Every finding on record at Emmanuel Center for Nursing

Based on review of clinical records, facility policies, Resident Council meeting minutes, grievances filed at the facility, and resident and staff interviews, it was determined that the facility failed to act upon and effectively address recurring concerns raised by the Resident Council regarding prolonged staff response times to residents' requests for care and assistance and failed to demonstrate its response and rationale for addressing the recurring concerns. The same concerns were identified during three consecutive Resident Council meetings conducted and remained ongoing during a Resident Council group interview conducted on August 5, 2026, when six out of six residents interviewed (Residents 2, 22, 38, 48, 53, and 62) reported continued concerns regarding prolonged staff response times. Independent interviews with two residents, 12 and 82) corroborated that residents continued to experience prolonged response times when requesting staff assistance.Findings include: A review of the facility policy titled Answering the Call Light, last reviewed by the facility on July 21, 2026, revealed it is a facility policy that the facility will ensure timely response to the resident's request and needs. A review of the facility policy titled Grievance Process, last reviewed by the facility on July 21, 2026, revealed it is facility policy to ensure that staff are responsible for ensuring customer satisfaction within the facility and when concerns arise, a system is in place to assist with resolving the issues at hand to the satisfaction of all parties involved. A review of Resident Council meeting minutes dated May 18, 2026, revealed that residents raised concerns regarding prolonged call bell response times and reported extended waits for staff assistance when requesting help to use the bathroom. Resident 62 also expressed frustration with staff responses when requesting care and reported that a staff member stated, I forgot you were mine. A review of a grievance filed on May 18, 2026, on behalf of Resident 62 revealed a reported 45-minute wait for assistance to use the bathroom. The grievance also documented that a nurse aide told the resident that staff forgot the resident was on their assignment. The facility documented the grievance as resolved on May 20, 2026. A review of Resident Council meeting minutes dated June 15, 2026, revealed that residents again reported that prolonged call bell response times remained an issue, particularly after breakfast and before the evening meal. A review of a grievance filed on June 16, 2026, on behalf of Resident 22 revealed concerns regarding prolonged call bell response times for assistance to use the bathroom. The facility documented the grievance as resolved on June 17, 2026. A review of Resident Council meeting minutes dated July 20, 2026, revealed that residents again reported that prolonged call bell response times remained an issue. Some residents identified breakfast as the time when delays were most problematic, while others identified the evening shift. Residents reported prolonged waits for staff assistance to get off the toilet, including one resident whose delay caused the resident to arrive late to the Resident Council meeting. Residents further reported that they rang their call bells for such extended periods that they began yelling for help. A review of a grievance filed on July 21, 2026, on behalf of the Resident Council revealed concerns regarding prolonged call bell response times for staff assistance. The facility documented the grievance as resolved on August 4, 2026. A review of Resident Council meeting minutes dated May 18, June 15, and July 20, 2026, revealed that residents repeatedly raised the same concerns regarding prolonged waiting times for care and staff assistance. The records contained no documented evidence demonstrating how the facility's actions effectively addressed the recurring concerns or the rationale for the facility's response. During a Resident Council group interview conducted on August 5, 2026, at 10:00 AM, six out of six residents interviewed (Residents 2, 22, 38, 48, 53, and 62) reported continued concerns regarding prolonged wait times for staff assistance after using their call bells. During the group interview, Resident 62 reported regularly experiencing prolonged wait times for staff assistance. Resident 62 stated that residents had raised the issue during previous Resident Council meetings but that the resident did not know what actions the facility had taken to address the concern. Resident 62 stated that prolonged response times remained an ongoing problem.During the group interview, Resident 22 reported that facility staff left the resident sitting on the toilet for a long time while waiting for assistance.During the group interview, Resident 38 reported that staff frequently responded to the call bell, turned it off, and stated that they would return; however, the resident subsequently waited an additional one to two hours for assistance.During the group interview, Resident 53 reported waiting as long as two hours for staff assistance after requesting care.During the group interview, Resident 48 reported that prolonged wait times for care had been a problem for an extended period and that response times appeared worse on hallways where residents required greater levels of care. A review of Resident 82's Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed a score of 15. The BIMS is a standardized assessment used to evaluate a resident's attention, orientation, and ability to remember information. A score of 13 through 15 indicates intact cognition. During an interview on August 4, 2026, at 12:00 PM, Resident 82 reported that during the previous evening, the resident waited approximately one hour for assistance after using the call bell. Resident 82 stated that a staff member initially responded to the call bell but did not return for approximately one hour to assist the resident back to bed. A review of Resident 12's BIMS assessment dated [DATE], revealed a score of 15, indicating intact cognition. During an interview on August 5, 2026, at 9:30 AM, Resident 12 reported frequently experiencing prolonged call bell response times, particularly during the evening shift. Resident 12 stated that delayed responses were upsetting when the resident requested incontinence care because the resident had a pressure ulcer (damage to the skin and tissue underneath, often caused by staying in a position for too long) on the buttocks. Incontinence care is assistance provided to keep a resident clean and dry following an involuntary loss of urine or stool. During an interview on August 6, 2026, at 2:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that residents reported experiencing prolonged call bell response times. The NHA and DON were unable to provide documented evidence demonstrating how the facility effectively addressed the recurring concerns raised during Resident Council meetings or the facility's rationale for its response to those concerns. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of select facility policy, observations, and resident and staff interviews, it was determined the facility failed to maintain a safe and homelike environment by not ensuring a bathroom safety handrail (grab bar) was securely affixed to the wall in two out of three resident shower rooms (200 and 300 hall shower rooms) and failed to maintain a comfortable temperature in one of three shower rooms (100 hall shower room). Findings include: A review of the facility policy titled Safety and Supervision of Residents, last reviewed by the facility on July 21, 2026, revealed it is facility policy that resident safety, supervision and assistance to prevent accidents are facility wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, reporting processes, and a facility wide commitment to safety at all levels of the organization. During a resident council meeting on August 5, 2026, at 10:10 AM, interviews with three cognitively intact residents, Residents 22, 38, and 62, it was reported that the temperatures inside the 100 hall shower room was frequently cold and uncomfortable. All residents reported nursing staff were aware, but nothing was addressed. During an interview with a cognitively intact resident, Resident 53, it was revealed that in the 100 hall shower room the grab bars for the toilet had been loose for quite some time and he was afraid to use them, so he avoided use of the toilet when he was in the shower room. Resident 53 reported nursing staff were aware, but nothing was addressed. Observations of the 100 hall resident shower room in the presence of the facility's maintenance director present on August 5, 2026, at 1:00 PM, revealed the environmental temperature was only 69 degrees Fahrenheit and felt uncomfortably cold. An observation of a locked thermostat meter revealed it was set to 40 degrees Fahrenheit, and an unlocked thermostat meter next to it read 50 degrees Fahrenheit. Observations of the 100 hall resident shower room in the presence of the facility's maintenance director present on August 5, 2026, at 1:00 PM, revealed grab bars were loosely attached to the wall and floor, unsteady, and did not provide support, and the tiles around the bar attached to the wall had begun to chip. Observations of the 300 hall shower room revealed the right side grab bar for the toilet was loose and unsteady. During an interview with the facility's maintenance director on August 5, 2026, at 1:10 PM, it was reported that he does not do any regular temperature checks throughout the facility or inspections to ensure grab bars remain secure. The maintenance director had stated that if the residents would like the temperature to be changed, he has a key to unlock the box, and after hours, the nursing supervisor has a key to unlock the thermostat meter. The above findings were reviewed with the facility's Nursing Home Administrator (NHA) on August 5, 2026, at 2:10 PM, and confirmed the resident's shower rooms should be maintained to assure comfortable temperatures and in a safe condition for a homelike environment. 28 Pa Code 201.18 (b)(1) Management. 28 Pa Code 211.10 (c) Resident care policies.

