Every finding on record at Fairview Manor

Based on review of facility documentation, clinical record, observations and staff interviews, it was determined that the facility failed to implement sufficient safety interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of 17 residents reviewed who were at risk for elopement with secure care devices from the facility (Resident R1).Findings include: Resident R1's clinical record revealed diagnoses to include: bipolar disorder, unspecified psychosis, impulsiveness, suicidal and homicidal ideations, auditory and visual hallucinations and a re-admission date of 6/29/26, from a hospital stay related to mental health concerns.Review of Resident R1's elopement evaluations revealed the following: Evaluation dated 5/27/26 with a score of 8.0; evaluation dated 6/29/26 with a score of 9.0; an evaluation dated 7/2/26 with a score of 7.0; evaluation dated 7/9/26 with a score of 10.0; and an evaluation dated 7/20/26 with a score of 10.0. A score of 1.0 or higher indicated a risk of elopement. Review of information submitted by the facility dated 7/8/26, revealed that Resident R1 had exited the building and was walking towards the parking lot. Staff saw the resident at the top of the driveway, turning on to the road and proceeded to go after him. When asked why he left, he stated No reason, I just wanted to see how far up I could go. The resident is a known risk for elopement and has an order to wear a secure care bracelet. Upon returning to the building the secure care bracelet was not present on his body. When asked what happened to his bracelet, he stated he had removed it with a dinner knife that he had retrieved from the dining room. The secure care bracelet was later found in the silverware container in the dining room. The resident was ordered to have a one-on-one sitter to begin immediately.Review of information submitted by the facility dated 7/17/26, revealed that Resident R1 had cut his secure care bracelet off and exited the facility. He was found on a road away from the facility up a hill that intersects with another road approximately a quarter of a mile from the facility. The resident has a history of elopement. A one-on-one sitter was an intervention to prevent elopements. The sitter reported he appeared to be asleep in his bed with the secure care bracelet intact and on his left ankle at approximately 8:45 p.m. The sitter reported that he/she went to assist with another resident on the hall and when they returned less than 15 minutes later, [Resident R1] was not in their room. Went to search for Resident R1, another staff member who had left the facility for the day, was bringing Resident R1 back down the driveway. When asked why he left, [Resident R1] stated he just wanted to see how far he could get. When asked what happened to his bracelet, he stated he had removed it with a butter knife that he had retrieved from the dining room prior to exiting the building as he only receives a plastic fork and spoon with his meals. Resident R1 had obtained a knife from the dining area. Review of Resident R1's progress notes revealed the following:6/29/26 3:22 p.m. Resident readmitted to the unit, secure care applied to left ankle. Wandering off/unit6/30/26 12:16 p.m. (Physician assessment note) Resident was admitted to behavioral health hospital on 6/4/26 and returned to the facility on 6/29/26. Resident had voiced suicidal ideations and requested to go to the hospital for help7/1/26 2:45 p.m. Wandering in unit, going on/off dining/kitchen area. Resident cut secure care twice and secure care re-applied each time.7/2/26 11:55 a.m. Elopement evaluation: resident exhibits wandering behavior; resident has a cognitive impairment or diagnosis with impaired judgement; history of attempted leaving the facility without informing staff.7/5/26 12:35 p.m. Dietary aide reported that resident was outside walking up road, up the hill. Stated he just wanted to see how far he could get, his secure care was in his room and noted to resident trash7/5/26 12:40 p.m. Secure care reapplied to right ankle, nurse left room, re-entered room to remove any sharp objects and resident was observed using butter knife to try and remove new secure care, knife removed. 7/5/26 1:10 p.m. Resident walked into suite mate's room and took his butter knife off his tray, nurse aide took butter knife from resident7/5/26 5:50 p.m. Resident constantly going into other residents rooms, arguing with staff, not listening to staff directions7/7/26 11:57 p.m. Resident continues to enter other residents rooms and take things, continues to ignore staff/residents requests of staying out of other rooms.7/8/26 5:03 a.m. Resident up wandering at 2:45 a.m. and attempting to go into another resident room7/8/26 7:26 p.m. Resident was screaming for help at the front door that Resident R1 had cut off his secure care and was heading for the street. Staff responded and brought him back inside. Resident was already at the street walking toward the lake. Held out his leg and said here, put another one on. Secure care was found in the silverware container where he used a utensil to cut his secure care off before he went outside. He returned to his unit and his room but shortly afterward he was roaming the halls7/9/26 9:42 a.m. Elopement evaluation score of 10.07/9/26 2:05 p.m. Resident continues with strange behaviors7/11/26 4:27 a.m. Registered Nurse (RN) was informed by Licensed Practical Nurse (LPN) that the resident had cut secure care bracelet off and requesting a new device be put on resident. The device was found on bed, resident not in room and found sleeping in a bed that was not his own. Secure care placed on resident before waking.7/11/26 11:02 a.m. Resident seen by RN walking up hallway towards the front entrance of the building, writer attempted to redirect resident back towards D hall while heading towards him, resident replied and said hold on one second and kept walking towards the door. This writer had to run towards resident to try to prevent him from leaving the building. Resident made it out of both front doors and was combative when staff went to redirect him back inside. Once back inside this writer noticed the secure care and a pair of scissors sitting on the nurse's station. Another secure care reapplied. 1 on 1 initiated.7/12/26 1:55 p.m. Writer informed by staff while taking resident for a walk around the facility resident tried to hurry and run outside of the front door while other resident's family were leaving. Aide was able to interfere and stop him7/14/26 8:14 a.m. Resident observed putting butter knife in pocket, knife confiscated, nurse stood between resident and silverware, resident again tried to take knife, knife confiscated, resident asked to leave dining room, resident left without incident.7/14/26 8:28 a.m. Resident observed taking butter knife from in front of another resident, other resident didn't say anything about resident taking knife, knife confiscated, resident continued to round dining room, resident observed taking another butter knife from another resident, knife confiscated, resident asked to leave dining room, resident left dining room without incident.7/14/26 8:59 a.m. Resident observed in dining room looking for butter knife, resident bus cart moved into dish room, resident asked to leave dining room, resident returned and immediately went to dish room, dish room locked, resident asked to leave dining room.7/17/26 7:04 a.m. Resident caught attempting to go out front door. When checked for secure care, resident had cut it off (he had it on all 3rd shift). When questioned where secure care was, he stated it was in his room. Secure care found under pillow on bed with 2 butter knives which were used to cut it off. New secure care strap and box reapplied.7/17/26 9:17 p.m. On July 17th resident had a sitter with him for the second shift. At 8:45 p.m. the sitter saw resident sleeping in his bed. Sitter allowed him to sleep and went to help other CNA's [Certified Nurse Aides] on the floor with their work. Fifteen minutes later he returned to find Resident R1 gone. Resident had stolen a butter knife out of the dirty dish bin and cut off his secure care band. Sitter immediately went to the front door to look for him. A car drove up to the front entrance and resident was in the car7/19/26 2:57 p.m. Resident seen headed towards the front door. Staff went after him to see what he was doing. Resident was trying to leave the building. His secure care bracelet was not present. Resident reported that he found a knife in the silverware drawer in the dining room and cut it off. Secure care was replaced.7/20/26 Two Elopement evaluations this date each with score of 10.0Observations on 7/22/26, at 9:35 a.m. in the B Unit Dining room revealed 11 table settings that included butter knives in the dining room on tables. A Unit Dining room had 13 table settings with butter knives. Observations on 7/22/26, at 11:05 a.m. at the C Unit Nurse's Station revealed a pair of scissors, a screwdriver, and pliers accessible to anyone passing through that area.Observations on 7/22/26, at 11:00 a.m. at the B Unit Nurse's Station revealed a pair of fingernail clippers accessible to anyone passing through that area.Observations on 7/22/26, at 12:13 p.m. on the B and D Unit Dining Rooms revealed the dirty dish cart in the dining area with knives present.Interview with the Nursing Home Administrator on 7/22/26, at 12:40 p.m. confirmed that knives shouldn't be left unattended and there was no policy regarding one to one guidelines and that the one to one should be within arm's length and within sight of the resident. An Immediate Jeopardy (IJ) situation was identified to the NHA on 7/22/26, at 2:23 p.m. and the IJ template was provided to the NHA, related to Resident R1's elopement from the facility. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of adequate safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. On 7/22/26, at 4:41 p.m. an acceptable immediate action plan was approved which included the following interventions: 1:1 supervision in place to prevent elopement and access to knives and scissorsResident room checked for knives and scissorsCharge nurse will check resident room [ROOM NUMBER] times per shift for knives and scissorsNurses stations screened for cutting tools, any items found were removedKnives were removed from all kitchenettes outside of meal times, during meal times, only those residents requesting knives will be provided one.All residents at risk for elopement re-evaluated for risk and interventionsAll Secure Care devices checked for placement and functionAll other residents will have elopement risk assessments re-evaluated, anyone found to be at risk will have proper interventions in placeAll current staff in the facility will be educated on 1:1 expectations, Elopement policy and knife and scissor safety immediately on 7/22/2026. All staff incoming shifts will be educated as they arrive all scheduled staff will be educated by 7/23/26Emergency QAPI meeting will be completed today 7/22/2026. After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 7/23/26, at 1:54 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and elopement prevention interventions were effectively implemented in the facility. Findings include: The NHA's job description revealed that the NHA's position summary included: directs the overall operations of the care community in accordance with current local, state, and federal regulations governing long-term care in-order to ensure the highest level of quality care is provided to each resident. The DON's job description revealed that the DON's position summary included: manages and directs resident care within the nursing department in-order to maintain resident standards of care and ensure that each resident functions at his/her highest level. The findings in this report identified that the facility failed to consistently supervise and maintain all safety interventions to prevent elopement for their residents, and the NHA and the DON failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed.Refer to F68928 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(c) Nursing Services28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and facility policy, and staff interviews, it was determined the facility failed to ensure physician medication orders were entered in the clinical record upon admission for the resident's immediate care needs for one of one residents (Resident R1). Findings include: Review of facility policy entitled Physician Services dated 12/1/25, indicated All orders must be recorded in the resident's clinical record. Review of Resident R1's clinical record revealed an admission date of 4/22/26, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), end stage renal disease (a diseases where the kidneys no longer work to meet the body's needs), and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R1's physician's orders faxed from the discharging facility to the receiving facility revealed a fax date and time stamp of 4/22/26, at 10:54 a.m. Review of Resident R1's census list (area in the clinical record that shows the date and time of admission) revealed that he/she was admitted to the facility on [DATE], at 1:50 p.m. over two and a half hours after the receiving facility received his/her physician's orders. Review of Resident R1's physician's orders from the discharging facility revealed only three medications were ordered morphine 20 mg/ml (milligrams/milliliter) place 0.25 ml under tongue every one hour if needed for discomfort, lorazepam place 0.5 ml under the tongue every one hour if needed for anxiety and acetaminophen 325 mg take two tablets every four hours as needed for headache or fever. Review of the facility's physician's orders for Resident R1 lacked evidence that medication orders were entered into Resident R1's clinical record in a timely manner. During an interview on 6/18/26, at 3:19 p.m. the Director of Nursing confirmed that the physician's orders for Resident R1 were not entered into their clinical record in a timely manner. He/she also confirmed that Resident R1's physician orders should have been entered into the clinical record in a timely manner. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical records, and hospital records, and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards of practice by failing to follow physician-ordered blood glucose monitoring for one of seven residents (Resident R1) reviewed, which required hospitalization and actual harm resulting in Hyperosmolar Hyperglycemic State (a serious complication of diabetes characterized by extremely high blood sugar levels and severe dehydration, often leading to confusion and other mental status changes requiring immediate medical attention to prevent life-threatening outcomes). Findings include: Review of the facility policy Nursing Policy and Procedure dated 12/02/25, indicated a combination of resource material is used to reflect nursing policy as it pertains to resident care. It also indicated that nurses follow these guidelines in addition to specific physician orders when rendering care. Clinical record review revealed Resident R1 was admitted to the facility on [DATE], with diagnoses to include protein calorie malnutrition, diabetes mellitus, malignant neoplasm of the bladder (uncontrolled growth of abnormal cells in the bladder), dehydration, hypo-osmolality (condition where blood plasma, have a lower concentration of solutes), hyponatremia (low sodium in the blood) and hypokalemia (low potassium in the blood). Review of Resident R1's pre-admission hospital physician's progress note dated 3/28/26, for assessment and plan indicated that under diabetes mellitus - Since appetite is poor we will hold glipizide (a diabetes medication) for now. Will order Accu-Checks (blood glucose monitoring) and correction scale and start insulin if needed if sugars are high. Review of Resident R1's admission physician orders dated 4/01/26, included an order to please check resident b/g (blood glucose) in the AM and HS (bedtime) for diabetes. Review of Resident R1's Medication Administration Record (MAR) for April 2026, lacked evidence of blood sugar monitoring twice daily. Review of Resident R1's Impaired Nutritional Status care plan dated 4/06/26, revealed interventions that included, monitor for signs and symptoms of hyper/hypoglycemia and will administer accu -checks (blood sugar levels) and intervene as ordered. Review of progress notes dated 4/28/26 indicated Resident R1 had been lethargic all day, and family had asked about how Resident R1's blood sugars were and that Licensed Practical Nurse (LPN) Employee E1 informed the family member that blood sugars were not being checked. Blood sugar was checked and it was 581. Physician was notified and family requested resident sent out for evaluation. Review of progress note dated 4/29/26, revealed that Resident R1 had been admitted to the Intensive Care Unit with diagnoses of Hyperosmolar Hyperglycemic state, Urosepsis (serious condition related to untreated urinary tract infection spreads to the kidneys), Hyperglycemia (elevated blood sugar level), Hypernatremia (elevated blood sodium level) and hypercalcemia (elevated blood calcium level). During an interview on 5/04/26 at 11:45 a.m. the Director of Nursing (DON) confirmed that the facility was unable to provide evidence that the physician ordered blood glucose checks were completed as ordered for Resident R1 which resulted in hospitalization with Hyperosmolar Hyperglycemic state. The DON also confirmed that the blood glucose order was transcribed incorrectly by Licensed Practical Nurse (LPN) Employee E4 into the electronic health record for Resident R1 and therefore was not on the MAR. LPN Employee E4 was educated on the correct ordering procedure along with the licensed nursing staff. Interview with Registered Nurse (RN) Employee E2 on 5/04/26, at 1:45 p.m. indicated that he/she was provided education on entering an order for blood sugars into the electronic health record that will be visible on the MAR. Interview with RN Employee E3 on 5/04/26 at 1:50 p.m. indicated that he/she was provided education on entering orders for blood sugars into the electronic health record that will be visible on the MAR. Interview with Licensed Practical Nurse (LPN) Employee E4 on 5/04/26 at 2:00 p.m. indicated that he/she was provided education on entering orders for blood sugars into the electronic health record that will be visible on the MAR. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for a resident requiring blood sugar monitoring to meet a resident's needs for one of seven residents reviewed (Resident R1) resulting in hospitalization and actual harm of Hyperosmolar Hyperglycemic State (a serious complication of diabetes characterized by extremely high blood sugar levels and severe dehydration, often leading to confusion and other mental status changes requiring immediate medical attention to prevent life-threatening outcomes). Findings include: Review of facility policy entitled, Care Plan Policy dated 12/2/25, indicated The Manor will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs . Clinical record review revealed Resident R1 was admitted to the facility on [DATE], with diagnoses to include protein calorie malnutrition, diabetes mellitus, malignant neoplasm of the bladder (uncontrolled growth of abnormal cells in the bladder), dehydration, hypo-osmolality (condition where blood plasma, have a lower concentration of solutes), hyponatremia (low sodium in the blood) and hypokalemia (low potassium in the blood). Review of Resident R1's pre-admission hospital physician's progress note dated 3/28/26, for assessment and plan indicated that under diabetes mellitus - Since appetite is poor we will hold glipizide (diabetes medication) for now. Will order Accu-Checks (blood glucose monitoring) and correction scale and start insulin if needed if sugars are high. Review of Resident R1's admission physician orders dated 4/01/26, included an order to please check resident b/g (blood glucose) in the AM and HS (bedtime) for diabetes. Review of Resident R1's Medication Administration Record (MAR) for April 2026, lacked evidence of blood sugar monitoring twice daily. Review of Resident R1's Impaired Nutritional Status care plan dated 4/06/26, revealed interventions that included, monitor for signs and symptoms of hyper/hypoglycemia and will administer accu checks (blood sugar levels) and intervene as ordered. As of 4/28/26, a period of 22 days accu checks were not implemented. Review of progress notes dated 4/28/26 indicated Resident R1 had been lethargic all day, and family had asked about how Resident R1's blood sugars were, Licensed Practical Nurse (LPN) Employee E1 informed the family member that blood sugars were not being checked. Blood sugar was checked and it was 581. Physician was notified and family requested resident sent out for evaluation. Review of progress note dated 4/29/26, revealed that Resident R1 had been admitted to the Intensive Care Unit with diagnoses of Hyperosmolar Hyperglycemic state, Urosepsis (serious condition related to untreated urinary tract infection spreads to the kidneys), Hyperglycemia (elevated blood sugar level), Hypernatremia (elevated blood sodium level) and hypercalcemia (elevated blood calcium level). During an interview on 5/05/26, at 2:50 p.m. the Director of Nursing (DON) confirmed that the plan of care for Resident R1's impaired nutritional status with interventions that included monitoring for signs and symptoms of hyper/hypoglycemia and to administer accu-checks were not implemented resulting in hospitalization and actual harm of Hyperosmolar Hyperglycemic State. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 25 residents reviewed (Residents R12, R9, and R10).Findings include: Resident R12's clinical record revealed an admission date of 7/31/25, with diagnoses that include malignant neoplasm of lower lobe, left bronchus or lung (lung cancer), and major depressive disorder (a serious mood disorder that causes feelings of sadness, loss of interest in daily activities, emotional and physical problems that impact daily life). Resident R12's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R12 and/or his/her representative. During an interview on 4/9/26, at 2:09 p.m. the Nursing Home Administrator (NHA) and Director of Nursing confirmed that the clinical record for Resident R12 lacked evidence that a written summary of the baseline care plans, and order summaries were provided to the resident and/or their representative upon admission to the facility. Resident R9's clinical record revealed an admission date of 5/23/25, with diagnoses that include Anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and High Blood Pressure. Resident R9's clinical record lacked evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R9 and/or their representative. Resident R10's clinical record revealed an admission date of 12/3/25, with diagnoses that include Encephalopathy (a group of conditions that cause problems with the brain that can appear as confusion, memory loss, and personality changes), Respiratory Failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and Sepsis (a reaction to an infection that causes extensive inflammation throughout the body, potentially leading to tissue damage, organ failure, and even death). Resident R10's clinical record lacked evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R10 and/or their representative. During an interview on 4/10/26, at 9:30 a.m. the NHA confirmed there was no evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Residents R9 and R10 and/or their representatives. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 201.18 (b)(1) Management

Based on review of clinical records, and staff interviews it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital, for five of six residents reviewed (Residents R7, R9, R10, R48, and R54).Findings include: Resident R7's clinical record revealed an admission date of 12/2/23, with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Resident R7's clinical record revealed progress notes revealed notes dated 8/21/25, and 10/26/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R9's clinical record revealed an admission date of 5/23/25, with diagnoses that included Anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and High Blood Pressure. Resident R9's clinical record revealed a progress note dated 12/13/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R10's clinical record revealed an admission date of 12/3/25, with diagnoses that included Encephalopathy (a group of conditions that cause problems with the brain that can appear as confusion, memory loss, and personality changes), Respiratory Failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and Sepsis (a reaction to an infection that causes extensive inflammation throughout the body, potentially leading to tissue damage, organ failure, and even death). Resident R10's clinical record revealed a progress note dated 10/29/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R48's clinical record revealed an admission date of 1/10/24, with diagnoses that included quadriplegia (paralyzed in both arms and both legs), hyperlipidemia (high cholesterol), and atrial fibrillation. Resident R48's clinical record revealed progress notes dated 10/2/25, and 3/3/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R54's clinical record revealed an admission date of 2/16/26, with diagnoses that included diabetes, congestive heart failure, and gastro esophageal reflux disease. Resident R54's clinical record revealed a progress note dated 4/7/26, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 4/10/26, at 10:10 a.m. the Director of Nursing confirmed that Residents R7, R9, R10, R48, and R54's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred and that clinical information should have been provided to the receiving healthcare provider upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect an elopement (an at-risk individual leaving a supervised care setting without staff knowledge) for one of 25 residents