Every finding on record at Gardens at Orangeville, The

Based on a review of clinical records, facility policy, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to protect one of 23 residents reviewed (Resident 110) from neglect by failing to ensure staff implemented the resident's individualized care plan requiring the assistance of two staff members for transfers resulting in actual harm in the form of a fracture of the right distal tibia and fibula (the two bones of the lower leg located between the knee and ankle) that required hospital evaluation and treatment. This deficient practice is cited as past noncompliance.Findings include: A review of the Abuse Policy last reviewed by the facility on May 1, 2026, revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy required the facility to implement processes to include screening, training, prevention, identification, protection, investigation, reporting, and response to allegations of potential or actual allegations to ensure they are treated seriously, reported promptly and investigated thoroughly, and addressed with appropriate corrective or disciplinary action based on the findings, severity, circumstances, and regulatory requirements. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of Resident 110's clinical record revealed admission to the facility on June 11, 2026, with diagnosis that included a Tri malleolar fracture of the left lower leg (a severe and unstable type of ankle break where three parts of the ankle joint break), polyosteoarthritis (a degenerative joint disease where multiple joints break down from wear and loss of protective cartilage over time), and muscle weakness. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 11, 2026, revealed that Resident 110 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 intact cognition). The assessment revealed the resident required total assistance from staff for transfers and toileting. A review of Resident 110's comprehensive care plan dated June 11, 2026, revealed the resident had an activities of daily living (ADL, routine self-care activities such as transferring and toileting) self-care performance deficit related to immobility and a left ankle fracture. The care plan required assistance from two staff members for transfers and toileting and directed staff to maintain the resident as non-weight-bearing through the left lower extremity (not allowing any body weight to be placed on the injured left leg). A review of physician orders dated June 11, 2026, revealed an order directing staff to transfer Resident 110 with the assistance of two staff members and to maintain non-weight-bearing status on the left lower extremity. A review of nursing documentation dated June 27, 2026, at 10:30 AM revealed Employee 3, Nurse Aide, reported that while transferring Resident 110 from the toilet to a wheelchair, the resident stood without difficulty; however, during the pivot transfer the resident's right foot turned inward and both the resident and Employee 3 heard a loud pop. The resident immediately complained of increased pain. Nursing documentation dated June 27, 2026, at 4:40 PM revealed a mobile radiology service completed an x-ray that identified an acute fracture of the right tibia (a new break in the shinbone). The nurse practitioner ordered the resident transferred to the hospital emergency department for further evaluation and treatment. Review of the hospital records dated June 27, 2026, at 8:39 PM revealed diagnostic imaging confirmed fractures of the distal right tibia and fibula (a broken lower right leg near the ankle, involving both the shinbone and the outer calf bone close to where they form the ankle joint). Hospital records revealed the resident was scheduled to undergo surgical repair the following day. A review of the facility's abuse and neglect investigative documentation dated June 27, 2026, revealed Employee 3 transferred Resident 110 from the toilet to the wheelchair using only one staff member despite the resident's physician order and care plan requiring assistance from two staff members. The investigation concluded the transfer was performed contrary to the resident's individualized plan of care and resulted in the resident sustaining a fracture of the right distal tibia. A review of a written statement completed by Employee 3 dated June 27, 2026, revealed Employee 3 documented that while assisting Resident 110 from the toilet to the wheelchair, both Employee 3 and the resident heard a pop as the resident turned to sit in the wheelchair. Employee 3 documented the resident was seated in the wheelchair and the nurse was immediately notified. Continued review of the facility's abuse and neglect investigative documentation revealed Employee 3 failed to follow the resident's individualized care plan requiring assistance from two staff members during transfers. The facility substantiated caregiver neglect and concluded that the failure to follow the resident's care plan directly resulted in the resident sustaining fractures of the right distal tibia and fibula. The investigation further revealed Employee 3 was suspended during the investigation and subsequently terminated following substantiation of neglect. During an interview conducted on August 29, 2026, at 9:00 AM the Nursing Home Administrator acknowledged Employee 3 did not follow Resident 110's physician order and care plan requiring assistance from two staff members for transfers. The Nursing Home Administrator acknowledged the facility's investigation determined the failure to implement the required transfer intervention resulted in Resident 110 sustaining fractures of the right distal tibia and fibula requiring hospital treatment and confirmed Employee 3's employment was terminated following the substantiated finding of neglect. The facility failed to ensure staff implemented Resident 110's physician order and individualized care plan requiring assistance from two staff members during transfers. As a result, Resident 110 sustained fractures of the distal right tibia and fibula requiring diagnostic testing, hospital transfer, and surgical intervention. The facility alleged corrective actions were completed following the incident, including; Upon Resident 110's return from the hospital, the facility completed an assessment and updated the resident's comprehensive care plan as appropriate based on the resident's current condition and care needs. The facility identified that all residents requiring assistance from two staff members for transfers had the potential to be affected. The facility provided re-education to staff regarding the requirement to review the Kardex (a resident-specific care summary that communicates current care instructions) before providing care and to consistently follow each resident's individualized plan of care. The facility also provided re-education regarding the facility's Abuse Policy. Licensed nurses and nurse aides conducted random observations to verify staff followed each resident's individualized plan of care for transfer assistance and transfer status. The facility provided additional re-education to licensed nurses and nurse aides regarding implementation of residents' individualized plans of care, including reviewing the Kardex before providing care and complying with the facility's Abuse Policy. The Nursing Home Administrator, or designee, monitored a sample of transfer observations through random audits to verify residents received transfer assistance as ordered. The facility implemented audits weekly for four weeks and monthly for two additional months, with audit results reviewed by the Quality Assurance and Performance Improvement Committee for recommendations and follow-up as indicated. Survey findings supported that substantial compliance was achieved on July 1, 2026. Therefore, this deficiency is cited as past noncompliance. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, a review of clinical records, physician orders, select facility policies, and staff interviews, it was determined that the facility failed to provide the necessary care and services to maintain residents' highest practicable physical well-being by failing to consistently implement physician-ordered treatments and care planned interventions to maintain skin integrity for two of 23 sampled residents (Residents 15 and 27).Findings include: A review of the facility policy titled Skin and Wound Management System, last reviewed by the facility on May 1, 2026, revealed it is facility policy to identify residents with existing wounds or pressure injuries, assess residents at risk for impaired skin integrity, implement appropriate preventive and treatment interventions, and provide ongoing monitoring to promote skin integrity and wound healing. Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with a Stage III pressure ulcer (a full-thickness skin loss that does not expose bone, tendon, or muscle and may have dead tissue identified and documented as slough or necrotic in nature). A review of Resident 15's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 22, 2026, revealed that Resident 15 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 12 through 15 indicates cognitively intact). It was also identified on this assessment the resident was at risk for impaired skin integrity, had an unhealed unstageable pressure injury of the sacrum (the lower back area immediately above the tailbone where the wound depth cannot be determined because it is covered with slough or dead tissue), and required staff assistance to turn and reposition in bed because the resident could not independently reposition herself. During interviews conducted on July 28, 2026, at 11:00 AM, and July 29, 2026, at 2:00 PM, Resident 15 stated she depended on staff to reposition her while in bed. The resident reported that on the evening of June 4, 2026, staff placed her on a bedpan. The resident stated she accidentally fell asleep while on the bedpan, was embarrassed that she had fallen asleep, and did not realize she remained on the bedpan until she awakened the following morning. The resident stated she activated the call bell after awakening and staff then removed the bedpan. A review of the nursing note and Pressure Ulcer Investigative Report, dated June 5, 2026, at 7:00 AM, and an interview with the Director of Nursing on July 30, 2026, at 2:00 PM, confirmed staff placed Resident 15 on a bedpan on June 4, 2026, at 10:30 PM. The documentation revealed the resident remained on the bedpan until approximately 6:30 AM on June 5, 2026, when the resident activated the call bell for assistance. After staff removed the bedpan, they identified a red