Every finding on record at Forest Hills Rehabilitation & Healthcare Center

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 foodborne illness in the food and nutrition services department and on three of four resident pantry areas (Area 1, Area 3, and Area 4). 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 conducted with the facility's registered dietitian (RD) on March 10, 2026, at 9:20 AM revealed the perimeter floor areas of the kitchen including under the stainless steel counter next to the juice machine, under equipment located in the cooks area, and under the ice machine were visibly soiled with a heavy buildup of dirt and debris. An observation on the Area Two resident area on March 10, 2026, at 12:40 PM during the lunch meal revealed the lower rims and rubber bumpers of two food delivery carts were visibly soiled. An observation on the Area Three resident area on March 12, 2026, at 12:15 PM during the lunch meal revealed the lower rim and rubber bumper of one food delivery cart was visibly soiled. Observation on March 12, 2026, at 12:20 PM of the Area Three resident food pantry revealed a stringy thick black substance hanging from the end of the ice machine's condensation drain hose (a hose that transports moisture produced by the ice machine to a floor drain). There was food splatter adhered to the interior surface of the pantry microwave. There was an accumulation of debris under three ceiling light shields located in the pantry. Observation on March 12, 2026, at 12:30 PM of the Area Four resident food pantry revealed the top interior surface of the microwave had a worn appearance and a buildup of food splatter. Observation on March 12, 2026, at 12:45 PM of the Area One resident food pantry revealed the ice machine had two condensation hoses which were both visibly soiled with bluish and black colored substances. The floor area under and surrounding the ice machine was visibly soiled. There was an accumulation of debris under two ceiling light shields located in the pantry. During an interview on March 12, 2026, at 1:30 PM the Nursing Home Administrator confirmed that the ice machines and resident pantry areas were to be maintained in a sanitary manner. Observation conducted with the food service director (FSD) on March 13, 2026, at 11:00 AM of the dish room in the food and nutrition services department revealed a two-foot strip of vinyl molding which had pulled away from the wall area behind the dishwasher. There was a buildup of dirt on the concrete wall area in front of the dishwasher. Interview with the FSD at the time of the observation confirmed the food and nutrition services department was to be maintained in a sanitary manner to minimize the potential to introduce contaminants into food and prevent the potential for foodborne illness. 28 Pa. Code 201.18(e)(2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services.

Based on the clinical record review, select facility policy review, documentation provided by the facility, and staff interview, it was determined the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit, in accordance with professional standards of practice and facility policy, for five of 36 sampled residents (Residents 8, 68, 132, 161, and 166).Findings include: A review of the facility Physician Progress Notes Policy, last reviewed February 24, 2026, indicated that physician progress notes must be maintained for each resident residing in the facility. Physician progress notes reflect the resident's progress and response to his or her care plan, medications, etc. The resident's attending physician must write, sign, and date the physician's progress notes upon each visit. A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (the most common form of arthritis, occurring when the protective cartilage cushioning the ends of bones wears down over time). Review of the clinical record for Resident 8 revealed a physician progress note dated June 28, 2025. There were no further documented physician progress notes. There were no additional physician progress notes documented in the clinical record following that date. Upon surveyor inquiry on March 11, 2026, the facility provided physician progress notes faxed to the facility on March 11, 2026, which indicated the physician visited Resident 8 on August 2, 2025; August 23, 2025; September 6, 2025; September 20, 2025; October 11, 2025; October 18, 2025; November 16, 2025; December 27, 2025; January 31, 2026; and March 7, 2026. These visits were not supported by timely written, signed, and dated physician progress notes maintained in the clinical record at the time of review. A review of the clinical record revealed that Resident 161 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and hypertension (high blood pressure). Review of the clinical record of resident 161 revealed a physician progress note dated June 28, 2025, with no additional documented physician progress notes thereafter. Upon surveyor inquiry on March 11, 2026, the facility provided physician progress notes faxed to the facility on March 11, 2026, which indicated the physician visited Resident 161 on August 2, 2025; September 6, 2025; October 11, 2025; November 16, 2025; and January 31, 2026. These visits were not supported by timely written, signed, and dated physician progress notes maintained in the clinical record at the time of review. A review of the clinical record revealed that Resident 68 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) and Parkinsonism (a group of neurological disorders that cause movement problems similar to those seen in Parkinson's disease, such as tremors, slow movement, and stiffness). Review of Resident 68's clinical record revealed a physician progress note dated June 7, 2025, with no additional documented physician progress notes thereafter. Upon surveyor inquiry on March 11, 2026, the facility provided physician progress notes faxed to the facility on March 11, 2026, which indicated the physician visited Resident 68 on June 12, 2025; June 26, 2025; August 16, 2025; August 23, 2025; September 20, 2025; October 25, 2025; November 29, 2025; December 13, 2025; January 10, 2026; and February 14, 2026. These visits were not supported by timely written, signed, and dated physician progress notes maintained in the clinical record at the time of review. A clinical record review revealed Resident 132 was admitted to the facility on [DATE], with diagnoses that included anoxic brain damage (a serious type of acquired brain injury caused by a total interruption of oxygen supply to the brain, leading to cell death). A review of Resident 132's clinical record revealed a physician progress note dated June 14, 2025. with no additional documented physician progress notes thereafter. Upon surveyor inquiry on March 12, 2026, the facility provided physician progress notes faxed to the facility on March 12, 2026, which indicated the physician visited Resident 132 on July 19, 2025; August 23, 2025; October 4, 2025; November 8, 2025; January 17, 2026; and February 21, 2026. These visits were not supported by timely written, signed, and dated physician progress notes maintained in the clinical record at the time of review. A clinical record review revealed Resident 166 was admitted to the facility on [DATE], with diagnoses that include dementia. Review of the clinical record revealed a physician progress note dated June 14, 2025, with no additional documented physician progress notes thereafter. Upon surveyor inquiry on March 12, 2026, the facility provided physician progress notes faxed to the facility on March 12, 2026, which indicated the physician visited Resident 166 on July 19, 2025; August 23, 2025; October 4, 2025; November 8, 2025; December 20, 2025; January 17, 2026; and February 21, 2026. These visits were not supported by timely written, signed, and dated physician progress notes maintained in the clinical record at the time of review. An interview with the Director of Nursing on March 11, 2026, at 11:00 AM confirmed that physicians are expected to write, sign, and date a physician progress note at each visit. The Director of Nursing confirmed that the physician visited Residents 8, 68, 132, 161, and 166 as required; however, the physician did not consistently provide written, signed, and dated progress notes after each visit for inclusion in the residents' clinical records. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.2 (d)(8) Medical director. 28 Pa. Code 211.5 (f)(ii)(iv) Medical records.

Based on review of clinical records, select facility policy review, and staff interview, it was determined the facility failed to ensure a resident was free of chemical restraints that were not necessary to treat the resident's medical symptoms, were without justification, and did not demonstrate individualized, nonpharmacological approaches to care for one out of 36 residents reviewed (Resident 39).Findings include: A review of the facility policy titled Psychotropic Medication Use, last reviewed by the facility on February 24, 2026, revealed it is the facility policy to ensure residents do not receive psychotropic medication (medications that affect the chemical makeup of the brain and nervous system, altering mood, cognition, and perception) that are not clinically indicated and necessary to treat a specific condition documented in the medical record. The policy also indicates that behavioral and other non-pharmacological approaches (approaches used to manage symptoms or behaviors, such as environmental, behavioral, or comfort measures) are used to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction. Psychotropic medication may be considered appropriate when non-pharmacological approaches have been attempted but did not relieve the medical symptoms that are presenting a danger or significant distress. The clinical record review revealed Resident 39 was admitted to the facility on [DATE], with diagnoses that include cerebral palsy (a group of permanent movement and posture disorders caused by abnormal brain development or damage to the developing brain) and intellectual disabilities (a lifelong condition characterized by significant limitations in both intellectual functioning, such as learning, reasoning, and problem-solving, and adaptive behavior). A review of Resident 39's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 1, 2026, revealed that Resident 39 was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00 to 07 indicates severe cognitive impairment). A review of the comprehensive care plan revealed Resident 39 had a problem with inappropriate verbal and physical behaviors related to cognitive impairment (a condition that affects memory, understanding, and decision-making) and intellectual disability. Documented behaviors included attempting to grab female staff, combative behavior during care, spitting at staff and others, screaming, inappropriate exposure, and striking out at staff and others. The care plan, initiated December 29, 2025, included interventions such as continuous supervision by one staff member, administration of medications as ordered, use of distraction techniques, playing soft music, allowing the resident to calm in his room, and providing visual stimuli such as observing birds. A review of physician orders revealed lorazepam gel 0.5 mg/ml was prescribed on January 8, 2026, with directions to apply to the posterior neck (back of the neck) every eight hours as needed for anxiety, agitation, or aggression related to anxiety disorder. Lorazepam is a psychotropic medication (a drug that affects the brain and alters mood, behavior, or perception) and is classified as a central nervous system depressant, meaning it slows brain activity and produces calming and sedative effects. The method of administration of lorazepam in topical gel form to the posterior neck allowed for rapid application without the resident's awareness or ability to refuse, particularly given the resident's cognitive impairment. This method limited the resident's opportunity to participate in decision-making. The order was discontinued and reinitiated on January 23, 2026, discontinued again on February 10, 2026, and reinitiated on February 10, 2026, with the same directions. The clinical record failed to demonstrate that the facility defined Resident 39's specific behavioral expressions of anxiety, agitation, or aggression in measurable and observable terms to guide staff in determining when administration of lorazepam gel was clinically indicated. Without defined parameters, staff lacked objective criteria to ensure the medication was administered appropriately and consistently. A review of the medication administration record dated January 2026 revealed Resident 39 was administered lorazepam gel 0.5 mg/ml on the following dates:January 10, 2026, at 08:12 AMJanuary 12, 2026, at 11:44 AMJanuary 13, 2026, at 11:09 AMJanuary 14, 2026, at 10:01 AMJanuary 15, 2026, at 07:46 AMJanuary 15, 2026, at 02:09 PMJanuary 18, 2026, at 02:30 PMJanuary 19, 2026, at 11:13 AMJanuary 20, 2026, at 08:03 AMJanuary 21, 2026, at 08:23 AMJanuary 30, 2026, at 12:56 PMA review of the medication administration record dated February 2026 revealed Resident 39 was administered lorazepam gel 0.5 mg/ml on the following dates:February 1, 2026, at 01:51 AMFebruary 2, 2026, at 02:01 AMFebruary 10, 2026, at 02:31 PMFebruary 15, 2026, at 08:57 AMFebruary 20, 2026, at 01:02 PMFebruary 23, 2026, at 08:00 AMFebruary 24, 2026, at 11:44 AM Review of Resident 39's medical record revealed no evidence non-pharmacological interventions were attempted and found to be ineffective prior to each use of lorazepam gel 0.5 mg/ml on the 18 aforementioned psychotropic medication administrations. During an interview on March 13, 2026, at 9:50 AM, the above information was reviewed with the Director of Nursing. The DON could not provide documented evidence that the facility utilized non-pharmacological interventions prior to administering lorazepam gel 0.5 mg/ml 18 times from January 10, 2026, through February 24, 2026. Also, the director of nursing could not provide documented evidence that the facility defined Resident 39's behavioral expression of anxiety, agitation, or aggression that objectively indicated the appropriate use for lorazepam gel 0.5 mg/ml. The facility did not ensure Resident 39 was free of unnecessary psychotropic medication and did not demonstrate that individualized, nonpharmacological approaches were used before administering PRN (as needed) psychotropic medication. 28 Pa. Code 211.2(3) Medical director. 28 Pa. Code 211.5(ii)(xi) Clinical records. 28 Pa. Code 211.8(e) Use of restraints. 28 Pa. Code 211.9(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on observation, review of clinical records, select facility policy, and staff and resident interviews, it was determined the facility failed to consistently provide timely and necessary foot care for one of 36 residents sampled (Resident 66).Findings include: A review of the facility policy Care of Fingernails and Toenails, last reviewed by the facility on February 24, 2026, revealed it is the purpose of the policy to clean the nail bed, keep nails trimmed, and prevent infections. General guidelines in the policy included watching for and reporting any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. The policy also indicated reporting to the nurse supervisor if there is evidence of ingrown nails, infections, or pain or if nails are too hard or too thick to cut with ease. Clinical record review revealed Resident 66 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of Resident 66's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 14, 2025, revealed that Resident 66 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A physician's order indicating Resident 66 may have a consultation with follow-up treatment as indicated for podiatry services was initiated on December 10, 2025. A clinical record review revealed Resident 66's last podiatry (branch of medical care focused on assessment, diagnosis, and treatment of conditions affecting the feet, ankles and lower extremities) visit was on December 22, 2025. An observation on March 10, 2026, at 11:42 AM revealed Resident 66's toenails, on both feet, were thickened, yellowed, and extended past the tips of his toes, and the surface of the nails was rough and uneven. The skin on Resident 66's toes was thick and scaling across the top and side of the toes. The skin appeared dry, flaky, and crusty with a white-gray chalky appearance. Resident 66 indicated that he has diabetes, and he was upset because he has not seen the podiatrist recently. He explained that he is not receiving routine foot care. Resident 66 indicated that the length of his toenails causes him discomfort. During the interview, Resident 66 indicated that he independently ambulates and is not currently receiving physical therapy services. During an interview on March 13, 2026, at 9:50 AM, the above information was reviewed with the director of nursing (DON). The DON was unable to provide documented evidence that Resident 66 received podiatry care and services to ensure his feet were well-kept, free of signs of infection, and his foot discomfort was addressed. The facility failed to ensure Resident 66 was provided podiatry services to meet his foot care needs. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on clinical record review, policy review, observations, and staff interviews, it was determined the facility failed to identify the use of a physical restraint and failed to implement the facility policy regarding restraints for one of 36 sampled residents (Resident 56).Findings include:Clinical record review revealed that Resident 56 had diagnoses of dementia (a condition that affects memory, thinking, and decision-making abilities) and a history of falls. A review of Resident 56's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2026, revealed that Resident 56 was unable to be interviewed and required partial to moderate assistance with sitting and standing at the side of the bed. Review of the facility policy titled Use of Restraints, last reviewed February 24, 2026, revealed that restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. When the use of a restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. A restraint is defined as a device or equipment that an individual cannot remove, which restricts freedom of movement. Restraints may only be used if the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve symptoms. Care plans will reflect the use of restraints and interventions implemented to systematically eliminate the need for restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident/resident representative. Once a restraint is initiated, the resident is to be observed at least every 30 minutes by nursing personnel, and the resident's condition documented in the clinical record. The opportunity for motion and exercise will be provided for a period of not less than 10 minutes during every 2 hours the restraint is applied. Documentation regarding the restraint shall include full documentation of the episode leading to the use of physical restraint, a detailed description of the medical symptoms, how the restraint benefits the resident, the type of restraint, the length of effectiveness, observations, range of motion (movement of joints to maintain flexibility and prevent stiffness) provided, and repositioning efforts.A review of the care plan dated January 16, 2026, indicated Resident 56 was at risk for falls and included interventions such as bed and chair alarms (to alert staff of unsafe, unassisted attempts to get out of bed or chair), maintaining the bed in a low position, and use of a floor mat. The care plan did not include the use of a mattress placed directly on the floor.Observations conducted on March 10, 2026, at 10:00 AM, March 11, 2026, at 9:00 AM, and March 12, 2026, at 11:26 AM revealed Resident 56 lying on a mattress placed directly on the floor which reduced the height of the sleeping surface to floor level and may limit the resident's ability to independently reposition, transfer, or rise from the sleeping surface.Review of Resident 56's current physician orders and the care plan failed to identify the purpose of placing the mattress on the floor, failed to include this intervention, and failed to show evidence of an interdisciplinary team evaluation prior to implementation. The clinical record lacked documentation to indicate assessment of potential effects on the resident's mobility (ability to move independently). During an interview on March 12, 2026, at 12:30 PM, the Director of Nursing (DON) stated the mattress was placed on the floor in an effort to reduce the risk of falls and indicated this decision was not evaluated by the interdisciplinary team it was a decision to keep the resident safe. The DON was unable to provide information at the time of this interview if placing a mattress on the floor, thus reducing vertical height, reducing the resident's mobility or if this was evaluated prior to the initiation of the bed mattress on the floor. During an interview on March 13, 2026, at 10:30 AM, the Director of Nursing stated the placement of the mattress on the floor reduced Resident 56's bed mobility (ability to move and reposition in bed) creating a potential restraint. The clinical record failed to indicate that a physician order was obtained for this intervention and failed to show physician involvement in the decision-making process. The clinical record lacked documentation to demonstrate that the use of a mattress placed directly on the floor was assessed as the least restrictive intervention or that alternative interventions were attempted and determined ineffective. The clinical record failed to show the intervention was incorporated into the current care plan, failed to show the resident or resident representative was notified of the change or that consent was obtained prior to implementation, and failed to include documentation of ongoing monitoring, including observations of the resident's condition and safety at regular intervals while the intervention was in place. During an interview on March 13, 2026, at 1:00 PM, the Director of Nursing stated the facility had not identified the placement of the mattress on the floor as a restraint and was unable to provide documentation to indicate the facility implemented its policy related to restraint use for this intervention. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing service. 28 Pa. Code 211.8(c.1)(1)(2)(3)(i)(ii)(d)(e) Use of Restraints