reviewed (Resident R53).Findings include:Review of facility policy entitled Care Plan Policy dated 12/2/25, revealed Periodically reviewed and revised by a team of qualified persons after each assessment.Resident R53's clinical record revealed an admission date of 1/16/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (brain changes that cause a decline in mental ability that interferes with daily life due to memory loss, thinking/language difficulties, and personality changes), and hypertension (high blood pressure) .Review of facility documents revealed Resident R53 had an elopement on 5/13/25. Review of Resident R53's care plan for elopement created on 1/17/25, revealed Resident R53 was an elopement risk, and the care plan was never revised to reflect he/she had an elopement on 5/13/25. During an interview on 4/9/26 at 1:55 p.m. the Nursing Home Administrator confirmed that Resident R53's elopement care plan was not reviewed/revised following his/her elopement and that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of one residents reviewed for respiratory care (Resident R60). Findings include: A facility policy dated 12/2/25, entitled Oxygen Concentrators - Care and Maintenance of Oxygen Concentrators revealed If there are external cabinet filters present, these are to be cleaned weekly by washing the filters with warm water. Allow the filter to dry thoroughly before replacing. Some concentrators have these filers on the sides or on the back of the unit. Resident R60's clinical record revealed an admission date of 2/29/24, with diagnoses that included Hemiparesis (partial weakness on one side of the body) and Hemiplegia (complete paralysis or loss of ability to move one side of the body) related to Cerebral Infarction (occurs when the blood flow to a part of the brain is interrupted preventing oxygen and nutrients from reaching brain cells causing them to die), Diabetes - a health condition caused by the body's inability to produce enough insulin, and High Blood Pressure. Resident R60's clinical record revealed a physician's order dated 3/31/25, for oxygen at 0 - 4 liters per minute (lpm) via nasal cannula (a thin tube with two prongs that fit in a resident's nostrils to deliver oxygen) or mask to maintain oxygen saturations levels at or greater than 90%. Further review revealed a physician's order dated 10/7/25, to clean oxygen concentrator filter weekly every night shift every Tuesday. Observation on 4/7/26, at 12:44 p.m. revealed Resident R60 sitting in his/her wheelchair with oxygen in place and the oxygen concentrator liter flow set on 2 lpm via nasal cannula. Further observation of the concentrator filter on both sides of the oxygen concentrator revealed a large amount of gray fluffy substance covering the entire filter. During an interview on 4/7/26, at 12:50 p.m. Licensed Practical Nurse Employee E3 confirmed that Resident R60's oxygen concentrators filters contained a large amount of a gray fluffy substance and should be cleaned. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plan for a resident requiring intravenous (IV) therapy that included measurable objectives and timetables to meet a resident's needs for one of 25 residents reviewed (Resident R4).Findings include: Review of facility policy entitled, Care Plan Policy dated 12/2/25, indicated The Manor will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Review of Resident R4's clinical record revealed an admission date of 3/1/26, with diagnoses that included Cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked), malignant carcinoid tumor of the small intestine (cancer in the digestive tract), and hypertension (high blood pressure). Review of Resident R4's physician's orders revealed an order to change dressing system and measure PICC (peripheral inserted central catheter) every seven days, and PRN (as needed) dated 3/2/26, and another order for sodium chloride flush intravenous solution 10 cc (cubic centimeters) every day dated 3/2/26. Review of Resident R4's person centered plans of care lacked evidence that a plan of care for intravenous therapy was developed. During an interview on 4/10/26, at 10:38 a.m. the Director of Nursing (DON) confirmed that a plan of care for intravenous therapy was not developed for Resident R4. The DON also confirmed that an intravenous therapy plan of care should have been developed. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical records, facility documents, and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records for two of 25 residents reviewed (Residents R4 and R53).Findings include: Review of facility policy entitled Documentation Policy dated 12/2/25, revealed The Manor will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care, (i.e., nursing progress notes, episodic charting, and plan of care.) Appropriate information to assist the physician in ordering medications, treatments, and diet. The purpose of the clinical record is to provide ongoing, individualized information regarding the status of the resident. Review of facility policy entitled Accidents and Incidents Policy dated 12/2/25, states, Documentation in the clinical record will reflect the same information and/or incident report.Follow up documentation will be made in the clinical record each shift for seventy-two hours including, but not limited to: vital signs, reaction to incident and physical findings. Review of facility policy entitled Missing Resident Policy dated 12/2/25 states, DocumentationClinical Record-Information recorded in the clinical record should include facts only.The time the resident was noted missing.A description of procedures taken to locate resident.Resolution including the resident condition.Time family and physician were notified.Care plan change to prevent future occurrence. Review of Resident R4's clinical record revealed an admission date of 3/1/26, with diagnoses that include Cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked), malignant carcinoid tumor of the small intestine (cancer in the digestive tract), and hypertension (high blood pressure). Review of Resident R4's physician orders revealed an order to change dressing system and measure PICC (peripheral inserted central catheter) every seven days, and PRN (as needed) dated 3/2/26, and another order for sodium chloride flush intravenous solution 10 cc (cubic centimeters) every day dated 3/2/26. Review of Resident R4's progress notes revealed a note on 4/2/26, indicating that Resident R4 had a right chest tunneled central venous catheter (CVC, an intravenous catheter that is placed in the neck, chest, or groin and is surgically inserted). Resident R53's clinical record revealed an admission date of 1/16/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (brain changes that cause a decline in mental ability that interferes with daily life due to memory loss, thinking/language difficulties, and personality changes), and hypertension (high blood pressure). Review of information dated 5/15/25, submitted by the facility, revealed Resident R53 had an elopement (an at-risk individual leaving a supervised care setting without staff knowledge) on 5/13/25. There was no documentation in Resident R53's clinical record related to his/her elopement. During an interview on 4/9/26 at 1:55 p.m. the Nursing Home Administrator confirmed that the facility failed to have complete documentation related to the elopement in R53's clinical record. During an interview on 4/10/26, at 10:38 a.m. the Director of Nursing confirmed that Resident R4's clinical records did not have accurate documentation regarding a CVC. 28 Pa. Code 211.5(f)(i)(ii)(iii)(iv)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure medications were properly dated when opened in one of five medication rooms reviewed and one of five medication carts reviewed (Main Medication Room and D-Wing Medication Cart). Findings include: Review of a facility policy entitled Vials and Ampules of Injectable Medications dated 12/2/25, indicated that, .The date opened is recorded by the first person to use each multidose vial.multi-dose vials expire 28 days after initial use, unless otherwise indicated by the manufacturer. Manufacturer's recommendations for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Manufacturer's guidelines for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Observation on 4/7/26, at 1:10 p.m. of the Main Medication Room refrigerator revealed an opened vial of Tubersol without an open date, therefore staff were unable to determine the expiration date. At that time, the Director of Nursing confirmed that the open vial of Tubersol lacked an open date. Observation on 4/7/26, at 2:04 p.m. of the D-Wing Medication Cart revealed an open injector pen of Lantus