Based on observation, review of resident grievances, activity schedules and activity participation records, and staff interviews, the facility failed to provide and implement an ongoing activity program that accommodated residents' individual interests, preferences, routines, and participation needs, including alternative activity opportunities and assistance needed to access activities, for 6 of 92 residents who resided in the facility (Residents 10, 23, 31, 36, 75, and CR1).Findings include: Review of a grievance filed on behalf of residents residing on the 100-nursing unit regarding the weekend of July 4 and July 5, 2026, revealed concerns that scheduled activities were not completed and that residents received no interaction from Activity Department staff during those days. Review of the grievance resolution revealed that the facility identified the need for staff education regarding documentation of completed activities and the provision of meaningful activities to residents. The Activity Department completed 90-minute training addressing these concerns on July 20, 2026. Despite the facility's identified corrective action, subsequent observations and record reviews revealed continued concerns regarding the provision of resident-centered activity opportunities. During an observation of the 100-nursing unit dining/recreation area conducted between 10:00 AM and 11:30 AM on August 4, 2026, eight residents were observed in the area. Four residents were sleeping, while four residents were awake and seated separately from one another without an observed individual or group activity. Activity staff were not observed offering or attempting to engage these residents in an activity at the time of the observation. During an observation of the 100-nursing unit dining/recreation area conducted between 10:00 AM and 11:30 AM on August 5, 2026, eight residents were observed in the area. Four residents were sleeping, while four residents were awake and seated separately from one another without an observed individual or group activity. Activity staff were not observed offering or attempting to engage these residents in an activity at the time of the observation. During an observation of the 100-nursing unit dining/recreation area conducted between 10:00 AM and 11:30 AM on August 6, 2026, 11 residents were observed in the area. Four residents were sleeping, while seven residents were awake without an observed individual or group activity. Activity staff were not observed offering or attempting to engage these residents in an activity at the time of the observation. Review of July 2026 activity participation records for the 300-nursing unit revealed the following:Resident 10 had no documented activity offered, provided, or declined from July 27 through July 31, 2026.Resident 23 had no documented activity offered, provided, or declined from July 27 through July 31, 2026.Resident 31 had no documented activity offered, provided, or declined on July 28, July 29, and July 31, 2026.Resident 36 had no documented activity offered, provided, or declined on July 27, July 28, July 30, and July 31, 2026.Resident 75 had no documented activity offered, provided, or declined on July 28, July 29, July 30, and July 31, 2026.Resident CR1's activity records from July 27 through July 31, 2026, documented one activity each day, consisting of an individual visit by Activity Department staff. During an interview on August 6, 2026, at 1:00 PM, the Activity Director stated that individual visits generally lasted approximately 10 minutes. The Activity Director could not provide evidence that staff offered or provided activities to Residents 10, 23, 31, 36, and 75 on the dates when the activity records contained no documentation of an activity being offered, provided, or declined. Review of activity participation records for the 100-nursing unit dated July 30, 2026, revealed that staff documented 27 of 45 residents, or 60 percent, as unavailable for scheduled activities. During the August 6, 2026, at 1:00 PM interview, the Activity Director stated that residents documented as unavailable were sleeping in their rooms when staff attempted to provide the scheduled activities. The Activity Director could not provide evidence that staff adjusted activity times to accommodate these residents' routines or preferences or subsequently offered alternative activity opportunities. For residents who later received an individual visit, the Activity Director stated that these visits generally lasted approximately 10 minutes. During an interview on August 6, 2026, at 1:30 PM, Employee 1, a speech-language pathologist, stated that two residents participated in the exercise group. Review of the activity calendar did not identify an alternative group activity scheduled for residents of the 200-nursing unit who did not participate in the exercise group. Further review of the August 2026 activity calendar revealed that the Activity Department did not schedule activities after 4:30 PM.During an interview on August 6, 2026, at 1:00 PM, the Activity Director stated that the Activity Department experienced difficulty getting residents to activities conducted outside of their nursing units because there were not enough Activity Department staff available to assist residents to the activity locations. The Activity Director further stated that she had not formally requested assistance from the Nursing Department to transport residents to activities when needed. The Activity Director could not provide evidence that the facility adjusted activity schedules, provided alternative activity opportunities, or arranged assistance for residents who were unable to attend scheduled activities because they required assistance to reach the activity location. During an observation of the Activity Department office conducted between 10:30 AM and 11:15 AM on August 5, 2026, two Activity Department staff members were observed in the office. No residents were observed participating in an activity in the office at the time of the observation. During an interview on August 7, 2026, at 11:00 AM, the Nursing Home Administrator was asked to provide evidence demonstrating how the facility provided activity opportunities that accommodated residents' individual interests, preferences, routines, and participation needs. The Nursing Home Administrator did not provide additional evidence demonstrating how the facility consistently provided or adapted activity opportunities to accommodate these resident needs.`28 Pa. Code: 201.29(a) Resident rights.28 Pa. Code: 211.10(d) Resident care policies.

Based on observation, review of facility policy, and staff interview, it was determined that the facility failed to store food under sanitary conditions, properly label and date opened food products, discard food according to established use-by dates, and maintain clean food storage areas in the dietary department and a resident activity room that created the potential for food contamination, microbial growth, and foodborne illness.Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of the facility policy entitled Food Storage, last reviewed by the facility on July 21, 2026, revealed that staff were to store, thaw, and prepare food in accordance with good sanitary practices. The policy directed staff to date products when received or prepared and mark food containers with a use date according to the timetable in the Dry, Refrigerated, and Freezer Storage Chart. The policy directed staff to place opened dry foods in seamless plastic or glass containers with tight-fitting lids or resealable bags and label the products with the received date, opened date, and expiration date. Fresh vegetables shall be left in cartons, bags, or paper wrapping and labeled with the received date, opened date, and expiration date and use them within three to five days. Staff were also to label prepared foods, leftovers, and opened products stored for later use according to applicable food safety standards and state and local requirements. During an initial tour of the dietary department on August 4, 2026, at 10:49 AM, conducted with the Food Service Director, observation of the dry storage area revealed three clear plastic dispensers containing cereal. One dispenser containing Cheerios was labeled June 10 with a use-by date of July 10; one dispenser containing Corn Flakes was labeled June 10 with a use-by date of July 10; and one dispenser containing Mini Wheats was labeled June 8 with a use-by date of July 8. All three cereals remained available in the dry storage area after their documented use-by dates. Observation of the dry storage area revealed two opened boxes of gluten-free pasta dated as opened on May 1, 2026. Neither box contained a documented discard date. During the observation, the Food Service Director confirmed that staff should have documented a discard date on the boxes and that staff should have discarded both boxes. Observation of the walk-in produce cooler revealed an opened bag of fresh broccoli without a label or date to identify when staff received or opened the product or when staff were to discard it. Observation of the refrigerator/freezer unit located in the resident activity area serving the 100 and 200 hallways revealed a brown-colored substance spilled on the exterior freezer door and on the floor adjacent to the unit. Inside the freezer, observation revealed ice crystal accumulation on several individual single-service ice cream cups, an opened box of popsicles without a label or date, and sticky, brown-colored spots on an interior surface. Inside the refrigerator, observation revealed an opened bottle of chocolate-flavored syrup dated February 19, 2026, with a sticky brown substance around the squeeze-top opening; an opened container of Limburger cheese without a label or date; and an opened bottle of Catalina salad dressing dated June 10, 2026. Sticky yellow- and brown-colored substances adhered to the refrigerator shelving. Further observation of the activity room revealed wheelchair leg rests stored directly on the floor underneath a mobile cart adjacent to the refrigerator. During an interview on August 6, 2026, at 2:10 PM, the above findings were reviewed with the Nursing Home Administrator (NHA). 28 Pa. Code 201.18 (e)(2.1) Management. 28 Pa. Code 211.6(f)Dietary Services. 28 Pa Code 211.10(c) Resident care policies.

Based on clinical record review and staff interview, it was determined the facility failed to follow professional standards of nursing practice by failing to implement a physician-approved medication order for one of 20 residents reviewed (Resident 57). Findings include: A clinical record review revealed that Resident 57 was admitted to the facility on [DATE], with diagnoses that included a cerebrovascular accident (CVA, commonly called a stroke, which occurs when blood flow to part of the brain is interrupted, causing brain tissue damage), ischemic stroke (a type of stroke caused by blockage of a blood vessel supplying the brain), ambulatory dysfunction following a stroke (difficulty walking), and mild cognitive impairment (a decline in memory or thinking abilities that is greater than expected with normal aging but does not necessarily interfere significantly with everyday activities). A review of Resident 57's progress notes revealed that on April 27, 2026, the resident expressed fearfulness to nursing staff and social services. A progress note dated April 28, 2026, at 11:11 AM revealed that social services provided Resident 57 with a supportive visit after the resident expressed difficulty coping with the resident's current living arrangements. Social services referred Resident 57 to the facility's contracted psychogeriatric service (services that provide evaluation and treatment of mental health and behavioral conditions affecting older adults) for additional evaluation and support. A review of progress notes dated May 1 through May 28, 2026, revealed that Resident 57 exhibited increasing behavioral symptoms that included refusing care, arguing with staff, increased paranoia (persistent unreasonable fear or suspicion that others intend harm), tearfulness, verbal aggression toward staff and other residents, and agitation. A review of the initial psychiatric consultation