Based on the clinical record and select policy review, documentation provided by the facility and staff interview, it was determined the facility failed to timely identify and address risk factors for the development of a pressure ulcer and failed to implement and sustain effective interventions to prevent recurrence for one of 36 sampled residents (Resident 3).Findings include: Clinical record review revealed that Resident 3 had diagnoses including dementia (a decline in cognitive function affecting memory and decision making), failure to thrive (a condition characterized by weight loss, poor appetite, and decline in physical functioning), and finger contractures (a condition in which the fingers are permanently bent inward toward the palm, limiting the ability to open the hand and increasing the risk for pressure and skin injury). A review of Resident 3's annual Minimum Data Set assessment, or MDS, a federally mandated standardized assessment process conducted periodically to plan resident care, dated February 18, 2026, indicated Resident 3 was unable to participate in an interview due to cognitive impairment.A care plan dated February 18, 2026, identified Resident 3 as being at risk for skin breakdown, including the palms of the hands related to finger contractures. Interventions included the use of palm protectors (hand splints designed to reduce pressure and prevent the fingers from curling tightly into the palm). The care plan directed that the devices were to be worn in each hand at all times and removed periodically for skin observation and hygiene. Review of nurse aide documentation for February 2026 indicated that skin checks of the palms were to be completed once per shift. This required removal of the palm protectors to assess skin condition, evaluate positioning, and identify early signs of pressure or injury. Review of investigative documentation provided by the facility dated February 12, 2026, at 6:10 PM revealed that a nurse aide removed the palm protectors and identified an open area between the right thumb and index finger. The documentation identified the root cause as rubbing from the palm protector and the resident's fingernails. The facility indicated that alternative palm protectors without straps would be implemented and that the resident's fingernails would be trimmed. Review of a nurse's note dated February 13, 2026, at 6:52 AM documented that the open area appeared related to pressure from the strap of the palm protector. An occupational therapy evaluation dated February 17, 2026, indicated that Resident 3 was referred for treatment due to skin breakdown between the right thumb and index finger associated with the use of palm guards. The evaluation documented implementation of an alternative device without straps to prevent recurrence. There was no documented clinical rationale explaining why a device without a strap was not initially considered, given the resident's inability to independently open the hand due to contractures. A wound evaluation completed by a wound care physician on February 16, 2026, identified the wound as a Stage III pressure ulcer. A Stage III pressure ulcer is defined as full-thickness skin loss, meaning the outer layer of skin (epidermis) and underlying layer (dermis) are lost, and the injury extends into the tissue beneath. The wound measured 0.3 centimeters (cm) by 1.1 cm by 0.3 cm and contained 15 percent slough (dead, non-viable tissue that appears yellow, tan, or stringy and can delay healing). The evaluating wound specialist identified the cause of the ulcer as pressure from the resident's fingernails. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown, last reviewed February 24, 2026, indicated that nursing staff and practitioner are responsible for identifying and assessing significant risk factors for pressure ulcer development, and implementing appropriate interventions.Observations of Resident 3 on March 11, 2026, at 10:30 AM and March 12, 2026, at 11:30 AM revealed that the fingernails of the right hand were long and sharp, in need of trimming. These findings were consistent with a previously identified contributing factor to the development of the Stage III pressure ulcer on February 12, 2026.Interview with the Director of Nursing (DON) on March 13, 2026, at 11:00 AM did not include evidence that the facility evaluated whether once-per-shift skin observation was sufficient for a resident with contracted fingers and with a device previously identified as a source of pressure. There was no documented evidence that the facility analyzed how the palm protector strap contributed to pressure, such as improper application, fit, or condition of the device, to guide appropriate corrective interventions including staff education or equipment replacement. The DON was unable to provide evidence that the facility implemented and monitored effective interventions to maintain the resident's fingernails in a trimmed and safe condition following identification of fingernails as a root cause of the pressure ulcer. The resident's fingernails were not trimmed until March 12, 2026, at 11:30 AM, after surveyor observation and notification. The facility failed to ensure that identified risk factors, including pressure from medical devices and untrimmed fingernails, were consistently addressed, monitored, and revised as necessary and failed to ensure that interventions were effective and sustained to prevent recurrence, which resulted in a potentially avoidable Stage III pressure ulcer in accordance with facility policy. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing service.

Based on a review of clinical records, facility policy, and staff and resident interviews, it was determined the facility failed to ensure residents received necessary behavioral health services, including trauma-informed evaluation and follow-up psychological services, to attain or maintain their highest practicable mental and psychosocial well-being for two of 36 sampled residents (Residents 66 and 22). Findings include: A review of the facility policy titled Behavioral Health Services, last reviewed by the facility on February 24, 2026, revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Residents who exhibit signs of emotional or psychosocial distress receive services and support that address their needs and goals for care. A review of the facility policy titled Trauma-Informed and Culturally Competent Care, last reviewed by the facility on February 24, 2026, revealed it is the facility policy to address the needs of trauma survivors by minimizing triggers or re-traumatization. Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to all effects of all types of trauma. Traumatic events, which may affect residents during their lifetime, include interpersonal or community violence. A trigger is a highly individualized, psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. Assessment involves an in-depth process of evaluating the presence of symptoms and their relationship to trauma, as well as the identification of triggers. A clinical record review revealed Resident 66 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and depression (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of Resident 66's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 14, 2025, revealed that Resident 66 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of an admission evaluation form dated December 9, 2025, revealed Resident 66 had never experienced a traumatic event and did not have a diagnosis of post-traumatic stress disorder. However, psychology progress notes dated December 15, 2025, December 29, 2025, January 5, 2026, January 19, 2026, February 23, 2026, and March 9, 2026, consistently documented that Resident 66 reported a history of trauma, specifically that he had been recently mugged. Review of Resident 66's clinical record failed to identify documented evidence that the facility completed a trauma assessment, evaluated the presence of trauma-related symptoms, or identified potential triggers following these repeated reports. During an interview on March 10, 2026, at 11:25 AM, Resident 66 indicated that he was assaulted and mugged when he was living at a homeless shelter prior to his admission to the facility. He explained that he continues to be bothered by the experience even months after the occurrence. During an interview on March 13, 2026, at 9:50 AM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The DON and NHA were unable to provide documented evidence the facility completed an assessment of trauma symptoms, evaluated the relationship of symptoms to the reported trauma, or identified triggers following documentation beginning December 15, 2025 for Resident 66. A clinical record review revealed Resident 22 was admitted to the facility on [DATE], with diagnoses that include bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts), generalized anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning), and borderline personality disorder (a serious mental health condition characterized by long-term instability in moods, relationships, self-image, and behavior). A review of Resident 22's quarterly MDS assessment dated [DATE], revealed that Resident 22 was cognitively intact with a BIMS score of 15 (a score of 13 through 15 indicates cognition is intact). A review of the care plan initiated October 24, 2025, identified Resident 22 with impaired psychiatric and mood status and included interventions such as behavioral heath consults (psychological services) as needed. A physician's order dated November 11, 2025, indicated psychological evaluation and treatment as appropriate for Resident 22. A psychological services note dated February 9, 2026, documented that Resident 22 received supportive psychotherapy (a type of counseling focused on emotional support and coping), stress management, and solution-focused therapy (a goal-directed approach to problem solving). The note recommended continued treatment for three to six months and follow-up within two to three weeks. Review of the clinical record revealed no documented evidence that Resident 22 received a follow-up psychological services appointment or session as recommended in the psychological services note dated February 9, 2026. During an interview on March 10, 2026, at 10:50 AM Resident 22 indicated that he has bipolar depression and is currently not receiving counseling or therapy. Resident 22 explained that he believes he would benefit from additional sessions. During an interview on March 13, 2026, at 9:50 AM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The NHA and DON were unable to provide documented evidence that the facility arranged or ensured completion of the recommended follow-up psychological services. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and interview, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift.Findings Include: Observations in the facility first floor lobby and second floor lobby on March 11, 2026, at 1:25 PM and March 12, 2026, at 8:10 AM revealed that the facility's nurse staffing information was not posted in the facility's designated area. An interview with the Assistant Director of Nursing on March 12, 2026, at 8:20 AM revealed that the nurse staffing information should be posted daily at the beginning of each shift in a prominent location.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on a review of clinical records, the facility's abuse prohibition policy, select facility-provided investigative documentation, staff interviews, and direct observation, it was determined that the facility failed to ensure that one resident (Resident C2) was free from physical abuse perpetrated by another resident (Resident CR1), for one out of eleven residents sampled for abuse prevention.Findings include: A review of a facility policy entitled Abuse Policy last reviewed by the facility on April 22, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Further review of a facility policy entitled One-to-One Supervision Guidelines last reviewed April 22, 2025, indicated it was the responsibility of the staff assigned to provide one to one continuous observation, and under the supervision and guidance of the nursing supervisor, and must keep the resident within the line or vision and within reach, and not be left alone (not even with family). A review of Resident CR1's clinical record revealed admission to the facility on December 10, 2025, with diagnoses to include intraspinal abscess (swelling and infection involving the spinal cord area) and granuloma (a localized area of inflammation that forms around infection or foreign material), chronic pain due to trauma, panic disorder (an anxiety disorder characterized by sudden and recurrent episodes of intense fear or discomfort), generalized weakness, and difficulty walking. A review of Resident CR1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 16, 2025, indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition or no cognitive impairment). A review of Resident C2's clinical record revealed admission to the facility on June 6, 2022, with diagnoses that included cerebral palsy (a condition affecting movement and muscle coordination caused by early brain development changes), unspecified intellectual disability (a condition limiting intellectual functioning and independent living skills), conduct disorder (a pattern of aggressive or disruptive behaviors), and mood affective disorder (a condition affecting emotional regulation). A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 4, severe cognitive impairment.A review of Resident C2's comprehensive, person-centered care plan initiated on December 15, 2023, identified behavioral symptoms related to cognitive impairment, including sliding or placing self on the floor, impulsive actions, attention-seeking behaviors, thrusting self from the chair without warning, spitting, inappropriate verbal and physical behaviors, combative behavior during care, and yelling at others. To address these identified behaviors and reduce the risk of unsafe interactions, the facility developed interventions that included continuous one-to-one supervision, supervision during social and recreational activities, avoidance of environmental stimuli such as conversations, television, or radio programming that could trigger or escalate behaviors, referral to psychological or psychiatric services as indicated, and administration of medications as prescribed. A review of facility-provided investigative documentation completed by Employee 1 a Registered Nurse Supervisor and dated December 28, 2025, at 4:00 PM, indicated that Resident CR1 exited his room and approached the nurses' station, reporting that music being played on a laptop was bothering him. According to the documentation, Resident CR1 then removed the external speaker from the computer and threw it onto the floor. The documentation further indicated that Resident C2, who was identified as being on one-to-one supervision at the time, spit on Resident CR1, after which Resident CR1 spit back at Resident C2. The documentation reflected that Resident CR1 encouraged Resident C2 to repeat the behavior, and Resident C2 spit on Resident CR1 again. While staff attempted to redirect and separate Resident C2, the documentation indicated Resident CR1 began striking Resident C2 in the face multiple times. The investigative documentation further reflected that Resident C2 was taken to his room; however, Resident CR1 continued attempting to gain access to Resident C2's room by pushing on the door while a supervisor held it closed. The documentation indicated both residents were eventually separated and Resident CR1 returned to his room. Immediate actions documented by the facility included contacting the police department by calling 911, maintaining one-to-one supervision for Resident C2, and notifying both residents' attending physicians and representatives. The documentation further indicated that the incident was reported to appropriate protective authorities and that the facility initiated an abuse investigation. The documentation reflected Resident C2 was transported to the hospital for further evaluation and treatment, and Resident CR1 was also transported to the hospital and did not return to the facility. A review of emergency department provider documentation dated December 28, 2025, at 9:51 PM indicated diagnostic testing and imaging were completed for Resident C2, with final results that may represent an acute nondisplaced nasal fracture, defined as a possible crack in the nasal bone without displacement. A review of a written witness statement completed by a Licensed Practical Nurse, Employee 2 dated December 28, 2025, with no time indicated, reflected that at approximately 4:45 PM the nurse was administering medications while music was playing through an external speaker at the nurses' station. The statement indicated Resident C2 was in the hallway listening to music, and Resident CR1 made statements about changing the music. The statement further reflected that Resident C2 requested the music be turned up due to difficulty hearing. According to the statement, Resident CR1 exited his room into the hallway near the nurses' station, and the nurse observed shouting and banging before witnessing Resident CR1 strike Resident C2 and attempted to spit in Resident C2's face. The statement indicated the external speaker was observed on the floor approximately fifteen feet from the nurses' station and Resident C2's eyeglasses were knocked off during the physical interaction. The statement further reflected that the nurse intervened by positioning herself between the residents as Resident CR1 continued attempting to approach Resident C2. The statement indicated Resident CR1 swung at staff, yelled profanities, and accused staff of lying. The supervisor was paged and responded immediately, both residents were separated, Resident C2 was taken to his room, and Resident CR1 continued attempting to access Resident C2's room, requiring staff to barricade the door to prevent further contact. A review of a written witness statement completed by Employee 3, a Nurse Aide assigned to provide one-to-one supervision for Resident C2, dated December 28, 2025, at 4:45 PM, reflected that Resident C2 and Employee 3 were at the nurses' station listening to music and watching videos. The statement indicated Resident CR1 approached staff and stated the music was bothering him. According to the statement, Resident CR1 removed the speaker from the computer and threw it onto the floor. The statement further reflected that Resident C2 spit on Resident CR1, Resident CR1 spit back, and encouraged Resident C2 to repeat the behavior. The statement indicated Resident C2 repeated the behavior and attempted to pull away, after which Resident CR1 struck Resident C2 in the face multiple times. The statement reflected the nurse aide called for assistance, and additional staff responded to separate the residents. A review of emergency department provider documentation dated December 28, 2025, indicated imaging results that may represent an acute nondisplaced nasal fracture, defined as a possible crack in the nasal bone without displacement. The documentation did not identify functional decline, neurological impairment, or lasting injury. A review of follow-up specialty documentation revealed that Resident C2 was evaluated by an ear, nose, and throat (ENT) physician on December 30, 2025, due to emergency department findings that identified a possible nondisplaced nasal fracture, defined as a potential crack in the nasal bone without displacement. The ENT consultation documented that the resident exhibited no changes in breathing, normal airway function, and no clinical indication for medical or surgical intervention at that time. The physician documented that the resident was advised to return for further evaluation only if symptoms worsened. The documentation further reflected that no worsening symptoms were reported, and the resident was observed without visible bruising. During on-site survey conducted on January 2, 2026, at 2:15 PM, Resident C2 was observed seated in a wheelchair outside of his room, across from the nurses' station, with a lunch tray placed on a bedside table and independently eating. At the time of observation, no staff member was present providing one-to-one supervision as required by the resident's care plan and the facility's One-to-One Supervision Guidelines. The assigned nurse aide (Employee 4) was observed seated behind the nurses' station at a computer, and Resident C2 was not maintained within the staff member's direct line of vision or within reach, as required by facility policy. During an interview conducted on January 2, 2026, at 2:18 PM, Employee 4, nurse aide confirmed Resident C2 required one-to-one supervision and reported being assigned to provide that supervision. Based on the facility's investigative documentation and written witness statements, Resident C2 was identified as requiring one-to-one supervision at the time of the resident-to-resident physical altercation on December 28, 2025. However, the facility's documentation did not consistently demonstrate that one-to-one supervision was effectively maintained during the incident, as evidenced by Resident CR1's ability to approach, engage, and physically strike Resident C2 prior to staff intervention. An attempt was made by the surveyor to contact the assigned nurse aide (Employee 3) to obtain clarification regarding supervision at the time of the incident; however, the nurse aide did not respond to surveyor contact attempts. The subsequent observation on January 2, 2026, revealed continued noncompliance with the facility's one-to-one supervision policy for Resident C2, demonstrating the facility was unable to consistently implement required supervision interventions intended to prevent unsafe resident-to-resident interactions. During an interview with the Director of Nursing on January 2, 2026, at 3:30 PM, the surveyor reviewed the findings related to the resident-to-resident physical altercation and the observations regarding one-to-one supervision. The Director of Nursing confirmed Resident C2 required one-to-one supervision per the care plan and facility policy. The facility failed to demonstrate consistent implementation of required one-to-one supervision for Resident C2, limiting the facility's ability to ensure the resident was protected from physical abuse by another resident. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services.