outline corresponding to the shape of the bedpan measuring approximately 23 centimeters (cm) by 14 cm on the resident's skin. Resident 15 required turning and repositioning every two to three hours. Had staff implemented those interventions as documented in the resident's care, staff would have identified that the resident remained on the bedpan before 6:30 AM on June 5, 2026. During an interview on July 30, 2026, at 2:00 PM, the Director of Nursing was unable to provide evidence that staff completed the required turning and repositioning every two to three hours while Resident 15 remained on the bedpan or otherwise monitored the resident during that period. A review of the June 2026 physician orders revealed Resident 15 had an order for a calcium alginate dressing (a wound dressing made from seaweed fibers that absorbs wound drainage and promotes healing) to the resident's sacral pressure injury. A review of the nursing note and Skin Tear Investigation, dated June 6, 2026, at 10:00 PM, revealed staff removed an existing dressing from the resident's sacral wound and, during removal, the resident sustained a skin tear to the left buttock measuring 1.5 cm in length by 1 cm in width by 0.1 cm in depth. The facility's investigation determined staff had failed to apply the physician-ordered dressing. During an interview on July 30, 2026, at 2:00 PM, the Director of Nursing stated the incorrect dressing closely resembled the physician-ordered dressing but lacked the silicone component intended to facilitate gentler removal and reduce trauma to the surrounding skin. The Director of Nursing was unable to provide evidence that staff consistently applied the physician-ordered dressing or otherwise ensured the resident received appropriate wound care to treat the existing pressure injury and minimize additional skin injury. A review of the clinical record revealed a similar failure to implement physician-ordered interventions intended to maintain skin integrity for Resident 27. A review of the clinical record revealed Resident 27 was admitted to the facility on [DATE], with diagnoses including intracerebral hemorrhage (bleeding within the brain caused by rupture of a blood vessel) and cerebral infarction (death of brain tissue caused by interruption of blood flow to the brain). A review of Resident 27's care plan, initiated on February 26, 2025, identified actual and potential impairment of skin integrity related to decreased mobility, environmental changes, and the need for extensive to total assistance with transfers, toileting, and mobility. Interventions included maintaining clean and dry skin, performing skin assessments each shift, and applying a left palm roll (a padded positioning device placed in the hand to keep the fingers open, reduce pressure from fingernails against the palm, absorb moisture, and decrease the risk of skin breakdown) as tolerated. A review of physician orders revealed an order dated June 5, 2025, directing staff to maintain the left palm roll as tolerated and remove it each shift for hygiene and range of motion (movement of a joint through its normal extent of motion) exercises. Observation on July 28, 2026, at 11:36 AM, revealed Resident 27 sitting in a chair in the resident's room with the left hand tightly clenched. The physician-ordered left palm roll was not in place. When prompted, the resident was unable to voluntarily open the hand. During an interview on July 28, 2026, at 11:38 AM, Employee 1, a Licensed Practical Nurse (LPN), confirmed the left palm roll was not in place. Employee 1 stated the device became soiled during the previous night shift and nursing assistants did not replace it with a clean palm roll. Employee 1 manually opened the resident's left hand and observed nail indentations on the resident's palm. A review of the July 2026 documentation survey report revealed documentation indicating Resident 27's left palm roll had been applied on July 28, 2026, at 2:22 AM. The clinical record contained no documentation indicating when the left palm roll was removed for hygiene, when it became soiled, or when a clean palm roll was reapplied after removal. During an interview on July 31, 2026, at 9:45 AM, the Nursing Home Administrator and Director of Nursing reviewed the above findings and were unable to provide evidence that staff consistently implemented the physician's order and the resident's care planned intervention requiring use of the left palm roll. As a result, the facility failed to implement the physician's order and care planned intervention intended to maintain skin integrity, placing Resident 27 at increased risk for skin breakdown and pressure-related injury to the left palm. 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, the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, select facility policy, resident interviews, and staff interviews, it was determined that the facility failed to consistently implement physician-ordered restorative nursing services in accordance with residents' physician orders and care plans to maintain or improve mobility for three of 23 residents reviewed (Residents 85, 15, and 64).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the MDS dated [DATE], requires the assessment to accurately reflect the resident's status; a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. According to the RAI manual, Section O 0500: Restorative Nursing Programs, states that movement occurring incidentally during activities such as dressing, bathing, or other routine care does not constitute a formal restorative nursing program. For inclusion in this section, active or passive range of motion must be a component of an individualized program that is planned, monitored, evaluated, and documented in the resident's medical record. Range of motion should be delivered by staff who are trained in the procedures. A review of the facility policy titled Restorative Nursing Services, last reviewed by the facility on May 1, 2026, revealed residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Restorative goals may include supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining, or strengthening his physiological and psychological resources; maintaining his dignity, independence, and self-esteem; and participating in the development and implementation of his plan of care. A clinical record review revealed Resident 85 was admitted to the facility on [DATE], with diagnoses that included muscular dystrophy (a group of inherited diseases that cause progressive muscle weakness and loss of muscle function). A review of Resident 85's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 16, 2026, revealed that Resident 85 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 initiated on November 29, 2023, directed staff to provide passive range of motion exercises (movement of a resident's joints performed by another person without the resident actively moving the limb) to both lower extremities twice daily. The order required three sets of 10 repetitions through all joints and planes of motion (moving each joint through its full, normal range in every direction). A physical therapy Discharge summary dated [DATE], revealed recommendations for Resident 85 to receive restorative nursing program services that include bilateral lower extremity passive range of motion exercises across all joints and planes, three sets of ten repetitions daily. A review of Resident 85's annual MDS dated [DATE], Section O 0500: Restorative Nursing Programs, indicated the resident received passive range of motion restorative nursing services for at least 15 minutes on six of the seven days during the assessment look-back period. A review of the resident's care plan initiated on September 13, 2023, revealed Resident 85 was at risk for falls related to decreased mobility and muscular dystrophy. Interventions included participation in a restorative nursing program consisting of passive range of motion exercises to both upper and lower extremities (arms and legs) using three sets of 10 repetitions through all joints and planes. During an interview on July 28, 2026, at 10:42 AM, Resident 85 stated staff assisted with dressing, hygiene, and transfers but did not perform repetitive passive range of motion exercises to the arms and legs as ordered. The resident stated no one routinely performed the prescribed restorative exercises. A review of the July 2026 restorative nursing documentation revealed staff documented passive range of motion services ranging from five to 30 minutes on July 27, July 29, and July 30, 2026. The document indicated Employee 2, Nurse Aide (NA), implemented five minutes of passive range of motion exercise with Resident 85. During an interview on July 30, 2026, at 12:14 PM, Employee 2, Nurse Aide (NA), stated that while providing personal care, she stretched Resident 85's legs twice but did not perform passive range of motion exercises to both upper and lower extremities consisting of three sets of 10 repetitions through all joints and planes as ordered by the physician. Employee 2 was unable to explain how the physician-ordered restorative exercises were to be performed. During an interview on July 31, 2026, at 9:45 AM, the findings were reviewed with Nursing Home Administrator (NHA) and Director of Nursing (DON). The facility failed to consistently implement physician-ordered restorative nursing services for Resident 85. Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with the diagnosis of diabetes (elevated sugar in the blood) and gait instability (difficulty maintaining normal balance while walking). A review of Resident 15's annual MDS dated [DATE], revealed that Resident 15 was cognitively intact with a BIMS score of 15 a score of 13 through 15 indicates cognition is intact. Physician's orders for July 2026 directed staff to provide restorative nursing services consisting of active range of motion exercises (movement performed by the resident using his or her own muscles) to both lower extremities through all joints and planes every day using two sets of 15 repetitions. Physician's orders also directed staff to provide active range of motion exercises to both upper extremities through all joints and planes every day using three sets of 10 repetitions. During an interview on July 28, 2026, at 11:00 AM, Resident 15 stated staff were not providing restorative exercises for either the upper or lower extremities. A review of Resident 15's July 2026 restorative nursing documentation revealed active range of motion exercises were documented as not applicable on July 1, July 14, and July 23, 2026. The clinical record contained no documentation explaining why the interventions were recorded as not applicable, such as resident refusal, inability to tolerate the intervention, or another documented clinical reason. Review of the July 2026 restorative nursing documentation revealed treatment times ranging from five to 15 minutes without documentation explaining the variation in treatment duration. During an interview on July 30, 2026, at 9:05 AM, Employee 11, NA, stated range of motion exercises were sometimes completed while assisting residents with dressing and grooming. Employee 11 was unable to explain the physician-ordered restorative exercises, describe what was meant by exercises through all joints and planes, or explain the variation in documented treatment times. The RAI User's Manual specifies that movement occurring incidentally during dressing, bathing, or other routine care does not constitute a formal restorative nursing program.During an interview on July 30, 2026, at 9:30 AM, Employee 12, Occupational Therapist, stated physician-ordered active or passive range of motion exercises performed through all joints and planes would include the shoulders, elbows, wrists, and fingers for the upper extremities and the hips, knees, ankles, and toes for the lower extremities. The facility failed to consistently implement physician-ordered restorative nursing services for Resident 15. Clinical record review revealed that Resident 64 had a diagnosis of right-sided weakness. A review of Resident 64's quarterly MDS dated [DATE], revealed that Resident 64 was cognitively intact with a BIMS score of 15 a score of 13 through 15 indicates cognition is intact. Physician's orders for July 2026 directed staff to provide restorative nursing services to Resident 64 consisting of active and passive range of motion exercises to the right upper extremity and both lower extremities. The physician ordered three sets of 10 repetitions daily. During an interview on July 29, 2026, at 11:20 AM, Resident 64 stated staff were not providing restorative exercises and indicated a desire to participate in therapy to become stronger and improve the ability to return home. A review of the July 2026 restorative nursing documentation revealed active and passive range of motion exercises were documented as not applicable on July 1, July 3, July 7, July 8, July 23, and July 26, 2026. The clinical record contained no documentation explaining why the physician-ordered interventions were not completed. Review of the July 2026 restorative nursing documentation revealed treatment times ranging from five to 15 minutes without documentation explaining the variation in treatment duration. During an interview on July 30, 2026, at 9:05 AM, Employee 11, NA, stated range of motion exercises were sometimes completed while assisting residents with dressing and grooming. Employee 11 was unable to explain the physician-ordered restorative exercises, describe what was meant by exercises through all joints and planes, or explain the variation in documented treatment times. During an interview on July 30, 2026, at 9:30 AM, Employee 12, Occupational Therapist, stated physician-ordered active or passive range of motion exercises performed through all joints and planes would include the shoulders, elbows, wrists, and fingers for the upper extremities and the hips, knees, ankles, and toes for the lower extremities. During an interview on July 30, 2026, at 2:00 PM, the Director of Nursing was unable to provide evidence demonstrating that Residents 15 and 64 consistently received physician-ordered restorative nursing services or that nursing assistants had been instructed on how to perform the ordered restorative range of motion program in accordance with the physician's orders. The facility failed to consistently implement physician-ordered restorative nursing services for Residents 85, 15 and 64. 28 Pa. Code: 211.5(f) (ii) Medical records.28 Pa. Code: 211.10 (c) Resident care policies.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement, evaluate, and revise behavioral health interventions in response to persistent and escalating behavioral symptoms for one of 23 sampled residents reviewed for behavioral health services (Resident 63).Findings include: A review of the facility policy titled Behavioral Health Services, last reviewed by the facility on May 1, 2026, revealed it is facility policy to provide behavioral health services as needed to assist residents in attaining or maintaining their highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care, and staff must promote dignity, autonomy, privacy, socialization, and safety as appropriate for each resident and are trained in ways to support residents in distress. Clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses including bipolar disorder (a mental health disorder that causes episodes of significant changes in mood, energy, activity, and concentration), anxiety (a condition characterized by excessive fear, nervousness, or worry), and intellectual disability (a lifelong condition involving limitations in intellectual functioning and adaptive skills such as learning, reasoning, and problem solving). A review of Resident 63's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 4, 2026, revealed that Resident 63 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). Review of nursing documentation revealed a persistent pattern of escalating behavioral symptoms occurring on multiple shifts throughout the day and night. Documented behaviors included yelling, screaming, cursing, verbal aggression, physical aggression, throwing objects, destruction of property, threats toward staff, self-injurious behaviors, sexualized behaviors, refusal of care, and behaviors that disrupted other residents.The clinical record documented, in part, the following:On March 2, 2026, at 2:50 PM, Resident 63 pulled a needle from his arm during a blood draw, spit at and cursed the phlebotomist (a healthcare professional trained to obtain blood samples), yelled obscenities (offensive language), and threw personal belongings into the hallway. April 7, 2026, at 4:36 AM, the resident became resistive and combative with care and threw staff out of his room, threatening to punch them if they returned, and resident then began throwing items from his room out into the hallway, including a garbage can, remote control, call bell and bed control. April 7, 2026, at 8:11 AM, the resident's room was noted to be disarrayed (messy) with soiled briefs, linen, and cereal scattered throughout the floor. The resident cursed and threw multiple staff members out of the room and threw a fork at a staff member, a butter knife at another staff member, and then continued to throw meal lids and cups out into the hallway and was unable to redirect. Female residents and surrounding residents reported to the nurse that they were fearful of the man yelling and throwing things. April 7, 2026, at 9:22 AM, the resident threw more items across the hall into the adjacent room while cursing at staff and yelling obscenities and threatened to hit staff if they came into the room. April 7, 2026, at 1:47 AM, the resident entered his room and ripped the hand sanitizer drip tray off the wall and yelled obscenities to staff. April 7, 2026, at 4:30 PM, resident was noted with behaviors throughout the shift and was evaluated by behavioral health support and provided better coping skills, however shortly afterward the resident was noted to be throwing items in their room and smashing clock on the floor. April 7, 2026, at 10:28 PM, the resident was aggressive and yelling at staff and continued to throw items in the hall such as yogurt, utensils, cups, wall clock, and call bell, threatened to beat up staff, re-direction was ineffective and behaviors and threats continued. On April 8, 2026, at 11:24 AM, the resident ripped the call bell from the wall, threw objects throughout the room and into the hallway, struck another resident in the leg with a highlighter, threatened to kill a nurse by stating he would put his hands around the nurse's neck, and required staff to close the room door to protect other residents. On May 10, 2026, at 2:21 PM, the resident distributed sexually inappropriate notes to staff, threatened to kill a staff member, threw objects, and became increasingly agitated despite redirection. On May 13, 2026, at 5:30 PM, the Nursing Home Administrator (NHA) documented discussions with a case manager regarding possible hospital admission due to Resident 63's escalating behavioral symptoms. Later that day, on May 13, 2026, at 8:00 PM, nursing documentation revealed Resident 63 displayed unprovoked aggressive behaviors and made statements suggesting self-harm when staff approached to provide care. When staff asked whether the resident had a plan to harm himself, the resident did not respond, began yelling, and struck himself. Staff initiated one-to-one observation for resident safety. Documentation further revealed the resident screamed at staff, made sexually inappropriate gestures, and displayed an obscene hand gesture. When staff offered voluntary (willing) transfer to the hospital, the resident refused. The resident then became tearful, increasingly angry, and physically aggressive, throwing items from the bed onto the floor. The resident pulled the call bell from the wall and threw it across the room, then threw a knife that nearly entered the hallway. The resident repeatedly slapped himself and struck his head, chest, and upper thigh with closed fists and used a television remote to strike himself in the head. Staff documented the resident could not be calmed. A behavioral health crisis assessment was completed, and the evaluator recommended hospital transfer for inpatient psychiatric evaluation. A 302 (an involuntary emergency psychiatric commitment under Pennsylvania law) was initiated, and the resident was transferred to the hospital for further evaluation. On May 14, 2026, at 1:46 PM, the NHA documented the resident remained hospitalized for psychiatric concerns and noted discussions regarding the possibility of identifying an alternate placement upon the resident's discharge from the hospital. A review of outside hospital records provided by the facility, dated May 18, 2026, revealed Resident 63 presented to the hospital on May 13, 2026, for psychiatric evaluation following violent behaviors and statements expressing a desire to kill himself. Hospital documentation revealed the psychiatry service initially recommended involuntary psychiatric hospitalization through a 302 commitment. However, the resident experienced a decline in medical status requiring admission for medical treatment. After the resident's medical condition