Every finding on record at Fox Subacute at South Philadelphia

Based on observation, clinical record review and interviews with staff, it was determined the facility failed to ensure Resident R1 was kept safe from accidents related to exposed bedframe parts for one of 10 residents reviewed. This failure resulted in actual harm to Resident R1 who sustained lacerations to the forehead and inside of the mouth as well as bruising to the left eye when the resident's face came into contact with the bed frame during care. Resident R1 required transfer to the hospital. This deficiency is cited as past non-compliance. (Resident R1) Findings Include:Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including, acute and Chronic Respiratory Failure, Anoxic (resulting from lack of oxygen) brain damage, tracheostomy status (a tube placed into the airway through the neck and into the trachea to assist with breathing), and generalized muscle weakness. Review of Resident R1's most recent Minimum Data Set (MDS- assessment of care needs), dated December 10, 2025, section GG, Functional Abilities and Goals, revealed that the resident was dependent on staff for bed mobility. Review of the resident's care plan dated May 16, 2023, revealed that Resident R1 required a one person assist for bed mobility. Review of documentation submitted to the State Survey Agency on February 24, 2026, revealed [Resident R1] is a tracheostomy dependent, bed bound, alert but not oriented young [gentleman/lady]. [Resident R1] requires 1 person to assist (her/his) with bed mobility and incontinence care. At approximately 0500am on 2/20/2026 the CNA (nurse aide) was providing incontinent care to [the resident] and as he rolled (her/him) onto (her/his) left side (her/his) face hit in the corner of the metal bed frame where the circumferential rail meets the rail for the headboard. He turned (her/his) back he noticed blood on (her/his) face and immediately called for the nurse who promptly responded to the room to access the resident. The nurse asked the respiratory therapist to get the house supervisor as she assessed the resident and dressed the lacerations on (her/his) forehead. The supervisor assessed [Resident R1] to be at (her/his) baseline neurological condition and noted two lacerations to (her/his) forehead, swelling and bruising to (her/his) left eye and a small cut in (her/his) mouth. The medical team was notified and 911 (EMS - Emergency Medical Service) was called. [The resident]'s son and responsible party was notified of the incident and her transfer to the hospital.Review of the incident investigation revealed nurse aide, Employee E3 was assisting the resident with continence care on February 20, 2026. The witness statement from nurse aide, Employee E3 stated As I was providing care to [Resident R1], I turned (her/him) over onto (her/his) left side.for just about 30-40 seconds. When I finished and turned (her/him) back, I noticed blood streaming down (her/his) face coming from (her/his) eyebrow.I saw drops of blood on the wooden and metal part of the headboard.All I could guess was (she/he) might have cut (her/his) eyebrow against the headboard .911 was called. An unsigned statement identified by the DON as being from Licensed nurse, Employee E4, stated LPN entered room and observed bleeding from supraorbital (region immediately over the eye socket) area. 2 lacerations observed, blood in oral cavity noted, discoloration and inflammation to left eye note[d] .MD made aware, order given to send to emergency department .Resident exited the facility at 0559 via stretcher.Review of statement from Licensed nurse, Employee E5, revealed Pt (patient) has 2 cuts on (her/his) forehead, above the [right] & [left] eyes, a bump in between the cuts, & a black eye. Mouth was bleeding too, I wiped the blood and noticed that the patient has a small cut insider (her/his) [right] upper mouth .I checked the side of the bed & noticed that there was blood on the [right] corner side of the bed frame .EMS came to pick up the [patient] . Review of the timeline compiled and provided by the DON (Director of Nursing) revealed, at 6:30 a.m. on February 20, 2026, I was informed that [resident R1] sustained an injury during care and needed to go to the hospital and at 10:15 a.m. she spoke to resident [physician] at [hospital] emergency department. I thoroughly explained what caused (his/her) injuries. During an interview on March 4, 2026, at 1:45 p.m., the Director of Nursing (DON), Employee E2, revealed that she believed the resident's facial injuries were sustained when the resident's face made contact with an exposed pin used to secure two pieces of the bedframe to each other. She stated that she believed that the pin was sticking up and the two sharp ends made contact with the skin above the resident's eyebrows, causing the lacerations when the resident was repositioned onto (his/her) back, dragging the pin over the skin. Employee E2 stated that she believed the black eye and swelling of the forehead were caused by the resident's face making contact with an exposed knob on the frame. Further review of the incident report revealed nurse aide, Employee E3 was evaluated for repositioning competency following the incident. Review of facility performance evaluation worksheet titled Turning and Positioning completed on February 27, 2026, revealed the following standards were to be met: 12. To bring the resident towards you (to turn away), slide arms under resident's shoulders, and.move the resident's shoulders toward you on top of your arms.13. Slide both arms under the resident's upper thighs and lower back and. move the resident's buttocks toward you on the bed.14. Slide both arms under the resident's lower legs and.move the resident's legs toward you on the bed.15, Cross the resident's arms across his/her chest.16. To turn the resident away from you, cross the leg nearest to you over the far leg at the ankle, or bend the knee up with foot on bed.17. Place one hand on the resident's shoulder nearest you and your other hand on the hip nearest you.18. Turn the resident gently to his/her side facing away from you. Make sure resident will not be lying too close to either side rail as resident should be in the center of the bed. All expectations evaluated were documented as met by the nurse aide, Employee E3. Observation conducted on March 4, 2026, in the presence of the Director of Nursing, Employee E2 of the bedframe used by resident had at the time of the incident revealed that there was an exposed [NAME] pin (a bent wire piece resembling a large [NAME] pin) securing the connection between the base of the bedframe and the headboard. This area was observed to sit approximately two inches below the top of the deflated air mattress. DON confirmed that the mattress was inflated while the resident was using it. When asked how the resident's face came into contact with this part which was well below the surface of the mattress, the DON stated that the resident was boomerang shaped due to contractures which did not allow the resident to straighten out fully. She stated that this caused the resident's head and feet to overlap the edge of the mattress when repositioned onto (her/his) side during care. DON confirmed that the resident's spine had not been aligned with the edge of the bed nearest to the nurse aide when repositioned at the time of the incident. This deficiency was identified as actual harm past non-compliance for failure the failure of the facility to provide a safe bedframe for Resident R1. On March 4, 2026, the Director of Nursing presented documentation, indicating that the facility initiated a plan of correction on February 20, 