Based on a review of clinical records, the facility's abuse prohibition policy facility-provided documentation, and resident and staff interviews, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated, corrective actions implemented, and results reported to the State Survey Agency within five working days, in accordance with regulatory requirements and facility policy, for 1 of 10 residents reviewed (Resident 1).Findings included:A review of the current facility policy titled Abuse Policy revealed the policy stated each resident has the right to be free from abuse, neglect, misappropriation of resident property (wrongful taking or use of a resident's belongings), and exploitation (improper use of a resident for personal gain) as defined in regulation. The policy defined abuse as the willful (deliberate) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish (severe emotional distress). The policy further defined willful to mean the individual acted deliberately, not that the individual intended to cause injury or harm. The policy defined mental abuse as humiliation, harassment, threats of punishment, or withholding of treatment or services. The policy indicated if an individual has a reasonable suspicion that a crime has been committed against a resident, a report must be submitted to law enforcement and the State agency in accordance with the Elder Justice Act (federal law requiring owners, operators, employees, or contractors of federally funded long-term care facilities to report any reasonable suspicion of a crime against a resident within 2 hours if serious bodily injury is involved, or within 24 hours if no serious bodily injury is involved, to the State Survey Agency and local law enforcement). The policy further revealed if any individual observed or suspected resident abuse, an immediate report should be obtained including names of individuals involved, date and time of incident, type of abuse, and names of witnesses. The policy revealed once an allegation of potential abuse is received, the facility will investigate immediately. If the allegation involves an employee, the investigator conducts an interview, obtains a statement, and suspends the accused individual pending the outcome of the investigation. The policy indicated such suspension would remain in place until the investigation is completed. The policy indicated that when staff suspect a crime has occurred against a resident, they must report the incident to the State Survey Agency and local law enforcement. The policy further detailed that staff must report suspicion of a crime to the State Survey Agency and at least one local law enforcement entity within the required time frames by email, fax, or telephone. The policy specified that if the event results in serious bodily injury, the staff member shall report the suspicion immediately but no later than 2 hours after forming the suspicion. If the event does not result in serious bodily injury, the staff member shall report the suspicion no later than 24 hours after forming the suspicion. The policy further revealed the facility will assist staff in reporting suspicions of a crime using the Crime Reporting Form at the time the facility becomes aware of the suspicion that the report will be submitted to the State Survey Agency and local law enforcement within required time frames, and that the facility shall maintain a record of these reports. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including vascular dementia with psychotic disturbance (loss of thinking ability caused by impaired brain blood flow) and primary insomnia (chronic difficulty sleeping). The resident's comprehensive person-centered plan of care initiated on May 10,2024, and revised on December 19, 2024, indicated the resident had behaviors related to impaired psychiatric/mood status due to dementia. The interventions included providing a calm, safe environment when emotional or frustrated and allowing time to voice feelings. The interventions also included approaching the resident in a calm, positive reassuring manner, and redirecting the resident as needed. Review of Resident 1's Annual MDS (Minimum Data Set, a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], revealed the resident had a BIMS score of 0 (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis), which indicated that the resident had severe cognitive impairment. A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included vascular dementia (cognitive impairment caused by reduced blood flow to the brain) and insomnia (difficulty sleeping). Additionally, the resident had severe cognitive impairment and utilized a wheelchair for mobility as indicated by the Annual MDS assessment dated [DATE], as evidenced by a BIMS score of 2 (score of 00-07 indicates severe cognitive impairment). A review of facility-provided documentation revealed that on January 18, 2026, at approximately 8:00 PM, an incident occurred involving Resident 1 and Resident 2. The documentation included a written witness statement by Employee 1 (Nurse Aide), which indicated Employee 2 (Licensed Practical Nurse) engaged in a verbal argument with Resident 1 and threw a cup of water into Resident 1's face, followed by a second cup of water. The statement documented Resident 1 then attempted to spit toward Employee 2 but instead spit on Resident 2, who became agitated and struck Resident 1 in the face. The statement documented Employee 1 removed Resident 1 from the area while Employee 2 remained to clean the spilled water. Professional standards of practice and the facility's own policy required staff to report and investigate allegations when an action could reasonably be interpreted as abusive. Even when residents exhibit behavioral symptoms such as yelling or spitting, staff are expected to use trained behavioral and de-escalation interventions. The documented action of Employee 2 intentionally throwing two cups of water into Resident 1's face constituted conduct that a reasonable person (objective standard used to evaluate how an average individual would interpret an action) could view as humiliating, distressing, or punitive in nature. Therefore, the allegation met the facility policy threshold requiring immediate reporting, investigation, and documentation to determine whether abuse occurred. During an interview on February 12, 2026, at 10:00 AM, Employee 2 LPN confirmed she threw a cup of water in Resident 1's face. Employee 2 stated that when she began her shift at 3:00 PM, she observed Resident 1 to be agitated. She stated she approached Resident 1 to administer medications, at which time Resident 1 began yelling profanities at her. Employee 2 stated she threw the water in reaction to Resident 1, after which she reported Resident 1 spit at her. Employee 2 stated she provided a statement to police regarding her encounter with Resident 1 and the physical interaction between Resident 1 and Resident 2. She stated that after speaking with police she returned to the unit to complete charting. Employee 2 stated she had previously been scheduled to leave early and departed the facility between approximately 9:30 PM and 10:00 PM but could not recall the exact time. Employee 2 stated she was not instructed to leave the facility and departed at her previously approved early time. A review of the written statement by Employee 2, provided by the facility documented Resident 1 was agitated with another resident and was using derogatory language toward that resident. The statement documented that after Employee 2 administered Resident 1 his medications, he began calling her names. The statement further documented Resident 2 was walking down the hallway when Resident 1 spit medication and water toward Employee 2, also simultaneously hitting Resident 2 with the medication/water spit combination. Employee 2 wrote she threw the water on Resident 1 out of impulse. Employee 2 then wrote that she continued to pass medications to other residents and monitored Resident 1. Review of facility-provided information revealed the facility reported the incident to police and the Area Agency on Aging as a resident-to-resident altercation. However, the facility was unable to provide documentation showing it investigated or reported the allegation of staff-to-resident abuse involving Employee 2 throwing water at Resident 1. During interview on February 12, 2026, at 1:55 PM, Employee 3 (Registered Nurse Supervisor) stated she became aware of the incident between approximately 8:00 PM and 8:30 PM on January 18, 2026, and directed Employee 2 to leave the floor and write a statement. She stated Employee 2 was argumentative and said the water was thrown accidentally. Employee 3 stated she did not believe it was accidental because she was informed Employee 2 filled a second cup and again threw water on Resident 1. Employee 3 stated she contacted police regarding the resident-to-resident altercation and stated Employee 2 did not return to the floor to complete her shift, despite Employee 2's statement that she returned to the floor to complete her shift. Review of Employee 2's time records showed she clocked out at 9:33 PM. Review of Resident 1's January Medication Administration Record documented Employee 2 recorded completion of an Accu-Chek (finger-stick blood sugar test) at 9:30 PM one and a half hours after the alleged incident was first documented, as indicated by her statement she returned to the floor to finish documentation. During interview on February 12, 2026, at 11:20 AM, the facility Risk Manager stated he became aware of the incident the following day and stated the facility did not report or further investigate the staff action because there was no serious bodily injury, sexual abuse, or death and therefore it was not considered reportable. When asked whether documentation existed showing the facility ruled out physical, mental, or psychosocial abuse (harm affecting emotional or psychological well-being), the facility was unable to provide such documentation. The facility was unable to provide documentation that the allegation involving Employee 2 throwing water on Resident 1 was reported to the State Survey Agency as required by facility policy. The facility was also unable to provide documentation of a complete investigation into the allegation, including evidence of interviews of all involved individuals, investigative findings, or documentation demonstrating abuse was ruled out. These findings were reviewed with the Nursing Home Administrator on February 12, 2026, at 1:10 PM. At that time, no additional documentation was provided demonstrating that a thorough investigation had been conducted or that the staff-to-resident allegation had been reported in accordance with facility policy and reporting requirements. 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights28 Pa. Code 211.10(a)(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on review of clinical records, the facility's abuse prohibition policy, and select facility investigative documentation and staff interview, it was determined the facility failed to ensure that one resident (Resident 1) was free from physical abuse perpetrated by another resident (Resident 2) out of 6 residents sampled for abuse prevention, which resulted in serious harm and injury, a fractured humerus (arm) and femur (leg). This deficiency is cited as past non-compliance.Findings include: A review of a facility policy entitled Abuse Policy last reviewed by the facility on April 22, 2025, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful, as used in this 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 2's clinical record revealed admission to the facility on March 29, 2022, with diagnoses to include dementia with behavioral disturbance (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]).A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 10, 2025, indicated that the resident was severely cognitively impaired with a BIMS score of 3 (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 0-7 indicates severe cognitive impairment).Review of Resident 2's care plan, initiated on January 20, 2022, indicated the resident exhibits verbal and physical agitation and aggression (combative with cares such as striking out at staff, loud verbal outbursts, disruptive to self and others, spits on others, screams at others, and makes accusatory statements). The planned interventions were to administer mediations as ordered, allow time to respond, approach slowly and slightly to the side, be aware of resident's personal space, gain resident's attention before speaking, give clear and concise explanations, leave resident if behavioral interventions are not working, provide diversional activities, remove from public area when behavior is disruptive, speak in a low-pitch, calm and reassuring tone, and use consistent routines and caregivers. A review of Resident 1's clinical record revealed admission to the facility on June 11, 2019, with diagnoses to include dementia, mood disorder, and chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe).A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 4, severe cognitive impairment.A review of the care plan, initially dated December 26, 2023, indicated that Resident 1 was at risk for alterations in psychosocial well-being. The risk was related to unsettled relationships and conflicts, verbal and physical agitation, and aggression toward other residents and roommates. The care plan documented that Resident 1 had a history of making rude or hostile comments directed toward staff and others, being verbally abusive to roommates, and having previously struck a roommate. These behaviors were identified as being associated with the resident's cognitive impairment and history of substance abuse.A review of a nursing progress note dated August 7, 2025, at 10:35 PM revealed documentation that a fall code had been announced. The note indicated that nursing staff entered Resident 1's room and observed Resident 1 lying on her left side on the floor while yelling out. Resident 2 was documented as ambulating near the doorway of the room. The note further indicated that Resident 1 stated Resident 2 had been in her bathroom, and when she stood from her wheelchair and approached the bathroom, Resident 2 exited and pushed her, causing her to fall. The documentation indicated Resident 1 complained of pain in her left shoulder and hip, with vital signs noted to be stable. Staff separated the residents, initiated neurological checks (series of assessments performed at regular intervals to monitor a resident's nervous system) along with every 15-minute observation checks, notified the physician and guardian, and ordered diagnostic x-rays.A review of facility investigative documentation dated August 8, 2025, at 10:30 AM revealed that the facility classified the incident as physical abuse. The documentation indicated that Resident 1, identified as the victim of the aggression, was in her room when Resident 2, identified as the aggressor, exited the bathroom, pushed Resident 1, and caused her to fall to the floor. Resident 1 was noted to have called for help, and staff responded to find her sitting on the floor. Resident 1 was assessed, assisted to bed, and complained of pain in her left shoulder and left hip. The documentation further indicated that the residents were separated. Both residents placed on every 15 minute observation checks. The physician and resident representatives were notified, and x-rays were ordered. The documentation reflected that the incident was reported to appropriate protective authorities, and an abuse investigation was initiated by the facility.Resident 1 was transferred to the emergency department on August 8, 2025, where she was diagnosed with an acute (sudden) fracture of the left humeral neck (upper arm bone, near the shoulder joint) and an acute fracture of the left femoral neck (upper portion of the thigh bone). Review of the x-ray report dated August 8, 2025, revealed Resident 1 sustained an acute, displaced (bone moves out of normal alignment),transverse (type of bone break where the fracture line runs horizontally across the bone) fracture through the neck of the proximal femur and an acute, displaced, comminuted (bone breaks into three or more pieces) fracture through the neck of the proximal humerus as a result of the fall. On August 10, 2025, Resident 1 underwent a left hip hemiarthroplasty (surgical procedure where only the femoral head [the ball portion of the hip joint] is replaced with a prosthetic implant). At the time of the survey ending August 13, 2025, Resident 1 remained hospitalized . The above findings regarding the incident and the facility's classification of the event as physical abuse were reviewed with the Nursing Home Administrator on August 13, 2025, at 10:45 AM.This deficiency was cited as past non-compliance.The facility's corrective action plan included the following:1. Resident obtained a fracture from a resident-to resident altercation over the bathroom.2. Director of Nursing (DON)/designee to conduct an audit to identify residents with wandering behaviors. Those identified will have individualized interventions implemented with care plans updated. Residents will be discussed at weekly IDT (Interdisciplinary Team) meetings. 3. DON/designee to educate the nursing staff on the Abuse Policy and behavioral intervention suggestions to assist staff with re-directing behavioral residents. 4. DON/designee to conduct random weekly audits on residents with wandering behaviors to implement individualized interventions weekly x 4 weeks then monthly x 2 months. Results will be reviewed at monthly QAPI. The facility's compliance date was August 11, 2025, and completion of the corrective action plan noted above was confirmed during the survey ending August 13, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 36 residents reviewed (Resident 105). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145 b. IV therapy curriculum requirements: (f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1). (1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as a CRNP, physician, physician assistant, podiatrist or dentist). (g) An LPN who has met the education and training requirements of S 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145 a and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. A review of a facility policy titled Administering Medications by IV last reviewed by the facility on April 22, 2025, revealed the facility is to verify the nursing staff scope of practice and competency requirements for this procedure with the State Nurse Practice Act. Clinical record review revealed that Resident 105 was admitted to the facility on [DATE], with diagnosis to include intracranial abscess and granuloma (collection of pus that develops in the brain due to an infection) and adult failure to thrive (gradual decline in health characterized by weight loss, decreased appetite, poor nutrition and inactivity), and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). Physicians orders dated April 12, 2025, revealed an order to administer Ceftriaxone Sodium (antibiotic medication) Injection Solution Reconstituted 250 MG. Use 2 grams intravenously (IV) every 12 hours for abscess until May 9, 2025. Infuse 2 grams into a venous catheter (PICC) every 12 hours. A review of the April 2025 Medication Administration Record (MAR) revealed that between April 13 through April 30, 2025, Employee 5, LPN, Employee 6, LPN, Employee 7, LPN, Employee 8, LPN, Employee 9, LPN, Employee 10, LPN, and Employee 14, LPN signed the MAR as administering the IV antibiotic medication to Resident 105 through the PICC line. A review of the May 2025 MAR revealed that between May 1 through May 8, 2025, Employee 9, LPN, Employee 10, LPN, Employee 11, LPN, Employee 12, LPN, Employee 13, LPN, and Employee 14, LPN signed the MAR as administering the IV antibiotic medication to Resident 105 through the PICC line. The facility was unable to produce any documentation verifying that these LPNs had completed the required IV therapy education and training in accordance with S21.145 (b). There was no evidence of current competency validation, supervision documentation, or internal training specific to PICC line administration. During an interview conducted on May 15, 2025, at approximately 10:50 AM, the Director of Nursing (DON) confirmed that the facility did not provide education or training regarding administration of medications through PICC lines to LPNs. The DON further stated that it was the facility's policy that only RNs were permitted to administer medications via PICC lines. Despite this, multiple LPNs administered IV antibiotics through a central venous access device (PICC line) to Resident 105 over a 26-day period. There was no documented oversight by an RN or qualified healthcare provider, and no documentation existed confirming the LPNs met the education, training, or supervision requirements stipulated in the Pennsylvania Nurse Practice Act. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review, payor source data, and resident and staff interview, it was determined the facility failed to provide timely and necessary dental services for two residents (Resident 48 and 103) and failed to provide routine dental for one resident (Resident 55) out of 36 residents reviewed who were Medicaid recipients. Findings included: A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Type 2 diabetes (trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues). A quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 23, 2025, indicated the resident was moderately cognitively impaired with a BIMS score of 10 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 8-12 indicates moderate cognitive impairment). Review of Resident 48's Dental Summary Report dated July 22, 2024, revealed the resident had an emergency dental exam due to complaints of pain and food getting stuck in his teeth. The probable cause of resident's complaints was identified as cavities and poor contact of teeth #30 and #31. Treatment recommendations were to extract decayed teeth. Review of Resident 48's Dental Summary Report dated October 18, 2024, revealed the resident was scheduled for an extraction. The procedure was not performed as the resident was to receive an antibiotic one hour prior to the appointment and the facility failed to administer the medication. The dentist reported she spoke with the nurse and the nurse stated she was unaware that he was to be given an antibiotic. Extraction was to be reschedule for another visit. At the time of the survey ending May 16, 2025, the facility was unable to provide documented evidence that a follow-up visit was rescheduled with the dentist for Resident 48 to undergo the extraction procedure as recommended by the dentist. A review of Resident 103's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), type 2 diabetes, and moderate protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health). A significant change of status MDS dated [DATE] indicated the resident was severely cognitively impaired. Nursing documentation dated November 12, 2024, at 9:36 PM revealed that the LPN (licensed practical nurse) reported that Resident 103 lost her upper denture. Her diet was downgraded to mechanical soft. The Physician and Resident Representative (RP) were notified. Nurse documentation dated November 26, 2024, at 1:22 PM revealed that the RP was made aware the dentist was scheduled onsite to see the resident on December 9, 2024, for dentures. Review of Resident 103's Dental Summary Report dated December 9, 2024, revealed the resident was not seen by the dentist as the resident was brought to the clinic and refused to be seen. The dentist indicated on the report that Resident 103 stated she did not want dentures. There was no documented evidence the RP was notified of the outcome of dental visit and the resident's refusal for dentures. Nursing documentation dated February 4, 2025, at 4:29 PM revealed the RP expressed concern that the resident never got her new dentures. The nurse discussed with the RP about the resident refusing to be seen by the dentist. The RP reported she believes it was a bad day for the resident and would like for the facility to try and have her seen by the dentist again. The RP stated that dentures were always very important to the resident, and she thinks she may eat more if she had dentures. At the time of the survey ending May 16, 2025, the facility was unable to provide documented evidence that Resident 103 was scheduled for a dental appointment for dentures at the request of the RP on February 4, 2025. A review of Resident 55's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include metabolic encephalopathy (chemical imbalance in the blood that affects the brain which can cause loss of memory and difficulty coordinating motor tasks) and moderate protein-calorie malnutrition. An annual MDS dated [DATE], indicated the resident was cognitively intact with a BIMS of 14 (a score of 13-15 indicates cognitively intact responses). During an interview with Resident 55 on May 13, 2025, at 12:00 PM she reported she has not seen a dentist in the past year while residing in the facility. There was no documented evidence at the time of the survey ending May 16, 2025, the resident had been offered dental services in the past year. During an interview on May 15, 2025, at approximately 11:00 AM the Director of Nursing (DON) was unable to produce documentation to demonstrate that routine dental was provided for Resident 55 or that timely and appropriate dental services were provided for Resident 48 and 103. The DON could not explain the delay in the dental referral or the prolonged timeline for dental services. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of clinical records, select facility policy, and resident and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 141) out of 36 residents sampled. Findings include: Review of the facility Restorative Nursing Services Policy last reviewed April 22, 2025, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and plan of care. Review of the clinical record revealed that Resident 141 was admitted to the facility on [DATE], with diagnoses which include vascular dementia (a form of dementia caused by an impaired supply of blood to the brain), diabetes, and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should). Review of an annual Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 28, 2025, indicated the resident had a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 10 (a score of 8-12 indicates moderate cognitive impairment) and the resident had the ability to walk 10 feet with supervision or touching assistance, but refused to walk 50 feet or 150 feet in a hall or similar space. During an interview with Resident 141 on May 13, 2025, at approximately 12:30 PM the resident stated that he feels like he is getting weaker and is not being ambulated by staff on a consistent basis. Review of Resident 141's Physical Therapy Discharge Summary dated November 29, 2024, revealed the resident met his goal to ambulate 150 feet using a RW (rolling walker- wheeled mobility aid designed to provide support and stability for individuals with difficulty walking, featuring wheels for easy movement without lifting) with stand by assistance. A restorative nursing program for ambulation with RW 150 feet with contact guard and wheelchair follow was recommended for the resident. Review of Resident 141's care plan in effect at the time of the survey ending May 16, 2025, failed to reveal as per facility policy an individualized and resident-centered care plan with restorative goals and objectives to address the resident's restorative ambulation program which was recommended by therapy. Review of Resident 141's December 2024 through May 14, 2025, Task Documentation Reports revealed a Restorative Ambulation Task to ambulate the resident 150 feet with RW and wheelchair follow on the 7:00 AM to 3:00 PM shift. Further review of the reports revealed that staff documented resident refusal or NA (not applicable) on most days. Further review of the clinical record revealed no documented evidence the resident's restorative ambulation program was reevaluated based on the resident's noted refusals and not being offered to ambulate as indicated by the documentation of the nurse aide on the resident's Task Documentation Reports. During interview with Resident 141 in the presence of Employee 3 (RN Unit Manager) on May 15, 2025, at approximately 10:00 AM the resident confirmed he is not being provided the opportunity to ambulate. Interview with the Director of Nursing on May 15, 2025, failed to provide documented evidence that Resident 141's restorative ambulation program was implemented and being monitored in a manner to ensure the resident's goals for ambulation are met to the extent possible as per facility policy. 28 Pa. Code: 211.5(f)(viii) Medical records 28 Pa Code 211.12(c)(d)(5) Nursing services