insulin without an open date, therefore staff were unable to determine the expiration date. At that time, Licensed Practical Nurse Employee E3 confirmed that the open injector pen of Lantus lacked an open date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 25 residents reviewed (Residents R14, and R60).Findings include: A facility policy dated 12/2/25, entitled Care Plan Policy revealed Residents will have the opportunity to discuss their goals for care including their preferences for advance care planning and Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse and a STNA [state tested nurse aide] with the responsibility for the resident, a member of the food and nutrition staff, and other appropriate staff and disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's representative. A facility policy dated 12/2/25, entitled Resident Rights Policy revealed The right to participate in the development and implementation of his or her person-centered plan of are, including but not limited to: The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care and The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. Resident R14's clinical record revealed an admission date of 3/9/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), gastroesophageal reflux disease GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and High Blood Pressure. During an interview on 4/07/26, at 1:10 p.m. Resident R14 revealed he/she did not recall when he/she was last invited to or attended a care plan meeting. Resident R14's clinical record revealed the following MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment with the following Assessment Reference Date (ARD - a look back period of time for the MDS assessment): quarterly MDS with ARD 5/8/25, quarterly MDS with ARD 8/8/25, quarterly MDS with ARD 11/8/25, quarterly MDS with ARD 2/8/26, annual MDS with ARD 2/17/26. Resident R14's clinical record revealed that a care plan meeting was held with resident and resident representative on 10/2/25, which was prior to the MDS ARD of 11/8/25. Further review of Resident R14's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the 5/8/25, 8/8/25, and 2/8/26, quarterly MDS's and the 2/17/26 annual MDS. Resident R60's clinical record revealed an admission date of 2/29/24, with diagnoses that included Hemiparesis (partial weakness on one side of the body) and Hemiplegia (complete paralysis or loss of ability to move one side of the body) related to Cerebral Infarction (occurs when the blood flow to a part of the brain is interrupted preventing oxygen and nutrients from reaching brain cells causing them to die), Diabetes - a health condition caused by the body's inability to produce enough insulin, and High Blood Pressure. During an interview on 4/07/26, at 12:44 p.m. Resident R60 revealed he/she did not recall when he/she was last invited to or attended a care plan meeting. Resident R60's clinical record revealed the following MDS assessments with the following ARD: quarterly MDS with ARD 6/4/25, quarterly MDS with ARD 7/16/25, quarterly MDS with ARD 10/11/25, quarterly MDS with ARD 1/11/26, and annual MDS with ARD 3/5/26. Resident R60's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the 6/4/25, 7/16/5, 10/11/25, or 1/11/26 quarterly MDS's and the 13/5/26 annual MDS. During an interview on 4/9/26, at 2:33 p.m. Social Worker stated they have not consistently had care plan meetings. When asked if the care plan meetings are scheduled in conjunction with the MDS schedule, he/she stated no, but they should be. The Social Worker confirmed that the clinical records lacked evidence of Resident R14, and R60 and/or their representatives being routinely invited to attend care plan meetings. 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement sufficient monitoring and supervision to prevent elopement (an at-risk individual leaving a supervised care setting without staff knowledge) and failed to adequately implement search procedures related to an elopement for one of 25 residents reviewed (Resident R53). Findings include: Review of the facility policy entitled, Accidents and Incidents Policy, dated 12/2/25, states, The Manor will ensure that the resident's environment remains free of accident hazards and each resident receives adequate supervision and assistive devices to reduce accidents. Review of facility policy entitled Missing Resident Policy dated 12/2/25, states It shall be the policy of our organization that all necessary steps are taken to locate any resident that is missing from a Community.Building and Grounds Search: Upon discovery that a resident is missing an announcement of code brown or other approved statement will be made. A building and grounds search will be conducted simultaneously by staff assigned by the Person In Charge (PIC).Check Sign-Out Sheet. The resident sign-out sheet will be checked to see if the person is out of the Community.Internal Community Search. Staff are to check all areas of Community as assigned per PIC. Areas to be searched include the following: resident rooms, lobbies, hallways, dining areas, closets, bathrooms, public rooms, lounges, therapy rooms, basements and employee break areas. (Note: this list may not be all inclusive)External Community Search. Staff will check external areas assigned per the PIC to include: patios, grounds, parking lots, vehicles, outside structures, storage buildings and dumpsters.DocumentationClinical Record-Information recorded in the clinical record should include facts only.The time the resident was noted missing.A description of procedures taken to locate resident.Resolution including the resident condition.Time family and physician were notified.Care plan change to prevent future occurrence . Resident R53's clinical record revealed an admission date of 1/16/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (brain changes that cause a decline in mental ability that interferes with daily life due to memory loss, thinking/language difficulties, and personality changes), and hypertension (high blood pressure). An elopement care plan created on 1/17/25, indicated an intervention for a secure care (a device that sets off an alarm if an induvial is exit seeking or has exited the building) on Resident R53 at all times was added on 3/19/25. Review of information dated 5/15/25, submitted by the facility, revealed the following information: Staff indicated they did hear the secure care alarm and did not see Resident R53 outside or near the door inside. He/she was last seen 20 minutes prior related to medication administration.His/her secure device was tested and functioning. It is believed that Resident R53 left with a small group of visitors. Review of the two written statements obtained related to the elopement revealed the following information: Employee Licensed Practical Nurse (LPN) E1indicated around supper time the Registered Nurse Supervisor received a call asking if one of the facility's residents might be going up to the road in a wheelchair. Both headed to the parking lot where a car was pulling in and Resident R53 was being pushed back to the facility. Resident R53 indicated he/she was heading to the mall. LPN Employee E1 brought Resident R53 back to his/her hall and notified the staff working on his/her hall. LPN Employee E2 indicated he/she was the hall nurse on two units, so he/she was going back and forth between the two units. At dinnertime he/she was passing medications when LPN Employee E1 advised that Resident R53 was outside. LPN Employee E1 indicated the charge nurse received a call from someone driving that one of the residents was outside in the parking lot, so the two of them ran out right away to get him/her. LPN Employee E2 had personally encountered Resident R53 20 minutes prior related to administering medications. During an interview on 4/9/26 at 1:55 p.m. the Nursing Home Administrator confirmed that the facility failed to properly supervise Resident R53 and failed to respond appropriately related to the secure device alarm, by completing a head count and going outside of the facility and looking thoroughly. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12 (d) (5) Nursing Services