2026, to address the failure of the facility to provide a safe bedframe which resulted in actual harm to Resident R1 who sustained lacerations to the forehead and inside the resident's mouth. The facility's plan of correction included the following: The facility alleged a date of compliance of February 27, 2026. The plan of correction stated the following:Resident's bed was replaced. A thorough investigation was conducted into the incident ruling out neglect. The CNA caring for [Resident R1] at the time of the incident was taken off the schedule until his competency and technique were evaluated by the DON and a direct education regarding safety during turning and positioning was provided on 2/27/26.All residents that are on the same model bed were identified. Therapy secured foam padding to the corners of the bedframes immediately mitigating the risk for injury on 2/20/26.Acquired a new bed vendor to replace all beds of the same make and model. Staff were educated on the use of the new bed. In-servicing on turning and positioning safety was completed by all CNAs on 2/27/26.Maintenance will conduct monthly audits to ensure safety and proper function of beds. DON or designee will verify that proper positioning during care is being maintained weekly during clinical rounds. Results from audits will be reported at monthly QAPI and Safety meetings overseen by the Administrator x 3 months. Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of appropriate turning and positioning procedure. Random staff and resident interviews were conducted to verify compliance with the plan of correction. QAPI (Quality Assurance Improvement Plan) records reviewed to verify ongoing monitoring. Resident beds were verified to be padded for safety. Invoices were reviewed to confirm new frames were ordered. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa. Code 201.14. (a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that personal privacy was provided during treatment and medication administration for two of 16 residents reviewed (Residents R27 and R28).Finding include: Review of Facility policy on Resident's Rights dated November 18, 2018, revealed that under section Policy Statement: All residents in long term care facilities have rights guaranteed to them under federal and state law. Under section POLICY INTERPRETATION #1. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. #2. The facility will promote the exercise of rights for each resident including any who face barriers (such as communication problems hearing problems and cognition limits) in the exercise of these rights. #3. The facility will protect and promote the rights of each resident including each of the following rights: exercise his or her rights privacy and confidentiality. The nursing home shall establish and implement written policies and procedures setting forth the rights of residents for the protection and preservations of dignity individuality and to the extent medically feasible. Independent residents and their families or other representatives shall fully informed, and documentation shall be maintained in the resident's file of the following rights #a. privacy in treatment and personal care. Review of Resident R27's clinical record revealed that Resident was admitted to the facility on [DATE], with diagnoses of Chronic Respiratory Failure. Review of physician's order dated January 15, 2026, revealed an order for L (left) Elbow cleanse with NSS (normal saline solution), apply Medi honey, cover with wound dressing one time a day. Observation of Resident R27's bedroom conducted on February 8, 2026, at 11:25 AM revealed that resident R27 was in a single room further Resident R27's bed did not have a privacy curtain around it. Wound care observation with licensed Employee E5 conducted on February 8, 2026, at 11:30 AM revealed that Resident R27 was in bed. Further observation revealed that Employee E5 proceeded to perform wound care on Resident R27's elbow without closing the residence door. Resident R27 was visible from the hallway with resident R27's door open. Interview with Employee E5 conducted at the time of the observation, confirmed that she did not close Resident R 27's door while performing wound care on Resident R27's elbow. Observation on February 8, 2026, at 9:05 a.m. revealed Employee E6, licensed nurse, administer medications to Resident R28 via the resident's feeding tube in his stomach. Resident R28's bed was directly across from Resident R26's bed and there was no privacy curtain between the beds, allowing for full observation of the medication administration by Resident R26. Interview, at the time of the observation, Employee E6, licensed nurse, confirmed that there was no privacy curtain between the residents' beds. 28 Pa Code 201.29(a) Resident rights 28 Pa Code 211.10(a) Resident care policies

Based on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed ensure that a person-centered care plan was developed for one of sixteen residents reviewed. (Resident R27)Review facility policy on plan of care and interdisciplinary care conference revealed that under section policy the facility will develop a meaningful plan of care and compliance with state and federal regulatory requirements that meets the individual needs of the resident in order to provide quality of care and the components that are necessary for the quality of life of the individual. Review of Resident R27's clinical record revealed that Resident was admitted to the facility on [DATE], with diagnoses of Chronic Respiratory Failure. Review of physician's order dated January 15, 2026, revealed an order for L (left) Elbow cleanse with NSS (normal saline solution), apply Medi honey, cover with wound dressing one time a day. Further review of physician's orders revealed an order dated January 23, 2026, for Left ear: cleanse area with NSS pat dry apply skin prep, leave open to air every shift for Wound Tx (treatment). Further review of Resident R27's physician's orders revealed an order dated December 29, 2025, for: Foley care per protocol Q (every) shift. May change foley PRN (as needed) for blockage or leakage, if Foley flush protocol is unsuccessful. Size:14fr 5-15cc balloon every shift. Review of progress note dated January 21, 2026, revealed Resident R27 was seen by the wound nurse and wound MD during wound rounds for evaluation and treatment of areas of the Left elbow, and left ear. Left elbow unstageable 1.8x2.0x0.1, 100 black necrosis, treatment for Medi honey in place. Left ear stage 2 1.0x0.3x0.1, 100 scab treatment for skin prep in place. Review of wound note dated January 21, 2026, revealed that resident had developed a stage 2 pressure ulcer on her ear and an unstageable pressure ulcer to left elbow. Review of Resident R27's care plans revealed that there was no care plan addressing Resident R27's pressure ulcers. Further review of resident ours 27's care plans revealed that there was no care plan addressing Resident R27's Foley Catheter. Observation of Resident R27 conducted on February 8, 2026, at 11:28AM revealed that Resident R27 was in bed. Further, Resident R27 had a urine bag hanging under her bed. Follow up observation of Resident R 27 conducted with Director of Nursing Employee E2 on February 9, 2026, at 11:15 AM, revealed that resident R27 had a foley catheter connected to a urine bag. Interview with Employee E2 conducted at the time of observation confirmed that resident R27 had a Foley catheter. Interview with Employee E2 conducted on February 10, 2026, at 10:15 AM confirmed that there was no care plan addressing Resident R27's pressure ulcer to the left ear and pressure ulcer to the left elbow. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that a resident's representative was informed of a resident's change of status to make treatment decisions, for one of 16 residents reviewed (Resident R16). Findings include: Review of facility policy, Resident Rights dated November 18, 2018, revealed that residents and their families or other representatives have the right to be fully informed by a physician of his/her health and medical condition. The facility shall give the resident and family the opportunity to participate in planning the resident's care and medical treatment. Review of Resident R16's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 20, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including respiratory failure (not enough oxygen passes from your lungs to your blood) requiring use of a mechanical ventilator (machines that act as bellows to move air in and out of the lungs), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), hearing loss, seizure disorder (abnormal electrical activity in the brain), paraplegia (paralysis of the legs and lower body) and cerebrovascular accident (damage to the brain from interruption of its blood supply). Continued review revealed that it was very important to the resident to have family involved in discussions about their care. Review of Resident R16's care plan, dated June 12, 2024, revealed that the resident had impaired cognitive function/impaired thought processes with interventions including to assist the resident with decision making regarding care. Interview with Resident R16's representative on February 9, 2026, at 9:30 a.m. revealed that the facility has not been allowing him to participate in making informed treatment decisions regarding the resident's care. Resident R16's representative continued that, the facility has not been informing him of the resident's condition, scheduled appointments, lab or diagnostic results and changes in the resident's treatment plan. Review of progress notes for Resident R16 revealed that on February 4, 2026, the resident went to an ENT (Ears, Nose and Throat) appointment and returned to the facility with recommendations for a different tracheostomy (a surgically created hole in your trachea that allows for breathing) tube size. Continued review of progress notes revealed that on February 8, 2026, at 8:52 p.m. nursing staff informed the nurse practitioner of lab and chest x-ray results. The nurse practitioner gave an order to obtain additional labs and new orders for medications. Further review revealed no evidence that Resident R16's representative was notified or given the opportunity to participate in treatment decisions regarding the resident's ENT appointment, labs and medication changes. Continued interview with Resident R16's representative confirmed that he was not informed or given the opportunity to participate in treatment decisions regarding the resident's ENT appointment, labs and medication changes. Interview with the Director of Nursing on February 9, 2025, at 10:00 a.m. revealed that Resident R16's representative should have been notified of the Resident's appointment, labs and medication changes. 28 Pa Code 201.29(a) Resident rights28 Pa Code 211.10(a) Resident care policies

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that Enhanced Barrier Precautions were followed during treatment and medication administration for three of 16 residents reviewed (Residents R8, R28 and R33).Findings include: Review of facility policy, Enhanced Barrier Precautions dated November 30, 2022, revealed, Enhanced Barrier Precautions expand the use of PPE [Personal Protective Equipment] beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during specific high contact resident care activities. Continued review revealed, Enhanced Barrier Precautions may be implemented for residents in the facility when the following the following are present . wounds and/or indwelling medical devices are present (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator). Further review revealed that high contact care activities include: dressing, bathing, transferring, providing hygiene, changing linens, toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing). Observation on February 8, 2026, at 9:05 a.m. Employee E6, licensed nurse, administered medications to Resident R28 via the feeding tube in the resident's stomach. During the administration, Employee E6 wore gloves and a face mask. Employee E6 then exited the resident's room, changed gloves, and prepared medications for Resident R8. Employee E6 then entered the resident's room and administered medications to Resident R8 via the feeding tube in the resident's stomach. During the administration, Employee E6 wore gloves and a face mask. No hand hygiene was preformed between changing gloves between residents and Employee E6 did not wear a gown while administering medications to either resident. Interview on February 8, 2026, at 9:50 a.m. Employee E6, licensed nurse, revealed that the employee did not know that Residents R28 and R8 required the use of Enhanced Barrier Precautions and stated I was instructed to just wear gloves. Review of R33's clinical records revealed that resident R33 was admitted to the facility on [DATE], with diagnosis of but not limited to Chronic Respiratory Failure. Review of Resident R33's physician orders revealed an order dated September 25, 2025, for: May suction resident every shift and prn every shift AND as needed. Review of resident R33 MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated September 29, 2025, revealed that section O0110. Special Treatments, Procedures, and Programs, D1. Suctioning was marked X indicating that Resident R33 was on suctioning. Observation conducted on February 8, 2026, at 10:23 AM revealed that there was no enhanced by precautions signage observed outside of Resident R 33's room, further there was no enhanced barrier precaution signage observed inside resident R33's room. Observation of Resident R33 conducted on February 8, 2026, at 10:26AM revealed that Resident R33 was in bed. Further, Resident R33 had tracheostomy. Tracheostomy care and suctioning observation conducted on February 8, 2026, at 11:05 AM, with Employee E3 revealed that Employee E3 performed tracheostomy care and suctioning on Resident R33 wearing only a mask and gloves. Interview with Employee E3 conducted at the time of the observation revealed that she did not have to wear a gown because she did not perform a high-contact procedure. Interview with Director of Nursing Employee E2 conducted on February 8, 2026, at 11:07AM, confirmed that staff must follow the Enhance Barrier Precaution (EBP) signage posted outside of the staff lounge which indicated that staff must wear gloves and gowns When providing tracheostomy care including suctioning. Interview with Infection preventionist Employee E7 conducted on February 9, 2026, at 10:32 AM revealed there are no signage for enhance barrier precaution outside resident's rooms and that enhanced barrier precaution signage are posted on the walls around the facility. Further, Employee E7 revealed that all staff must wear gowns and gloves for residents on enhanced barrier precautions. Further, Employee E7 revealed that respiratory care and suctioning require an enhanced barrier precaution. Review of enhanced bar precaution signage posted outside the staff lounge revealed the following: everyone must clean their hands including before entering and when leaving the room, providers and staff must also wear gloves and gown for the following high-contact resident care activities: device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care and skin opening requiring a dressing.