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of four medication carts observed (Master Hall Three). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility April 22, 2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of the medication cart located on Master Hall Three unit on May 14,2025 at 9:20 AM, in the presence of Employee 15 (Registered Nurse) of medication stored in the medication cart, revealed two (2) multi-dose insulin pens of Insulin Aspart ( a rapid acting insulin medication used to lower blood sugar ) and Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for use, but not dated when initially opened. An interview with Employee 15 (RN) on May 14, 2025 at 9:30 AM confirmed both multi dose insulin pens: Insulin Aspart and Insulin Glargine were opened, and available for use, and not dated. Interview with the Director of Nursing (DON) on May 14,2025, at approximately 11:00 AM, confirmed the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records, select facility policy, and staff interviews it was determined the facility failed to timely provide care and services, consistent with professional standards of practice, to promote healing of pressure ulcer development for one of four residents reviewed. (Resident 10) Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of the facility Pressure Ulcer Policy last reviewed April 22, 2025, indicated staff will examine the skin of a new admission for ulcerations or alterations in skin. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for the type of skin alteration. Review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (chronic autoimmune disease that affects the brain and spinal cord) and a pressure ulcer to the right hip. A review of the Admission Evaluation dated December 31, 2024, noted that Resident 10 required the assistance of two staff for bed mobility. However, there was no documented evidence that a turning and repositioning program was initiated upon admission, despite the presence of an existing pressure ulcer and the resident's dependence on staff for bed mobility. Review of Resident 10's January Task Documentation Report revealed that a turning and repositioning every two hours program was not implemented until January 3, 2025 (three days after admission). Review of a Wound Evaluation note dated December 31, 2024, upon admission to the facility documented the presence of a Stage 4 (full-thickness skin and tissue loss with exposed bone, muscle, or tendon) pressure ulcer on the right hip which measured 1 cm length by 1cm width by 0.8 cm depth with undermining (wound edges are separated from the surrounding healthy tissue, creating a pocket beneath the wound surface) 1 cm at 12 o'clock, no odor, 20% granulation (tissue that will fill in a wound that is healing), 30% slough (dead tissue separating from living tissue, a mass of dead tissue), and no pain. The note indicated a new treatment was ordered. However, further review of the clinical record revealed no physician orders for wound treatment to the Stage 4 pressure ulcer dated December 31, 2024. The first available treatment order for the right hip pressure ulcer was dated January 3, 2025 (three days after the resident was admitted to the facility), noted an order to cleanse right hip with soap and water, pat dry, pack loosely with 1/4 inch iodoform (antiseptic agent) gauze (type of wound packing where a sterile gauze strip is impregnated with iodoform and used to fill the wound cavity) and cover with bordered dressing once daily. An interview conducted with Employee 4, Registered Nurse Wound Care Nurse, on May 16, 2025, at approximately 11:00 AM, failed to produce documented evidence that a wound treatment was implemented upon admission as indicated in the Wound Evaluation dated December 31, 2024. During an interview conducted with the Director of Nursing on May 16, 2025, at approximately 11:30 AM, the DON was unable to provide documentation that timely wound care and pressure ulcer interventions were initiated to promote healing of Resident 10's Stage 4 pressure ulcer upon admission. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. 28 Pa. Code 211.5(f)(i)(viii) Medical records.

