (persistent worry and/or fear) and Depression (persistent feeling of sadness). Resident CR3 was also diagnosed with [REDACTED]. An interview with the Director of Nursing on October 27, 2017, at 1:30 PM confirmed the above information. There was no further documentation indicating that staff had completed skin checks when providing care. The resident was discharged to the hospital on September 16, 2017, and failed to return to the facility. 28 Pa. Code 211.10(c) Resident care policies Previously cited 9/23/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 9/23/16 and 12/13/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 9/23/16, 12/13/16, and 6/16/17

Based on review of select facility policies, clinical record review, and staff interviews, it was determined that the facility failed to prevent neglect that resulted in actual harm of a [MEDICAL CONDITION] lower leg for one of seven residents reviewed (Resident CR1). Findings include: The facility policy entitled, Resident Abuse and Neglect, last reviewed without changes on August 2016, revealed that abuse, neglect or misappropriation of resident property will not be tolerated. The facility will take all reasonable measures to ensure that residents are not subjected to abuse by anyone, including facility staff, other residents, consultants, volunteers, staff of other agencies, contractors, family members or legal guardians, friends, visitors, or any other individual. All management and staff are jointly and individually responsible to ensure each resident is free from abuse, neglect, and misappropriation of property. The facility has a plan in place to assure appropriate steps are taken to protect each resident from mistreatment, neglect, abuse, and misappropriation of property. The facility admitted Resident 74 on December 3, 2013, with a [DIAGNOSES REDACTED]. Review of Resident 74's Quarterly Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated May 12, 2017, indicated the resident required extensive assist of one with locomotion on the unit and that her memory was impaired. The clinical record review for Resident 74 revealed a progress note dated June 7, 2017, at 7:45 AM that indicated Employee 1, Nurse Aide, was pushing Resident 74 from the shower room to the hallway telling her to keep her feet up. Resident 74 dropped her feet and her left foot was pulled under the wheelchair. Resident 74 stated that she had pain in the left knee. The Nurse Practitioner's progress note dated June 7, 2017, at 1:35 PM revealed that X-rays of the left knee would be obtained. Review of the radiology report dated June 7, 2017, revealed that Resident 74 had [MEDICAL CONDITION] of the left knee. The Nurse Practitioner's progress note dated June 8, 2017, at 3:03 PM indicated that she would order an X-ray of the left lower leg due to increased ecchymosis (bruising), [MEDICAL CONDITION] (swelling), and redness. Review of the radiology report from June 8, 2017, revealed that Resident 74 had a [MEDICAL CONDITION] tibia anteriorly (the bone in front of the lower part of the leg, referred to as the shin bone, the end near the foot). The clinical record review of Resident 74's Profile History Report (a report indicating care needs of the resident), revealed an undated entry for a left leg rest on the wheelchair at all times when in the wheelchair. Interview with the Director of Nursing on June 16, 2017, at 1:10 PM revealed that this entry on Resident 74's Profile History Report was not present prior to Resident 74's fracture. Review of the facility's investigation into the fracture revealed a statement from Employee 1, signed and dated on June 7, 2017, at 6:30 AM that revealed she had been assigned to Resident 74 for a few weeks. Employee 1 confirmed that she transported Resident 74 from the shower room to the hallway without her leg rest. Employee 1 indicated that she forgot to put Resident 74's leg rest on her wheelchair. Interview with the Nursing Home Administrator and the Director of Nursing on June 16, 2017, at 1:10 PM confirmed that Employee 1 should have had the left leg rest on Resident 74's wheelchair. The facility failed to provide the necessary care and services to prevent neglect of Resident 74 resulting in actual harm. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/13/16, 9/23/16, 3/29/16, 10/30/15 28 Pa. Code 201.18(b)(2) Management Previously cited 9/23/16, 10/30/15 28 Pa. Code 201.18(e)(1) Management Previously cited 9/23/16, 3/29/16, 10/30/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 9/23/16, 3/29/16, 2/19/16, 10/30/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 12/13/16, 9/23/16, 3/29/16, 3/3/16, 2/19/16, 10/30/15

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and provide interventions to prevent falls with injury for four of 24 residents reviewed (Residents 57, 98, 99, and 102). Findings include: The facility policy entitled, Incidents/Accidents, Investigative Reports, last reviewed on April 14, 2016, revealed that it is the policy of the facility to investigate incidents/accidents in order to determine possible causative factors and implement interventions that may prevent a reoccurrence of the same or similar event. The charge nurse will complete an investigative report appropriate to the type of incident/accident following each incident/accident. The charge nurse will initiate the implementation of appropriate interventions to prevent a reoccurrence of the same or similar event as soon as possible. Nursing staff will update the resident's care plan with new or revised interventions/approaches. The facility policy entitled, Incident Report, Investigative Procedure, last reviewed on April 14, 2016, revealed that the facility would identify possible causes such as staff action (e.g. lack of supervision or improper procedure) or equipment failure (e.g. defective, improper use, not available, etc.) to prevent recurrence. The facility will interview any involved persons including witnesses, visitors, family members, employees, and residents, as soon as possible and obtain signed and dated witness statements. The Nursing Home Administrator or designee will determine if the resident incident must be reported per the state or federal regulations; and will then notify the appropriate agencies. Nursing documentation dated July 29, 2016, at 11:13 AM revealed that Resident 57 had a fall while transferring with the staff assist of one. Resident 57 was noted to have a hematoma (bruise) to her right shin measuring 8.5 cm (centimeters) by 7.25 cm, a skin tear on