improved, psychiatry re-evaluated the resident and determined inpatient psychiatric hospitalization was no longer indicated. The resident was subsequently discharged from the hospital and returned to the skilled nursing facility on May 18, 2026. Following the resident's return from the hospital on May 18, 2026, the clinical record continued to document frequent and escalating behavioral symptoms despite implementation of behavioral interventions, including the following: May 23, 2026, at 11:23 AM the resident was yelling, cursing, striking himself with a television remote, and overturning furniture. On June 14, 2026, at 2:41 PM, Resident 63 became verbally aggressive toward housekeeping staff and refused to allow staff to enter the room. On June 15, 2026, at 2:56 PM, Resident 63 became impatient during care, yelled, screamed, swore, threw objects throughout the room, directed staff to leave the room, and refused care. On June 25, 2026, at 3:43 PM, nursing documentation revealed Resident 63 repeatedly yelled and threw objects throughout the room several times during the day after certain staff members and visitors walked past the room. On June 29, 2026, at 3:42 AM, Resident 63 stood in the hallway yelling profanities at staff, punched a nearby door while continuing to curse, and threatened a staff member by stating that the next time he would get them in the face. On June 30, 2026, at 12:55 PM, Resident 63 yelled and cursed at staff and threw objects throughout the room against the walls and bed. On July 1, 2026, at 11:11 PM, Resident 63 screamed and threw objects throughout the room. On July 3, 2026, at 8:15 PM, Resident 63 attempted to transfer independently despite requiring the assistance of two staff members, became verbally aggressive toward staff, and spit prescribed medications onto the floor. On July 4, 2026, at 6:41 PM, nursing staff notified the physician of Resident 63's continued verbal aggression, use of vulgar language, and spitting prescribed medications onto the floor. On July 9, 2026, at 10:02 AM, Resident 63 became agitated, yelled and cursed at staff, and pushed a bowl from the bedside tray table to the floor. On July 10, 2026, at 6:04 PM, Resident 63 threw a hand sanitizer dispenser at a staff member in the hallway. Staff redirected other residents away from Resident 63 to maintain their safety. Resident 63 then threw his hat toward staff and spit at staff members. Staff informed the resident that the behavior was inappropriate and instructed him to return to his room. The resident then repeatedly slapped his forehead and kicked the metal door endplate with his foot. On July 11, 2026, at 3:22 PM, Resident 63 exhibited increased behavioral symptoms by yelling and swearing at staff as they walked past the room, throwing objects throughout the room, and striking himself in the head with a television remote control. On July 13, 2026, at 10:25 AM, nursing documentation revealed Resident 63 exhibited constant mood swings throughout the shift, yelled and cursed at staff, and threw objects into the hallway. When staff attempted to intervene, the resident threw a coffee cup at staff, called staff inappropriate names, threatened to wrap the call bell around his neck, and was placed on one-to-one supervision. On July 17, 2026, at 3:28 PM, Resident 63 yelled and cursed at staff and threw objects throughout the room. On July 18, 2026, at 5:48 PM, Resident 63 approached the nurse while screaming and holding a cord, stating that someone had cut the cord to his refrigerator. On July 19, 2026, at 10:49 AM, staff observed Resident 63's room in disarray, with objects scattered across the floor and a large puddle of red liquid, water, and cereal on the floor. Although the resident initially agreed to allow staff to clean the room, he began yelling and throwing objects when staff entered. On July 19, 2026, at 12:30 PM, Resident 63 yelled at staff to leave the room, stated that a housekeeper had cut the cord to his refrigerator, and became belligerent (angry and aggressive). On July 19, 2026, at 2:00 PM, Resident 63's sister contacted the facility and expressed concerns regarding the resident's behaviors, stating she believed the resident might require inpatient psychiatric admission. On July 20, 2026, at 2:10 PM, a social worker contacted the behavioral health service regarding Resident 63's increased yelling, swearing, throwing objects throughout the room, negative comments toward staff, threats of self-harm, and other inappropriate statements and behaviors. On July 21, 2026, at 6:06 AM, Resident 63 threw objects throughout the room and pulled the call light from the wall. On July 21, 2026, at 7:10 AM, staff found Resident 63 lying on the floor in the middle of the room. When staff attempted to assist him, the resident yelled, cursed at staff, and ordered them to leave the room. After staff assisted the resident to a position of safety, he threw objects within reach across the room and toward the doorway. The resident then attempted to wrap the call bell around his neck. Staff immediately intervened, and one-to-one supervision was initiated. On July 21, 2026, at 8:54 AM, Resident 63 yelled obscenities, threw objects throughout the room, and overturned the bedside tray table. The resident repeatedly struck himself in the head with the bed control while the assigned one-to-one observer remained positioned outside the room to promote the safety of the resident and staff. Staff contacted the behavioral health service for further evaluation. On July 25, 2026, at 3:43 PM, Resident 63 cursed and threw objects throughout the room while alone. On July 27, 2026, at 11:48 AM, Resident 63 pulled the call bell from the wall and threw it toward the doorway. Staff documented trash cans, briefs, shredded paper, colored pencils, and crayons scattered throughout the room. The resident repeatedly struck his head and legs with the bed control. On July 29, 2026, at 2:44 PM, Resident 63 approached staff and stated he was upset because his sisters were afraid of him and wanted him to go to the hospital. On July 30, 2026, at 2:04 AM, Resident 63 yelled, threw objects within reach, spit at staff, and repeatedly ordered staff to leave the room. A review of the resident's care plan dated July 24, 2025, identified they were at risk related to the resident engaging in self-harm behaviors, had a problematic manner characterized by physical abuse, inappropriate behavior identified as by cursing at staff, hits self, throwing trays and cups, throwing objects at staff, physical abuse of staff and striking staff members while providing care, inappropriate public sexual behavior, and rejection of care due to anger and cognitive impairment. Resident 63's care plan directed staff to allow the resident to freely express feelings, leave the resident's door ajar to promote self-soothing and behavioral de-escalation, monitor and document behavioral triggers associated with potential self-injurious behaviors, position the resident in the lowest position when agitated, reinforce that inappropriate behaviors were unacceptable, leave the room and reapproach after five to ten minutes, and discourage the resident from throwing objects from the room into the hallway. However, review of the clinical record revealed a persistent pattern of escalating behavioral symptoms documented throughout April, May, June, and July 2026, including yelling, screaming, cursing, verbal threats, throwing objects, destruction of property, self-injurious behaviors, aggression toward staff, and behaviors that disrupted other residents and required repeated behavioral health evaluations, one-to-one supervision, and hospital transfer. Despite the resident's continued pattern of behavioral escalation while receiving the care-planned behavioral interventions, the clinical record did not demonstrate the interdisciplinary team evaluated the effectiveness of those interventions or revised the comprehensive care plan in response to the resident's changing behavioral needs. During an interview on July 31, 2026, at 1:00 PM, the Nursing Home Administrator (NHA) was unable to provide evidence the interdisciplinary team evaluated the effectiveness of the resident's existing behavioral interventions, including allowing the resident to self-soothe, monitoring behavioral triggers, reapproaching the resident after periods of agitation, and discouraging the resident from throwing objects into the hallway, or revised the resident's behavioral care plan in response to the persistent pattern of escalating behaviors documented throughout April, May, June, and July 2026, despite repeated behavioral health evaluations, physician notification, one-to-one supervision, and psychiatric hospitalization. Refer to F610.28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services.28 Pa. Code 211.10(a) Resident care policies.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined that the facility failed to implement physician-ordered Enhanced Barrier Precautions and failed to maintain appropriate infection prevention and control practices for one resident (Resident 109) with an indwelling urinary Foley catheter out of 23 residents reviewed. Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on May 1, 2026, indicated enhanced barrier precautions (EBPs) are infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organism (MDRO's, bacteria that are resistant to multiple antibiotics) during high contact resident care activities. EBPs apply when: a resident is infected or colonized with a MDRO but does not have a wound or indwelling medical device and does not have secretions or excretions that cannot be covered or contained; a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. The policy stated indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheotomies. The policy required signage to be posted outside the resident's room identifying the required precautions and the personal protective equipment (PPE, specialized clothing or equipment worn to reduce exposure to infectious organisms) to be used before providing care. A clinical record review revealed Resident 109 was admitted to the facility on [DATE], with diagnoses including an unstageable pressure ulcer of the sacral region (severe full-thickness skin and tissue loss at the tailbone area at the base of the spine. The true depth cannot be measured because the wound bed is completely covered by thick, dead tissue), and osteomyelitis of the vertebra, sacral and sacrococcygeal region (a serious bacterial or fungal infection and inflammation of the bone and bone marrow at the base of the spine, specifically involving the sacrum and tailbone. It often develops when a pressure ulcer breaks the skin or when an infection spreads through the blood). Nursing documentation dated June 8, 2026, at 3:57 PM documented Resident 109 was admitted with an indwelling Foley catheter (a flexible tube inserted through the urinary opening and into the bladder to drain urine into a drainage bag) and a Stage IV sacral pressure ulcer (a full-thickness pressure injury with exposed muscle, tendon, or bone). A physician's order July 20, 2026, indicated Resident 109 required enhanced barrier precautions due to the presence of a Foley catheter and wounds. Observations conducted on July 28, 2026, at 10:40 AM and July 29, 2026, at 10:08 AM revealed no Enhanced Barrier Precautions signage was posted outside Resident 109's room and no instructions identified the required PPE before entering the room, contrary to the physician's order and facility policy. During these observations, Resident 109 was resting in bed, and the Foley catheter drainage bag was lying directly on the floor on its side rather than being maintained off the floor, creating the potential for contamination of the urinary drainage system. During an interview on July 29, 2026, at 10:08 AM, Employee 4, Nurse Aide, confirmed the Foley catheter drainage bag was lying directly on the floor. During an interview on July 29, 2026, at 10:22 AM, Employee 5, Registered Nurse Supervisor, confirmed Resident 109 required Enhanced Barrier Precautions because of the Foley catheter and wounds and acknowledged the required precaution signage was not posted outside the resident's room. During an interview on July 30, 2026, at 1:55 PM, the Nursing Home Administrator acknowledged Resident 109 required Enhanced Barrier Precautions, confirmed the required signage was not in place, acknowledged the Foley catheter drainage bag had been left on the floor, and stated the facility is responsible for implementing infection prevention and control practices to reduce the risk of infection. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c )(d)(1)(5) Nursing services.

Based on a review of clinical records, employee records, the facility assessment, facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program, based on the facility assessment, to ensure licensed nursing staff demonstrated the knowledge, skills, and documented competencies necessary to provide care for a resident with a peripherally inserted central catheter (PICC) line for one of 23 residents reviewed (Resident 6). Findings included: Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The training program must be based on the facility assessment and designed to ensure staff possess the knowledge and competencies necessary to care for residents according to their assessed needs and care plans. Pennsylvania State Board of Nursing Regulations (49 Pa. Code Chapter 21) require Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) who perform intravenous therapy, including central venous catheter care, to complete Board-approved education, receive supervised clinical instruction, and demonstrate competency. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision. A review of the facility assessment section titled Resident Acuity Affecting Licensed Nurses revealed the facility routinely cared for an average of three residents receiving high-risk intravenous or intramuscular medications or infusions. The facility assessment further indicated staff would receive education consistent with their assigned responsibilities and that staff competencies and skill sets necessary to meet resident needs would be identified. A clinical record review revealed Resident 6 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis (an infection of the bone). A physician's order dated June 24, 2026, directed the maintenance of a peripherally inserted central catheter (PICC a long, thin, flexible tube inserted into a vein in the upper arm and advanced into a large vein near the heart for the administration of medications and other therapies) with instructions to monitor the catheter insertion site each shift for signs and symptoms of infection or infiltration (the unintended leakage of IV fluid or medication into the surrounding tissue). A physician's order dated July 14, 2026, directed Vancomycin (antibiotic) Intravenous Solution 1,000 milligrams (mg) to be administered intravenously once daily for treatment of osteomyelitis. A review of the July 2026 Medication Administration Record (MAR) revealed Employee 8, LPN, documented administering Vancomycin Intravenous Solution 1,000 mg through the PICC line on July 20, 2026, at 4:00 PM. The July 2026 MAR revealed Employee 9, LPN, documented administering Vancomycin Intravenous Solution 1,000 mg through the PICC line on July 21, 2026, at 4:00 PM, and again on July 28, 2026, at 4:00 PM. A review of employee records revealed Employee 8 was hired on February 16, 2026, and Employee 9 was hired on June 30, 2026. The employee files contained no documented competency assessment or validation demonstrating either employee had completed competency requirements related to PICC line management, maintenance of central venous catheter patency (keeping the catheter open and functioning properly), or administration of medications through a central venous catheter. Additionally, the competency documentation section designated for recording completion dates contained no entries for either employee. During an interview conducted on July 31, 2026, at 9:45 AM, the findings were reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA and DON were unable to provide documentation demonstrating that Employees 8 or 9 had completed competency validation for PICC line management or intravenous medication administration through a PICC line before providing care to Resident 6. The facility did not provide evidence demonstrating it had developed, implemented, and maintained an effective training program, based on its facility assessment, to ensure licensed nursing staff possessed the documented knowledge, skills, and competencies necessary to provide specialized PICC line care before assigning Employees 8 and 9 to administer intravenous medications through Resident 6's PICC line. 28 Pa. Code 201.20(a) Staff development.28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to failed to promptly notify the attending physician of a significant change in condition for one out of three closed records reviewed (Resident 107). Findings include: A review of the facility policy titled Change in a Resident's Condition or Status, last reviewed by the facility on May 1, 2026, revealed it is the facility's policy to promptly notify the attending physician of changes in the resident's medical condition or status. The policy indicates the nurse will notify the resident's attending physician or physician on call when there has been a refusal of treatment or medication two or more consecutive times, or a significant change in the resident's physical condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing clinical interventions and impacts more than one area of the resident's health status. A clinical record review revealed Resident 107 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs) and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 26, 2026, revealed that Resident 107 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' progress note dated June 30, 2026, at 10:25 AM revealed Resident 107 was seen for weight gain and increasing oxygen requirement. The note indicated Resident 107 refused his intramuscular diuretic (a medication that makes the body produce more urine, helping to clear out extra salt and water) this morning but did take it yesterday. He has lost 0.5 lbs since Sunday. Resident 107 continues to refuse to go to the hospital or change his code status. New orders to increase resident oxygen to 5.0 liters per minute (L/min). A progress note dated June 30, 2026, at 10:56 AM revealed the physician is aware the resident refused intramuscular diuretic medication. New order to increase oral furosemide to 80 mg and oxygen to 5.0 L/min. A physician's order for furosemide oral tablet with the direction to give 80 mg by mouth two times a day was initiated on June 30, 2026. A physician's order for oxygen at 5.0 L/min by way of nasal cannula as needed for shortness of breath initiated on June 30, 2026. A progress note dated June 30, 2026, at 5:58 PM indicated Resident 107 refused furosemide 80 mg oral tablet. A review of Resident 107's blood oxygen saturation (the percentage of red blood cells carrying oxygen through your body; a measure of 95% to 100% is normal, a measure below 90% means the body's organs and tissues are not getting enough oxygen to work properly) vital records from June 1, 2026, through June 29, 2026, revealed the resident average blood oxygenation on room air or while receiving oxygen was 95%. A review of Resident 107's blood oxygen saturation (a measure of 95% to 100% is normal; a measure below 90% means the body's organs and tissues are not getting enough oxygen to work properly) revealed that on: June 30, 2026, at 4:39 AM, 87.0% with oxygen via nasal cannula.June 30, 2026, at 8:34 AM, 89.0% with oxygen via nasal cannula.June 30, 2026, at 10:02 AM, 89.0% with oxygen via nasal cannula.June 30, 2026, at 9:49 PM, 88.0% with oxygen via nasal cannula.July 1, 2026, at 12:06 AM, 88.0% with oxygen via nasal cannula. A clinical record review revealed no documented evidence the facility notified the physician of Resident 107's refusal to take another diuretic medication (furosemide 80 mg) on July 30, 2026, at 5:58 PM. There was no documented evidence the facility notified the physician of the resident's continued low blood oxygen saturation despite the increase of oxygen to 5.0 L/min on June 30, 2026, or July 1, 2026. A progress note dated July 1, 2026, at 5:30 AM documented Resident 107 was found unresponsive. Review of the clinical record revealed no documented evidence the physician had been notified after the resident continued to demonstrate oxygen saturation levels between 87% and 89% despite the increased oxygen order or after the resident refused the newly prescribed oral furosemide. During an interview on July 31, 2026, at 9:45 AM, the Nursing Home Administrator and Director of Nursing reviewed the above findings. The clinical record contained no documented evidence the facility notified the physician after Resident 107 refused the newly prescribed oral furosemide or after the resident continued to exhibit oxygen saturation levels of 87% to 89% despite implementation of the physician's revised oxygen order. The facility failed to promptly notify the physician of the resident's continued change in condition in accordance with facility policy. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, the facility's Abuse Policy, documentation provided by the facility, observations, and staff and resident interviews, it was determined that the facility failed to conduct a thorough internal investigation after receiving an allegation of possible misappropriation of resident property for one of 23 residents reviewed (Resident 63). Findings include: A review of the facility policy titled Abuse Policy, last reviewed by the facility on May 1, 2026, revealed it is facility policy that the facility will have processes in place to include screening, training, prevention identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The policy required all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source, or a reasonable suspicion of a crime shall be promptly reported to local, state, and federal agencies as defined by current regulations and thoroughly investigated by the administrator and/or designee. Investigations should be timely and thorough and include investigations into all reports and allegations of abuse. If the investigation revealed findings of abuse, such findings will be reported to the state abuse registry. If the investigation revealed that the allegations of abuse are founded, the employees may have disciplinary action up to and including termination taken. The resident and/or representative may be notified of the outcome upon conclusion of the investigation. A clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety (a mental condition that causes a felling of worry, nervousness or unease), and intellectual disability (a lifelong condition marked by limits in functioning and adaptive behavior such as trouble with learning, reasoning, and solving problems. A review of Resident 63's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 4, 2026, revealed that Resident 63 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 a nurse's progress note dated July 18, 2026, at 5:48 PM documented that Resident 63 approached the nurses' station carrying the electrical cord from the resident's personal refrigerator. The note documented that the cord had been cut in two places. The resident stated someone had entered the room and cut the cord, demanded that someone be held responsible, and stated the resident intended to contact law enforcement and a family member. The nurse documented that the resident's sister was notified and that the Nursing Home Administrator and Director of Nursing were informed. Maintenance was contacted to respond. A witness statement completed by Employee 6, Registered Nurse, dated July 18, 2026, documented that Resident 63 reported someone had cut the refrigerator cord and stated someone owed the resident a new refrigerator. A review of a nurse progress note from Employee 7, Licensed Practical Nurse, dated July 19, 2026, at 12:30 PM, documented that Resident 63 alleged a housekeeper cut the refrigerator cord. Employee 7 documented that housekeeping staff did not work during the time identified by the resident. The resident then became belligerent (angry and verbally aggressive) and yelled obscenities (offensive language). During an interview on July 28, 2026, at 11:30 AM Resident 63 stated someone had cut the refrigerator cord but did not know who damaged it or how it occurred. Observation at the time of the interview revealed the resident's personal refrigerator remained in the room with the electrical cord cut completely at one location and partially cut at a second location. The refrigerator was not operational. During an interview on July 29, 2026, at 12:00 PM, the Nursing Home Administrator and Director of Nursing confirmed they did not know how the cord was cut, who cut it, why it was cut, or the location of the severed portion of the cord until surveyor inquiry prompted additional discussion. The Nursing Home Administrator then stated the Maintenance Director possessed the severed portion of the cord. During an interview on July 30, 2026, at 1:00 PM, Employee 10, Maintenance Director, stated Employee 6 contacted him on July 18, 2026, at approximately 5:21 PM to report that Resident 63's refrigerator cord had been cut and that electrical power had been lost to rooms [ROOM NUMBER]. The Maintenance Director stated he responded to the facility, restored electrical service by resetting the circuit breaker, spoke with Resident 63, and was told the resident had been moving the refrigerator when the cord became damaged. The Maintenance Director stated he later located the severed portion of the electrical cord concealed in the resident's room and removed it because it presented a safety hazard. During an interview on July 30, 2026, at 2:00 PM, the Nursing Home Administrator confirmed the facility could not provide documentation demonstrating that it completed a comprehensive investigation into the resident's allegation. The Nursing Home Administrator confirmed the facility did not provide documentation demonstrating that it: obtained a statement from Resident 63;obtained a statement from the Maintenance Director;identified and interviewed all relevant witnesses;documented review of staff assignments or other relevant investigative information;completed a written investigative summary; ordocumented investigative findings or a conclusion regarding the allegation. The facility produced nine employee witness statements; however, documentation demonstrating completion of the remaining investigative activities was not available. During a follow-up interview on July 31, 2026, at 2:00 PM, the Nursing Home Administrator again confirmed the facility could not provide documentation demonstrating that all relevant witnesses were interviewed or that the allegation was fully investigated in accordance with the facility's Abuse Policy. Cross Refer F740 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2) Management.28 Pa. Code 211.10(a) Resident care policies.

Based on review of select facility policy, Resident Council meeting minutes, grievance logs, and resident and staff interviews, it was determined the facility failed to thoroughly investigate a grievance, ensure prompt, ongoing efforts to resolve a grievance, provide timely status updates regarding the grievance resolution progress, and closed the grievance as resolved without providing a written decision or follow-up to the residents while the residents continued to experience severe delays in care for three of seven residents reviewed (Residents 2, 3, and 4).Findings include: A review of the facility's policy titled Grievance Policy last reviewed by the facility on May 1, 2026, indicated that residents have the right to prompt efforts to resolve grievances. The reasonable timeframe the resident can expect a completed review of the grievance is within 5 to 7 business days. The Grievance Official will be responsible to oversee the grievance process, receive and track grievances through their conclusion, lead any investigations by the facility, issue written grievance decisions to the resident, and take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. The Grievance Official shall ensure all written grievance decisions include: the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Review of Resident Council meeting minutes dated March 31, 2026, revealed five residents complained about call bells not being answered timely. A grievance form was filed on behalf of the residents and submitted to the proper departments. Review of the Resident Council meeting minutes dated May 26, 2026, revealed three residents, Residents 2, 3, and 4, reported that their call bells were still not answered in a timely manner. All three residents were cognitively intact with a BIMS score between 13-15 (Brief Interview for Mental Status, a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). A grievance was filed on their behalf. Review of the facility's grievance logs from May through June 2026 revealed four grievances filed regarding call bell response times, all marked as resolved. A specific review of the grievance filed on behalf of Residents 2, 3, and 4, dated May 26, 2026, indicated the steps taken to investigate the grievance: Random call bell audits will be completed. Summary of the pertinent findings or conclusions regarding the resident's concerns: Random call bell audits will be completed to ensure they're answered in an appropriate amount of time. The grievance substantiation was marked as not confirmed. Corrective action taken or to be taken by the facility as a result of the grievance: Will continue random call bell audits to improve waiting time. The resolution of the grievance was dated June 1, 2026. There was no documented evidence the facility actively investigated the grievance, interviewed the affected residents, or provided a written decision or follow-up conversation to the residents prior to closing the file on June 1, 2026.During consecutive interviews conducted on June 16, 2026, residents confirmed facility failed to make good faith efforts to investigate or resolve their concerns.During an interview on June 16, 2026, at 12:35 PM, Resident 2 stated that since the May 26, 2026, meeting, no staff member had approached her regarding her call bell complaint. She stated she still waits a long time, sometimes up to an hour noting it happens more on the later shifts, and confirmed there has been no resolution. During an interview on June 16, 2026, at 1:00 PM, Resident 3 reported zero follow-up from the facility regarding her compliant reported during the Resident Council meeting in May. She stated the facility never interviewed her to gather additional details regarding long wait times. She expressed frustration, stating that a few days prior, she, rang the bell from 9:30 AM to 12:15 PM and not a single soul come in here, leaving her feeling uncomfortable with her care.During an interview on June 16, 2026, at 1:45 PM, Resident 4 reported she continues to wait one hour or more for her call bell, stating, I'm tired of peeing in my clothes. She noted that the wait times are significantly longer during the second shift. She confirmed no one from administration had interviewed her or provided a status update regarding the May Resident Council meeting. During an interview on June 16, 2026, at 2:15 PM the Nursing Home Administrator (NHA) was unable to provide evidence of prompt, good faith efforts to investigate or resolve the residents grievance, nor could the NHA provide evidence that the residents were kept appropriately apprised of the resolution progress. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.10 (c) Resident care policies.