Based on review of clinical documentation and staff interviews, it was determined the facility failed to ensure adequate supervision during care by not ensuring two staff members were present for one of five residents reviewed (Resident R1). This failure constituted neglect and resulted in actual harm to Resident R1, who fell during the provision of incontinence care and sustained a fracture of the right humeral head (upper arm bone at the shoulder). This deficiency was identified as past noncompliance.Findings include:Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of Sequelae of Cerebral Infarction (area of brain tissue that has died) due to thrombosis of left middle cerebral artery, acute infarction of intestine, obstructive fluid, Subdural Hematoma, cognitive communication deficit, muscle weakness, Pulmonary Embolism without acute heart pulmonale, need for assistance with personal care, tracheostomy status, Chronic Respiratory Failure unspecified whether with hypoxia or hypercapnia, pain. Review of Resident R1's quarterly MDS (Minimum Data Set, periodic assessment of resident care needs), section G, Functional Status, dated [DATE], revealed the resident required extensive assistance of two or more staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture).Review of Resident R1's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. Review of Resident R1's physician orders dated [DATE], revealed an order indicating, bed mobility, two-person assist, and transfer with Hoyer lift, two-person assist.Review of Resident R1's care plan dated [DATE], revealed the following intervention: bed mobility, two-person assist, and transfer with Hoyer lift, two-person assist.Review of facility documentation submitted to the State Survey Agency on [DATE], alleged that Resident R1 was alert and oriented x3 but severely Aphasic (disorder that affects language abilities due to brain damage). Resident R1 was flaccid on (his/her) right side and had minimal use of (his/her) left side. On [DATE], at approximately 5:30 p.m., Certified Nursing Assistant (CNA) Employee E3 positioned Resident R1 on (his/her) left side to complete incontinence care. During care, Resident R1 kicked (his/her) left leg out of the bed, followed by (his/her) right leg, and began to slide out of the bed feet first. Employee E3 yelled for help while attempting to hold Resident R1 in the bed but was unable to do so. Employee E3 assisted Resident R1 to the floor while protecting (his/her) head. The nurse responded to the room and observed Resident R1 on the floor with Employee E3 kneeling behind (resident), supporting (his/her) head and upper body. Resident R1 was immediately assessed and transferred back to bed via Hoyer lift. Neurological checks were completed. Resident R1 reported no pain, and (his/her) vital signs were stable. Bilateral fall mats were placed for safety. On [DATE], Resident R1 reported pain in (his/her) right arm, which (resident) had reported in the past; however, due to the recent fall, the medical team ordered an X-ray of (his/her) arm and administration of PRN pain medication. On [DATE], the X-ray revealed a fracture of the right humeral head. The medical team was immediately notified and ordered Resident R1 be sent to the emergency room for further evaluation and treatment. Resident R1 was sent to the ER (emergency room) by orthopedics and underwent a body CT (type of imaging that uses X-ray techniques to create detailed images of the body) scan for additional injuries. Resident R1 returned to the facility on [DATE], with a follow-up orthopedic appointment scheduled for [DATE]. Employee E3 was terminated for failure to follow safety policies and procedures, as Resident R1 required a two-person assist. Facility-wide re-education and in-service training were initiated.Review of the facility's internal investigation, completed by the facility, revealed on [DATE], an interview was conducted with Certified Nursing Assistant (CNA) Employee E3, who had a language barrier and provided the following written statement: I was changing (Resident R1), and when I turned (him/her), (he/she) fell. (Resident) was not hurt because I caught (him/her) before (he/she) fell.Review of the facility's internal investigation statement conducted on [DATE], by the Director of Nursing (Employee E2), revealed that due to Employee E3's language barrier, with English as a second language, a follow-up interview was also conducted. Employee E2 reported that Employee E3 stated she positioned Resident R1 on resident's left side to complete incontinence care when Resident R1 placed (his/her) leg off the side of the bed and began to slip. Employee E3 yelled for help and attempted to hold Resident R1 in the bed by grabbing (resident) around the trunk. Employee E3 was unable to keep Resident R1 in the bed and supported the resident's head and upper body while assisting (him/her) to the floor.Further review of facility's interval investigation revealed an incident report progress noted dated, on [DATE], by Licensed Nurse Employee E4, which stated: During care, CNA Employee E3 lowered the resident to the floor as (he/she) was sliding out of the bed. Resident R1 denied pain or discomfort.Review of the radiology results report dated [DATE], revealed the following findings: Views of the right humerus demonstrate a comminuted fracture of the humeral head with dislocation of the humeral head from the glenoid in an anteroinferior position. Mild degenerative changes of the shoulder and minimal cortical irregularity were noted. No joint effusion was present. Generalized soft tissue swelling was observed. Conclusion: Fracture-dislocation of the right humeral head.Review of timeline created by the Director of Nursing revealed a statement dated [DATE], from an interview conducted with Employee E3 by the Director of Nursing, Employee E2. The statement revealed: E3 reported that she positioned Resident R1 on (resident's) left side to complete incontinence care when Resident R1 put (his/her) legs off the side of the bed and began to slide off. I (E3) yelled for help and tried to hold Resident R1 in the bed. When I was unable to hold (him/her), I assisted (resident) to the floor. Employee E2 asked Employee E3 if she was aware that Resident R1 required a two-person assist. E3 responded, Yes, but (he/she) can help with (his/her) left hand, so I thought it would be okay. Employee E2 asked if Employee E3 had asked anyone for help, to which Employee E3 replied, No. Employee E2 informed Employee E3 of Resident R1's injury to (his/her) right arm and asked if the arm was caught or hit on anything. E3 replied, No. When asked how she assisted Resident R1 to the floor, Employee E3 stated that she held Resident R1 around the waist and slid (him/her) to the floor. The bed was at Employee E3's waist height. Employee E2 asked if Resident R1 had hit (his/her) head, and Employee E3 replied, No.Further review of facility timeline included a statement dated [DATE], of an interview attempted with Resident R1 by the Director of Nursing, Employee E2. Employee E2 reported: Attempted to interview Resident R1. Resident R1 was in great spirits and smiled when (he/she) saw me. I asked if (he/she) had any pain, and Resident R1 said no. I asked if (Resident R1) remembered falling, and (he/she) said yes. I asked if (he/she) remembered how it happened, and Resident R1 said no. I asked again, and Resident R1 said yes. I asked if (he/she) had slid (his/her) legs out of the bed during care, and Resident R1 said yes. I asked if Resident R1 was trying to stand, and (he/she) became frustrated, saying random words, including numbers and phrases. Due to Resident R1's Aphasia, it was difficult to decipher if (his/her) communication was accurate.On [DATE], at 11:43 a.m., review of facility records revealed Certified Nursing Assistant (CNA) Employee E3 was terminated on [DATE], for failure to comply with safety and security regulations and standards.On [DATE], at 2:31 p.m., an interview with the Director of Nursing, Employee E2, revealed the facility had conducted an internal investigation which initially concluded the investigation was unsubstantiated for neglect. However, during this interview, the Director of Nursing indicated the investigation should have been substantiated for neglect, as Employee E3 failed to follow appropriate procedures when providing care. The facility subsequently revised the determination of the internal investigation to substantiated for neglect.It was further noted that the Director of Nursing presented documentation indicating the facility initiated a plan of correction on [DATE]. The plan addressed ensuring nursing staff were aware of residents' required levels of assistance, knowledgeable of bed mobility status, and verified that safety interventions, including floor mats, were in place.Review of the facility's Action Plan/Follow-Up documentation revealed the following:After a thorough investigation, it was determined that the Certified Nursing Assistant (CNA) did not follow the two-person assist policy for bed mobility as documented in the resident's care plan.No other residents were impacted by this event. Resident care plans were reviewed to ensure accuracy and appropriate care planning for bed mobility.CNA Employee E3 was terminated. CNA staff were educated regarding bed mobility orders, fall prevention, and safe turning and positioning. The therapy department will review bed mobility orders and update clinical staff daily.Random safety audits will be completed weekly by the Director of Nursing (DON) or designee. Audit results will be reported at monthly QAPI and Safety meetings overseen by the Administrator for a period of three months.The facility alleged a date of compliance with this plan of correction of [DATE].Facility education records and subsequent audits were verified for completion. Staff were interviewed to verify education of facility policy on assistance level verification for ADL care. Nursing staff and resident interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, interview or observation.This deficiency was cited as past non-compliance.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of clinical record, facility policy, facility documentation, and interviews with staff, it was determined that the facility failed to ensure that adequate assistance was provided to prevent a fall for one of two sampled residents reviewed for falls (Resident R33). This deficiency was identified as past non-compliance. Findings include: Review of Resident R33's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 14, 2024, revealed Resident R33 had severe cognitive impairment and diagnosis that included but not limited to chronic respiratory failure, anoxic brain damage (brain deprived of oxygen), and muscle wasting and atrophy. Further review of Resident R33's MDS dated [DATE], revealed Resident R33 was dependent (helper does all the effort) for all activities. Resident R33 required assistance of two or more helpers for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Review of Resident R33's comprehensive care plan dated September 11, 2024, revealed Resident R33 had ADL (activities of daily living) deficit related to chronic illness as evidenced by: transfer dysfunction, decreased strength, decreased bed mobility, decreased cognitive and physical function. Further review of Resident R33's comprehensive care plan revealed interventions dated September 12, 2024, Resident R33 required assistance of two staff members for bed mobility. Review of facility documentation submitted to the State Survey Agency on December 05, 2024, revealed on December 05, 2024 Resident R33 had a witnessed fall from bed while one staff member attempted to reposition Resident R33. Review of facility documentation revealed an incident report dated December 05, 2024, that revealed nurse aide, Employee E7, was preparing to provide care for Resident R33. Nurse aide, Employee E7, raised Resident R33's bed to knee height and moved the floor mat. Nurse aide, Employee E7, then removed the other floor mat to allow for another caregiver to stand on opposite side of bed. Nurse aide, Employee E7, then removed the pillow from under Resident R33's hip, turned to put the pillow on the mat, and Resident R33 rolled on to the floor. No other staff members were present to assist nurse aide, Employee 7, to turn/reposition Resident R33 in bed. Review of nurse aide, Employee E7, statement dated December 05, 2024 revealed during patient care the nurse aide, Employee E7, removed side pillow from Resident R33 and then turned away from Resident R33's bed to put pillow on matt behind his/her self. Nurse aide, Employee E7, then heard a bump and saw Resident R33 on the floor. Interview on February 10, 2025, at 10:15 a.m. with Director of Nursing, Employee E2, confirmed Resident R33 should have been assisted with two staff members during turning and repositioning in bed. On December 05, 2024, following the incident, the facility immediately implemented the following corrective actions: -On 12/05/24 [Resident R33] care plan immediately updated to include fall incident and bilateral fall mats. - On 12/05/24 Director of Nursing, Employee E7, provided direct education to Employee E7 and nurse who was assigned to Resident R33 on bed mobility orders and the required assistance when turning/ repositioning resident. -Starting on 12/05/24 and completed on 12/10/2024, Director of Nursing, Employee E2, re-educated all nursing staff on understanding bed mobility orders and where to find what assistance is required for residents. -Starting on 12/09/24 and completed on 12/10/2024, Director of Nursing, Employee E2, re-educated all nursing staff on understanding floor mats and the removal of floor mats when the required assistance is present and ready to assist. -Starting on 12/06/2024 and continuous auditing through 01/29/25, Director of Nursing, Employee E2, conducted safety audit bed mobility/floor mats to ensure bed mobility orders were followed accordingly and floor mats were in place for residents who required them. Interviews with nursing staff on February 11, 2024 at 9:45 a.m. confirmed that they had all been in-serviced on reviewing bed mobility orders and ensuring proper assistance is being provided during care. Review of clinical records and observations revealed proper assistance was being provided for bed mobility orders and floor mats were in placed as ordered for residents. This deficiency was identified as past non-compliance. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that adequate catheter care was provided for two of two sampled residents with urinary catheters reviewed (Residents R4, and R39). Findings include: Review of Resident R4's clinical record revealed Resident R4 was admitted to the facility on [DATE] for a diagnosis that included but not limited to chronic respiratory failure, anoxic brain damage (complete lack of oxygen to the brain), and retention of urine. Observation on February 10, 2024 at 12:22 p.m. revealed Resident R4's indwelling urinary catheter drainage bag (a flexible catheter used to drain urine from the bladder into a drainage collection bag) lying flat on floor on the right side of Resident R4's bed. Interview on February 10, 2025 at 12:26 p.m. with Employee E5, Nurse Aide, confirmed Resident R4's indwelling urinary catheter drainage bag should not be on the floor. Review of Resident R39's clinical record revealed Resident R39 was admitted to the facility on [DATE] for a diagnosis that included but not limited to chronic respiratory failure, muscle weakness, and retention of urine. Observation on February 10, 2025 at 1:00 p.m. revealed Resident R39's indwelling urinary catheter drainage bag lying flat on floor on the right side of Resident R39's bed. Interview on February 10, 2025 at 1:05 p.m. with Employee 6, Registered Nurse, confirmed Resident R39's indwelling urinary catheter drainage bag should not be on the floor. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on the observations, review of clinical records, and interview with staff, it was determined that the facility failed to ensure that a resident with limited range of motion, received appropriate services to prevent further decline in range of motion and maintain appropriate positioning for two of 13 resident s reviewed. (Resident R26 and Resident R33). Finding Include: Review of physician order for Resident R26 dated May 9, 2024, revealed an order for hand grip splint to be alternated right to left every 4 hours with a schedule of 12 AM, 4AM, 8AM, 12PM, 4PM and 8PM. Review of physician order for Resident R26 dated July 31, 2024, revealed an order for elbow positioning wedges to be applied bilaterally 4 hours then removed 4 hours with a schedule of 12 AM, 4AM, 8AM, 12PM, 4PM and 8PM. Review of MDS (Minimum Data Set- Assessment of resident care needs) for Resident R26 dated January 14, 2025, revealed that the resident's range of motion was limited on both sides on both upper and lower extremities. Observation of Resident R26 on February 9, 2025, at 10:20 a.m. revealed that the resident was lying in the bed. It was observed that residents appeared to be contracture to her upper extremities. Residents was not wearing any devices or splints to the affected area. There was a white colored hand splint and blue elbow splint on the windowsill. Further observation of Resident R26 on February 9, 2025, at 12:46 p.m. revealed that the resident was lying in the bed. Residents was not wearing any devices or splints to the hands or elbow. The white colored hand splint and blue elbow splint was on the windowsill at the same location. Interview with Employee E8, Licensed Practical Nurse, on February 9, 2025, at 12:46 p.m. stated Resident R26 should wear splint as ordered by the physician every 4 hours Review of clinical record for Resident R33 revealed that the resident had diagnosis of muscle wasting, atrophy and abnormal posture Review of physician order for Resident R33 dated November 15, 2024, revealed an order for Abductor wedge to be positioned between legs at all times as tolerated. Review of physician order for Resident R33 dated December 28, 2024, revealed an order for bilateral upper extremity splint to be applied for 4 hours and remove for 4 hours. Observation of Resident R33 on February 9, 2025, at 10:25 a.m. revealed that the resident was lying in the bed. Residents was not wearing any devices or splints. There was no splint or devices in resident's room. Further observation of Resident R33 on February 9, 2025, at 12:44 p.m. revealed that the resident not wearing any devices or splints. There was no splint or devices in resident's room. Interview with Employee E8, Licensed Practical Nurse, on February 9, 2025, at 12:46 p.m. stated she was not sure if resident should be wearing splint or any devices, the employee searched the room and could not locate splint or devices. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code: 201.18 (b)(2) Management 28 Pa. Code: 211.10 (d) Resident care policies

Based on observation, a review of select facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to ensure the evaluation of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom and failed to timely obtain informed consent prior to the use of restraint for one of one sampled residents with restraints. (Residents R5) Findings include: A review of a facility policy titled Restraints - revised on September 1, 2016, revealed Physical restraints include, but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions and lap trays the resident cannot remove. To provide guidelines for appropriate use of restraints to prevent injury to the patient or other patients only as necessary. A. An initial assessment will be completed whenever the use of a physical device is considered. 1. Included in the assessment will be a. To determine the need for any device b. To determine what is the appropriate and least restrictive device. 2. The use of restraints will be deemed appropriate only if a specific medical condition/symptoms are present and documented and presented on the initial restraint assessment. B. Less restrictive alternatives are considered/attempted and documented. Review of facility documentation Restraint notification and Consent Information revealed that the facility had a process of obtaining informed consent prior to the use of restraints including documentation of benefits, potential negative outcome, recommendation and the written acknowledgement of resident representative of the understanding of benefits and negative outcome of restraint use. Observation Resident R5 on February 9, 2025, at 10:37 a.m. revealed that the resident was using hand mitt (a thumbless mitten device is used to restrain a patient's hands) to the both hands. Clinical record review revealed that Resident R5 was admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure and tracheostomy (a surgical procedure that creates an opening (stoma) in the front of the neck into the trachea (windpipe)) status. A review of the admission Minimum Data Set Assessment (MDS) - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 25, 2024, revealed Resident 5's BIMS interview (Brief Interview for Mental Status- a tool to assess cognitive function) was not completed, which indicated that the resident was unable to provide or did not provide answers to complete this section). Further review of the MDS revealed that the resident used limb restraint daily. A physician order for Resident R5 dated December 18, 2024, revealed an order for hand mitt to both hands and remove every 2 hours for skin integrity check. Review of clinical record for Resident R5 revealed no evidence that the resident was evaluated of resident's need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint for Resident R5 on December 18, 2024. Further review of clinical record for Resident R5 revealed no evidence that the facility obtained informed consent prior to the use of restraint. There was no consent available in the clinical record. An undated restraint consent provided during the survey provided no indication of the date the consent was obtained. Interview with Director of Nursing on February 12, 2025, at 10:00 a.m. confirmed that the facility did not evaluate Resident R5 of residents' need and use of restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom when the facility started using restraint and obtained documented informed consent prior to the use of restraint. 28 Pa. Code 211.8 (c.1)(f) Use of restraints 28 Pa. Code 211.12(d) Nursing services