top of her right shin measuring 1.5 cm by 1.5 cm, a skin tear to her right knee measuring 2.5 cm by 4.0 cm, and a skin tear to her left shin measuring 3.5 cm by 2 cm. The note revealed that the intervention was to educate the staff and that Resident 57 would be contact guard (close contact with transfers) at all times during ambulation and transfers. Review of the facility's investigation dated July 29, 2016, revealed that Resident 57 was transferring from her bed to wheelchair with the assistance of one nurse aide. The employee statement from the nurse aide present when the fall occurred revealed that during the transfer, Resident 57's walker slipped out from under her. There was no evidence that the facility investigated that the walker slipped out from under Resident 57 while transferring with the nurse aide or that the facility educated the nurse aide. Interview with the Director of Nursing on September 23, 2016, at 10:15 AM confirmed that the facility failed to investigate thoroughly to determine the cause of Resident 57's fall and to implement appropriate interventions to prevent further falls. Nursing documentation dated June 14, 2016, at 5:55 AM indicated that the Licensed Practical Nurse (LPN) was supervising Resident 98 on a one on one basis because only she and one nurse aide staffed the nursing unit. The LPN indicated that the nurse aide was answering alarms and call bells. The LPN documented that while she was, getting another resident her medication, Resident 98 leaned forward to get out of her chair and slid herself to the floor on her hands and knees. A Registered Nurse assessed Resident 98 and then remained with her as her one to one supervision. Review of the facility's investigation of Resident 98's fall on June 14, 2016, revealed that the facility did not obtain a witness statement from the nurse aide assigned to the nursing unit at the time of the fall. Interview with the Director of Nursing on September 22, 2016, at 3:20 PM revealed that the facility could not provide any education, policy, or plan of care, that instructed staff regarding the level of supervision (e.g. line of sight at all times) Resident 98 required when out of bed to her Broda (specialized reclining wheelchair) chair. The Director of Nursing confirmed that it is the acceptable standard of practice that medication nurses have the minimal amount of distractions when completing their medication pass. The Director of Nursing confirmed that the facility's investigation did not determine the proximity of the medication nurse to Resident 98 at the time of her fall. The interview confirmed that the medication nurse had the task of medication administration while attempting to supervise this resident on a one to one basis. The Director of Nursing could not provide the procedure that the LPN implemented when entering resident rooms for medication administration while supervising Resident 98 on a one to one basis (while maintaining other residents' privacy). A physician's orders [REDACTED]. Observation of Resident 98 on September 22, 2016, at 4:00 PM revealed that she was wearing a torso restraint while in her Broda chair in the hall. Employee 10, LPN/Medication Nurse, was the only staff visible on the nursing unit at the time of the observation. Employee 10 was turned sideways at her medication cart, preparing medications, and not maintaining visualization of Resident 98. At 4:10 PM, Employee 10 left the hall to administer medications in resident room 210. No other staff were present in the hallway at that time. Continued observation of Resident 98 on September 22, 2016, at 4:11 PM revealed that Employee 9, a Nurse Aide, walked past Resident 98 while pushing a resident lift. Interview with Employee 9 at the time of the observation revealed that she had to help someone and that is why she was not keeping Resident 98 in her line of sight. Employee 9 confirmed that no other staff were visible on the nursing unit; however, she left the area to provide assistance in the shower room. Continued observation of the nursing unit revealed that Employee 10 returned to the hallway at 4:12 PM. Interview with Employee 10 on September 22, 2016, at 4:12 PM confirmed that Resident 98's plan of care required that staff maintain line of sight supervision of her while she is in the Broda chair with the restraint. Employee 10 confirmed that she could not have maintained line of sight supervision of Resident 98 while passing her medications. Interview with the Director of Nursing on September 23, 2016, at 8:30 AM revealed that the staff notified her of the above surveyor's observations of Resident 98. The interview confirmed that Resident 98's plan of care requires the staff to maintain line of sight supervision while she is restrained in her Broda chair. Clinical record review for Resident 99 revealed a plan of care developed by the facility to address her self care deficits with activities of daily living. The interventions listed noted that Resident 99 required extensive assistance of two for bed mobility, total assistance with personal hygiene, total dependence for dressing, and the extensive assistance of two staff for all transfers. A Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], assessed Resident 99 as receiving the physical assistance of two staff for bed mobility, surface transfers, dressing, and hygiene. Nursing documentation dated June 13, 2016, at 1:01 PM revealed that while a nurse aide provided care to Resident 99, Resident 99 started to roll out of bed while the nurse aide went to the closet to obtain an incontinence brief. The nurse aide noted Resident 99's lower body in the bed while her upper torso was close to the ground. Resident 99 sustained a laceration to her left eyebrow measuring 1 cm by 4 cm by 0.2 cm. Review of the facility's investigation of Resident 99's incident June 13, 2016, included one nurse aide statement providing details of the event. The investigation did not include a review of the level of staff assistance provided (one nurse aide) versus the level of staff assistance required (two nurse aides) while providing care. A plan of care developed by the facility to address Resident 99's risk for falls listed interventions initiated by the facility on June 14, 2016, that included the use of fall mats (a mat placed on either side of the bed to provide a softer landing). Listed interventions also included the use of a clip alarm when in bed, initiated July 27, 2016, to alert staff of Resident 99's attempts to roll/transfer out of