completed by the psychogeriatric nurse practitioner (NP, a registered nurse with advanced education and clinical training who may diagnose and treat medical conditions within the practitioner's scope of practice) on May 28, 2026, revealed that the NP evaluated Resident 57 because of paranoia, verbal aggression, irritability, and uncooperative behaviors. During the May 28, 2026, evaluation, the NP completed a Brief Interview for Mental Status (BIMS a standardized assessment of cognitive function that evaluates attention, orientation, and short-term memory). Resident 57 scored 10, (a score of 8-12 equates to being moderately cognitively impaired) which indicated moderate cognitive impairment. The NP also completed an anxiety screening. The assessment revealed that during the preceding two weeks, Resident 57 experienced several days of feeling nervous, anxious, or on edge and becoming easily annoyed or irritable. During the evaluation, Resident 57 reported feeling better that day but described having experienced a difficult period several weeks earlier. Resident 57 reported experiencing disturbing thoughts that staff members and other individuals were trying to kill the resident and stated that these thoughts continued to occur at times. Resident 57 also reported occasionally feeling depressed and anxious because the resident was alone and no longer had a home. The psychogeriatric NP recommended Seroquel 25 milligrams (mg) (an antipsychotic medication used to treat certain psychiatric symptoms) by mouth at bedtime for distressing paranoid delusions (firmly held false belief that persists despite evidence that the belief is not true). During an interview on August 6, 2026, at 1:40 PM, the Director of Nursing (DON) stated that Resident 57's attending physician reviewed and approved the psychogeriatric NP's recommendation for Seroquel 25 mg at bedtime during physician rounds on June 4, 2026. A review of Resident 57's Medication Administration Record (MAR, the clinical record used to document medications administered to a resident) revealed that licensed nursing staff did not initiate the physician-approved Seroquel 25 mg at bedtime until June 23, 2026. Licensed nursing staff failed to implement the physician-approved medication order from June 4 through June 22, 2026. During the August 6, 2026, interview, the DON confirmed that licensed nursing staff did not implement the physician-approved medication order until June 23, 2026, and acknowledged that staff had missed the order. Resident 57 did not receive the prescribed Seroquel for 19 days after the attending physician approved the medication for the treatment of the resident's distressing paranoid delusions. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, facility policies, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to protect one of five residents reviewed (Resident 5) from abuse and neglect by not implementing the individualized care plan intervention requiring two staff members for bed mobility assistance, resulting in actual harm in the form of a spiral fracture of the distal left femur. This deficiency is cited as past noncompliance. Findings include: A review of the facility policy titled Freedom from Abuse, Neglect and Exploitation last reviewed by the facility in December 2025, revealed the facility will take appropriate steps to prevent occurrence of abuse, neglect, and misappropriation of resident property. All allegations are treated seriously, reported promptly and investigated thoroughly, and addressed with appropriate corrective or disciplinary action based on the findings, severity, circumstances, and regulatory requirements. The policy defines neglect as the failure of the facility, its team members, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of Resident 5's clinical record revealed admission to the facility on May 4, 2022, with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the dominant right side. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 16, 2026, revealed that Resident 5 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). The assessment revealed the resident required total staff assistance for self-care activities, bed mobility, and transfers. Review of the resident's plan of care dated September 15, 2022, indicated that Resident 5 had an ADL self-care performance deficit related to bed mobility with prescribed interventions that included the use of bilateral bed enabler bars (assistive devices attached to both sides of the bed to help support movement and positioning) and the assistance of two staff members for bed mobility. A review of Resident 5's Documentation Survey Report for May 2026, reflected staff completion of resident care tasks, also identified that the resident required assistance from two staff members for bed mobility. Nursing documentation dated May 19, 2026, at 1:39 PM revealed Employee 1, Nurse Aide, reported to the nurse that while rolling Resident 5 to change her, Employee 1 heard a crack in the resident's left hip area, and the resident immediately complained of pain. Nursing documentation dated May 19, 2026, at 1:43 PM indicated an x-ray was completed by a mobile x-ray service, which determined the resident had a fracture of the left distal femur (break in the thigh bone). The physician and nurse practitioner were notified and ordered the facility to send Resident 5 to the hospital emergency department for evaluation and treatment. Review of the x-ray report dated May 19, 2026, revealed Resident 5 sustained a mildly separated, slightly displaced acute spiral fracture (a twisting break in the thigh bone located just above the knee joint) of the distal left femur, indicating a corkscrew pattern break near the knee, with slight misalignment of the broken ends. A review of the facility's abuse and neglect investigation dated May 19, 2026, revealed Employee 1, Nurse Aide, and Employee 2, Nurse Aide, transferred Resident 5 back to bed utilizing a mechanical lift (a device used to safely transfer residents who require extensive physical assistance). Following the transfer, Employee 2 left the room. Employee 1 remained alone with the resident and continued care. While turning the resident in bed, Employee 1 heard a cracking or popping sound and the resident stated Oh, that felt good. The resident then reported pain in her left hip area. A review of a written statement completed by Employee 1 dated May 19, 2026, (no time indicated) revealed Employee 1 and Employee 2 transferred the resident to bed using the mechanical lift. After Employee 2 left the room, Employee 1 removed the resident's pants and rolled the resident onto her right side to provide incontinence care. During the turn, Employee 1 reported hearing a horrible popping sound. A review of a written statement completed by Employee 2 dated May 19, 2026, at 4:44 PM revealed Employee 2 assisted with transferring the resident into bed utilizing the mechanical lift and then left the room. Employee 2 documented that Employee 1 took care of rolling her and providing incontinence care independently. Review of the facility's abuse and neglect investigation revealed Employee 1 did not follow the resident's care plan intervention requiring assistance from two staff members for bed mobility. The facility concluded Employee 1 provided care alone despite the resident's identified need for two-person assistance. The facility's investigation substantiated caregiver neglect and determined the failure to follow the resident's care plan resulted in the resident sustaining the left femur fracture. Employee 1 was suspended during the investigation and subsequently terminated following substantiation of neglect. During an interview on June 10, 2026, at 11:45 AM the Nursing Home Administrator acknowledged Employee 1 failed to follow Resident 5's care plan requirement for two-person assistance with bed mobility. The Nursing Home Administrator further acknowledged the facility's investigation determined this failure resulted in the resident sustaining the left femur fracture and confirmed Employee 1's employment was terminated. The facility's failure to ensure staff implemented Resident 5's care plan intervention requiring two-person assistance for bed mobility resulted in actual harm when the resident sustained a spiral fracture of the distal left femur requiring diagnostic evaluation and hospital transfer. Therefore, the deficient practice constituted neglect and resulted in actual harm. Corrective actions implemented by the facility included: Upon Resident 5's return from the hospital, an assessment will be conducted, and the care plan updated accordingly. The bed mobility status for all residents will be reviewed with input from direct care staff. All residents with a questionable status will be reviewed by therapy. Nursing staff will undergo education regarding the importance of adhering to care plan and the facility's abuse policy. An audit will be conducted on all residents to ensure bed mobility is care planned accurately. The Director of Nursing or designee will perform weekly bed mobility audits once a week for 4 weeks, then monthly for 3 months, and report the findings to the Quality Assurance and Performance Improvement committee. The facility alleged, and survey findings supported, that substantial compliance was achieved on June 8, 2026. Therefore, this deficiency is cited as past noncompliance. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, staff interviews, review of clinical records, and the census of the designated Hospice Specialty Unit, it was determined the facility failed to ensure sufficient and appropriately deployed nursing staff to consistently provide timely quality of care, supervision, and services necessary to meet the physical and mental well-being of 10 residents receiving hospice services. Findings include: Review of facility census revealed 10 residents currently receiving Hospice services in the designated Hospice Specialty Unit. The unit was staffed with one LPN (licensed practical nurse) and one nurse aide. Observation of the Hospice Unit on May 7, 2025, at 11:35 AM revealed six residents seated in the common area in wheelchairs and/or specialty chairs. The assigned LPN was stationed at the medication cart. Interview with Employee 1 (LPN) at the time of observation confirmed there was no other staff present as the assigned nurse aide was off unit on a scheduled break. During continued observation, two separate call bell lights were observed activated in resident rooms. Employee 1 responded to one call bell, leaving the common area unattended. While in the resident's room, Resident 8, seated in the common area and identified by the facility as a fall risk with poor safety awareness, was observed attempting to stand unassisted from her wheelchair, activating her chair alarm. Upon hearing the chair alarm, Employee 1 left the private resident room and rushed into the common area to address the sounding alarm. No staff member was present to supervise the common area while Employee 1 was answering call bells and attending to other residents' needs. Interview with Employee 1 on May 7, 2025, at 11:45 AM revealed that when a staff member takes a scheduled break, there is no assigned staff member to relieve and/or replace that staff member during their break, leaving the unit with only one staff member to care for all 10 residents. Continued interview with Employee 1 revealed that the Hospice unit is not adequately staffed to meet the acuity of needs of the residents (a measure of the level of care someone needs, considering factors like the severity of their illness, the frequency of interventions required and potential for complications). Three out of the ten hospice residents use a mechanical lift (a lift that uses hydraulic power to transfer a person while cradled in a sling. Requiring the use of two staff members to operate.) for transfers, seven residents require two staff member assistance for bed mobility, transfers, and assist with cares, and seven require total staff assistance for feeding. Employee 1 stated that when the nurse and the nurse aide are providing care to resident who requires 2 staff assistance such as for transfers, toileting or bed mobility, the other residents in the