Based on clinical record review, observations, and resident and staff interviews it was determined the facility failed to provide the necessary staff assistance with activities of daily living to maintain good personal grooming for residents dependent on staff assistance for nail care for two of five residents sampled (Residents 25 and 141). Findings include: Review of the clinical record revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses which include dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning). Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 5, 2024, indicated the resident had a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 2 (a score of 0-7 indicates severe cognitive impairment) and required substantial/maximal assistance (staff does more than half the effort) with personal hygiene. Observations of Resident 25 conducted on May 13, 2025, at 12:15 PM and May 15, 2025, at 9:45 AM revealed the fingernails on the resident's left hand were dirty with a build-up of a dark colored debris under the nails. Interview with employee 2 (Registered Nurse Regional Consultant) on May 15, 2025, at 9:45 AM confirmed that Resident 25's fingernails were dirty. Review of the clinical record revealed that Resident 141 was admitted to the facility on [DATE], with diagnoses which include vascular dementia (a form of dementia caused by an impaired supply of blood to the brain). Review of an annual MDS dated [DATE], indicated the resident had a BIMS score of 10 (a score of 8-12 indicates moderate cognitive impairment) and required substantial/maximal assistance for personal hygiene. Observations of Resident 141 on May 13, 2025, at 12:50 PM and May 15, 2025, at 9:50 AM revealed that the fingernails on the resident's right hand were long and there was a build-up of dark colored debris under the nails. During interview with Resident 141 on May 15, 2025, at 9:50 AM the resident revealed that he is able to trim the fingernails on his left hand but does not have enough strength to trim the fingernails on his right hand. Interview with the assistant director of nursing on May 15, 2025, at approximately 10:30 AM confirmed that staff were to provide residents' nail care to maintain good personal grooming and hygiene. 28 Pa Code 211.12 (d)(5) Nursing services

Based on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interviews, it was determined the facility failed to assure that one resident (Resident 28) out of 36 sampled were free from physical abuse perpetrated by another resident (Resident 133). Findings include: A review of facility policy titled Facility Abuse Policy last reviewed by the facility on April 22, 2025, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this 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 178's clinical record revealed he was admitted to the facility on [DATE], with a diagnosis which included Multiple Sclerosis (a chronic autoimmune disorder that affects the central nervous system) and Cellulitis (a bacterial infection that affects the inner layers of the skin). A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 20,2025, indicated the resident was severely cognitively impaired With a BIMS score of 5 (Brief Interview for Mental Status - a tool to assess cognition, a score of 0-7 indicates severe cognitive impairment). A review of Resident 133's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified sequelae of cerebral infarction (refers to the long term affects and complications that can occur after a stroke ), aphasia (a communication disorder that results from damage to parts of the brain that is responsible for language and affects a person's ability to speak) and vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain ). A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident had impaired cognitive function. The assessment indicated Resident 133 had a BIMS score of 99 (Brief Interview for Mental Status - a tool to assess cognition, a score of 99 indicates the resident did not provide or was unable to provide the answers to complete this section). Nursing notes from December 2024 through January 2025 documented a pattern of physically aggressive behaviors, including yelling, throwing items, banging fists against the medication cart, and exhibiting threats to others. On January 3, 2025, at 10:00 PM, staff responded to loud yelling from the shared room of Resident 133 and another resident. Resident 133 was removed and placed on one-to-one supervision. Subsequently, a nursing note on January 4, 2025, at 12:26 AM documented that Resident 133 allegedly struck his roommate, Resident 178, twice in the chest with a closed fist. Review of the mandatory abuse report dated for January 4, 2025, revealed staff responded to the room occupied by Residents 178 and 33 when they heard yelling. Resident 33 was found at the bedside of Resident 178 and noted to be yelling. Resident 133 was immediate removed to the hallway. Further review revealed Resident 178 stated he was laying in his bed when Resident 133 came over and started to yell at him, then punched him twice, once in the arm and once in the chest. Resident 178 was assessed with no injuries to be noted. A review of nursing documentation revealed a nursing note dated January 8,2025 at 3:38 PM revealed the Interdisciplinary Team met to discuss Resident 133's one to one supervision status. Resident 133's agitation and yelling were noted to be during the 3:00 PM to 11:00 PM shift and was noted to be calm and sleeping during the 11:00 PM to 7:00 AM shift. Resident 133 was to remain a one-to-one supervision for both day and evening shifts but was changed to every 15-minute checks for the night shift. Review of Resident 133's care plan dated March 1, 2024, and revised February 3,2025, identified issues related to behaviors of refusing showers, care and medications. Continued review revealed Resident 133 was identified having behaviors of being aggressive towards staff and other residents, throwing items (bed side table, cabinets, chairs), slamming doors, banging his head off the wall or kicking the side rails, and purposely placing himself on the floor. Further review of the care plan revealed interventions to include, monitor behavior episodes and attempt to determine underlying cause, attempt to redirect resident when exhibiting behaviors, re-approach resident when behaviors have deescalated, attempt distraction during behavioral episodes by offering a coloring activity, converse about baseball, offer a snack, assist with getting the resident to a quiet area to self soothe, take resident for a walk. A new intervention dated April 11, 2025, stated that Resident 133 was to receive 1:1 observation on the day and evening shifts and every 15-minute checks overnight. A review of Resident 28's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mood disorder characterized by persistent feeling of sadness and loss of interest in activities once enjoyed). and essential hypertension (high blood pressure). A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognition, a score of 13-15 indicates cognition was intact). On April 16, 2025, at 3:30 AM, a physical altercation occurred between Resident 133 and Resident 28 in their shared room. According to nursing documentation, Resident 133 threw water and a cup at Resident 28 near the bathroom door, then slapped Resident 28 in the face. Resident 28 attempted to disengage but returned the slap before staff intervened. Both residents were assessed, and no physical injuries were documented. Resident 133 was relocated to a different room following the incident. A review of Resident 133's hourly observation log for April 16, 2025, revealed inconsistencies. CNA documentation indicated that the resident was observed sleeping at both 3:00 AM and 4:00 AM. However, this contradicts the timeline of the incident, and no evidence was provided that every-15-minute checks were performed as required by the care plan. An interview with the Director of Nursing (DON) conducted on May 16, 2025, at 11:00 AM confirmed the facility did not maintain consistent or effective supervision of Resident 133 during the overnight shift and failed to ensure safety protocols were followed. The DON acknowledged that the lack of supervision directly contributed to a slap in the face of Resident 28. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on observation and staff interviews it was determined the facility failed to provide a sanitary environment for residents, staff, and the public in one of out of three buildings sampled (Garage 1). Findings include: An observation on January 13, 2025, at 8:54 AM, revealed Garage 1 with approximately 50 filled clear plastic garbage bags stored on the ground in the building. The building had an unpleasant and foul odor. The garbage bags were observed to contain a variety of refuse including blue latex gloves, used resident briefs, bed protective barriers, human and food waste. Cardboard boxes and loose latex gloves were also observed on the garage floor not in plastic bags. The bags were piled approximately 4 feet high and extended 20 feet across the garage floor. The bags were blocking the egress to enter the building further than 8 ft. During an interview on January 13, 2025, at 9:00 AM, Employee 1, Director of Maintenance, indicated the trash compactor was filled on January 1, 2025, and the excess facility garbage was stored in the garage until an additional pick-up could be scheduled. He explained the waste could be moved to the facility's compactor, but the compactor would fill up again before the next scheduled pickup. Employee 1, Director of Maintenance, indicated the facility needed an additional pick-up to get caught up on the facility's waste removal. During an interview on January 13, 2025, at approximately 12:30 PM, the Nursing Home Administrator (NHA) confirmed there were approximately 50 bags of garbage stored in the facility's garage 1. He explained it was the refuse the facility produces in one day including resident personal garbage, dietary waste, and used products from direct resident care such as briefs and gloves. The NHA confirmed the garage building is used by facility staff. He confirmed the 50 bags of garbage were stored in the garage since January 1, 2025. The NHA confirmed it is the facility's responsibility to provide a sanitary environment for residents, staff, and the public. 28 Pa. Code 201.14 (b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(3)(e)(2.1) Management.