Based on observations, review of facility policy, and interviews with staff, it was determined that the facility failed to properly date medication vials upon opening and failed to discard expired medication for two of three medication carts (Medication Cart Four and Medication Cart Five) and and two of two medication rooms (Room Two). Findings include: Review of facility policy titled Storage of Medication, dated 2016, revealed insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Observation conducted on February 11, 2025 at 11:43 a.m. in medication storage Room Two revealed two tuberculin (TB) vials (used to diagnosis tuberculosis). TB vial one was opened and undated and vial two had an opened date of [DATE]. Instructions listed on TB vial manufacturing package was to discard after 30 days upon opening. Interview on February 11, 2025 at 11:50 a.m. with Employee E3, Registered Nurse, confirmed TB vial one was opened and not dated and TB vial two was expired. Observation on February 11, 2025 at 11:57 a.m. on Medication Cart Five revealed five insulin vials that were opened and undated, which included two Humalogs, two Novalogs, and one Lantus. Interview on February 11, 2025 at 12:00 p.m. with Employee E3, Registered Nurse, confirmed the five insulin vials were opened and undated. Observation on February 11, 2025 at 12:10 p.m. on Medication Cart Four revealed two opened insulins, Novalog opened [DATE] and Humalog opened [DATE], exceeding the recommended 28 days to discard after vial opening date. Interview on February 11, 2025 at 12:15 p.m. with Employee E5, License Practical Nurse, confirmed both insulin vials were expired. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy Food and Nutritional Services Administration and Requirement dated September 1, 2016, revealed Refrigerators freezers and dry storage areas will be checked for temperature twice daily (at opening and closing times) and temperature will be recorded on the log, Review of facility policy Kitchen Dishwasher temperature dated September 1, 2016, revealed, All temperatures are to be recorded on the dishwasher temperature log once per meal service, An initial tour of the Food Service Department was conducted on February 9, 2025, at 12:00 a.m. with Employee E13, Food Service Manager, which revealed the following: The facility dish machine temperature log for February 2025, revealed that the temperature recording was available only up to February 3, 2025. There was no temperature available for February 4, 5, 6, 7, 8, and February 9 breakfast time. The Refrigerator temperature log for one of the refrigerators revealed that the last recorded temperature was on December 29, 2025. There was no temperature available on or after December 30, 2024. The three compartment sink log for February 2025, revealed that the Sanitizer recording was available only up to February 3, 2025. There was no sanitizer recording available for February 4, 5, 6, 7, 8, and February 9 breakfast time. Observation of the walk-in refrigerator with Employee E13 revealed that there were boiled eggs in the refrigerator with no expiration date. There was a container of dessert without open date, package date or expiration date. There were also 3 boxes of breads without any date or labels. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on review of clinical records and a staff interview, it was determined that the facility failed to ensure that the resident's representative was notified timely about a hospital transfer for one of three discharge records reviewed (Residents R49). Findings include: A review of clinical records revealed that Resident R47 was admitted to the facility on [DATE], with diagnosis to include Chronic Respiratory Failure (is a serious condition that affects your lungs and blood oxygen levels which may require a ventilator). Further review revealed a progress note dated January 10, 2024, which stated, Labs were drawn this am because they were ordered. PT (physical therapist) noted that the patient's abdomen was distended, called the doctor and got an order for BMP and abdominal X-ray. The labs were done and am waiting for X-Ray . I sent labs to attendings and took a verbal order. to send patient out to ER 9emergency room ) for Eval. I called [hospital] and gave report to . 911 was called to transport patient to local ER. Continued review revealed no documentation that the responsible party was notified of the transfer to the hospital. Interview with the Administrator and Director of Nursing on April 12, 2024, at 11:00 a.m., confirmed that Resident R47's responsible party and/or power of attorney was not notified of the resident need for hospitalization . 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure nurse aide staff received in-service training to be proficient and competent and that the training be no less than 12 hour annually for two of three nurse aide staff. (Employee 16 and Employee 17). Findings Include: A request for nurse aides annual in-service training record for nurses' aides was requested on April 10, 2024. Review of nurses' aides training records revealed that nurse aides, Employee E16 and Employee E17 did not have the required 12 hours of annual in-service training as required. Interview with Director of Nursing, Employee E2 on April 11, 2024 at 1:02 p.m. confirmed there was no further record on in-service trainings for nurse aides' Employee E16 and Employee E17. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observation, a review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans regarding the use of hand mitt restraints for one of 13 residents reviewed. (Resident R37). Findings include: A review of clinical records revealed that Resident R37 was admitted to the facility on [DATE], with diagnosis to include Chronic Respiratory Failure (is a serious condition that affects your lungs and blood oxygen levels which may require a ventilator). Further review revealed an April 4, 2024, physician's order for please place hand mitts for safety and preventing dislodgement of new midline every shift for safety. Observation of Resident R37 in the Activity Room adjacent to the nursing station on April 9, 2024, at 11:45 a.m. revealed that the resident was wearing the hand mitts while sitting at the table with several other resident during an activity program. Observation of Resident R37 in room [ROOM NUMBER] on April 10, 2024, at 11:32 a.m. revealed that the resident was wearing the hand mitts while in bed. Review of Resident R37's care plan revealed no care plan for the use of hand mitt restraints. Further review of Resident R37's Medication Administration Record for April 1, 2024 to April 30, 2024, revealed that the hand mitts were placed each shift starting April 5, 2024. An interview on April 12, 2024, at 11:30 a.m. with the Director of Nursing confirmed that the resident did not have a comprehensive care plan regarding the use of hand mitt restraints. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The untitled and undated policy for food storage states, Food is stored in compliance with applicable Federal, State and Local regulations regarding sanitary food storage. An initial tour of the Food Service Department was conducted on [DATE], at 11:00 a.m. with Employee E3, Food Service Director, which revealed the following: Observation in the walk-in freezer revealed a box of carrots that was open with the inner plastic liner open to the circulating air. Observation in the reach-in freezer revealed a bag of breaded chicken tenders that was open to the circulating air. Interview with Food Service Director on [DATE], at 11:15 a.m., confirmed the above findings. Observation of the resident storage refrigerator on [DATE]. 2024 at 11:50 a.m. revealed several items that were expired or not labeled. The refrigerator and freezer had several spills that were not cleaned. In the refrigerator there was a carton of milk that was expired on [DATE]. A container of tuna salad with no date and no label. A container of yogurt and granola labeled [DATE]. A container of yogurt and blueberries with no date and no label. A container of peaches labeled [DATE]. A contained of macaroni salad labeled [DATE]. A salad with tuna with no date and no label that appeared soggy. Interview with the Registered Dietician, Employee E7 on [DATE] at 12:20 p.m. confirmed the findings and the refrigator and stated that the kitchen is in charge of cleaning out the refrigerator once a week. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater, in two out of twenty-five medications reviewed. Findings include: On April 9, 2024, at 9:41 a.m., observed that Employee E11, a Licensed Nurse, administered to Resident R16, Vitamin D3 (Cholecalciferol), 1000 unit (25 mcg), one tablet, by mouth. Review of physician order for R16, dated April 3, 2024, revealed an order to administer Vitamin D3 Tablet (Cholecalciferol), 2000 unit (50 mcg), by mouth, one time a day, for Nutritional Deficiency. At the time of the observation, interviewed Employee E11, Licensed Nurseand confirmed the findings. On April 9, 2024, at 12:02 p.m., observed that Employee E10, a Registered Nurse, prepared to administer to Resident R25, Aspirin Enteric Coated 81 mg tablet, via G-Tube, but its administration was averted, as, Enteric Coated tablets should not be crushed. (Enteric coated tablets are tablets that are coated with an enteric coating. Crushing enteric coated tablets may result in the drug being released too early, destroyed by stomach acid, or irritating the stomach lining. Review of medical literature, in, https://newsnetwork.mayoclinic.org/discussion, revealed that with enteric-coated aspirin, research indicated that bloodstream absorption may be delayed and reduced, compared to regular aspirin absorption. Regular aspirin is quickly dissolved and absorbed in the stomach. As a result, enteric-coated aspirin may not be as effective as regular aspirin at reducing blood clot risk). Review of physician order for Resident R25, dated July 10, 2023, revealed an order to administer Aspirin Tablet, 81 mg, via G-Tube one time a day. At the time of the observation, interviewed E10, and confirmed the findings. This erroneous medical administration incurred a medication error rate of 8%. The facility incurred a medication error rate of 8 %. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that medications were discarded according to manufacturer instructions for 1 of 3 medication carts reviewed (Medication Cart Main B). Findings include: Review of medications stored in the Medication Cart Main B, conducted on April 11, 2024, at 1:19 p.m., in the presence of Licensed Nurse, Employee E6, revealed the following expired medications: Oxycodone HCl (IR) 5 mg tablet, 17 tablets, expired on March 2024, marked for Resident R17; Tramadol HCl 50 mg tablet, 25 tablets, expired on March 2024, marked for Resident R17; and Lorazepam 1 mg tablet, 23 tablets, expired on December 2023, marked for Resident R5. Interview with the of Licensed Practical Nurse, Employee E6, at the time of the finding, confirmed that the expired medications should have been discarded according to manufacturer instructions, and facility policy. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's for seven of 12 residents reviewed. (Resident R14, R30, R6, R4, R41, R10, R40). Findings Include: Review of an undated facility protocol Respiratory care shift duty assignments, revealed that on Day shift (7am to 7pm shift, Sunday: Change suction tubing and canisters and portables. Please make sure all equipment is dated with initial. Observation of Resident R14's suction canister revealed that the canister was last changed on May 7, 2023. There was no date on suction tubing. Observation of Resident R30's suction canister and tubing revealed that the canister and tubing was last changed on May 7, 2023. Observation of Resident R6's suction canister revealed that the canister was last changed on May 7, 2023. Observation of Resident R4's suction canister revealed that the canister and tubing had no date. Observation of Resident R41's suction canister and tubing revealed that the canister and tubing had no date. Observation of Resident R10's suction canister revealed that the canister was last changed on May 7, 2023. Observation of Resident R40's suction canister revealed that the canister was last changed on April 2, 2023. Above observations were confirmed wtth Employee E11, Respiratory Lead Technician on June 6, 2023 at 1:55 p.m. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, review of facility policy, interviews with residents and staff, and review of facility documentation, it was determined the facility failed to ensure residents were informed and had access to grievance/concern forms for two of 44 residents reviewed (Resident R7 and R9) Findings Include: Review of policy Abuse Complaint and Grievance Policy revised on, November 2018 revealed there is no part of the procedure that states how residents can obtain and file a grievance anonymously. Further review of the same policy states, all complaints/grievances are cited on paper, thoroughly investigated and all necessary and appropriate corrective actions are taken. During interviews with Resident R9 and Resident R7, on June 6, 2023, at 1:15 p.m. and June 7, 2023, at 11:00 a.m. respectively, the residents revealed they were unaware how to file a grievance and/or an anonymous grievance at the facility. A tour of the facility on June 8, 2023, at approximately 10:00 a.m., with the Nursing Home Administrator and the Activity Director confirmed there were no postings throughout the facility of the right to file grievances orally or in writing, the right to file grievances anonymously, or the contact information of the grievance official with whom a grievance can be filed. 28 Pa. Code: 201.29(i) Resident Rights.