common area are left unsupervised. There have been times when a bed or chair alarm are sounding but no one is available to check on the situation of the alarm as 2 staff members are tending to another resident's needs. Review of the Hospice unit information provided by the facility identified seven out of the ten residents required assistance with feeding and were unable to safely consume their meals without staff assistance. Continued observations of the common area on May 7, 2025, at approximately 12:20 PM revealed the meal trays were delivered on open carts to the Hospice unit. Six residents were seated together at the dining table. Five of the six residents seated at the table required staff assistance. Employee 1 and the Director of Nursing were the only two staff members present to assist with feeding the five dependent residents in the dining room. The nurse aide was providing feeding assistance to a dependent resident who preferred to eat in his room. One additional resident, who preferred to eat in her room, was required to wait until a staff member was available. Observation at 2:45 PM showed Resident 9 attempting to stand from a recliner chair unassisted, and Resident 8 again attempting to stand from her wheelchair. Both are identified fall risks. The Hospice unit census reflected that 9 out of 10 residents are considered fall risks. Interview with Employee 2 (LPN) on May 7, 2025, at 2:55 PM revealed that on May 6, 2025, during second shift, Employee 2 attempted to obtain assistance from staff on the 200 unit (unit adjacent to the Hospice unit) however no staff were available. She reported that it is not uncommon that the 200 unit cannot spare an employee to assist with the Hospice unit. Interview with Employee 3 on May 7, 2025, at 3:00 PM revealed that on May 4, 2025, during the second shift, the LPN called off and the facility did not provide an LPN for the Hospice unit. There was only one employee, a nurse aide, assigned to care for the entire Hospice unit. The LPN from the 200 unit was required to work the 200 unit and the Hospice unit. Employee 3 reported that the LPN was too busy performing the medication and treatment management for residents on both the 200 unit and the Hospice unit that Employee 3 was not provided with a second team member to assist with care. She reported it was difficult to manage the entire unit when many residents required the assistance of two staff members for safe transfers and bed mobility. Further interview with Employee 2 at 3:05 PM revealed that inadequate staffing during critical periods, such as when a resident is actively dying, prevents the nurse from offering necessary emotional support to grieving families, as the nurse is also responsible for routine cares, repositioning, and responding to call bells. Interview with the Nursing Home Administrator and Director of Nursing on May 7, 2025, at approximately 3:30 PM confirmed the facility failed to account for resident acuity in determining adequate staffing and acknowledged that current staffing levels on the Hospice unit are insufficient to meet the needs of the resident population. 28 Pa. Code 201.18(b)(1)(e)(1)(2)(3)(6) Management 28 Pa. Code 211.12(c)(d)(1)(3)(4)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department and in the 100-Hall and 200-Hall medication room refrigerators. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of the facility policy entitled Sanitation and Infection Control provided by the facility on December 23, 2024, indicated that all foods are labeled, dated, stored, and securely covered, and use-by dates are monitored and followed. During the initial tour of the dietary department conducted with the facility's weekend day-shift dietary supervisor on December 21, 2024, at 9:30 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Upon entry to the dietary department/kitchen area two garbage cans with lids were full of trash and had red splatter on their exteriors. These cans were located near the tray line area where resident meal trays were being prepared for lunch. Another garbage can, soiled with visible trash inside, was located underneath a stainless-steel sink/workstation and was missing a lid. Near the tray line, clean pitcher lids were stored next to dirty cleaning rags. Two black bins containing bowls with visible debris and food particles were observed on the food preparation sink area, directly across from the tray line. Two boxes of uncovered Danish pastries were stored next to a bottle of cleaning solution and a staff member's personal drink. Several dome lids covers, and clear plastic covers were scattered beneath the sink, and some were uncovered. The lid of the bulk sugar container had visible debris and a yellowish substance adhered to its surface. The lid of the bulk flour container also had visible debris on its surface. The tubing attached to the filter of the ice machine had a heavy accumulation of dust. The blue plastic ice scoop was cracked, with sharp edges and missing pieces, posing a contamination and safety hazard. Observations of the cook's area revealed the ventilation hood over the cooking equipment had a heavy accumulation of greasy residue combined with dust particles adhered to the pipes and grates. The bulletin board displaying laminated department postings was splattered with dried, crusty substances. Shelving used to store facility manuals and binders was splattered with visible debris. Observations of the cold food prep area revealed on the bottom shelf of a wire rack, a case of bananas was stored less than six inches off the floor, violating proper food storage guidelines. Upon entering the dry food storage room, observed the lid of a gray garbage can had visible food splatter adhered to its surface. Observations inside of the dry food storage room revealed several boxes and bags of pasta were open and not securely sealed or stored in containers to prevent contamination. The dietary day-shift supervisor confirmed these findings and acknowledged that the dietary department must be maintained in a sanitary manner to prevent foodborne illness. Observations of the 100-Hall medication room on December 23, 2024, at 8:51 AM, revealed there were four 4-ounce strawberry nutritional shakes, nine 4-ounce chocolate nutritional shakes, and eight 6-ounce apple cranberry juice drinks were not labeled with a thaw date or use-by date. According to manufacturer instructions, once thawed, these products must be used within 14 days. Additionally, in the presence of Employee 4 an LPN observed that on the 200-Hall Medication Room that there four 6-ounce orange juice drinks and three 6-ounce apple cranberry juice drinks were also found without thaw dates or use-by dates. An interview with Employee 4 on December 23, 2024, at 9:00 AM, confirmed all supplements should be labeled and dated as per manufactures recommendations. Further interview with the Nursing Home Administrator (NHA) on December 22, 2024, at 1:00 PM, confirmed the facility's dietary department is expected to meet sanitary standards to prevent the risk of contamination and foodborne illness. and all nutritional supplements must be properly labeled and stored in accordance with manufacturer instructions. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two residents out of the 20 residents sampled (Residents 19 and 21) and experiences reported by five out of the six residents during a resident group interview (Residents 5, 12, 19, 21, and 42). Findings include: A review of Resident Council meeting minutes dated October 21, 2024, revealed residents in attendance raised concerns about long wait times for staff to respond and provide care after ringing their call bells for assistance. The residents in attendance indicated that staff will initially respond to their call bell, turn off the bell, but do not provide care. A review of Resident Council meeting minutes dated November 22, 2024, revealed residents in attendance raised concerns that staff are turning off the call bell lights but not providing care. Residents in attendance indicating that a staff will initially respond and turn off her call bell light but not perform care until after some time passes. A review of Resident Council meeting minutes dated December 17, 2024, revealed residents in attendance raised concerns regarding not having enough staff to assist residents back to their rooms after meals in the dining room. A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included disease of the spinal cord, unspecified (damage to the spinal cord that is not otherwise specified). A review of a significant change in status Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 2, 2024, revealed that Resident 19 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on December 21, 2024, at 10:25 AM, Resident 19 indicated she often waits 20 minutes for staff to provide her care after she rings her call bell for assistance. She explained that it has been an ongoing problem that staff initially respond, turn off her call bell light, but do not provide her care for 15 or 20 minutes later. She indicated that she has had to adapt to going to the bathroom when staff are available. She explained she had to learn how to s&*t on command because staff may not be available the next time she rings her bell for assistance. Resident 19 indicated when the facility uses agency staff, it extends the wait times for care, because they do not know the residents as well as the in-house staff. She explained that the facility uses agency staff a few times a week. A clinical record review revealed Resident 21 was admitted to the facility on [DATE], with diagnoses that included hydrocephalus (a condition where cerebrospinal fluid builds up in the brain, increasing pressure on brain tissue). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 22, 2024, revealed that Resident 21 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on December 21, 2024, at 11:35 AM, Resident 21 indicated she often waits a while for care. She explained the wait time for staff to provide care has been up to an hour when staffing is low. She explained staffing is low a few times a week. Resident 21 indicated she is happy her ability to care for herself is increasing, because now she doesn't have to wait as much for staff assistance to take her to the bathroom. During a group interview with alert and oriented residents on December 22, 2024, at 10:00 AM, five out of the six residents (Residents 5, 12, 19, 21, and 42) interviewed indicated they have concerns about the long wait times to receive care from staff after ringing their call bells for assistance. Residents 5, 12, 19, 21, and 42 explained they are frustrated and upset because they rely on staff for care. During the group interview, Resident 12 indicated she waits an hour to an hour and a half for care. She explained the long wait times for care are the worst when agency staff are working at the facility. During the group interview, Resident 5 indicated she waits 20 to 30 minutes for care. She explained often, staff will turn off her call bell light without providing her care. Resident 5 indicated she is embarrassed because she sometimes soils herself while waiting for staff to assist her to the bathroom. During the group interview, Resident 4 indicated he sometimes waits an hour to an hour and a half for staff to provide care after he rings his call bell for assistance. He explained he is frustrated because he often waits and waits for staff. During the group interview, Resident 42 indicated she waits a long time for staff to escort her from the dining room. She explained there is not enough staff to escort residents back to their rooms after meals. Resident 42 indicated she is often pushed to the hallway and waits 20 or 30 minutes in the hallway for staff to be available to assist her back to her room after meals. During an interview on December 22, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified all residents at the facility should be treated with dignity and respect and provided care in a manner that promotes each resident's quality of life. The NHA and DON were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance and care. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(c)(d)(4) Nursing services.