bed. Nursing documentation dated July 26, 2016, at 9:10 PM revealed that the registered nurse assessed Resident 99 after she fell out of bed to the floor. The nurse assessed bleeding from Resident 99's nares (nose), a contusion (bruise) to her left nares, with edema (swelling). Nursing documentation dated July 26, 2016, at 9:20 PM noted that the staff obtained a physician's orders [REDACTED]. An interdisciplinary nursing documentation entry dated July 27, 2016, at 11:36 AM revealed that the facility determined that Resident 99's fall mat was not in place at the time of her fall; and that she sustained a nose fracture. Review of the facility's investigation of Resident 99's fall, on July 26, 2016, at 9:10 PM confirmed that the fall mat was not in place. Nursing documentation by the Registered Nurse (RN) dated July 29, 2016, at 9:15 PM revealed that (staff) called the RN to the resident's room after Resident 99 fell out of bed on to her fall mat. Resident 99 had bleeding from her nose and edema to the right side of her upper lip. The documentation indicated that all fall precautions were in place (including the clip alarm). Nursing documentation dated July 29, 2016, at 10:44 PM noted that upon entering Resident 99's room, the Licensed Practical Nurse noted Resident 99 lying on the right side of her bed on the mat, actively bleeding from the nose. The documentation indicated that the LPN notified the RN immediately. The documentation indicated that a tabs alarm (clip alarm) was in place. Review of the facility's investigation of Resident 99's fall on July 29, 2016, revealed that the staff heard, Help, and upon entering Resident 99's room, found her lying on the fall mat. The investigation indicated that the alarm did not sound/function (contradicting the documentation by the LPN and RN above). The investigation did not evaluate the equipment failure to implement an appropriate intervention in an effort to prevent recurrence of future falls. Review of Resident 99's plan of care developed by the facility to address her risk for alteration in skin integrity revealed interventions that included the use of a low air loss mattress to her bed. The intervention instructed the staff to check the pressure, function, and that the air mattress was secured to the bed frame every shift (initiated January 20, 2016). Nursing documentation dated June 11, 2016, at 7:24 AM indicated that Resident 99's roommate alerted the staff that Resident 99 fell out of bed. The staff noted that Resident 99's air mattress was incorrectly set to 250 pounds rather than the correct setting of 100 pounds. Review of the facility's investigation of Resident 99's fall on June 11, 2016, confirmed that the staff failed to ensure the proper inflation setting of her air mattress presenting a potential accident hazard. The investigation indicated that the facility would educate the staff regarding ensuring the proper inflation of air mattresses. Clinical record review for Resident 102 revealed late entry nursing documentation dated August 3, 2016, at 6:10 AM indicating that Resident 102 went to roll over while in bed and slid out of bed. The documentation indicated that Resident 102's air mattress was overinflated. Review of the facility's investigation of Resident 102's fall (dated August 2, 2016, at 12:59 PM) confirmed that the staff found Resident 102 sitting on the floor mat. Resident 102 stated that she just rolled over and rolled out onto the floor. The investigation did not note, or investigate, the failure of the staff to ensure the appropriate mattress inflation for Resident 102. Review of the facility's education provided to staff following Resident 99's fall out of bed (while her mattress was overinflated) on June 11, 2016, failed to include evidence that the nurse aide providing care to Resident 102 on August 2, 2016, received the education. Interview with the Nursing Home Administrator and Director of Nursing on September 22, 2016, at 2:00 PM confirmed the above findings for Residents 98, 99, and 102. 483.25 (h) Free of Accident Hazards/Supervision/Devices Previously cited deficiency 3/29/16, 3/3/16, 10/30/15 28 Pa. Code 201.18 (b)(1)(e)(1)Management Previously cited 3/29/16, 10/30/15 28 Pa. Code 211.10 (d) Resident care policies Previously cited 3/29/16, 2/19/16, 10/30/15 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 3/29/16, 3/3/16, 2/19/16, 10/30/15 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 3/29/16

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide planned interventions to prevent a fall resulting in harm for one of six residents reviewed (Resident 115). Findings include: Nursing documentation dated March 21, 2016, at 10:00 AM revealed that Resident 115 had a fall from the shower liter to the floor. Resident 115 was noted to have a bruise on her left shoulder. Nursing documentation date March 21, 2016, at 2:01 PM revealed that Resident 115 complained of left shoulder pain and she was sent to the emergency room for evaluation. Review of radiology report from the hospital dated March 21, 2016, revealed that Resident 115 sustained a fracture of her left clavicle (collarbone). Review of the facility investigation dated March 21, 2016, revealed that Employee 1 (nurse aide) and Employee 2 (nurse aide) rolled Resident 115 over to dry her back, the side rails were down, and Resident 115 fell to the floor. Employee 1 stated the side rails were down because Resident 115 is a bariatric resident, and they are unable to turn her with the rails up. Employee 1 stated that the rails are always down when two staff are present. Employee 2 stated that when they rolled Resident 115, the mat was still a little wet, the rails were down, and she slipped off the litter. Interview with the Director of Nursing on March 29, 2016, at 12:50 PM revealed that the facility did not have a policy related to resident safety regarding bathing and the shower gurney. The Director of Nursing stated that immediately following the incident the facility implemented a Shower Trolley Procedure indicating the side rail must be raised at all times when a resident is in the shower trolley, unless the trolley is level with the bed. The facility failed to prevent an avoidable fall resulting in harm for Resident 115. 483.25 (h) Accidents Previously cited deficiency 3/3/16 28 Pa. Code 201.18 (b)(1)(e)(1)Management. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 2/19/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 2/19/16 and 3/3/16 28 Pa. Code 211.12(d)(2) Nursing services.