Based on observations and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for two out of two nursing units (Units East and West). Findings include:An observation on May 13, 2026, at 10:04 AM in resident room [ROOM NUMBER] revealed grey circular discolorations, dirt accumulation, and floor stains in front of the room entrance and bathroom. An observation on May 13, 2026, at 10:06 AM in resident room [ROOM NUMBER] revealed small grey circular discolorations and floor stains in front of the room's entrance, the bathroom's entrance, and around the bathroom commode. An observation on May 13, 2026, at 10:10 AM in resident room [ROOM NUMBER] revealed a garbage can with a folded plastic liner on the bottom of the can, which was not properly inserted into the garbage to properly contain refuse. Inside the garbage can was an empty soda bottle, a cup, and several devices utilized to clean intravenous (IV) sites. An observation on May 13, 2026, at 10:10 AM in resident room [ROOM NUMBER] revealed a bedside chair with an unfolded blanket placed on the seating surface, two pillows without pillow covers, a wheelchair with leg rests, a lifting harness, and seating devices placed on the wheelchair in front of cabinetry inhibiting access. An observation of resident room [ROOM NUMBER]'s bathroom revealed a urinal on the back of the toilet and a bedpan on the floor by the commode. The flooring inside the bathroom was spotted with debris and in need of cleaning. An observation on May 13, 2026, at 10:15 AM in resident room [ROOM NUMBER] revealed the bedside table with tan liquid stains on the white bed sheets and pillowcase. A blue disposable glove and white toilet paper pieces measuring 10 inches were observed under the resident's window-side bed. A clear plastic glove was observed on the floor in front of the garbage can. Dirt and debris pieces were around the garbage can. Gray circular discolorations and stains were observed on the floor near the door-side bed. An observation on May 13, 2026, at 10:24 AM in the East Unit Kitchen revealed a tile floor with a build-up of dirt, debris, and grime underneath the dishwashing station and extending 5 feet. A white PVC pipe with sediment and dirt stains. A plunger was observed underneath the stainless steel table to the right of the dishwashing sink. An observation on May 13, 2026, at 10:40 AM in resident room [ROOM NUMBER] revealed the window-side bed with tan linen stains and discolorations. Three clear urine graduates and a blue catch basin were on the floor near the commode, strewn on top of each other. The items were directly on the floor and not identified with resident names. An observation on May 13, 2026, at 10:49 AM in resident room [ROOM NUMBER] revealed a clear urine graduate container on the bathroom floor adjacent to the commode and a pink catch basin on the floor under the bathroom sink. The urine graduate container and catch basin were not identified with resident names. An observation on May 13, 2026, at 11:30 AM in resident room [ROOM NUMBER] revealed yellow and tan stains on the door-side bed linens. During an interview on May 13, 2026, at 1:00 PM, the above findings were reviewed with the nursing home administrator (NHA). The facility failed to provide services to maintain a clean and homelike environment for residents throughout the facility. 28 Pa. Code 201.18 (e)(1)(2.1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on clinical record review, grievance form review, and staff interview, it was determined that the facility failed to timely inform and update an interested family member regarding changes in condition, ongoing assessments, and changes in treatment for one of nine residents reviewed (Resident 1).Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of spinal stenosis (narrowing between the spaces between the spines, putting pressure on the nerves causing pain in arms and legs) and kidney disease. A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 20, 2026, revealed that Resident 1 is cognitively intact with a BIMS score of 13 (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). The clinical record identified the resident's daughter as an interested family member involved in the resident's care and well-being. Review of a nurse's note dated March 23, 2026, at 3:51 PM, revealed the resident was prescribed a new medication for elevated blood glucose (blood sugar) levels. Review of the clinical record failed to provide evidence that the interested family member was timely notified of the medication change. Review of a grievance form dated April 22, 2026, revealed the facility received a verbal grievance from the interested family member expressing concern that a medication affecting the resident's blood glucose levels had been prescribed without timely notification to the family. The grievance documentation indicated the facility would notify the interested family member of changes by telephone.Review of a nurse's note dated March 24, 2026, at 9:08 PM, revealed the resident's pain medication, Oxycodone, was increased from 2.5 milligrams to 5 milligrams as needed for back pain. Review of the clinical record failed to provide evidence that the interested family member was notified of the medication adjustment. Review of a nurse's note dated March 31, 2026, at 9:38 PM, revealed the resident had not voided (urinated) during the 7:00 AM to 3:00 PM shift or during the 3:00 PM to 11:00 PM shift. The note indicated that the resident's daughter was notified at 9:38 PM and that staff planned to administer 500 milliliters of fluid and reassess the resident's urinary status in six hours. Review of a nurse's note dated April 1, 2026, at 2:30 AM, revealed the resident continued not to void. A subsequent nurse's note dated April 1, 2026, at 6:06 AM, indicated staff had still not accounted for any urinary output. Review of both nurse's notes failed to provide evidence that the interested family member was updated regarding the resident's continued change in condition and ongoing assessment. Review of a diagnostic study report for a KUB (Kidney, Ureter, and Bladder) examination revealed the results were available on April 21, 2026, at 2:50 PM. Review of a nurse's note revealed the interested family member was not informed of the diagnostic study results until April 22, 2026, at 8:09 AM. During an interview on May 13, 2026, at 1:30 PM, the Nursing Home Administrator was unable to provide evidence that the facility timely informed or updated the interested family member regarding the resident's status changes, ongoing assessments, diagnostic results, or medication adjustments. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for two out of two nursing units (West and East Units), including experiences reported by one out of twenty-two residents sampled (Resident 43).Findings include: A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and paraplegia (a condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 14, 2025, revealed that Resident 43 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Observations on September 16, 2025, at 9:15 AM and September 19, 2025, at 9:30 AM in the Short Hall of the East Nursing Unit revealed the outer surface of the ice machine and the floor area surrounding the ice machine were visibly soiled. The wall fabric on the opposite wall of where the ice machine was located was stained and discolored. The vinyl baseboard molding was wavy and in need of repair. Observations on September 16, 2025, at 9:20 AM, 9:45 AM, and 12:20 PM, and on September 18, 2025, at 11:45 PM revealed a strong urine like odor in the Short Hall of the East Nursing Unit between Resident room [ROOM NUMBER] and the kitchen. An observation on September 16, 2025, at 10:50 AM of resident room [ROOM NUMBER] revealed the floors had a sticky and tacky feel. The room and hallway outside the room had a foul odor. An observation on September 16, 2025, at 10:52 AM of the bathroom between resident room [ROOM NUMBER] and #216 revealed a large soiled brief in the bathroom sink. During an interview on September 16, 2025, at 11:15 AM, Resident 43 indicated that last week she had a bowel movement when in her wheelchair. She explained that staff cleaned it up but missed areas of her wheelchair, and it upsets her that her chair is not clean. An observation following the interview on September 16, 2025, at 11:20 AM revealed Resident 43's wheelchair was in her room. The wheelchair back support was observed with a rip in the fabric forming a pocket. Inside the ripped fabric was a thick brown and black residue lining the pocket walls and base. An observation on September 18, 2025, at 12:15 PM in the resident dining/activity area located in the [NAME] Nursing Unit revealed a buildup of cobwebs behind the counter located next to the refrigerator. During an interview on September 19, 2025, at 10:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to provide services to maintain a clean and homelike environment for all residents living at the facility. 28 Pa. Code 201.18 (e)(1)(2.1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of scheduled activities and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents including experiences expressed by four out of five residents during a resident group interview (Residents 7, 8, 26, and 37).Findings include: During a resident group interview on September 17, 2025, at 10:00 AM, four out of five residents raised concerns that there were not enough evening activities available to meet their interests. Resident 8 explained that in the past, there were activities after dinner like a recreation card club that he participated in and enjoyed. He indicated there are no activities in the evening now and he would like to see them return. During the resident group interview Residents 7 and 26 explained they would like to have arts and craft activities offered in the evening after dinner. They indicated that currently there is not much to do in the evening and would like to have evening activities a few days a week. Resident 7 also indicated that she would like to have a movie night and bingo in the evening. Resident 37 indicated that he would like evening activities; however, he did not specify the type of activities that met his interests. A review of the Resident Activity Calendar, dated September 2025, revealed the latest activity is scheduled at 2:00 PM each day from September 1, 2025, through September 30, 2025. During an interview on September 17, 2025, at 11:30 AM, Employee 6, Director of Activities confirmed the facility did not currently have any scheduled workers facilitating programs in the evenings. Employee 6, Director of Activities, explained that residents have mentioned that they would like to have evening activities, but the facility has not been able to hire additional staff for evening activities. During an interview on September 19, 2025, at 9:15 AM the Nursing Home Administrator confirmed the facility did not currently offer structured evening activities for residents. The facility failed to provide an ongoing schedule of activities that support the physical, mental, and psychosocial well-being of residents by not providing activity that meets the needs and interests of residents, specifically evening activities. 28 Pa. Code 202.18 (b)(3)(e)(6) Management.