Based on review of clinical record and facility job descriptions, and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards by failing to ensure that a Registered Nurse (RN) conducted assessments for seven of 17 sampled residents requiring transfer to the hospital (Residents R10-R16).Findings include: Review of Title 49, Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, indicated that under Responsibilities of the RN, 21.11, General Functions. (a) The registered nurse [RN] assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. Review of the facility Job Description for LPNs indicated that the LPN will Administer resident care under the supervision of a RN and/or physician to maintain the highest level of resident care; function within the scope of practice according to the State Board of Nursing; and observe, evaluate, and report any abnormal findings . and any significant changes in condition. Review of the facility Job Description for RNs indicated that the RN will Administer resident care under the supervision of a the Director of Nursing [DON] and/or physician to maintain the highest level of resident care; function within the scope of practice according to the State Board of Nursing; and observe, assess, and report any abnormal findings . and any significant changes in condition. Resident R10's clinical record revealed an admission date of 5/07/24, with diagnoses including arthropathy (any disease or disorder affecting the joints, which can cause pain, swelling, stiffness, and reduced function), sacroiliitis (inflammation in the joints where your spine meets your pelvis), Type 2 Diabetes (condition in which the body cannot use insulin correctly and sugar builds up in the blood) and stroke. On 2/11/26, at 12:45 a.m. Resident R10 fell from his/her bed, sustained injury, and was transferred to the hospital for emergency evaluation and treatment. Resident R11's clinical record revealed an admission date of 1/27/24, with diagnoses including irregular heartbeat, depression, heart disease, and fibromyalgia (long-term condition that involves widespread body pain, fatigue, issues with sleep, memory and mood). On 2/14/26, at 5:12 a.m. Resident R11 fell in the hallway, sustained injury, and was transferred to the hospital for emergency evaluation and treatment. Resident R12's clinical record revealed an admission date of 1/10/26, with diagnoses including kidney stones, displacement of kidney drainage tube, urinary tract infection, and heart failure. On 1/14/26, at 5:22 p.m. Resident R12's kidney drainage tube became displaced and he/she required emergency transfer to the hospital to replace the tube. Resident R13's clinical record revealed an admission date of 6/26/19, with diagnoses including bacterial infection in the blood, heart failure, Type 2 Diabetes, and irregular heartbeat. On 1/14/26, at 12:43 a.m. Resident R13 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment. Resident R14's clinical record revealed an admission date of 1/20/26, with diagnoses including high blood pressure, emphysema (long term lung condition that causes shortness of breath due to damaged air sacs in the lungs), Type 2 Diabetes, and stroke. On 1/11/26, at 12:45 p.m. Resident R13 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment. Resident R15's clinical record revealed an admission date of 9/30/25, with diagnoses including stroke, heart attack, fainting, and heart disease. On 2/17/26, at 7:11 p.m. Resident R15 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment. Resident R16's clinical record revealed an admission date of 5/25/25, with diagnoses including bacterial infection in the blood, skin infection of the right leg, chronic obstructive pulmonary disease (COPD- lung disease that causes airflow blockage and breathing problems). On 2/09/26, at 10:49 p.m. Resident R16 experienced a change in condition and required transfer to the hospital for emergency evaluation and treatment. During interviews on 2/23/26, between 6:00 p.m. and 8:00 p.m. and 2/24/26, between 8:45 a.m. and 3:15 p.m. with LPN Employees E1 through E5 confirmed they are expected to complete their own assessments on residents newly admitted to the facility, residents sustaining injuries, and residents experiencing change in condition, and are responsible for obtaining provider's orders for emergency transfer to the hospital based on their assessments. LPN Employees E1 through E5 also confirmed that there are many times that there is not an RN available to complete the assessments on residents. Review of clinical records for Residents R10-R16 lacked evidence that they were assessed for injuries and/or change of condition by an RN prior to being transferred to the hospital for emergency evaluation and treatment. During an interview on 2/24/26, at 12:10 p.m. the DON confirmed that the assessments for the above residents were conducted by an LPN, without the oversight or assistance of an RN and that he/she was not aware that an RN was required to perform assessments for residents experiencing a change in condition. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record and facility documents and staff interview, it was determined that the facility failed to ensure that a complete and thorough investigation was performed related to an injury of unknown origin for one of 16 residents reviewed (Resident R1).Findings include: A facility policy entitled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated 12/01/25, indicated that: The person investigating the incident should generally take the following actions: interview resident, accused, and all witnesses; obtain a statement from the resident and each witness; and evidence of the investigation should be documented.After completion of the investigation, the evidence should be analyzed: and the Nursing Home Administrator [NHA] will determine if the suspicion is substantiated or unsubstantiated; ensure the involved resident's plan of care is reviewed and revised, as appropriate, consistent with the results of the investigation; determine if modifications to existing policies and procedures [or new policies and procedures] are needed to prevent similar incidents or injuries from occurring in the future; complete staff training, if appropriate, as determined by the results of the investigation; and implement any other measures as deemed necessary by the investigation. Resident R1's clinical record revealed an original admission date of 2/11/25, and readmission date of 11/11/25, with diagnoses that included dependence on renal dialysis [medical treatment that performs the function of the kidneys by removing waste, toxins, and excess fluid from the blood when the kidneys are unable to do so naturally], open wounds of the right foot, stage three kidney disease, and gout [form of arthritis that causes pain and swelling in your joints (usually your big toe)]. Interdepartmental progress notes dated 11/04/25, between revealed that:Resident R1 returned from dialysis at 9:30 a.m. in his/her wheelchair. At approximately 11:00 a.m. staff observed a large amount of blood on the floor and on the left foot with a blood clot to foot, large amount of blood soaked in the sock. A statement made by Resident R1 at that time indicated that the transport staff bumped into the curb when they brought him/her back.Resident's left foot was bleeding heavily from four of five toes. Abrasion present on all four toes. Great toe with a 0.5cm x 1.0cm x 0.1cm open area. The other toes with 0.2cm x 0.3cm x 0.1 cm abrasions. Heavily bleeding from all abrasion areas.Staff were unable to get bleeding on toes to stop. Left great toe had tissue missing from the end of the toe, fourth toe was missing the toenail, and the nail bed was bleeding, second and third toe were bleeding as well. Toes were cleaned and pressure dressing was applied.Departmental progress notes on 11/04/25, at 10:18 p.m. identified staff removing pressure dressing from the left foot toes began to bleed. Area cleansed and rewrapped. Review of email communication dated 11/05/25, between the NHA and the contracted transport company indicated that the driver was unaware of injuries occurring to Resident R1's toes. During an interview on 2/25/26, at 1:35 p.m. the NHA confirmed that he/she was unable to locate further documentation of interviews and investigation notes regarding the injuries to Resident R1's left toes. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services