Based on review of clinical records and select facility policy, observations and staff interview, it was determined the facility failed to provide meal service in an environment that maintains each resident's dignity for three residents out of 6 sampled (Residents 26, 44, and 58), and failed to provide medication in a manner that respected the resident's dignity for one resident out of 20 sampled (Resident 31). Findings include: Review of the facility policy titled Dignity- Quality of Life last reviewed by the facility in August 2024, revealed the facility promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. A review of Resident 26's clinical record revealed she was severely cognitively impaired. And required total assistance from staff to be fed her meals. An observation conducted on December 21, 2024, at 12:05 PM of the 100-nursing unit dining room revealed Resident 26 and Resident 44 seated together at a table. At 12:06 PM Resident 26's lunch meal was delivered and placed on the table in front of her. Staff continued to serve other residents their lunch meals in the 100-unit dining room while Resident 26's lunch meal remained in front of her. At 12:16 PM, Resident 44 was served her lunch meal and began eating, while Resident 26's meal remained untouched due to the lack of staff assistance. A staff member did not begin assisting Resident 26 until 12:20 PM, 14 minutes after her meal was delivered. Additional observation of the 100-nursing unit dining room revealed Resident 58 seated at a table with Resident 57. Resident 57 was served her lunch meal at 12:09 PM and began eating immediately. Resident 58 did not receive her lunch meal until 12:22 PM, 13 minutes later, by which time her tablemate had finished eating. A review of Resident 31's clinical record revealed diagnosis which included generalized osteoarthritis, neuralgia (severe, sharp pain that follows the path of the nerve), and neuritis (inflammation of the nerves). Review of Resident 31's physician orders revealed an order dated July 6, 2024, for Bio freeze External gel 4% (gel used to treat minor aches and pains of the muscle/joints), apply to left foot topically four times a day for pain. On December 21, 2024, at 12:28 PM, Employee 3 (a licensed practical nurse) was observed in the 100-nursing unit dining room, during the lunch meal, repositioning Resident 31's wheelchair, removing her left sock, and applying Bio freeze gel to her left foot. This procedure was conducted in the dining room's common area, in the presence of multiple residents, and during the lunch meal service. This action did not afford Resident 31 privacy or dignity, as the procedure was performed in a public space and inappropriately timed during the meal service. During an interview conducted on December 23, 2024, at 10:45 AM the Nursing Home Administrator and Director of Nursing confirmed that the lunch meal service on the 100-nursing unit was not conducted in a manner that promotes each residents' dignity. They also confirmed that it is the facility's expectation for employees to provide Bio freeze applications in residents' rooms to ensure privacy and dignity. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, observation, and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice, for two residents out of 20 sampled residents (Residents 41 and 43). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person. A cardiac loop recorder monitors the heart's electrical activity and transmits data to physicians for managing conditions like arrhythmias (irregular heart rhythms). Proper documentation and care planning ensure: Monitoring for Symptoms: Identifying signs of device-related complications or abnormal heart rhythms. Timely Intervention: Staff can promptly address concerns or escalate issues to a physician. Comprehensive Care: Avoiding complications, such as infections at the implant site, through routine assessments and interventions. A review of the clinical record revealed that Resident 41 was admitted to the facility on [DATE], with diagnoses that included hypertension (elevated blood pressure) and cerebral infarction (stroke). During an observation of Resident 41's room on December 21, 2024, at 11:33 AM, a remote electronic transmitter device (a device that records and sends data from a device implanted in a person directly to the physician's office using Wi-Fi or cellular data) was located on the resident's bedside table. During an interview with Resident 41, a cognitively intact resident, he confirmed he had some type of small device that resembles a paperclip implanted in his chest. He reported that he had the device for over two years, before he was admitted to the facility. A review of Resident 41's hospital records obtained by the facility on December 23, 2024, at the request of the surveyor, revealed the resident underwent a loop recorder implant (a heart recording device, implanted in the body under the chest skin, that records heart rate and rhythm continuously. It monitors the heart's electrical activity and records and sends the data to the cardiologist via a remote transmitter device) placement on January 26, 2022. A review of Resident 41's Admission assessment dated [DATE], failed to document the presence of the loop recorder implant. Review of Resident 41's admission assessment, physician orders, and care plan revealed no documentation of the loop recorder or any corresponding care requirements, despite the potential for heart rhythm complications. Review of Resident 41's plan of care, in effect at the time of the survey ending December 23, 2024, identified that Resident 41 had a potential for complications with heart/circulation due to atrial fibrillation (an irregular heartbeat that reduces the heart's ability to pump blood through the body, which means you do not get enough oxygen) or other dysrhythmia's and hypertension. The facility failed to identify the presence of, or the care for, the resident's implanted loop recorder on the resident's current plan of care. A review of the clinical record revealed that Resident 43 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke), and the presence of a cardiac and vascular implant and graft. During an observation of Resident 43's room on December 21, 2024, at 1:15 PM, a remote electronic transmitter device was located on the resident's bedside table. A review of Resident 43's hospital records obtained by the facility on December 23, 2024, at the request of the surveyor, revealed the resident underwent a loop recorder implant placement on August 16, 2024. Review of a nurses note dated August 16, 2024, at 3:15 PM revealed the Electrophysiology report was received from the procedure. The resident had a loop recorder implantation completed. A review of Resident 43's IDT (Interdisciplinary Team) care conference summary dated August 26, 2024, failed to identify, and document the presence of the newly implanted loop recorder. A review of the weekly skin check tool dated September 2, 2024, (first skin check performed since resident's procedure on August 16, 2024) indicated that there were no new skin issued noted. Review of Resident 43's physician orders failed to identify the presence of, or care for, the residents loop recorder implant. Review of Resident 43's plan of care, in effect at the time of the survey ending December 23, 2024, identified that Resident 43 had a potential for complications with heart/circulation due to carotid stenosis, hypertension, and peripheral vascular disease. The facility failed to identify the presence of, or the care for, the resident's implanted loop recorder on the resident's current plan of care. The facility was unable to provide documented evidence that the loop recorder implant site was assessed after the implant procedure on August 16, 2024. Interview with the Nursing Home Administrator and Director of Nursing on December 23, 2024, at approximately 11:00 AM confirmed the facility's failure to assess and document the presence of the loop recorders, obtain appropriate physician orders, and include the devices in the residents' care plans. This failure placed Residents 41 and 43 at risk for undetected complications and inadequate care. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f) Medical records.

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide appropriate treatment and services to restore normal bladder function for one out of 20 residents sampled (Resident 21). Findings include: A review of facility policy titled Bowel and Bladder Management, last reviewed by the facility on August 8, 2024, revealed it is the facility's policy to ensure that each resident with bowel or bladder incontinence receives appropriate treatment and services to achieve or maintain as much normal elimination function as possible. The policy indicates residents deemed appropriate will have an individualized toilet schedule or bladder training program. Residents' comprehensive, individualized, person-centered care plan will be updated or revised to include the resident's bowel and bladder needs, goals, and personal preferences. A clinical record review revealed Resident 21 was admitted to the facility on [DATE], with diagnoses that included hydrocephalus (a condition where cerebrospinal fluid builds up in the brain, increasing pressure on brain tissue). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 22, 2024, revealed that Resident 21 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). The admission MDS assessment dated [DATE], Section GG0170F Mobility, indicated Resident 19 requires substantial and maximal assistance for transferring to the toilet. The admission MDS assessment dated [DATE], Section H0200A Urinary Toileting Program indicated a trial of toileting (e.g., scheduled toileting, prompted voiding, or bladder training) has not been attempted on admissions, entry, or reentry or since urinary incontinence was noted in the facility. A care plan identifying Resident 21 had the potential for complications with bowel and bladder related to current medical and physical status. The care plan goal indicated Resident 21 will be clean and dry with incontinence cares provided as needed through December 3, 2024. Interventions in place are incontinence care with incontinence episodes, medications and creams as ordered, and observation of changes in color, consistency, frequency, odor, discomfort, distention, fever, or confusion. A review of urinary incontinence tracking from dated November 24, 2024, through December 23, 2024, revealed Resident 21 was incontinent of urine on 76 occasions. During an interview on December 23, 2024, at approximately 10:00 AM, the Director of Nursing (DON) was unable to provide documented evidence the facility determined if Resident 21 was appropriate for an individualized toilet schedule or bladder training program. The DON confirmed the facility did not implement a bladder training or individualized toileting schedule to attempt to restore normal bladder functioning for Resident 19. The DON confirmed it is the facility's responsibility to ensure residents are provided appropriate treatment and services to restore normal bladder function. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and select facility policy, observation, and staff interview it was determined the facility failed to consistently provide respiratory care and supplemental oxygen, as ordered by the physician for one resident out of 20 sampled. (Resident 2) Additionally, the facility failed to store respiratory equipment in a sanitary manner for one resident out of three sampled receiving oxygen therapy (Resident 41). Findings included: A review of the facility policy titled Oxygen Therapy last reviewed by the facility in August 2024, revealed the E-tanks (oxygen cylinders which contain oxygen under pressure) are used to allow residents to be mobile in the facility and participate in therapy, activities, and meals. The licensed nursing staff will monitor oxygen delivery systems hourly. E-tanks will be changed when they are approximately 1/4 full (at the top of the red areas on the gauge). Tanks and concentrators are checked hourly and initialed on the checklist when in use. During an initial facility tour on December 21, 2024, at 11:33 AM, oxygen tubing attached to the oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream), in Resident 41's room was observed lying on the floor. This tubing, including the nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen), was not in use but was not stored in a sanitary manner and was observed lying directly on the floor. Interview with Employee 3 (licensed practical nurse) on December 21, 2024, at 11:40 AM confirmed the oxygen tubing and nasal cannula were improperly stored on the floor. A review of Resident 2's clinical record revealed the resident was admitted on [DATE], with diagnoses to include respiratory failure with hypoxia (not enough oxygen passes from the lungs to the blood, making it difficult to breath), and congestive heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A physician order dated February 19, 2024, specified oxygen at 3 liters/min via nasal cannula continuously for congestive heart failure. A quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 5, 2024, indicated the resident was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 represents severe cognitive impairment). The resident required extensive assistance from staff for activities of daily living and bed mobility. An observation conducted on December 21, 2024, at 12:40 PM revealed that Resident 2 was seated in his wheelchair in the 100-nursing unit dining room. The oxygen tank, located on the back of the wheelchair, was observed to be empty. This observation was confirmed by Employee 3. Interview with the Director of Nursing (DON) on December 23, 2024, at approximately 10:45 AM revealed the facility was unable to provide documented evidence that oxygen tanks and concentrators were monitored hourly and recorded as required by the facility's policy. The DON confirmed that Resident 41's oxygen tubing was not stored in a sanitary manner and that the facility failed to provide oxygen therapy as prescribed for Resident 2. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure a resident's drug regimen was free of unnecessary antibiotic drugs for one out of 20 residents sampled (Resident 19). Findings included: A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included disease of the spinal cord, unspecified (damage to the spinal cord that is not otherwise specified). Further clinical record review revealed Resident 19 had physician orders for a Foley catheter, 16 French, with a 30 ml balloon (a type of indwelling urinary catheter, rubber tube inserted into bladder to drain urine) related to neuromuscular dysfunction of the bladder. A clinical record review revealed no documented evidence the resident had experienced any symptoms of a urinary tract infection, such as fever, chills, mental changes/confusion, fatigue, nausea/vomiting, pressure in the lower part of the pelvis, or an increase in urination from October 1, 2024, through October 2, 2024. A urine culture laboratory report dated October 2, 2024, revealed Resident 19's urine tested positive for Escherichia coli (ESBL-extended-spectrum beta-lactamase, which is an enzyme produced by some bacteria that makes them resistant to many antibiotics) quantities between 10,000 and 100,000 colonies/ml. A physician progress note dated October 3, 2024, revealed Resident 19 is feeling tired, experiencing pain under her rib cage, and experiencing nausea. The note indicated the resident does not have fever, chills, or changes in gastrointestinal function. Furthermore, the note indicated laboratory work was completed yesterday and the resident's urine is positive for bacteria. The note indicated Resident 19 is probable for a urinary tract infection and has previously responded well to ceftriaxone 1 gm IM (intra muscular-injection into muscle) daily. A review of a medication administration record dated October 2024 revealed Resident 19 received two doses of ceftriaxone (an antibiotic medication) sodium injection solution reconstituted 1 gm once, on October 3, 2024, and a second dose on October 4, 2024. The medication was discontinued on October 4, 2024. The urine culture laboratory report dated October 2, 2024, revealed the Escherichia coli organism identified in Resident 19's urine is resistant to ceftriaxone antibiotic medication. A McGeer Criteria for Infection Surveillance checklist (a set of standardized guidelines used to define and identify healthcare-associated infections in long-term care facilities, particularly in elderly populations) dated October 4, 2024, revealed Resident 19 did not meet criteria for the use of antibiotic medication. During an interview on December 23, 2024, at approximately 9:45 AM, Employee 2, Infection Preventionist (IP), indicated Resident 19 did not meet criteria to receive antibiotic medication for a urinary tract infection on October 3, 2024. Employee 2, IP, confirmed that Resident 19 did not have a fever, leukocytosis, acute mental status change, or acute functional decline. During an interview on December 23, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure that residents' drug regimens are free of unnecessary antibiotic drugs. The DON confirmed Resident 19 received two doses of ceftriaxone (an antibiotic medication) sodium injection solution reconstituted 1 gm once on October 3, 2024, and a second dose on October 4, 2024. The DON was not able to provide documented evidence for the clinical rationale indicating the need for Resident 19 to receive a ceftriaxone sodium injection. 28 Pa. Code 211.2 (d)(3) Medical director. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on the review of clinical records and staff interviews it was determined the facility failed to demonstrate coordination of services in the development of the comprehensive plan of care between the facility and a Hospice agency for two residents out of three sampled residents receiving hospice care (Resident 34 and 47). Findings include: Review of Resident 34's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included end stage dementia (very severe cognitive decline and affects individuals by declines in mobility, increased incontinence, increased infection, trouble swallowing/eating, and severe confusion with increased anxiety) with need for hospice care/services (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure with goals to enable patients to be comfortable and free of pain) and dysphagia (difficulty swallowing). A review of Resident 34's comprehensive person-centered plan of care indicated the resident had signs and symptoms of overall declining conditions and medical diagnosis of end stage dementia with disease process progression and need for hospice care with a goal for the resident to remain comfortable with physical, psychosocial, spiritual, so that life is neither hastened nor prolonged but follows residents process of concluding life. Planned interventions included hospice services, observe for factors that may affect resident's comfort and responses to interventions, observe for end of life needs and review with MD, representative, family for optimizing care, discontinue weights, and allow resident to refuse medications. A review of the clinical record revealed that Resident 34 passed away at the facility on December 22, 2024, at 6:00 PM. Resident 34's comprehensive person-centered plan of care (POC) failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis. An interview with the Nursing Home Administrator (NHA) on December 22, 2024, at 10:30 AM, confirmed the facility failed to ensure that Resident 34's comprehensive person-centered POC was coordinated and integrated with hospice services. A review of Resident 47's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included end stage Parkinson's disease (includes severe motor symptoms and cognitive issues like dementia and may have severe posture issues that require a wheelchair, and may be bedridden, increased risk of injuries, and infections) with need for hospice care/service to maintain comfort. A review of Resident 47's comprehensive person-centered plan of care indicated the resident had signs and symptoms of an overall declining condition and medical diagnosis of end stage Parkinson's disease with disease process progression and need for hospice care with a goal for the resident to remain comfortable with physical, psychosocial, spiritual, so that life is neither hastened nor prolonged but follows residents process of concluding life. Planned interventions included hospice services, observe for factors that may affect resident's comfort and responses to interventions, observe for end of life needs and review with MD, representative, family for optimizing care, discontinue weights, and resident may refuse medications. Through survey ending December 23, 2024, Resident 47's comprehensive person-centered POC failed to demonstrate coordination of services and integration between the facility/interdisciplinary team and Hospice agency. An interview with the Nursing Home Administrator (NHA) on December 23, 2024, at 10:33 AM, confirmed that the facility failed to ensure that Resident 47's comprehensive person-centered POC was coordinated and integrated with hospice services. 28 Pa. Code 201.21(c) Use of outside resources 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on observation and staff interview it was determined the facility failed to ensure that staff followed proper infection control techniques while passing medications to one of three residents (Residents 38) on the 200 Hall nursing unit. Findings included: An observation on December 22, 2024 at 9:13 AM revealed Employee 1 LPN (licensed practical nurse) was administering morning medications to Resident 38 on the 200 Hall nursing unit. Employee 1 was opened a bottle of calcium tablets and the employee used her bare hand without performing hand hygeine to block the pills from coming out of the bottle, touching the pills, and then picked up the the calcium pill with her ungloved hand and without performing hand hygiene or donning gloves, placed it in Resident 38's medication cup. Further observation revealed the employee knocked over the medication cup where two pills had spilled out on to the medication cart. The employee did not dispose of those pills but picked them up off the medication cart, with ungloved hand and without performing hand hygiene or donning gloves, and placed them back into the medication cup. The employee proceeded to administer the medications to Resident 38. The employee failed to wash her hands after administering the medications. Interview with the Director of Nursing on December 22, 2024, at approximately 11:00 AM confirmed that Employee 1 failed to follow proper infection control measures prior to the administration of these medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records and staff interview it was determined the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of one resident out of 20 residents sampled (Resident 10). Findings include: A review of Resident 10's clinical record revealed the resident was transferred to the hospital on December 5, 2024, and returned to the facility on [DATE]. There was no documented evidence the facility provided Resident 10 and/or her representative written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed-upon rate during a hospitalization ) at the time of transfer. Interview with the Nursing Home Administrator (NHA) on December 22, 2024, at approximately 1:00 PM confirmed that the facility was unable to provide documented evidence indicating Resident 10 and/or Resident 10's representative was provided the facility's bed hold policy upon hospital transfer. 28 Pa Code 201.18 (e)(1) Management. 28 Pa Code 201.29 (b) Resident rights.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of two resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During the initial tour of the food and nutrition services department with the foodservice director (FSD) conducted on January 9, 2024, at 10:00 AM the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness were identified: There was a build-up of debris in the ceiling light shields located above the two-door refrigerator, trayline, handwashing sink, spice rack area, and food preparation area were dust covered. The ceiling vents and ceiling blocks in these areas were also dust covered. The hood vents located above the stoves had a thick layer dust and were in need of cleaning. The perimeter of the floors throughout the kitchen were visibly soiled and had an accumulation of debris. Uncovered bowls of applesauce were being stored in the roll-in refrigerator. There was a build-up of a chalky brownish colored substance (identified by the FSD as limescale) on the outside surface of the dishwasher. The exterior surfaces of two garbage cans near the trayline were heavily soiled and in need of cleaning. The interior surface of several hot beverage mugs identified as clean were stained with a brownish colored residue. Interview with the foodservice director (FSD) at this time confirmed that the food and nutrition services department was to be maintained in a sanitary manner. The FSD also confirmed that at the present time the steamer (used to cook vegetables and other food items), the upper portion of the convection oven, and the trayline steamtable (one of five wells not heating up) needed repair. The FSD confirmed that a plan to cook items that would normally be cooked in the steamer on the stove top was in place. Interview with the administrator on January 9, 2024, at approximately 11:30 AM confirmed that the top convection oven has not been working since March 2023 and the steamer has not been working since April 2023. The steamtable was identified as needing repair on December 30, 2023. The administrator noted that new equipment was ordered and expected to be installed on February 23, 2024. Observation of the 100 nursing unit pantry on January 10, 2024, at 12:20 PM revealed a partially eaten breakfast tray on the counter and dirty mugs and plastic cups in the pantry sink; there was a build-up of a chalky brownish substance adhered to the dispensing spout and drip tray of the automatic ice dispenser; and there was a black substance on the end of the condensation hose of the automatic ice dispenser. Observation at this time also revealed a utility cart with five partially eaten breakfast trays in the hallway located between the resident lounge and the resident pantry. Interview with the administrator on January 10, 2024, at 1:15 PM confirmed that resident meal trays were to be timely collected and returned to the food and nutrition services department following each meal and resident pantry areas were to be maintained in a sanitary manner to prevent potential contamination of food and maintain acceptable practices for food storage items. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on a review of clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide care in a manner respectful of each resident's dignity for one resident (Resident 1), and failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by two residents out of 11 sampled (Residents 12 and 11). Findings include: A review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which have included malignant neoplasm of the prostate, chronic kidney disease, diabetes, COVID-19, bronchopneumonia, and clostridium difficile [C-diff] (a bacterium infection that causes an infection of the colon). A review of a nurses progress note dated February 11, 2024, at 1:19 AM, revealed that the resident was positive for C - diff, and was placed on contact precautions, and began treatment, Vancomycin (antibiotic). Observation on February 22, 2024, at approximately 11:20 AM, revealed that a metal apron on the wall outside the resident's room, 101, containing personal protective equipment (PPE) supplies. Continued observation revealed 2 paper signs taped on the door to the resident's room. The first sign noted C-Difficile requires special care with pink highlighted words, handwashing only and a line drawn to the information stating that the C-diff spores are not killed by alcohol - based hand sanitizer. The second sign read Contact precautions. A second observation on February 22, 2024, at approximately 12:40 PM, that the above noted two signs remained posted on the door to the resident's room. Interview with alert and oriented Resident 1 on February 22, 2024, at approximately 1:50 PM, revealed that the resident was aware of his diagnosis of c-diff, treatments, and safety precautions, but verified that he would not like that information shared with others as noted on the signs on the door to his room. Interview with the Nursing Home Administrator (NHA), on February 22, 2024, at approximately 2:10 PM, confirmed that signs identifying a individual medical condition, or resident care needs, should not have been placed on the resident's door, visible to others. During an interview with Resident 11 on February 22, 2024, at 10:30 AM the resident stated that staff do not consistently answer call bells timely and provide care in a timely manner. Resident 11 stated that he prefers to get out of bed each day between 6:30 and 7:00 AM. Resident 11 stated that on Saturday February 17, 2024, agency nursing staff did not get him out of bed until 8:00 AM. Resident 11 reported that this morning, February 22, 2024, his wife (Resident 12) rang the call bell to request staff assistance to get out of bed. Resident 11 stated that the call bell rang greater than 30 minutes before staff answered her call bell and assisted Resident 12 out of bed. Interview with the nursing home administrator on February 22, 2024, at approximately 2:30 PM verified that all residents at the facility should be treated with dignity and respect. The NHA confirmed that the facility staff were to answer call bells promptly and provide assistance in a timely manner to promote each resident's quality of life. Refer F 880 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide care in a manner respectful of each resident's dignity for one resident (Resident 1), and failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' request for assistance as reported by two residents out of 11 sampled (Residents 12 and 11). Findings include: A review of Resident 1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which have included malignant neoplasm of the prostate, chronic kidney disease, diabetes, COVID-19, bronchopneumonia, and clostridium difficile [C-diff] (a bacterium infection that causes an infection of the colon). A review of a nurses progress note dated February 11, 2024, at 1:19 AM, revealed that the resident was positive for C - diff, and was placed on contact precautions, and began treatment, Vancomycin (antibiotic). Observation on February 22, 2024, at approximately 11:20 AM, revealed that a metal apron on the wall outside the resident's room, 101, containing personal protective equipment (PPE) supplies. Continued observation revealed 2 paper signs taped on the door to the resident's room. The first sign noted C-Difficile requires special care with pink highlighted words, handwashing only and a line drawn to the information stating that the C-diff spores are not killed by alcohol - based hand sanitizer. The second sign read Contact precautions. A second observation on February 22, 2024, at approximately 12:40 PM, that the above noted two signs remained posted on the door to the resident's room. Interview with alert and oriented Resident 1 on February 22, 2024, at approximately 1:50 PM, revealed that the resident was aware of his diagnosis of c-diff, treatments, and safety precautions, but verified that he would not like that information shared with others as noted on the signs on the door to his room. Interview with the Nursing Home Administrator (NHA), on February 22, 2024, at approximately 2:10 PM, confirmed that signs identifying a individual medical condition, or resident care needs, should not have been placed on the resident's door, visible to others. During an interview with Resident 11 on February 22, 2024, at 10:30 AM the resident stated that staff do not consistently answer call bells timely and provide care in a timely manner. Resident 11 stated that he prefers to get out of bed each day between 6:30 and 7:00 AM. Resident 11 stated that on Saturday February 17, 2024, agency nursing staff did not get him out of bed until 8:00 AM. Resident 11 reported that this morning, February 22, 2024, his wife (Resident 12) rang the call bell to request staff assistance to get out of bed. Resident 11 stated that the call bell rang greater than 30 minutes before staff answered her call bell and assisted Resident 12 out of bed. Interview with the nursing home administrator on February 22, 2024, at approximately 2:30 PM verified that all residents at the facility should be treated with dignity and respect. The NHA confirmed that the facility staff were to answer call bells promptly and provide assistance in a timely manner to promote each resident's quality of life. Refer F 880 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of clinical records and select facility incident reports, and staff interview it was determined that the facility failed to timely implement individualized safety measures/assistance devices during wheelchair transport to prevent accident and serious injury, a lower leg fracture, for one resident (Resident 69) out of five residents reviewed. Findings include: A review of the clinical record revealed that Resident 69 had diagnoses, which included [CONDITION(S)] (a chronic condition in which the heart does not pump blood as well as it should), spinal stenosis (narrowing of the spaces in the spine), and polyosteoarthritis (type of arthritis in which five or more joints are affected with joint pain). A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated July 13, 2022, indicated Resident 69 was cognitively intact with a BIMS (brief interview for mental status- section of MDS that assesses cognition) score of 14 (a score of 13-15 indicates cognitively intact), required extensive assistance of two staff for transfers, staff assistance for locomotion (mobility) in a wheelchair on and off the nursing unit, and was non-ambulatory. A review of a quarterly Fall Risk Screening Tool dated July 13, 2022 revealed that the resident was at risk for falls due to weakness. A review of the resident's care plan for the problem of activities of daily living deficit related to weakness initially dated July 16, 2020, indicated that the resident's goal was to function at the highest level possible within medical and physical capabilities. An intervention dated March 9, 2022, was noted for staff to to use total mechanical lift for the resident's transfers with the assist of two staff. The resident's current care plan, in effect on August 5, 2022, did not include planned intervention related to the resident's actual or potential need for staff assistance for wheelchair mobility. A review of a facility investigation report dated August 5, 2022, revealed that prior to supper on August 5, 2022, at 4:50 PM staff moved Resident 69 forward in the wheelchair to navigate peers gathering in hallway for supper. The resident placed her foot down, and her knee bent in regular direction approximately 30 degrees. The resident stated that it hurt, but no gross abnormality was noted. When staff asked the resident if she was okay the resident stated yes. Staff assisted the resident to the main dining room and she ate supper in no distress. The resident continued with no complaint until retiring to bed that evening, when she stated that her right knee was hurting. Staff provided the resident with Tylenol and muscle rub. There was no [CONDITION(S)], swelling, or bruising noted. She was able to move extremity and bend. At the time of the incident before supper on August 5, 2022, the resident stated I bent my knee, that hurt. The incident report noted Predisposing Environmental Factors as the multiple peers in one area, requiring navigation past one another and polyosteoarthritis. The immediate action taken by the facility was that the CRNP (certified registered nurse practitioner) was notified. Resident to have imaging (x-ray) in morning to rule out internal injury. Notify responsible party in morning due to late hour. IDT (interdisciplinary team) review noted bilateral leg rest with foot pedals in place while being pushed. A review of a facility incident report dated August 6, 2022 at 12:00 PM revealed Resident 69 was being pushed by staff through the main dining room door at lunchtime. The resident placed her right foot onto floor causing a small bend of the knee under the wheelchair. The resident was noted to be visibly upset stating that it hurt. Some [CONDITION(S)] below the patella (kneecap) noted. The incident report noted that the Predisposing Situation Factors as the resident self-propels in hallways in wheelchair utilizing her bilateral lower extremities, without foot pedals, using the handrails. The report noted that the resident had a similar occurrence last evening. The immediate action taken was that the resident was returned to her room and placed her in bed. The resident's extremity was elevated and ice applied. She was provided with as needed Tylenol, awaiting mobile x-ray to arrive for x-ray of right knee (called in last evening). IDT intervention must have foot pedals on upon departure of room. A nurses note dated August 6, 2022 at 8:16 PM noted that x-ray of knee was completed. A nurses note dated August 6, 2022 at 10:02 PM noted that x-ray results showed acute transverse fracture (broken perpendicular to its length) with mild anterior angulation of the proximal right tibia (shin). CRNP made aware. New order was noted for the resident to be non-weight bearing to right lower extremity (RLE) and must keep RLE straight at all times. Keep RLE elevated and ice every four hours for 20 to 30 minutes, Tylenol 650 mg every 6 hours and ortho clinic on Monday (August 8, 2022). Message left with responsible party to call facility for update. A nurses note dated August 8, 2022 at 9:20 AM indicated that the nursing staff spoke to CRNP. The CRNP changed mind and the resident was to be sent to emergency room for evaluation instead of ortho clinic. A nurses note dated August 8, 2022 at 11:17 PM noted the resident returned from the emergency room . X-ray of right leg showed a right proximal tibial (shin bone) fracture. The right leg has a knee brace to hold it straight. Brace to be worn at all times. May be removed for hygiene and then replaced. After the two incidents on August 5th and 6th, while being pushed by staff in the wheelchair the facility revised the resident's care plan, adding the intervention that when the resident was being pushed in her wheelchair, staff are to ensure foot pedals are down, and her feet are on the pedals on August 9, 2022. Interview was attempted with the resident during the survey of September 15, 2022, but the resident was groggy and sleepy throughout the day and did not fully respond to questioning. An interview with the director of nursing on September 15, 2022 at approximately 11:30 AM failed to provide evidence that the facility promptly implemented individualized effective safety interventions to prevent accidents and injury to the resident that occurred on two consecutive days under similar circumstances while staff were transporting/moving the resident in the wheelchair. 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services