Based on observation, review of select facility policy and procedures and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards on two of four nursing units (Heirloom and Beaver Nursing Units). The facility also failed to provide adequate supervision and assistance devices to prevent injury for one of 10 residents sampled (Resident 95). Findings include: The policy entitled, "Incidents/Accident and Investigative Reports," last reviewed November 17, 2014, indicated that it is the policy of the facility to investigate incidents and accidents in order to determine possible causative factors and implement interventions that may prevent reoccurrence of the same or similar event. Review of an incident investigation dated January 29, 2015, at 3:30 AM, revealed that the nursing staff identified three blisters on Resident 95's feet. There was one blister on Resident 95's right great toe measuring 4.6 cm (centimeters) by 3.6 cm, one blister on her right second toe measuring 1.8 cm by 1.3 cm, and one blister on the ball of her left foot measuring 1.8 cm by 1.6 cm. The incident investigation indicated that per the nursing staff, Resident 95 was wearing socks and her feet were resting on the baseboard heater. The investigation contained no evidence that the facility identified the baseboard heater as a potential accident hazard. Observation of Resident 95's room on February 11, 2015, at 10:20 AM, revealed an electric baseboard heater located along the floor under Resident 95's window. The heater control knob was located on the wall adjacent to the heater, and was accessible to residents, staff, and visitors. This surveyor was able to insert her entire hand into the unit and touch the heating elements that emit heat. Interview with Employee 2, the Maintenance Director, on February 11, 2015, at 1:30 PM, revealed that Resident Rooms 2 and 8 on the Heirloom Nursing Unit, and Resident Rooms 203, 204, 205, 206, 207, 209, 212, 214, 219, and 221 on the Beaver Nursing Unit all have the same baseboard heating unit that was located in Resident 95's room (for a total of 13 resident rooms). On February 11, 2015, at 12:05 PM, Employee 2 and this surveyor turned the heater to its highest setting and observed the temperature of the heating coils rise to 243 degrees Fahrenheit within three minutes. Employee 2 and this surveyor placed their hands on top of the heating unit. The heating unit was uncomfortable to touch for both Employee 2 and this surveyor after only one minute of pressure. Review of Resident 95's clinical record revealed that she has a [DIAGNOSES REDACTED]. Review of Resident 95's care plans revealed that the nursing staff are to apply heel protectors (thick cushioning which is attached to the foot with Velcro straps) to Resident 95's bilateral heels to decrease the potential for pressure areas. The nursing staff is to monitor the resident for safety while in bed due to the potential for falls. Review of the facility's incident investigation dated January 29, 2015, at 3:30 AM, revealed that Employee 1, a Nurse Aide, provided a written statement, which indicated that Resident 95's right heel protector was not on at the time of finding Resident 95 with her feet on the baseboard heater. There was no evidence in the investigation to indicate that the facility pursued the reasoning behind why Resident 95's right heel protector was not in place. There was no evidence in the care plan or nursing documentation that Resident 95 removed her heel protectors. Interview with Employee 1 on February 11, 2015, at 2:05 PM, revealed that Resident 95's door was closed prior to finding her with her feet up against the baseboard heater. Employee 1 indicated that no one from the facility spoke to her regarding this incident. Employee 1 indicated that she provided her written statement only. There was no evidence in Resident 95's clinical record or in the incident investigation to indicate how nursing staff were monitoring Resident 95's safety with a closed door in order to prevent the potential for a fall or an accident as indicated in her plan of care. The nursing documentation dated February 6, 2015, at 9:17 AM, indicated that the facility sent Resident 95 to the emergency room for evaluation of her feet. Review of the orthopedic consultation report dated February 6, 2015, indicated that a physician noted that Resident 95's right great toe had a large eschar (blackened) area on the bottom secondary to a burn. Review of Resident 95's discharge instructions from the hospital dated February 8, 2015, indicated that if the wound does not heal, Resident 95 may need to have the right great toe amputated. Observation of Resident 95's right foot on February 11, 2015, at 11:00 AM, revealed a large blackened area covering the bottom of her great toe, and a blackened area covering most of the bottom of her right second toe. Interview with the Nursing Home Administrator and the Director of Nursing on February 11, 2015, at 2:15 PM, confirmed the above findings. The Nursing Home Administrator acknowledged that the facility did not alter the baseboard heater in Resident 95's room or in any of the other 12 Resident rooms to prevent similar injuries. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/16/15 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/26/14 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 9/26/14 and 1/16/15