Based on review of facility provided education and clinical records, observations, and staff interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift for one of one residents reviewed (Resident R1). Based on review of facility provided education and clinical records, observations, and staff interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift for one of one residents reviewed (Resident R1).Findings include:No facility policy provided.Review of a facility staff education entitled Skill Checklist Transferring a Resident From Bed to Chair Mechanical Lift provided on 10/09/25, revealed that two staff members must be utilized when transferring residents with a mechanical lift.Resident R1's clinical record revealed an admission date of 12/21/18, with diagnoses that included hemiplegia (a condition that causes paralysis or weakness affecting one side of body) and hemiparesis (weakness of one side of body affecting arm, leg and face) of left side of body, weakness, obesity, and vascular dementia (cognitive decline caused by damage to the circulatory system of the brain).Resident R1's physician orders dated 11/04/20, revealed Mechanical Lift X 2 for all transfers. Observation on 10/09/25, at 12:10 p.m. revealed Nurse Aide (NA) Employee E1 lowered Resident R1 into the bed without the assistance of a second staff member. During an interview on 10/09/25, at 12:11 p.m. NA Employee E1confirmed that he/she is supposed to have two people when using the mechanical lift, but only utilized one, himself/herself, when transferring Resident R1.During an interview on 10/09/25, at 12:11 p.m. Licensed Practical Nurse Employee E2 confirmed that all mechanical lifts are to have two staff to operate at all times.During an interview on 10/09/25, at 12:15 p.m. the Nursing Home Administrator also confirmed that mechanical lifts require two staff to operate.28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(c)(d) Resident Care Policies28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on resident interviews and review of resident council minutes, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for five of 23 residents interviewed (Residents R2, R9, R35, R37, and R82). Findings include: Review of resident council minutes from the last three months from January, February, and March of 2025, revealed the following: March 2025 resident council minutes revealed there were complaints of halls being noisy at all times and staff were observed on their cell phones in the hallways. February 2025 resident council minutes revealed concerns with staff on their cell phones in the hallways during resident care, staff being very loud and yelling in the hallways having conversations, weekend staff not present when needed, and residents waiting to be served during meals for long periods of time. January 2025 resident council minutes revealed concerns with staff using foul language and yelling in the hallways during meal service and while performing care on all hallways, non-homelike environment during meals and care due to staff speaking loudly and inappropriately, call bells not being answered on third shift for long periods of time, showers not being completed on designated days and sheets not getting changed on beds. Interviews during the Resident Council meeting on 4/9/25, between 10:00 a.m. and 10:45 a.m., revealed five out of five alert and oriented residents in attendance with concerns related to staff not responding to their call bells timely. Resident R82 indicated that it could take 30-45 minutes for his/her call bell to be answered and staff are typically seen in the hallways talking or on their phones. Resident R9 indicated that he/she will wait for 30 minutes to 60 minutes to receive assistance to use the restroom after placing his/her call bell on. Resident R9 further indicated if he/she is not able to use the restroom in his/her room due to it being too small and required assistance to the hallway restroom with assistance of two people. Resident R9 indicated that it takes a 30 minutes or longer most of the time to have call lights answered to use the restroom. Resident R9 further indicated that he/she is supposed to be walked, and staff are always too busy and never have time to walk him/her as ordered. Residents R2, R35 and R37 indicated they wait 30 minutes or longer when their call bell is placed on to be responded to by staff. All residents agreed that they observe staff on their phones and standing talking to one another during their shifts. During interview on 4/9/25, at 2:00 p.m. revealed that Resident R37 expressed concerns of poor call bell response times. Resident R37 revealed that on weekends and evenings he/she observes staff constantly watching tv, were on their phones, and talking in the back lounge area of B Hallway while call lights are on in the hallway. Resident R37 also indicated that he/she requires full assist with eating and there is not enough staff to assist everyone in a timely manner. By the time he/she gets someone to assist with his food it is cold and requires being heated up. Resident R37 stated this happens a lot. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and resident Pennsylvania Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 23 residents reviewed (Resident R29). Findings include: Facility policy entitled Pennsylvania Orders for Life-Sustaining Treatment policy (POLST) dated [DATE], indicated the purpose is to guide staff in providing care appropriate to the residents or surrogates wishes. It further stated that if a person is admitted with a POLST, it will be honored. If a person does not have one on admission, one will be completed with the person or surrogate. Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included kidney failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and high blood pressure. Resident R29's clinical recorded revealed a physician's order dated [DATE], for Full Code (staff to implement Cardiopulmonary Resuscitation [CPR] -emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). Resident R29's care plans revealed a care plan indicating Full Code. Resident R29's clinical record revealed a POLST dated [DATE], signed by both Resident R29 and his/her physician indicating DNR / Do Not Attempt Resuscitation (allow natural death). During an interview with the Director of Nursing on [DATE], at 11:50 a.m. he/she confirmed Resident R29's physician's orders, POLST, and care plan were not consistent with each other. He/she also confirmed that Resident R29's physician's orders, POLST and care plan should reflect Resident R29's Advance Directive wishes and be consistent with each other. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), clinical records and staff interviews, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for one of 23 residents reviewed (Resident R29). Findings include: Review of MDS instructions for Section H Bladder and Bowel subsection H0300 Urinary Continence indicated that urinary continence is to be coded as not rated if during the seven day look-back period the resident had an indwelling bladder catheter (tubing from the bladder to drain urine into the bag), condom catheter, ostomy, or no urine output for the entire seven days. Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included kidney failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and high blood pressure. Resident R29's clinical record revealed he/she had an Indwelling Catheter at the time of admission on 3/9/25. Resident R29's admission MDS with Assessment Reference Date (ARD) of 3/16/25, Subsection H0100 Appliances was coded as Indwelling Catheter and Subsection H0300 Urinary Continence was coded as Occasionally Incontinent, Medicare-5 day MDS with ARD of 3/16/25 Subsection H0100 Appliances was coded as Indwelling Catheter and Subsection H0300 Urinary Continence was coded as Always Incontinent, although Resident R29 had an indwelling catheter for the entire seven-day look-back period. During an interview on 4/10/25, at 2:00 p.m. Registered Nurse Assessment Coordinator confirmed that the 3/16/25 MDS's were coded inaccurately and urinary continence should have been coded as not rated for Resident R29. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records

Based on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for one of 11 residents reviewed (Resident R2). Findings include: Review of the facility policy entitled PPE [Personal Protective Equipment] and Isolation -COVID-19 Protocol dated 10/11/22, indicated that residents confirmed with COVID-19 should be moved to a single-person room and placed in droplet isolation. It is recommended that the door to the room remain closed to reduce transmission. It further indicated that if numerous residents simultaneously identified to have COVID-19 or symptoms, residents should remain in their current location. The policy did not address practices to include not cohorting COVID-19 positive and negative residents together in the same room. Review of the Pennsylvania Health Alert Network (PA-HAN) - 663, Long-Term Care Facility Guidance regarding Response to an Outbreak and Residents with Exposure to COVID-19 (a contagious viral disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated October 4, 2022, disclosed the following: A. Definition of an outbreak - a single new case of SARS-CoV-2 infection in any resident or HCP [Healthcare Personnel] should be evaluated as a potential outbreak. Residents with confirmed COVID-19 infection should be placed in a COVID single person room under isolation as described in PA-HAN-663 or its successor, Residents