Based on observation, a review of clinical records and select resident Unusual Occurrence Report/Investigative Guide reports and employee job descriptions and staff interview, it was determined that the facility failed to provide adequate supervision and implement effective safety interventions to prevent elopement by one resident (Resident CR2) and prolonged exposure to sun for one resident (Resident CR3), and to ensure safe transport of one resident (Resident CR1) out of 18 sampled residents. The facility further failed to maintain an environment free of potential safety hazards. Findings include: A review of a Driver and General Maintenance Job Description for Transportation revealed under Duties and Responsibilities: Assists residents in boarding and exiting vehicles to ensure safety, fastening seatbelts, using lifts, and fastening wheelchairs and other mobility equipment securely. The job description further indicated that the employee adheres to established safety and infection control regulations. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an Unusual Occurrence Report/Investigative Guide revealed that while out on an orthopedic appointment on March 31, 2015, Resident CR1's wheelchair rolled into a car and the resident's leg rest came in contact with the car. The resident had a right edematous ankle at the time of the incident as noted in one section of the report, but under the supervisor summary no right ankle edema at this time was noted. A notation on the report indicated that the most likely cause of the incident was that the protocol for safety Unusual Occurrence Report/Investigative Guide was not followed: the (wheelchair) brakes were not utilized. A review of a Progress Note dated April 2, 2015, revealed that the resident had slight edema in her right ankle. An x-ray was ordered and the results indicated that the resident may have a fracture. The resident was transported the the hospital emergency room for evaluation. The resident was complaining of pain below the knee in the lower leg and on the instep of her foot. An X-Ray revealed that the resident had a fracture in one of the bones in her foot. An interview with the Nursing Home Administrator on November 5, 2015, confirmed that Employee 1 (Facility Van Driver) failed to ensure that Resident CR1's safety while transporting the resident to an appointment, which resulted in the resident's wheelchair rolling into a parked vehicle and injury to the resident. During an initial observational tour of the 300 unit on November 3, 2015, at 10:30 a.m. a spray can of surface and deodorant disinfectant was observed in an unlocked bathroom. A bottle of Virex II 256 Disinfectant spray and two cans of surface and deodorant disinfectant were observed in an open closet in the residents' shower room. The cans were marked with a hazard warning. Push pins were observed on the cork bulletin boards on the 200 and 300 units. The Director of Nursing confirmed during interview on November 4, 2015, at 2 PM that these potentially hazardous items should be secured and not accessible to residents. A review of facility policy Wanderguard Bracelet with a review date of May 25, 2015, revealed that residents who are assessed as high risk for elopement from the facility will have a wanderguard placed (on the wrist, ankle, or wheelchair). Placement of the wanderguard will be checked every shift and initialed in the Treatment Administration Record (TAR). The wanderguard battery will be checked monthly to assure it is functioning. If the wanderguard is not functioning properly, batteries will be replaced or a new bracelet will be given. Review of the clinical record of CR2 revealed a [AGE] year old resident with diagnoses, that included Cerebral Vascular Attack (CVA-stroke) with right sided [DIAGNOSES REDACTED] (weakness), brain death, late effect cerebrovascular disease due to cerebrovascular disease, and convulsions. Review of the annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific intervals to identify resident care needs) dated December 8, 2014, revealed that the resident was cognitively impaired. Resident CR2 was non-ambulatory, used a wheelchair for mobility and required extensive assistance of staff for activities of daily living. Review of a facility documentation provided to the State Survey Agency revealed that on May 17, 2015, Resident CR2 was assisted from her bed and placed in her wheelchair at 4:30 PM. She was not seen again until 5:15 PM on May 17, 2015, when staff from another building on the facility's campus noticed her wheeling herself on the side of their building and notified the resident's nursing unit. The facility's report of the event also indicated that the resident's wanderguard did not sound when she exited the building. On November 5, 2015, at approximately 11:00 AM, the facility measured the distance from their front door (where the resident exited) to where she was located, which was a total of 778 feet (approximately 1/8 mile). The director of nursing, when interviewed on November 5, 2015, reported that the facility does not assess residents for risk of elopement. Review of monthly wanderguard tests revealed that the tests were not conducted for the months of January 2015, February 2015, March 2015, April 2015, and May 2015, and not until June 20, 2015, after the resident's elopement from the facility. Interview with the nursing home administrator and director of nursing on November 4, 2015, at approximately 2:00 PM confirmed that appropriate supervision of the resident was not provided to prevent Resident CR2's elopement. A review of the clinical record revealed that Resident CR3 had diagnoses, which included cerebrovascular accident with [DIAGNOSES REDACTED] (stroke) and seizure disorder. A annual Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired and required staff assistance for all activities of daily living. Review of a nurses' note dated August 15, 2015, at 5:33 p.m., revealed that Resident CR3 was found on the patio area (Unit 100) at 5:00 p.m. unresponsive. The resident's temperature was 102.4 degrees Fahrenheit (normal body temperature 98.6 degrees Fahrenheit). Other vitals included: pulse rate was 138 (elevated) respiration was 24 (decreased), SPO2 was 87% (decreased oxygen saturation rate), and blood pressure was 126/49. The resident was noted to be very warm. Ice packs and cool washcloths were applied to the forehead, neck, axillary (armpit), and groin areas to reduce the temperature. The resident was transported to the emergency room for evaluation. Review of the emergency room report dated August 15, 2015, indicated that the resident presented hyperthermic (heat related illness) and unresponsive from the facility. The resident was found to have been outside for an extended period of time in the heat and the direct sun. The resident was admitted to the hospital with [REDACTED]. Observation of the patio on unit 100 on November 3, 2015, at 1:45 p.m., revealed that the patio was located adjacent to the unit 100 lounge area. A steel fire door provided entry to the patio area. Once on the patio, a call bell would have to be activated to regain entrance to the facility. Interview with employee 5 (a restorative nurse aide) on November 3, 2015, at 2:00 p.m., confirmed that Resident CR3 required staff assistance to get through the door to go on the patio. Employee 5 confirmed that the resident would often go on the patio for sun. Further review of the clinical record and facility investigations revealed no documented evidence that the facility had completed an investigation into the aforementioned incident. There was no documented evidence that the facility provided adequate supervision of the cognitively impaired resident to ensure staff's ability to provide a timely respond to the resident in the event of an emergency. There was no evaluation of the facility's decision for leaving a cognitively impaired resident alone on the patio and for an extended time period. Interview with the director of nursing (DON) on November 4, 2015, at 10:00 a.m., confirmed that there were no procedures or protocols in place addressing precautions to be taken to avoid dangers of over exposure to the sun/heat and/or cold when the residents were outside or for supervision of cognitively and physically functionally impaired residents. The DON confirmed that there was no evidence that adequate supervision was provided to prevent prolonged sun and heat exposure to the resident, which resulted in a [DIAGNOSES REDACTED]. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 5/13/15, 11/14/14 28 Pa. Code 201.18(e)(1) Management Previously cited 11/14/14 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of clinical records, select incident/accident reports and facility policies and procedures and staff interview, it was determined that the facility failed to provide planned sufficient staff assistance to prevent a fall with injury for one resident out of 18 sampled ( Resident 25 ). Findings include: The facility's policy/procedure for "Falls and Injury Prevention Statement, " which required all staff members to sign, and was implemented in May 2010 stated that staff members are to be aware if a resident is a 1 or 2 person assist or a mechanical lift for transfer. This is noted on transfer cards located on place cards outside the residents room.(One dot indicated one staff member for transfer, two dots indicated two staff members are needed for a resident's safe transfer). Review of the clinical record of Resident 25 revealed that she has multiple [DIAGNOSES REDACTED]. She had a physician's orders [REDACTED]. Her Minimum Data Set quarterly assessment dated [DATE], indicated that she required extensive assistance of two persons for all transfers and ambulation. Her care plan reviewed by the facility in January 2010 and again in April 2010, identified her with impaired physical mobility related to her CVA with right sided [DIAGNOSES REDACTED]. Care planned interventions included the assistance of two persons for all transfers/ambulation. Review of nursing documentation and an incident/accident report revealed that on May 2, 2010, at 5:50 AM the resident sustained [REDACTED]. The facility's investigation noted that Employee 1 (a nurse aide) ambulated the resident, by herself, into the bathroom utilizing a gait belt (without the assistance of a second person as care planned). The resident's knees "gave out" and she fell to the floor. An ecchymotic area was noted on her right hand and an abrasion to her right hip. Later in the morning the resident was unable to place weight on her right foot. The physician was notified with orders to x-ray the right foot. Review of the x-ray report indicated that a fracture could not be excluded particularly of the right fibula; however according to the Assistant Director of Nursing interviewed on January 11, 2011 at 1:45 PM, the resident did sustain a fracture of her right ankle. Further review of the clinical record revealed that on May 3, 2010, new orders were received from the physician that included the use of the mechanical lift for all her transfers with the assistance of two staff, a splint to her right foot with no weight bearing on her right leg and a schedule two narcotic ( Percocet 5/325 ) for pain management. This significant change was noted on the resident's MDS assessment dated [DATE], which indicated that the resident was now non-ambulatory in her room. 28 Pa. Code 211.12 (d ) (5 ) Nursing services Previously cited on 3/5/2010, 4/12/2010, 4/16/2010 28 Pa. Code 211.11 (d) Resident care plan Previously cited on 3/5/2010, 4/12/2010,