Based on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered a resident's medications as scheduled for one of 35 reviewed (Resident 129). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. 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 including Medication Records. A review of the facility policy titled Administering Medications last reviewed by the facility on June 3, 2024, indicated that medications are administered within one hour of their prescribed time. A review of the clinical record of Resident 129 revealed admission to the facility on [DATE], with diagnoses which included Type 2 diabetes (failure of the body to produce insulin), and dementia with agitation dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A physician's order dated December 22, 2023, was noted for Lantus Subcutaneous Solution 100 unit/ml (medication used to treat diabetes), inject 12 units subcutaneously (administered under the skin) once daily for diabetes. A review of Resident 129's Medication Administration Record (MAR) for April 2024, revealed that the resident was prescribed Lantus injection and scheduled to receive the Lantus at 9:30 AM. Further review of the resident's MAR for April 2024, indicated that on the following dates, the Lantus injection for diabetes was administered more than one hour beyond the physician prescribed 9:30 AM administration time: April 3, 2024 11:02 AM April 6, 2024 11:15 AM April 7, 2024 1:21 PM April 12, 2024 1:53 PM April 21, 2024 11:18 AM April 25, 2024 11:22 AM A review of Resident 129's MAR for May 2024, revealed that the resident was prescribed Lantus injection and scheduled to receive the Lantus at 9:30 AM. Further review of the resident's MAR for May 2024, indicated that on the following dates, the Lantus injection for diabetes was administered more than one hour beyond the physician prescribed 9:30 AM administration time: May 9, 2024 11:18 AM May 10, 2024 11:24 AM May 13, 2024 11:24 AM May 16, 2024 11:56 AM May 18, 2024 12:49 PM May 23, 2024 11:54 AM A review of Resident 129's MAR for June 2024, revealed that the resident was prescribed Lantus injection and scheduled to receive the Lantus at 9:30 AM. Further review of the resident's MAR for June 2024, indicated that on the following dates, the Lantus injection for diabetes was administered more than one hour beyond the physician prescribed 9:30 AM administration time: June 2, 2024 10:48 AM June 7, 2024 1:58 PM June 10, 2024 11:06 AM June 20, 2024 10:46 AM June 22, 2024 10:47 AM June 24, 2024 11:08 AM Interview with the Director of Nursing on July 11, 2024, at approximately 1:00 PM confirmed that the late administration of Resident 129's Lantus medication is not consistent with the professional standards for diabetes management. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on review of clinical records, select facility policy and incident reports and staff interview it was determined that the facility failed to consistently provide necessary supervision required by a resident with a known history of unsafe behaviors to prevent a fall resulting in a fractured hip for one resident out of 35 sampled residents (Resident 172). Findings include: Review of a facility policy entitled Falls and Fall Risk, Managing that was last reviewed by the facility on May 5, 2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the clinical record revealed that Resident 172 was admitted to the facility on [DATE], with diagnoses of vascular dementia without behavioral disturbances [is a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain and causes problems with reasoning, planning, judgment, and memory], anemia, and protein calorie malnutrition. Resident 172's care plan, initiated December 29, 2022, revealed that the resident was at risk for falls due to impaired mobility, poor safety awareness related to dementia and history of falls with a goal to minimize risks for falls/minimize injuries related to falls. The planned interventions were to have commonly used items within reach, reinforce the need to call for assistance, anti-rollback device to wheelchair, maintain bed in the lowest position, and bed and chair alarm - check placement and function each shift. Resident 172's fall risk assessment dated [DATE], at 4:16 PM, indicated that the resident was at high risk for falls due to poor recall, judgement, and safety awareness, and was non-ambulatory/incontinent. The resident was also identified to have had poor vision (with or without glasses), 1-2 falls over the past three months, and predisposing diagnoses that contribute to fall that included dementia and anemia Review of Resident 172's admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) assessment dated [DATE], indicated that the resident had severe cognitive impairment and required extensive assistance of two plus persons physical assist for bed mobility, transfers, toileting, dressing, and with personal hygiene. The resident was also assessed as unsteady, only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and with surface-to-surface transfers. A review of a facility unwitnessed fall investigation report dated January 7, 2023, at 6:36 AM, revealed that the resident had an unwitnessed fall in his room while attempting to ambulate to the bathroom. No injuries were noted. The immediate intervention planned were to conduct every 15-minutes checks for 24-hours, a therapy screen, and a 3-day bowel and bladder assessment and toileting program. Nursing progress notes dated January 22, 2023, at 10:31 PM, revealed that the resident was restless and constantly rising from his wheelchair and walking about. The resident's chair alarm was sounding and the resident was easily redirected by nursing staff members. Nursing noted on January 24, 2023, at 6:31 AM, that the resident was up most of the night and was sitting at the nurse's station. The resident was getting up and down from his wheelchair and getting very argumentative about sitting down. Staff put him in bed, but he was back up again. He got loud with staff when asked to sit down and laughed at the staff. Nursing continued to note that the resident displayed unsafe behaviors such as restlessness and wandering on January 24, 2023, at 11:24 AM. An encounter note that was completed by the Physician's Assistant (PA-C) dated January 26, 2023, at 12:00 AM, revealed that upon assessment Resident 172 was very restless and somewhat agitated at the time of the visit. The PA-C noted that the resident was thoroughly confused and appeared to be on a mission looking for something, but could not verbalize what he wants exactly. The note indicated that nursing staff had reported to the PA-C that the resident did not sleep last evening and had intermittent episodes of agitation throughout the day and evenings and was impulsive and difficult to redirect. New orders for Trazadone [used to treat major depressive disorder. It may help to improve your mood, appetite, and energy level as well as decrease anxiety and insomnia related to depression], 50 mg by mouth, every night and Ativan [benzodiazepines used to treat anxiety disorders] 0.25 mg, 1 tablet every 8-hours as needed were noted. Nursing progress note dated January 26, 2023, at 11:17 AM, revealed that the resident continued to be very agitated with staff and other residents and was trying to exit his wheelchair without staff assistance and was self-propelling around the area. A review of a facility unwitnessed fall investigation report dated February 15, 2023, at 8:10 PM, revealed that the resident had an unwitnessed fall in the hallway near the nurse's station. The investigation noted that the resident had been seated in view of nursing staff near the nurse's station, but the nurse on duty went into the medication room for one minute and heard the chair alarm sound and immediately responded. Resident 172 was observed lying in supine position on the floor in front of his wheelchair and in front of the nurse's station. No injuries were noted. The planned immediate interventions were to monitor the resident's hours of sleep every shift, initiate alert charting to monitor behaviors and unsafe acts, offer resident a warmed blanket as a comfort/relaxation measure, and to restart Ativan 0.5 mg orally, every 8-hours as needed for anxiety. A nursing progress alert charting dated February 16, 2023, at 5:30 PM, revealed that the resident remained non-compliant with transfers and continued to self-transfer from the wheelchair. Staff made several attempts to redirect, but redirection was effective but constant throughout the shift and interventions were in place and effective according to the nursing entry A facility unwitnessed fall investigation report completed by Employee 2, a LPN, dated March 5, 2023, at 12:50 PM, revealed that the resident had an unwitnessed fall at the A2 Master Nurse Station. The report indicated that the resident was found lying on his left side on the floor in front of his wheelchair. His chair alarm was in place, but did not go off when the resident fell . Employee 2 had been called into the dining room, leaving Resident 172 unsupervised at the nurse station. Approximately 2-3 minutes later Employee 2 returned to observe the housekeeper standing by the resident, who was on the floor. The fall investigation report revealed that the RN assessed Resident 172 and that the resident was unable to recall the event due to diagnosis of dementia. The attending physician's CRNP was notified, and new orders were obtained for an x-ray of the left leg. An environmental inspection conducted revealed that the chair alarm was present, but did not sound. The pad was properly placed, alarm pad was plugged into the alarm box, but not functioning and a new pad and alarm were placed and functioning properly after the resident's fall. An employee witness statement from Employee 3, a nurse aide, dated March 5, 2023, (no time noted) indicated that the resident was by the nurse's station and that there were no other residents or staff nearby Resident 172. Employee 3 noted that the resident was very agitated that morning. She observed the resident to be fine, 10 minutes before the fall. Employee 3 noted that the resident was last toileted between 10 AM and 11 AM and was not incontinent at the time of the fall. Employee 3's statement continued to note that the resident was agitated all morning and was up and down from the wheelchair. Prior to the resident's fall, Employee 3 observed the resident sitting by the nursing station. The last time Employee 3 saw the resident was 10 minutes prior while passing meal trays. Employee 4's, a nurse aide, witness statement dated March 5, 2023, revealed that the resident was last observed in his wheelchair at the nursing desk with no other residents or staff nearby the resident. Employee 4's statement indicated that upon returning from lunch break to the A2 Nursing Station, Resident 172 was observed in his chair eating. Employee 4 noted that she went to check the stock in the clean utility room and when she came back around the corner the resident was observed on the floor, laying half on his side and half on his back, and was holding his head up and talking. He was wearing grippy socks and his chair alarm was not going off. Reviewed the March 2023 Survey Documentation Report (report that records when the resident's planned tasks were completed by nursing staff) indicated that on March 5, 2023, the resident's chair alarm was last documented checked at 11:17 AM. An eINTERACT SBAR Summary for Providers (change in condition document) form was completed by Employee 2 on March 5, 2023, at 4:02 PM, indicating that the resident was being set to the ED (emergency department) related to a fall with pain. Nursing progress notes dated March 5, 2023, at 10:06 PM, revealed that the resident was transferred to another acute care facility due to left hip and lumbar (lower back) fracture. Review of Resident 172's Physician's Mobile X-Ray report provided by the facility dated March 6, 2023, at 1:19 AM, revealed that the resident sustained an acute comminuted left intertrochanteric fracture (when the bone breaks & shatters into many pieces. Intertrochanteric refers to the top part of the femur. So, a complete, comminuted intertrochanteric fracture is the upper most part of the femur is completely shattered). Review of an IDT (interdisciplinary team) review date March 6, 2023, at 9:34 AM, revealed that the facility identified that the root cause of the resident's fall was due to the Resident 172's impulsive behaviors, poor insight, poor and safety awareness. Post environmental inspection was completed and identified that the resident's planned chair alarm did not sound, pad was properly placed, and replaced pad. Box was properly functioning, and resident care was provided 30-minutes prior. The IDT team review did not identify the lack of staff supervision of the resident at the time of the fall. Review of Admission/Re-admission Evaluation dated March 10, 2023, at 6:46 PM, revealed that the resident returned from the hospital post fall with fracture and required narcotic pain medication in addition to PRN pain medication to manage pain related to the injuries. The resident also had two unwitnessed falls without injuries after his return to the facility, one that occurred on March 15, 2023, at 3:19 AM, inside his room during which the resident was incontinent of urine, and another unwitnessed fall on March 19, 2023, at 12:19 PM, in the resident dining room. The planned interventions following these two unwitnessed falls were to ensure that the resident is placed in nurse view at the nurse's station when awake and ensure that the resident returns to the area after meals and activities, and not left unattended. The facility failed to consistently provide the necessary level of staff supervision the resident required to prevent falls and serious injury. The facility was aware that Resident 172 had poor safety awareness with unsafe behaviors and a history of falls but failed to consistently maintain the level of supervision the resident required to prevent falls and injury. The resident's chair alarm also did not function properly at the time of the resident's fall with fracture to alert staff to the unsafe transfer attempt. Interview with the Nursing Home Administer (NHA) on June 15, 2023, at 1:35 PM, confirmed that the facility failed to ensure sufficient staff supervision, at the level and frequency required, was provided to Resident 172 to prevent falls. The NHA confirmed that the resident had a known history of demonstrating poor safety awareness, unsafe behaviors such as self-rising from his wheelchair and unassisted ambulation, anxious behaviors, and a history of falls. 28 Pa Code 211.12(a)(c)(d)(1)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 211.11 (d)(e) Resident care plan

Based on review of select facility policy, clinical records, and information submitted by the facility and staff interview it was determined that the facility failed to ensure that one of three residents sampled was free from significant medication errors (Resident 77), which caused adverse effects, hypoglycemia, and required corrective treatment. Findings include: Review of the facility Administering Medications Policy last reviewed July 2022 indicated that medications are administered in a safe and timely manner, as prescribed. Only persons licensed by the state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medication errors, are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The individual administering the medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: checking the photograph attached to the medical record; and if necessary, verifying resident identification with other facility personnel. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The individual administering the medication initials the resident's Medication Administration Record on the appropriate line after giving each medication and before administering the next ones. Review of information dated November 29, 2022, submitted by the facility revealed that Employee 1, an agency LPN, erroneously administered Resident 77 medications, which were prescribed for his roommate, Resident 28, during a routine medication pass on November 29, 2022, at 11:22 AM. The facility reported that Employee 1 (agency LPN) administered the medications in error and that Employee 1 reported the error to nursing administration and resident's CRNP (certified registered nurse practitioner), who was in the facility at the time of the incident). The medications administered in error to Resident 77 were Cholecalciferol (Vitamin D, dietary supplement)1000 unit, Depakote (anticonvulsant medication) 125 mg 3 tablets by mouth every morning, Docusate Sodium (used to treat constipation) 100 mg one tablet, Fish Oil (dietary supplement) 1000 mg one capsule, Klonopin (antianxiety medication) 0.5 mg one tablet, Lantus (long-acting insulin used to help control high blood sugars) 55 units SQ (subcutaneous, injection is given in the fatty tissue just under the skin), Lisinopril (used to treat hypertension) 10 mg one tablet, Metformin (antihyperglycemic medication, used to control blood sugar) 500 mg one tablet, Metoprolol Tartrate ( used to treat hypertension) 50 mg one tablet, Miralax(laxative) 17 gms, Senna Plus (laxative) two tablets, and Seroquel (antipsychotic) 50 mg one tablet. The CRNP assessed Resident 77 and found that Resident 77 was lethargic. New orders were noted. Vital signs stable. Blood sugar 52 (Blood sugar below 70 mg/dl is considered low). Glucagon (used to treat low blood sugar) was ordered and administered immediately per CRNP orders. Resident to be monitored with vital signs every 3 hours for 24 hours. The CRNP ordered that Accu-checks (involves pricking the finger to test blood sugar level) every one hour for 24 hours. IV D5W (intravenous- administers fluid directly into a vein to correct low blood sugar and provide fluids) at 75 ml/hr. The resident's responsible party was notified. The resident's responsible party requested that Resident 77 be sent to the emergency room for evaluation. The CRNP was notified of the request. The resident was transferred to the emergency room for evaluation and treatment. A review of the facility incident report revealed that Resident 77 was given the roommate's medications in error. Employee 1 (agency LPN) was interviewed by nursing administration. Employee 1 (agency LPN) was sent home. Employee 1's (agency LPN) agency was called and notified of the medication error. Resident 77 was sent to the emergency room with paperwork. A report was called to the emergency room . Resident was alert and talkative. Vital signs stable. A nurses note dated November 29, 2022 at 8:51 PM noted the resident was admitted to the hospital with a diagnosis of low blood sugar and was treated for hypoglycemia while hospitalized . Interview with the director of nursing (DON) on December 21, 2022 at 2:00 PM confirmed that Employee 1 administered the incorrect medications to Resident 77, which required medical intervention and resulted in hospitalization for treatment of hypoglycemia. Employee 1 failed to identify the correct resident prior to administered the medications to Resident 77. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: Resident 77 had symptoms of hypoglycemia, blood sugar was obtained, Glucagon was given, IV fluids ran, condition was stable. Resident was sent to the emergency room for evaluation. Residents with insulin were assessed for signs/symptoms of hypoglycemia and the residents that were ordered such had a BIMS of 12 or greater and were interviewed to ensure medications and insulin were given. Nursing staff educated on Medication Administration Policy. Random weekly medication administration observations on area one to be done to ensure Six Rights of Medication Administration are followed weekly times four, then monthly times four. Results to be reported at monthly QAPI The results of the audit will be forwarded to the facility QAPI meeting. The facility's completion and compliance date was December 7, 2022. 483.45 - Pharmacy Services, 10-21-2022 edition 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 201.29(a)(c)(d) Resident Rights 28 Pa. Code 211.12(a)(c)(d)(1)(2)(3)(5) Nursing Services