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to assess and implement interventions to prevent skin breakdown for one of 24 sampled residents (Resident CR1). Findings include: The policy entitled "Pressure Ulcer Prevention and Management Program," last revised May 2014, revealed that the facility would provide a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers do not develop them unless the individual's clinical condition demonstrates that they are unavoidable. The closed clinical record review for Resident CR1 revealed that the facility admitted the resident on July 10, 2013. Review of the Admission Screening completed by Employee 7, Registered Nurse, dated July 10, 2013, revealed that Resident CR1 did not have any pressure areas. The nursing documentation dated July 10, 2013, at 6:50 PM, revealed that Resident CR1 was admitted with a fracture below the right elbow and a fractured pelvis. Employee 7 completed a Braden Scale (an assessment for predicting pressure ulcer risk) on July 10, 2013. Based on the facility's assessment, it was determined that Resident CR1 was at mild risk for developing a pressure sore, despite the resident's limited mobility with the fractured pelvis. Interview with Employee 8, Assistant Director of Nursing, Wound Nurse, on September 26, 2014, at 11:50 AM, confirmed that Resident CR1 was limited regarding the ability to respond to pressure related discomfort, the skin was occasionally moist due to being incontinent, the resident was chair fast, very limited in the ability to change and control body position, and the resdient had a potential problem of friction or shearing. Resident CR1 also had a history of [REDACTED]. Review of Resident CR1's care plan initiated July 12, 2013, did not address Resident CR1's potential for skin breakdown. Interview with Employee 8 on September 26, 2014, at 11:54 AM, confirmed that she did not initiate a plan of care to address Resident CR1's potential for further skin breakdown until August 5, 2013. Review of the nursing documentation dated July 14, 2013, at 6:58 PM, revealed that the nursing staff documented a dime size wound on Resident CR1's coccyx. Documentation dated July 14, 2013, at 9:36 PM, revealed that the new open area on Resident CR1's coccyx measured 1.5 centimeters (cm) length by 0.8 cm width, and 0.2 cm depth. Review of the Incident/Accident Report dated July 14, 2013, revealed that a nurse aide noted the pressure area on Resident CR1's coccyx during incontinence care. Interview with the Director of Nursing, confirmed that the mattress that Resident CR1 was on at this time, was the same mattress all residents receive on admission. The Director of Nursing was unable to provide any further documentation that the staff were turning and repositioning Resident CR1 or providing any other pressure relief measures. Review of Resident CR1's Wound Management Record dated July 16, 2013 through November 20, 2013, revealed that Employee 8 noted that Resident CR1 was admitted on [DATE], with the coccyx wound. During an interview with Employee 8 on September 26, 2014, at 12:55 PM, she confirmed that Resident CR1 was not admitted to the facility with any pressure areas. Employee 8 revealed that she never checked the clinical record to verify the history of Resident CR1's wound, despite the fact that Employee 7 indicated that the resident had no pressure ulcers on admission. Employee 8 indicated that a nurse aide told her that Resident CR1 came into the facility with the coccyx wound. Review of the Wound Management Record revealed the following for the coccyx wound: July 16, 2013, Stage III, 1.5 cm, by 1.0 cm, by 0.2 cm July 25, 2013, Stage III, 5.5 cm, by 2.0 cm, by unknown depth August 6, 2013, Stage IV (full thickness tissue loss with exposed bone, muscle, or tendon), 7.0 cm, by 4.5 cm, by 3.0 cm August 20, 2013, Stage IV, 6.0 cm, by 6.5 cm, by 3.0 cm August 27, 2013, Stage IV, 8.0 cm, by 6.5 cm, by 3.2 cm September 4, 2013, Stage IV, 9.0 cm, by 6.5 cm, by 4.0 cm September 9, 2013, Stage IV, 9.0 cm, by 5.5 cm, by 4.0 cm September 24, 2013, Stage IV, 10.0 cm, by 6.0 cm, 4.5 cm October 3, 2013, Stage IV, 10.0 cm, by 6.0 cm, by 4.0 cm October 9, 2013, Stage IV, 10.0 cm, by 6.0 cm, by 4.0 cm October 31, 2013, Stage IV, 10.0 cm, by 6.0 cm, by 4.0 cm November 8, 2013, Stage IV, 9.0 cm, by 6.0 cm, by 2.0 cm November 20, 2013, Stage IV, 8.0 cm, by 6.0 cm, by 1.5 cm Review of Resident CR1's treatment administration record dated July 2013, revealed that the facility did not place an alternating air mattress on Resident CR1's bed until July 16, 2013, when Resident CR1 had a Stage III (full thickness tissue loss) pressure ulcer. The facility failed to accurately assess and implement timely interventions to prevent skin breakdown. 28 Pa. Code 201.18 (b)(1) Management. Previously cited 10/4/13, 3/14/14, and 6/3/14 28 Pa. Code 211.10 (a) Resident care policies. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 10/4/13, 12/4/13, and 3/14/14. 28 Pa. Code 211.11 (a) Resident care plan. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services. Previously cited 10/4/13, 12/4/13, 3/14/14, and 6/3/14

Based on observation, clinical record review, staff interview and review of select facility policies, it was determined that the facility failed to implement interventions to prevent an accident for one of 24 sampled residents (Resident 122). The facility also failed to maintain an environment free from accident hazards on one of four sampled nursing units (Nittany Nursing Unit). Findings include: The policy entitled, "Summary of House Diets," last reviewed June 26, 2014, revealed that the mechanical soft diet provides fork tender meats that are ground or finely chopped. The clinical record review for Resident 122 revealed that the facility admitted the resident on December 3, 2013, with [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated June 6, 2014, indicated that Resident 122 required supervision and assistance with meals. The physician's orders [REDACTED]. The nursing documentation dated August 9, 2014, at 6:05 PM, revealed that Resident 122 started to cough on food due to a piece of food being lodged in the throat at dinner and the resident could not breathe. The staff performed the Heimlich maneuver and suctioned Resident 122. The staff suctioned a medium size chunk of meat out of Resident 122's throat. The staff then sent Resident 122 to the local emergency room for further evaluation. The incident report dated August 12, 2014, indicated that the nurse aide yelled for the Licensed Practical Nurse (LPN) to come into the feeding lounge. The LPN found Resident 