with confirmed COVID-19 infection should be placed in a single person room. The door should be kept closed (if safe to do so) under isolation as described in PA-HAN-663 or its successor, If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multidrug-resistant organism (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV 2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Review of PA-HAN 663 as referenced above, directed the following on Page 7: .However, quarantined patients and those with suspected infection should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. This PA-HAN Update provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made by CDC on September 23, 2022. Review of facility room assignments documented that one resident (Resident R2) who tested negative for COVID-19 on 4/11/23, remained in the same room (room [ROOM NUMBER]) with a roommate (Resident R3) who tested positive for COVID-19 on 4/11/23. The facility employs the antigen testing which confirms positive or negative results within 15 minutes. During interview on 4/14/23, at 11:05 a.m. the Director of Nursing (DON) confirmed that the COVID-19 negative resident, (Resident R2) in room [ROOM NUMBER] remained housed in the same room as a COVID-19 positive resident (Resident R3). Observations on 4/14/23, at 11:10 a.m. revealed that there were the following COVID-19 positive rooms 24, 25, 39, 40 on B Hall and rooms [ROOM NUMBERS] on C Hall, all doors were open and masks were not being worn by the residents in room [ROOM NUMBER], room [ROOM NUMBER]'s resident was sitting outside of the room without a mask on. The NHA and Director of Nursing were made aware that Immediate Jeopardy (IJ) existed for one resident on B Hall on 4/14/23, at 12:51 p.m. and a corrective action plan was requested. The IJ template was provided to the facility at that time. On 4/14/23, at 3:00 p.m. an acceptable corrective action plan was approved which included the following interventions: Resident that was exposed to covid positive roommate and tested covid negative will be moved immediately. Resident was POC COVID-19 swabbed completed and is negative. All doors of residents who are COVID positive have been closed and signs placed to inform staff and residents to leave door closed at all times. If keeping the door closed may pose resident safety risks and the door might need to remain open, alternative isolation protocols will be followed. The residents who are COVID-19 positive will be isolated to a single-person room and placed in droplet isolation. If limited single isolation rooms are available, or numerous residents are simultaneously identified to have known COVID-19, residents should cohort and remain in their current location. Limit transport and movement of the resident outside of the room to medically essential purposes. The staff will be educated on COVID-19 precautions, use of PPE and isolation protocol. The Director of Nursing to initiate education immediately, RN supervisors to continue education each shift until all nursing have been educated. Staffing contingencies for potential increase in COVID-19 positive residents consists of: Pool of HCF Fairview Manor employees, incentives for shifts picked up, agency pool staffing. DON or designee will monitor that doors to rooms remain closed immediately and once a shift for five days, once a day for five days and weekly thereafter for 3 months, all results will be reviewed by QAPI committee. On 4/14/23, between 1:30 p.m. and 3:10 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on 4/14/23, at 3:19 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm of a left lower leg and ankle fractures for one of four residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Resident Abuse Policy and Procedure and Mandatory Reporting of Alleged Abuse dated 2/20/23, revealed, abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident R1's clinical record revealed an admitted [DATE], that included diagnoses of stroke, high blood pressure, lung problems, muscle weakness, and seizures. A review of Resident R1's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 2/09/23, revealed that Resident R1 was total dependance and required two-person assist with transfers. A review of Resident R1's Self Care Deficit ADL (Activities of Daily Living) care plan, originally dated 5/09/19, revealed under the category, Transfer Status: Mechanical lift For Transfers assist of two people. A review of Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 3/28/23, at 7:35 a.m. Summoned to resident room by STNA [State tested Nurse Aide], reporting fall out of hoyer [mechanical] lift. Resident stated, I slid out of the lift onto my butt, the pad was too short. Resident assessed for injury with none noted. A nursing note dated 3/29/23, at 3:18 p.m. revealed Resident R1 had complaints of pain and swelling noted to left lower leg and ankle. Family and physician notified, orders obtained and x-ray's obtained. Ice applied and Tylenol (pain medication) administered. In-house x-ray's were ordered on 3/29/23, and impression indicated, Multiple Proximal & Distal left TIB/FIB [tibia/fibula-leg bones] fractures and left quadrant Malleolar & Trimalleolar [ankle bones] fractures. A nursing note dated 3/30/23, at 9:46 a.m. revealed that the Orthopedic physician recommended Resident R1 to be transferred to the hospital to be seen. Resident R1 sent to hospital and admitted , resident returned to facility on 4/02/23, with a leg splint / immobilizer to the left leg. Review of information submitted by the facility, dated 3/30/23, revealed that Resident R1 was transferred with a mechanical lift on 3/28/23, around 7:35 a.m. when Resident R1 slid out of the lift pad NA Employee E1 notified nursing staff that Resident R1, fell out of hoyer lift. Nursing staff notified of incident and checked for any injuries. Resident R1 did not complain of any pain until 3/29/23, at 3:20 p.m. which at that time RN supervisor was notified who then notified physician, x-rays ordered and impression indicated, Proximal and distal fractures of the left tibia, fibula and malleolar ankle fractures. Family and physician were notified. An orthopedic physician consult was ordered but the orthopedic physician felt Resident R1 needed to be seen at the hospital, Resident R1 was transferred to the hospital on 3/30/23. A review of documentation submitted by the facility, dated 3/29/23, revealed that the facility initiated an investigation, and the NA was removed from the schedule and would not be returning. Review of the Director of Nursing's (DON) note of the interview conducted with NA Employee E1, dated 3/29/23, reflected that NA, Employee E1, stated that they had been trained on the use of the lift on 12/21/22 and 2/21/23, and was aware that Resident R1 was a two-person lift, however transferred the resident independently without assistance. During an interview on 4/14/23, at 11:00 a.m. the DON confirmed that the NA Employee E1 should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility neglected to utilize the appropriate transfer for a resident as care planned which placed the resident at risk for injury from an improper transfer method. As a result, there was actual harm of a lower leg and ankle fractures to Resident R1 requiring medical treatment at the hospital. This deficiency is cited as past non-compliance. On 3/30/23, the facility submitted a plan to include: The NA Employee E1 was removed from the schedule and would not be returning. The facility initiated re-educating all nursing staff, prior to their next shift after the 3/29/23, investigation of the 3/28/23, incident on abuse/neglect, safety education and proper lift transfer procedures. The DON also is in process of monitoring all staff completing transfers. Interviews with Licensed Practical Nurse (LPN) Employee E6, RN Employee E2, and NA Employees E3, E4, E5 and E7 confirmed that they were re-educated on that any time a lift is used, there must be two staff to properly and safely complete the transfer with a lift. The employees stated that the information had been reviewed in February and were re-educated again the last two days of March and beginning of April. The facility continued education for safe proper mechanics of transfer using a lift in April 2023, after the 3/28/23, incident of all staff related to proper mechanics of a transfer, and were observed transferring a resident. The facility Nursing Home Administrator (NHA) stated that the facility was continuing the audits ongoing until compliance is determined. The audit sheets for April were reviewed. The facility has demonstrated compliance with the mechanical lifts procedure since 4/05/23. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services