Based on review of clinical records, select facility policy and investigative reports and staff interview, it was determined that the facility failed to ensure that at least three residents (Residents 120, 113, 181) were free from physical abuse and subsequent serious physical injury, a [MEDICAL CONDITION], for one resident (Resident 181) perpetrated by one resident (Resident 66) out of eight sampled residents. Findings include: A review of the facility's current policy entitled Abuse Policy, no revision date noted, revealed that it is the policy of the facility that all residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Further review of the policy indicated to aid in the prevention of abuse, residents with behavioral problems would be assessed and the development and implementation of care plans to address behavioral issues would be initiated. A review of the facility policy entitled Safety and Supervision of Residents, last revised on July 2017, revealed that it is the policy of the facility to make the environment as free from accident hazards as possible. Facility-wide priorities include resident safety and supervision and assistance to prevent accidents. The facility considers resident supervision a core component of the systems approach to safety and is defined as: when resident is in a staff members direct line of vision. The type and frequency of resident supervision is determined by the individual resident's assessed needs. In addition, the type and frequency of resident supervision may very among residents and over time for the same resident. A review of the clinical record revealed that Resident 66 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. in which people can not tell what's real from what is imagine). A review of a significant change change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated April 12, 2019, and a quarterly MDS dated [DATE], revealed that the resident's cognition was impaired. The July 2019 MDS also revealed that the resident exhibit behavioral symptoms that included physical and/or verbal directed toward others at least one to three days out of the seven day reference period. These behavioral symptoms included, hitting, kicking, pushing, grabbing, threatening, screaming and/or cursing at others. A review of the resident's care plan initiated on Janaury 16, 2018, and revised on April 8, 2019, revealed that the resident had the potential to exhibit behaviors, at times, as evidenced by continuous yelling out and urinating in inappropriate places. Resident 66's care plan, developed on February 1, 2018, and revised on August 8, 2019, indicated that the resident exhibited verbal and/or physical agitation and aggression as evidenced by hitting/pushing others, yelling at others, banging on doors, raising fists, attempting to push others while in their wheel chairs, and throwing items at others. Care planned interventions directed staff to administer medications per physican's orders dated Janaury 16, 2018, consult psych as needed, approach slowly and slightly to the side, be aware of patient's personal space and talk in a low pitch, calm voice to decrease/eliminate undesired behavior (all dated February 2, 2018), when talking to resident avoid making long eye contact dated August 8, 2019, provide resident ice cream dated July 7, 2019, and one-to-one (1 to 1) supervision/nursing measures in place to be provided by CNA (certified nusing aide) staff dated March 12, 2019. A review of a nursing documentation (progress notes) dated from June 2, 2019, through November 13, 2019, revealed documented behaviors of verbal and physical outbursts displayed by Resident 66. These included banging on doors and raising fists; attempting to kick others with 1 to 1 monitoring maintained at a safe distance; throwing items at others; pushing another resident in wheel chair, resident began attempting to punch staff and stomp on staff's feet when hands removed from wheel chair, trying to push resident (Resident 120) in wheel chair down hallway and when staff member tried to intervene, resident leaned over back of wheel chair and swatted at resident hitting her left shoulder and slapping her on her left forehead; attempting to scratch, hit and kick staff; threatening and cursing others; entered another resident's room and kicked resident in left lower leg; chasing 1 to 1 staff member down hallway; hit CNA; was on 1 to 1 and wandered into another resident's room (Resident 113) sitting on other resident's legs and then hit resident (Resident 113) on her left knee; kicking dresser in room when he became aggravated with 1 to 1 staff; punched door; was witnessed charging after another resident; upon entering area, female resident (Resident 181) on floor in front of nurse's station, staff reported resident pushed her to the floor. Similar instances of verbally and physically abusive behaviors directed at other facility residents were documented in the resident's clinical record by nursing staff on 23 occasions during the above referenced time period. A review of an facility incident report dated June 11, 2019, at approximately 1:45 p.m., a Department of Aging mandatory abuse report dated June 17, 2019, and investigative information submitted by the facility dated June 18, 2019, revealed that Resident 66 was on 1 to 1 monitoring by staff when the resident exited his bedroom and began pushing a wheelchair of a female peer, Resident 120, down the hallway. Resident 120, seated in her wheelchair, was crying and yelling to stop. As staff attempted to redirect Resident 66, he became agitated and slapped Resident 120 on her left forehead and left shoulder. Resident 120 was examined and found to have no injury to her left shoulder, but had sustained a pink/reddened area on the top of her left forehead. A review of a facility incident report dated June 15, 2019, at approximately 10:38 p.m., a Department of Aging mandatory abuse report dated June 18, 2019 and investigative information submitted by the facility dated June 15, 2019, revealed that Resident 66 was ambulating on the unit. While ambulating he came upon resident room [ROOM NUMBER] (the room of Resident 113). Resident 66 entered the room, with a staff member directly behind him and attempting to redirect him away from Resident 113. Resident 113 became upset and yelled at Resident 66 who kicked Resident 113 in her left lower leg. Resident 113 was examined and found to have a small abrasion on her leg. According to the facility's investigative report Resident 66 was placed on close 1 to 1 observation. On June 16, 2019, the resident continued with his aggressive behaviors and was sent to the local hospital and was admitted with a 302 (an involuntary admission to an inpatient psychatric hospital or mental health facility). A nurses' note dated June 16, 2019, at 7:12 a.m. indicated that Resident 66 chased 1 to 1 staff member down hallway behind nurse's station attempted to pickup printer to throw at staff member and when he couldn't pick up the printer, he began swinging his fists. A review of a facility incident report dated August 11, 2019, at approximately 11:15 p.m., a Pennsylvania Department of Aging Mandatory Abuse report dated August 14, 2019 and investigative information submitted by the facility dated dated August 11, 2019, revealed that Resident 66 entered Resident 113's room and sat on her leg while she was sleeping. Resident 113 kicked at Resident 66 in an effort to move him. Resident 66 turned and hit the resident 113's leg. The staff member who provided the 1 to 1 monitoring attempted to redirect him, but was unsuccessful. Another staff member was able to redirect him out of Resident 113's room. Resident 113 was examined and found to have a 3 cm x 3 cm faint bruise on her left knee. A review of a facility incident report dated November 8, 2019, at approximately 6:35 p.m. and investigative information submitted by the facility dated November 8, 2019, revealed that Employee 1 (LPN), had relieved the 1 to 1 aide assigned to Resident 66 to allow that aide to go to dinner break. Employee 1 was walking with Resident 66 (in hallway) when Employee 1 saw another resident about to fall out of a wheelchair (in the facility dining room, approximately about 15 feet away). Employee 1 ran over to assist that resident to prevent her from falling, leaving Resident 66 without 1:1 monitoring as required. As Employee 1 was returning to Resident 66, Resident 181 walked by the nursing station and began yelling at Resident 66 to get the hell away from me and with her arms raised up. Resident 66 pushed Resident 181 and she fell down. A review of facility staffing for the residents' (A2) unit on the evening shift on November 8, 2019, revealed five nurse aides, two licensed practical nurses and one activity aide on duty. According to the facility's nursing care hours the facility provided 3.19 hours of direct nursing hours in a 24 hour period on that date. The facility failed to demonstrate that staff on duty were effectively and efficiently deployed to ensure continuous 1:1 monitoring of Resident 66. A review of a nurses' note dated November 8, 2019, at 9:08 p.m., revealed that Employee 2 (RN) was called to the nurse's station and saw Resident 181 crying in pain, holding her right hip area and screaming. The resident was evaluated with her right leg slightly shorter than her left with slight outward rotation. The physican was called immediately with new orders to send the resident the ER for evaluation. At 10:47 p.m., a nurse documented that the ER doctor was contacted at the x-ray results were negative. On November 9, 2019, at 12:50 a.m., a nurse noted the resident (Resident 181) came back from the hospital with new orders. A review of a nurses' note dated November 10, 2019, at 1:40 p.m. revealed that Resident 181 complained of right hip and pelvic pain and was unable to ambulate. The resident was seen by a physican with new orders obtained to send the resident to ER for CT scan of pelvis and right hip. A review of an x-ray report dated November 11, 2019, indicated that Resident 181 suffered a right peri-trochanter (a type of [MEDICAL CONDITION] that occurs either in the upper or lower part of the thigh bone) [MEDICAL CONDITION] during the physical altercation with Resident 66 on November 8, 2019. A review of three Medication Management Assessments dated September 3, 2019, October 22, 2019 and November 4, 2019, revealed that the Resident 66 had periods of disorganized behavior overlapping mood lability, impulsivity, verbal and physical aggression and combative behavior. On the September 3, 2019, assessment, the CRNP (certified registered nurse practitioner) noted that the resident had ongoing periods of impulsivity and unsafe behavior and poor safety awareness. The assessment documentation noted a failed trial with q (every) 15 minute checks and that the resident remains on 1 to 1. According to the October 22, 2019 assessment report, the CRNP indicated the resident had periods of impulsivity with verbal and physical aggression per nursing. The November 4, 2019 assessment report revealed that the licensed clinical social worker wrote that the resident is able to process few thoughts and feelings with one word answers and continues to be delusional believing he is at work. A review of three nurses's notes, the week following the resident to resident altercation that resulted in Resident 181's fall and fracture, dated November 10, 2019, at 7:27 p.m., November 11, 2019, at 6:42 a.m. and November 13, 2019, at 6:24 a.m., all indicated that Resident 66 was still combative, yelling, threatening and striking out and pushing others and banging on doors. Interview with Employee 3 (LPN) on November 13, 2019, at approximately 11:58 a.m. revealed, that at times, Resident 66 could become agitated when ambulating by a group of people or if someone enters his space. Interview with Employee 4 (NA) on November 13, 2019, at approximately 12:49 p.m. also revealed that, at times, Resident 66 could become agitated if someone were to touch or speak to him. Employee 4 also indicated that the resident at times has a short fuse. She stated, that Resident 181 can become easily agitated when someone gets to close to her or in her space. The facility failed to prevent the physical abuse of Resident 181 resulting in serious physical injury and failed to prevent the physical and verbal abuse of other residents in the facility perpetrated by Resident 66, a resident with known abusive and aggressive behaviors. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/14/19, 10/1/19 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/14/19 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited 6/14/19, 10/1/19 28 Pa Code 201.29(a)(c)(d) Resident rights. Previously cited 6/14/19

Based on a review of clinical records and select medication error reports and staff interview, it was determined that the facility failed to ensure that one of 30 residents reviewed was free from a significant medication error, which resulted in the resident's hospitalization for low blood sugar and related complications (Resident 6). Findings include: A review of Resident 6's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].{kidney} Disease) with [MEDICAL TREATMENT], hypertension and diabetes. Further review of the resident's clinical record revealed that the resident attended outpatient [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays. Nurses' notes dated December 16, 2016, at 12:50 p.m. indicated that the resident's lunch Accu-check (device used to check blood sugar level) reading was Hi (a blood sugar result too elevated for the device to accurately register). The on-call physician was notified at that time and a new order was obtained for the administration of [MEDICATION NAME] Insulin (medication used to treat diabetes) 20 units, to be injected beneath the skin in the abdomen NOW (given as soon as possible). The resident's scheduled routine morning dose of insulin was increased to 22 units at that time as well. Nurses' notes dated December 16, 2016, at 2:00 p.m. indicated that the responsible party and the resident's physician were aware of the resident's blood sugar level and new order noted. They were also made aware the resident was going to [MEDICAL TREATMENT] this afternoon because of the, weather condition for 12/17. Nurses' notes dated December 16, 2016, at 2:52 p.m. indicated that the resident's physician was in the facility to see the resident and changes were made to the resident's insulin orders. A recheck of the resident's blood sugar level was obtained and was noted as 538 milligrams/deciliters mg/dl ({milligrams/deciliter) Normal blood sugar levels are between 72 to 108 mg/dl when fasting and up to 140 mg/dl, 2 hours after eating) and a new order was received and noted for 100 units of [MEDICATION NAME] (long acting insulin) NOW. Nursing noted that insulin was given without incident and the resident's Accu-check blood sugar result prior to [MEDICAL TREATMENT] pick-up was 358 mg/dl. Review of physician's orders [REDACTED]. [MEDICATION NAME] 30 units to be injected beneath the skin in the mornings starting December 17, 2016. [MEDICATION NAME] 5 units before meals for an Accu-check greater than or equal to 250 mg/dl. and no (insulin) coverage for the bedtime Accu-check. Further review of the resident's clinical record revealed that the above new physician's orders [REDACTED]. Employee 9 administered 100 units of [MEDICATION NAME] instead of the 10 units ordered. This error was also noted in the nurses' notes dated December 16, 2016 at 2:52 p.m. which indicated that 100 units of [MEDICATION NAME] were given to the resident. A review of Resident 6's Medication Administration Records (MAR) and Physicians Order Summary Report for December 2016, also noted that 100 units of [MEDICATION NAME] were given to the resident. Nurses' notes dated December 16, 2016, at 2:55 p.m. indicated that the resident left the facility in good condition with paperwork and a snack for [MEDICAL TREATMENT]. Nurses' notes dated December 16, 2016, at 6:32 p.m. indicated that the staff from [MEDICAL TREATMENT] notified the facility that the resident was at the hospital for evaluation because her blood sugar dropped very low. Nurses notes dated December 16, 2016, at 10:22 p.m. indicated that the resident was being admitted to the hospital with [REDACTED]. Hospital documentation indicated that Resident 6 became unresponsive and diaphoretic (sweating heavily), and her Accu-check was low at [MEDICAL TREATMENT]. At [MEDICAL TREATMENT] she was given three [MEDICATION NAME] of [MEDICATION NAME] (sugar) and was still hypoglycemic. EMS (emergency personnel) was activated and the resident's Accu-check on arrival of EMS was 31 mg/dl. Resident 6 was given additional [MEDICATION NAME] and [MEDICATION NAME] (treats severe low blood sugar) and was transported to the hospital emergency room . Initial Accu-check on arrival in the ER was 122 mg/dl. Initially, the resident began to respond, but was still experiencing frequent hypoglycemic episodes according to hospital documentation. Despite receiving additional [MEDICATION NAME], the resident still continued with significant [DIAGNOSES REDACTED] with varying levels of responsiveness and the resident was admitted to the hospital for evaluation and treatment. The resident continued with hypoglycemic episodes and was unresponsive with myoclonic jerking (sudden muscle contractions or brief lapses of contraction) and Accu-check readings too low to record. The resident was transferred to the Intensive Care Unit and monitored until the physician, on December 17, 2016, indicated that the resident could be transferred out of the Intensive Care Unit. Review of the facility's medication error report dated December 16, 2016, indicated that upon investigation, it was verified that the physician's orders [REDACTED]. The medication error report also indicated that Employee 9 was called and confirmed she gave the incorrect dose of insulin to the resident. Interview with the Director of Nursing on June 22, 2017, at 10:30 a.m. confirmed that Resident 6 received the incorrect dosage of insulin and required hospitalization and treatment. 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 6/4/15 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(a) Nursing services Previously cited 2/23/17, 12/6/16, 5/5/16, 2/9/16, 7/30/15, 6/4/15 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 2/23/17, 12/6/16, 5/5/16, 2/9/16, 10/19/15, 7/30/15, 6/4/15