122 slumped over in the wheelchair, was not breathing and was cyanotic (bluish discoloration) around the mouth. The LPN performed the Heimlich maneuver three times and Resident 122, "started to breathe and started to choke and gasping for oxygen." Interview with the Director of Nursing on September 24, 2014, at 1:30 PM, confirmed the above noted information. There was no documented evidence indicating that the staff served Resident 122's meat at the mechanical soft consistency when the resident choked on it on August 9, 2014.During the initial tour of the Nittany Nursing Unit on September 23, 2014, at 6:30 PM, the surveyor observed an unlocked door leading to a stairway accessible to residents near the dining room leading to the main floor.During the same tour, the surveyor noted an open stairway near the physical therapy department, accessible to residents leading to the main floor. An interview with the Director of Nursing on September 24, 2014, at 2:00 PM, confirmed this information. The facility failed to provide a facility free from potential accident hazards by maintaining stairways in which residents could climb and fall down causing bodily injury. 483.25 (h) Accidents. Previously cited 10/4/13, 12/4/13 28 Pa. Code 211.6(a) Dietary services. Previously cited 10/4/13 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 10/4/13, 12/4/13, 3/14/14 28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing services. Previously cited 10/4/13, 12/4/13, 3/14/14, and 6/3/14

Based on review of select facility policies, select facility reports, clinical record review, and staff interviews, it was determined that the facility failed to prevent resident neglect during a transfer for one resident (Resident 13). Findings include: The facility policy entitled "Resident Abuse and Neglect," last reviewed on April 2013, revealed that the facility would not tolerate abuse, neglect, or misappropriation of resident property. Every allegation of resident abuse or neglect should be promptly reported and the facility will comply with all pertinent laws and regulations. Neglect refers to the failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility policy entitled "Musculoskeletal Disorder Prevention - Resident Handling," last reviewed April 2013, revealed so that all residents would be assessed by the facility care plan team for assistance with transfer activities, mobility, or repositioning. Residents identified as totally dependent or extensive assistance are those who cannot bear weight or are inconsistent with weight bearing, offers minimal assistance with lifts/transfers, may have a single or double amputation, and weighs less than the maximum capacity of the total lift. All total dependent or extensive assist residents will be evaluated for lift/transfer equipment and/or other Resident assist devices as a primary intervention. Staff will transfer residents in accordance with their lift/transfer assessment, care plan, and written instructions, and per manufacturer's instructions and training. Staff will complete and document initial training to correct improper use and/or demonstrate understanding of safe Resident handling and movement. Staff training and documentation will be completed initially, annually, and as needed for corrective action. Nursing staff will report to their supervisors all injuries involving Resident handling and movement. Caregivers will comply with this policy; will use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of resident handling techniques; will notify their supervisor of any injury sustained and of any difficulty or uncertainty regarding the use of a mechanical lifting devices, other equipment/aids and lifting/moving techniques; will attend all required in-services; will complete skills check off prior to use of the lifts or transfer equipment; will report non-compliance to their supervisor; and will follow the care plan/aide assignment sheet for mode of transfer. Clinical record review for Resident 13 revealed a physician's orders [REDACTED]. Resident 13's care tracker profile dated June 7, 2013, indicated that the staff is to transfer the resident via the hoyer lift using a small lift pad and two staff for assistance. Resident 13's most recent lift evaluation dated February 24, 2014, revealed that she is a candidate for a full support lift and two staff members are required to turn and reposition the resident. Nursing documentation dated March 11, 2014, at 8:45 PM revealed that Employee 2, Nurse Aide, reported to nursing staff that Resident 13 was being transferred via lift and slid out of the lift pad. The nursing staff found Resident 13 on the floor, with a deformity to her left lower extremity. The staff splinted Resident 13's leg, contacted her physician, and sent her to the hospital for further evaluation. On March 11, 2014, at 11:52 PM, the nursing documentation revealed that Resident 13 returned to the facility with a posterior and stirrup splint in place, with orders not to remove it. Review of hospital documentation revealed a left tibia/fibula x-ray dated March 11, 2014, at 10:47 PM, which indicated that Resident 13 sustained a comminuted (multi-pieced) [MEDICAL CONDITION] distal (lower part) tibial (larger bone of the lower leg) shaft with the major distal fragment displaced laterally (to the outside) approximately one/third bone diameter, a [MEDICAL CONDITION] fibular (smaller bone of the lower leg) shaft with slight lateral displacement of the distal fragment (bone piece), and a comminuted [MEDICAL CONDITION] (upper part) fibula. Resident 13 was to follow up with an orthopedic surgeon. Resident 13 was complaining of pain, though she was unable to rate it on the pain scale. The staff contacted her physician and received new orders for a 25 mcg (microgram) [MEDICATION NAME] (used for moderate to severe pain). The receptionist documented on March 12, 2014, at 9:23 AM, that Resident 13 has an appointment with the orthopedic surgeon on Thursday, March 13, 2014, at 2:30 PM. Review of facility documentation regarding Resident 13's fall, revealed that Employee 2 received weight and lift competency training on April 23, 2013, including the use of a full support lift. Noted in Employee 2's full support lift competency checklist is that one employee will guide the resident while a second employee will maneuver the lift. The facility investigation revealed that Employee 2 admitted , "putting (Resident 13) to bed by myself with (the) lift. She slipped out of the lift." Employee 2 stated that the other staff were, "busy putting someone else in bed so I try to put (Resident 13) in bed." Review of employee statements revealed that there were two other nurse aides and one licensed practical nurse on the unit at the time of the incident. Each staff statement confirmed that Employee 2 failed to request their assistance to help transfer Resident 13 via hoyer lift. Interview on March 14, 2014, at 9:20 AM with the Director of Nursing confirmed the above, indicating that Employee 2 failed to follow facility policy and Resident 13's care plan. The Director of Nursing stated that Employee 2 was suspended without pay for three days and was given final disciplinary action. Employee 2 will receive re-education on resident safety and lift competency training upon return to the facility. 28 Pa. Code 201.18 (b)(1)(e)(1) Management. Previously cited 10/14/13 28 Pa. Code 201.18 (e)(1) Management. Previously cited 12/4/13 28 Pa. Code 211.10 (c)(d) Resident care policies. Previously cited 10/14/13 and 12/4/13 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. Previously cited 10/14/13 and 12/4/13

Based on review of select facility policies and procedures, incident investigations, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care in response to a choking incident resulting in death for the one resident reviewed (Resident CR1). Findings include: The policy entitled "Advance Directives," last reviewed by the facility [DATE], revealed that an Advance Directive, also known as a Living Will, is a written document voluntarily executed by the resident refusing life-sustaining treatment if the resident is incompetent and either in a terminal condition or a state of permanent unconsciousness. Life-sustaining treatment is defined as any medical procedure or intervention that serves only to prolong the process of dying or to maintain a resident in a state of permanent unconsciousness. Terminal condition is defined as an incurable and irreversible medical condition in an advanced state caused by injury, disease, or physical illness, which will, in the opinion of the attending physician, to a reasonable degree of medical certainty, result in death regardless of the continued application of life-sustaining treatment. Closed clinical record review for Resident CR1 revealed a "Living Will," dated February 14, 2013, signed by the resident indicating that if he had an end-stage medical condition (which will result in his death despite the introduction or continuation of medical treatment) or he is permanently unconscious such as an irreversible coma or an irreversible vegetative state and there is no realistic hope of significant recovery he did not want cardio-pulmonary resuscitation (CPR). He did want health care treatment to relieve pain or provide comfort. The policy entitled, "Aspiration (breathing in a foreign object) Precautions," last reviewed [DATE], revealed that the facility will implement aspiration precautions for patients at risk for choking or aspiration of liquid, or objects into the lungs. Aspiration precautions will include suction immediately available at the bedside. Review of Resident CR1's current plan of care indicated that he had a history of [REDACTED]. A speech therapy evaluation dated [DATE], indicated that Resident CR1 requires constant supervision and cues while eating to lower his aspiration risk. Review of Resident CR1's physician recapitulation orders dated [DATE], indicated that staff were to suction him as needed to maintain a patent (open, unobstructive) airway. The incident investigation dated [DATE], (untimed entry at lunch time) revealed that Resident CR1 returned from the dining room and was sitting in the hallway by the nurse's station when he began coughing. The nurse asked him if he was choking and he indicated that he was. Resident CR1 continued to cough but was unable to clear his airway. The nurse noted a tan colored mushy substance in his mouth. Nursing staff attempted the [MEDICATION NAME] maneuver (abdominal thrusts) several times and within less than a minute Resident CR1 was no longer coughing and became limp, unresponsive, cyanotic (bluish discoloration, indicating there is not enough oxygen in the blood), and with no respirations (no signs of breathing). Nursing staff returned him to his room, they did not attempt to suction him, nor did they initiate CPR. Review of Resident CR1's "Certificate of Death," revealed that he expired on [DATE], at 1:03 PM. The cause of death was listed as Cardiac [MEDICAL CONDITION] (irregular heart beat), Oxygen Deprivation, and Choking. Review of a similar incident dated [DATE], revealed that Resident CR1 began choking while eating in the main dining room. Staff initiated the [MEDICATION NAME] maneuver, which was ineffective. Resident CR1 became unconscious, and had no respirations or pulse so staff lowered him to the floor and CPR was initiated. After three rounds of chest compressions, large amounts of food came out of his mouth. The nurse continued the CPR and a pulse was felt when he began moaning. The emergency medical services and a doctor arrived. The doctor suctioned the resident and sent him to the emergency room . Upon his return, the physician advised staff to supervise the resident during meals. The speech therapist consult revealed that he was to be supervised at all meals. An interview with the Director of Nursing on [DATE], at 12:30 PM confirmed the previous information. The Director of Nursing revealed that CPR was not initiated because Resident CR1 was a "Do Not Resuscitate." She was not sure why staff did not attempt to suction him. The suction machine was not in his room, but there was one available. Resident CR1 indicated in his "Living Will" that he did not want CPR initiated if he had an end stage medical condition. Prior to the choking event on [DATE], there was no indication of any such condition. When Resident CR1 choked and the [MEDICATION NAME] maneuver was not successful, the facility failed to suction him or initiate CPR because they felt it was against his wishes. Resident CR1 had a history of [REDACTED]. Staff initiated CPR and suctioning and revived him. The same "Living Will" was in effect at that time. 