Based on a review of clinical records, an Event Report submitted to the State Survey agency and a resident incident\accident report and staff interview, it was determined that the facility failed to implement planned interventions and sufficiently supervise a resident with a known history of falls to prevent a fall with serious injury for one of 30 sampled residents (Resident 83). Findings included: A review of the clinical record revealed that Resident 83 was admitted to the facility February 11, 2014, at approximately 2:15 p.m., with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process to identify the needs and plan care of nursing home residents) dated May 12, 2014, revealed that the resident required extensive assistance from staff for transfers and was totally dependent on staff for ambulation. A resident incident\accident report and nurses notes dated February 10, 2014, at 2:35 p.m., revealed that Resident 83 fell from her wheelchair. The immediate intervention implemented by the facility in response to this fall was to add alarms to the resident's chair and bed (to alert staff to the resident's unassisted rising) and therapy was to evaluate the resident's wheelchair seating. The physical therapy notes dated February 12, 2014, indicated that the resident's seating was changed to a scoot chair (an adjustable, low to the ground, mobile chair which allows the resident to self propel. The back of the chair tilts back to limit the resident from rising from the chair while still allowing them to self propel ) due to attempts to rise out of the wheelchair. A review of the resident's care plan for the problem/need of being at high risk for falls dated May 26, 2014, revealed that Resident 83 will use a scoot chair, kept in the lowest position. A review of a resident incident report dated March 21, 2014, at 3:25 p.m., revealed that Resident 83 was found on the floor of the dining room. The immediate intervention initiated by the facility in response to this fall was to remove her to the nurses station for better visibility. The resident's next fall occurred on March 26, 2014, at 11:45 a.m., staff found the resident on the floor in the hallway. An incident report dated June 30, 2014, at 8:48 p.m., revealed Resident 83 was found on the floor of the dining room with a skin tear to her right elbow. The resident's scoot chair was found to be in the incorrect position. The noted intervention at this time was to reeducate staff on proper positioning of the resident in the scoot chair and not leaving any residents in the dementia unit alone in the dining room. According to an Event Report and a resident incident\accident report dated July 20, 2014, at 8:10 a.m., Resident 83 was found lying in her left side beside her scoot chair in the dining room with the chair alarm sounding. The resident was assisted back to the chair then to bed and the physician was contacted. The resident was sent to the hospital and admitted with a fractured left hip. The staff witness statements regarding this event dated July 20, 2014, revealed Employee 2 (a nurse aide) stated that she and Employee 3 (a nurse aide) completed Resident 83's a.m. care at 7:45 a.m. and took her to the dining room, leaving the resident unsupervised. These nurse aides did not return to the dining room prior to Resident 83's fall to the floor. There was no reference in either nurse aide witness statement as to the position of the scoot chair when this resident was found on the floor. Resident 83 was in the dining room for approximately 30 minutes with no staff supervision. During an interview July 25, 2014, at 11 a.m., Employee 4 (Registered Nurse Supervisor) stated that at the time of the incident, he was the nursing supervisor covering the building. He was called to the resident's unit and completed the incident report. He stated that he was told by the two nurse aides involved that the scoot chair was in the proper position. He confirmed, however, that there was no indication as to the position of the chair in either nurse aide witness statements. He also confirmed that there was no supervision of the residents in the dining room at the time of the fall. During an interview July 25, 2014, at 10:45 a.m., the facility's quality assurance nurse stated that she completed the facility's investigation into Resident 83's fall. The QA nurse stated that she documented that the scoot chair was in the low position, however stated that she did not witness the chair or its position at the time the resident was found. Review of an employee education form for proper positioning in the scoot chair dated July 2, 2014, revealed that Employees 2 and 3 did not receive this inservice prior to Resident 83's July 20, 2014, fall with serious injury. During an interview July 25, 2015, at 11:30 p.m., the Acting Director of Therapy stated that Resident 83 was placed in a scoot chair for safety due to multiple attempts to self rise from the wheelchair. She stated that if the scoot chair is in the proper seated position, the back and seat tilt so that the resident cannot self rise from the chair. There was no evidence that the facility provided adequate supervision and implemented planned safety interventions to prevent recurrent falls, with injury, for this resident with a history of falls. 483.25(h) Free of Accidents Hazards/Supervision/Devices previously cited 6/20/2013 28 Pa Code 211.11(d) Resident care plans previously cited 6/20/13 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5)Nursing Services previously cited 6/20/13

Based on clinical record and select policy review and staff and resident interview, it was determined that the facility failed to implement specific bowel regimens for three of 30 sampled residents (Resident 154, 57, and 1) and failed to ensure that a resident received prompt and adequate treatment for [REDACTED]. Findings include: Review of the facility's "Bowel Management Protocol" reviewed by the facility April 15, 2013, revealed that accurate recording of bowel movements is to occur on all three nursing shifts. The charge nurse on the 3 PM to 11 PM shift is to review the list for accuracy and ensure that those who have not had a bowel movements are included into the bowel regime. Those residents who have not had a bowel movement for two days will be administered 30 ccs (cubic centimeters - measurement of liquid) of a physiological laxative. Day three without a bowel movement, the resident is to be administered 30 ccs Milk of Magnesia. If there are no results on day four, the 30 ccs Milk of Magnesia is to be repeated. On the morning of the fifth day without a bowel movement, a fleets enema is to be administered. Clinical record review revealed that Resident 154 had [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the May 2013 Data Set (includes data related to the resident's bowel activity) revealed that the resident did not have a bowel movement from May 3, 2013, through May 9, 2013. Review of the May 2013, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A fleets enema was also not administered on May 8, 2013. Review of the May 2013 Data Set also indicated that Resident 154 did not have a bowel movement from May 12, 2013, through May 17, 2013. There was no evidence that day two, day three or day four protocol was implemented. Review of the May 2013 Data Set indicated that Resident 154 did not have a bowel movement from May 22, 2013, through May 26, 2013. During this time frame, the day two, day three and day five of the bowel management protocol was not implemented. A review of the clinical record revealed that Resident 57 had [DIAGNOSES REDACTED]. 5 days as needed. A review of the Data Set for June 2013 revealed that Resident 57 did not have a bowel movement from June 6, 2013 through June 9, 2013. Corresponding June 2013 Medication Administration Records indicated that the resident received 30 cc MOM on June 9, 2013 the fourth day without a BM, then received a suppository on June 10, 2013. The record indicated that he had a BM after receiving the suppository. The June Data Set revealed that from June 11, 2013 through June 13, 2013 Resident 57 did not receive any Physician ordered interventions for constipation, but on June 14, 2013 a suppository was given to this resident and he had a BM. Interview with the Director of Nursing on June 19, 2013, at 11:20 a.m., confirmed that the facility did not timely and accurately implement the established bowel management protocol for these residents. A review of the clinical record revealed that Resident 1 had [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. A review of the Resident Bowel Movement List for May 2013 revealed that Resident 1 did not have a bowel movement from May 16, 2013 through May 18, 2013. The resident's Bowel Function documentation also failed to indicate that the resident had a bowel movement between May 16, 2013 and May 18, 2013. A review of the May 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the Corporate Director of Clinical Operations on June 20, 2013, at 9:30 a.m., confirmed that the facility did not implement the facility's bowel management protocol. A review of the clinical record revealed that Resident 10 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment completed May 10, 2013, revealed that the resident was cognitively intact and required no assistance with bed mobility, ambulation, dressing, toilet use, and personal hygiene. The MDS pain assessment interview indicated that at the time of this MDS assessment the resident had no complaint of pain. A review of an event report dated May 17, 2013, revealed that the resident sustained [REDACTED]. A review of the front of the Post Event Nursing Note, with no time documented, revealed that the resident had no complaints of pain on the evening of May 17, 2013. However, a review of the Observations/Monitoring for Pain Control dated for the month of May 2013 revealed that on May 17, 2013, on the 3 PM to 11 PM shift the resident was complaining of mild back pain. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the front of Post Event Nursing Note, with no time documented, revealed that the resident complained of no pain on the night shift on May 18, 2013, but a review of the Observations/Monitoring for Pain Control dated for the month of May 2013 revealed that on May 18, 2013, on the 11 PM to 7 AM shift the resident was complaining of moderate back pain during activities and at rest. The May 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the front of the Post Event Nursing Note, with no time documented, revealed that the resident complained of pain on May 18, 2013, on the day shift and evening shift, that the resident had a change in her mobility status, and that there was no improvement to the injury area. Further review revealed that on day one, May 18, 2013, on the 7 AM to 3 PM shift, the resident complained of right leg/hip/groin pain and had difficulty moving her leg while in lying to sitting position. The resident felt better able to (move) when the head of bed was elevated. Tylenol and Physical Therapy treatment was helpful according to this documentation. A review of the Observations/Monitoring for Pain Control dated for the month of May 2013 revealed that on May 18, 2013, on the 7 AM to 3 PM shift the resident was complaining of moderate leg pain during activities and at rest. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A nursing note dated May 18, 2013, at 8:09 a.m. indicated that the resident received Tylenol for complaints of general discomfort. The resident was continent of bladder several times with extensive assist of one staff and that the resident was repositioned with extensive assist of two staff members. A note from Occupational Therapy dated May 18, 2013, revealed that the staff reported the resident fell and had increased tenderness over the right flank with no see-able bruising. No pinpoint discretionary pain was noted. Resident complained of right knee pain. Bed mobility was completed with the resident presenting with guarded movement. Resident received a treatment with decreased pain noted after the treatment. A nursing note dated May 18, 2013, at 11:01 PM completed by the 3 PM to 11 PM nurse indicated that the resident remained in bed throughout the shift and complained of pain in her right upper leg, as needed Tylenol was given, and there was decreased mobility noted. This nursing entry further indicated that the Registered Nurse was made aware (of the resident's status). A nursing note dated May 18, 2013, at 11:30 p.m. and completed by the 11 PM to 7 AM shift nurse for May 19, 2013, indicated that at the start of the shift the resident was found to have right hip swelling, right leg rotated inward, and shortened. Resident 10 stated that she was not out of bed all day (May 18, 2013). The Nursing Supervisor was called to the unit to assess the resident with the same findings as noted by the 11 PM to 7 AM shift. Nursing noted that the prior shift stated that the resident was incontinent. Resident denies pain at this time, only when she moves. Unable to bend her knee, and found with limited range of motion. Refused pain medication. The physician was notified of the above findings on May 19, 2013, at midnight and ordered that the resident be evaluated in the emergency room . A nursing note dated May 19, 2013, revealed that the resident had a right [MEDICAL CONDITION] and that she was being admitted to the hospital for pain management and further diagnostic tests to determine the extent of the fracture. An interview with Resident 10 on June 20, 2013, at approximately 11:15 a.m. revealed that she complained of pain in the right hip area after the fall (on May 17, 2013) and that she had pain the next day (May 18, 2013). An interview with Employee 9 on June 20, 2013, at approximately 11:45 a.m. revealed that on May 18, 2013, Resident 10 had a noticeable change in condition after the fall, that she remained in bed the entire shift, had an increase in pain especially with movement and that she reported it to the charge nurse. During an interview with the Director of Nursing on June 19, 2013, at approximately 9:45 a.m. she was unable to explain why the physician was not notified of the resident's increased pain until May 19, 2013, on the 11 PM to 7 AM shift. The facility failed to consistently and accurately assess the resident's physical condition and functional status after the fall on May 17, 2013, and failed to promptly identify and act upon the resident's change in condition, including signs and symptoms of pain, to timely ensure that the resident received the necessary care and services for treatment/management of the [MEDICAL CONDITION]. 483.25 Quality of Care Previously cited 5/17/12 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 5/11/12, 1/23/13 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on review of clinical records and select incident reports and staff interviews it was revealed that the facility failed to provide adequate supervision and/or assistance and safety measures to prevent a fall and injury for one resident out of five sampled (Resident A5). Findings include: Resident A5 was admitted to the facility on [DATE]. A review of the resident's clinical record revealed that the resident utilized a wheelchair with a cushion and Dycem (non-slip surface) above and below the cushion. There were no leg rests ordered to the wheelchair prior to March 6, 2011. A review of the nursing documentation in the clinical record revealed that on February 7, 2011 the resident was noted to be very restless, sitting at the very edge of his wheelchair and leaning forward. When attempts at redirection were attempted, the resident refused to sit back in the wheelchair. Additionally when the staff attempted to transfer the resident into another chair he was resistive and buckled his knees to prevent sitting. On February 11, 2011, the resident was noted to spit out his food. The resident was very lethargic and was placed in bed for a nap. During transfer to bed, the staff was unable to use the Stand Up lift as assessed for the resident, because he was too lethargic to participate in the transfer. According to nursing progress notes the resident was found on the floor in front of his wheelchair during the 3 PM to 11 PM shift on February 13, 2011. Subsequent to this fall the resident was screened by the physical therapy department on February 14, 2011. A review of this screen revealed that the Physical Therapy Aide stated that the resident's fall appeared to be "behavioral" in nature. The behaviors, which the person completing the screen thought to have been a contributing to the resident's fall, were not identified. It was determined that no physical therapy evaluation was warranted at this time. No recommendations regarding the resident's seating orders/plans were noted at that time. On March 1, 2011 the resident's daughter stated that she wanted to speak with the resident's attending physician regarding the possible discontinuation of pain medications since the resident was so tired. The nurse completing this entry noted that the resident had to be fed and was unable to sit up in the wheelchair. According to nursing progress notes the resident's attending physician came in to the facility to evaluate the resident on March 2, 2011. He was made aware that the resident was having continued poor intake and lethargy. An entry in the resident's clinical record completed on March 5, 2011 at 9:00 a.m. revealed that the resident was continuing to have periods of lethargy. According to a nursing progress note completed on March 5, 2011 at 11:15 a.m. a nursing assistant was transporting the resident in the wheelchair to the dining room. The resident was seated in an upright position in the wheelchair. The resident leaned forward in the wheelchair and fell out to his knees and hit his forehead on the floor. After this incident, the resident experienced apnea with blowing respirations and slight mottling of the knees. The resident was transferred to the hospital for evaluation. A review of physician's orders [REDACTED]. during transportation only. On March 7, 2011 resident's incident of March 5, 2011, was reviewed by the therapy department and the impression at that time was that no further evaluation was needed because the fall was likely related to a " medical problem." There was no mention of the use of the geri lounger and foot rests or if these devices provided the most beneficial interventions for the resident. No further recommendations were made regarding the residents seating requirements. Despite the resident's known change in physical condition, with increased lethargy and displayed behaviors, there was no indication that the facility consistently reassessed the appropriateness of the resident's wheelchair seating arrangement was optimal for positioning and promoting safety. 28 Pa Code 211.12 (a)(d)(3)(5) Nursing Services Previously cited 5/14/10, 12/15/10, 1/13/11 .