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE], [DATE], and [DATE] 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited [DATE], [DATE], and [DATE] 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE] and [DATE]

Based on review of select facility policies and procedures, incident investigations, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent a resident from choking resulting in death for the one resident reviewed (Resident CR1). Findings include: The policy entitled, "Aspiration (breathing in a foreign object) Precautions," last reviewed [DATE], revealed that the facility will implement aspiration precautions for patients at risk for choking or aspiration of liquid, or objects into the lungs. Review of an investigation into an incident dated [DATE], revealed that Resident CR1 had a history of [REDACTED]. Upon his return, the physician advised staff to supervise Resident CR1 during meals. The speech therapist consult revealed that Resident CR1 was to be supervised at all meals. Clinical record review for Resident CR1 revealed a speech therapy evaluation dated [DATE], indicating that Resident CR1 requires constant supervision and cues while eating to lower his aspiration risk. Review of Resident CR1's current plan of care, at the time of his death, indicated that he had a history of [REDACTED]. Review of an incident investigation dated [DATE], revealed that Resident CR1 was eating his lunch in the main dining room. During the meal, he left the dining room, went downstairs to the kitchen, and asked for a sandwich. The kitchen staff told him he could not have the sandwich because he was on a pureed diet, but gave him a bowl of pureed ham loaf and a bowl of pureed pasta. Resident CR1 then went back upstairs to the main dining room where a nurse aide thought he had taken food off the cart because she saw the bowls falling out of his sweater. Resident CR1 told her the kitchen staff had given him the food. Resident CR1 only stayed a few minutes and then went back to the nursing unit where he began choking. Nursing staff were unsuccessful at performing the Heimlich maneuver. Resident CR1 became cyanotic (bluish discoloration indicating a lack of oxygen in the blood), unresponsive, with no respirations (no signs of breathing). Review of Resident CR1's "Certificate of Death," revealed that he expired on [DATE], at 1:03 PM. The cause of death was listed as Cardiac Dysrhythmia (irregular heart beat), Oxygen Deprivation, and Choking. An interview with the Director of Nursing on [DATE], at 12:30 PM confirmed the previous information. The facility failed to ensure Resident CR1's safety by allowing him to leave the dining room during mealtime and going to the lower floor where the dietary staff gave him food while he was unsupervised. 483.25(h) Accidents Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE], and [DATE] 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE], [DATE], and [DATE] 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited [DATE], [DATE], [DATE]

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding resident assessments for one of six sampled residents (Resident 38). Findings include: The policy entitled "Assessment Guidelines," last revised June 2013, revealed that resident condition may be assessed by a licensed practical nurse (LPN) or registered nurse (RN), if any abnormal findings are obtained by the LPN, the findings need to be reported immediately to the RN for further assessment and follow up. Clinical record review for Resident 38 revealed a late entry in nursing documentation dated August 2, 2013, at 3:30 PM indicating that Resident 38's family member was concerned with Resident 38's right lower leg being cold to touch. Documentation indicated that the LPN assessed her leg and noted it was slightly darker in color than the left leg and slightly cooler to touch. The LPN indicated that she notified the RN at this time. Review of the clinical record revealed no further assessment of Resident 38's leg. Nursing documentation dated August 5, 2013, at 9:15 PM revealed that Resident 38's daughter called the RN to the resident's room because her right foot was dark purple in color from toes to the middle of her foot. The RN was unable to find a pedal pulse (pulse found in your foot) even with the Doppler (ultrasound test used to reflect sound waves to see how blood flows through a blood vessel). Resident 38's right lower calf was also red with several fluid filled blisters noted. Resident 38 was sent to the hospital for evaluation. Interview with the Director of Nursing on August 14, 2013, at 1:00 PM confirmed that an RN never assessed or made Resident 38's physician aware of the abnormal findings. The Director of Nursing stated that the LPN never reported the information regarding Resident 38 to the RN. The Director of Nursing stated that she would have requested a Doppler if she was aware of the concerns with Resident 38's leg. Resident 38 sustained an above the right knee amputation on August 7, 2013. 483.25 Quality of Care Previously cited deficiency 9/27/12 28 Pa. Code 211.10 (c) Resident care policies. Previously cited 9/27/12 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. Previously cited 9/27/12 28 Pa. Code 211.12 (d)(2) Nursing services.