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and one of two resident pantry areas (West Nursing Unit). 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).Observation on September 16, 2025, at 9:20 AM during the initial tour of the food and nutrition services department conducted with the foodservice director revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:There was a three-quarter inch hole in the wall grout located to the right of the handwashing sink. The floors area along the perimeter of the kitchen and under the tray line counter area in the kitchen had a build-up of dirt and debris. Observation on September 18, 2025, at 12:15 PM of the resident pantry area located on the [NAME] Nursing Unit revealed two four-ounce containers of applesauce, two four-ounce containers of canned pears, and two covered eight-ounce glasses of milk which were not dated when available for use. Interview with the food service director (FSD) on September 19, 2025, at 9:40 AM confirmed the food and nutrition services department was to be maintained in a sanitary manner and confirmed food items were to be dated to ensure quality and food safety to prevent opportunities for foodborne illness.28 Pa Code 211.6(f) Dietary services. 28 Pa Code 210.18 (e) (2.1) Management.

Based on review of clinical records, resident fund account information, facility admission documents, and staff and resident interviews, it was determined that the facility failed to protect the resident's personal funds by imposing charges against a resident's personal needs allowance (PNA) for a service for which payment is made under Medicaid for one of 22 sampled residents (Resident 7). Findings include: A review of the facility admission document titled Admissions Notice Packet revealed residents will pay the established Medicaid rate. The residents will be required to make payments towards the cost of care. The payment towards the cost of care is determined after allowing certain deductions. One such deduction is the monthly personal needs allowance (PNA the amount of a Medicaid recipient's monthly income they can keep for personal expenses in a nursing home or other long-term care facility. This money is not used to pay for their care and can be spent on items and services not covered by Medicaid, such as personal hygiene items, social activities, snacks, or gifts. The PNA amount varies significantly by state and is intended to allow residents to purchase extras to enhance their quality of life). The PNA is intended to allow residents to purchase non-covered items or services, such as toiletries, snacks, or gifts. As of January 1, 2025, the PNA for Pennsylvania residents is $60.00 per month. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it difficult to breathe). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 16, 2025, revealed that Resident 7 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of Resident 7's Medicaid benefit determination from the Pennsylvania Department of Human Services Office of Income Maintenance dated April 30, 2025, revealed Resident 7's total monthly income is $1,006.01. Her monthly payment towards the cost of care is this amount minus her personal needs allowance (as of January 1, 2025, the PNA is $60.00 for residents of Pennsylvania). Resident 7's liability for the cost of care each month was determined to be $946.01 as of April 30, 2025. During an interview on September 16, 2025, at 12:50 PM, Resident 7 reported she was upset that the facility charged her an additional $20.00 each month from her PNA. She stated she was told by the facility business office that the charge was to pay off her debt to the facility. She explained that at the beginning of her stay she maintained financial obligations to both the facility and her home in the community, which led to unpaid balances owed to the facility. An interview with Employee 5, the Business Office Manager (BOM), on September 18, 2025, at 11:00 AM confirmed Resident 7 accrued debt due to unpaid care charges. Employee 5 stated that in 2023, the facility became Resident 7's representative payee (a person or entity designated to manage a resident's Social Security or Supplemental Security Income benefits). Employee 5 stated Resident 7 agreed to pay an additional $20.00 monthly from her funds to reduce the debt. A facility-provided form titled Payment Agreement, dated October 5, 2023, revealed Resident 7 would pay $20.00 monthly until her balance was paid in full. The document included a clause stating, my failure to make payments without notification to the business office may result in further collection action. The document was signed by Resident 7. A review of Resident 7's financial account from October 5, 2023, through September 17, 2025, revealed the facility deducted $20.00 monthly from her PNA on 23 occasions, totaling $460.00. The account also reflected two additional debits of $35.00 each in January 2025, labeled as care cost payment, with unclear origin dated January 7, 2025, and January 14, 2025. During an interview on September 19, 2025, at 9:30 AM, the Nursing Home Administrator (NHA) confirmed the facility deducted an additional $20.00 each month from Resident 7's PNA since 2023. The NHA stated that while Resident 7 signed the payment agreement, the facility had no documented evidence to show that Resident 7 was informed she was not obligated to pay her outstanding balance from her PNA funds. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on observation, a review of clinical records and staff interviews, it was determined that the facility failed to develop a person-centered care plan to address a resident's limited range of motion to the left upper extremity and non-compliance with a therapeutic device to maintain skin integrity and prevent worsening range of motion for one resident out of 22 sampled (Resident 44). Findings include:A clinical record review revealed that Resident 44 was admitted to the facility on [DATE], with diagnoses that included cerebrovascular accident (stroke) and depression. A review of a quarterly Minimum Data Set assessment (MDS -a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 15, 2025, indicated the resident had a BIMS (brief interview mental screening tool used to screen and identify cognitive impairment) score of 12 (8 to 12 indicates moderate cognitive impairment) and impairment of the upper extremity (shoulder, elbow, wrist, hand) on one side. A physician order dated June 18, 2024, noted an order for soft palm roll (therapeutic device, cylinder or cushion used to prevent and treat a hand contracture which is a condition where the muscles, tendons, or other tissues in the hand tighten and shorten, causing one or more fingers to be permanently bent or pulled towards the palm, making it difficult to straighten the fingers) to the left hand at all times and may remove for range of motion, hygiene, and skin checks. An Occupational Therapy Discharge Summary (for therapy dates June 7, 2024, through June 28, 2024) dated July 1, 2025, noted the occupational therapist (OT) placed a soft roll to the resident's left hand to maintain skin integrity and prevent further issues. The OT noted the resident had an impaired grasp of the left hand, maintained the left hand in a fisted/flexed position, and was not compliant with therapy. Discharge recommendations included to continue the left hand soft palm roll and bilateral upper extremity passive range of motion three sets with 10 repetitions each all joints/planes once daily as tolerated. An observation of Resident 44 on September 18, 2025, at 9:20 AM revealed the resident was in bed without the soft palm roll in the left hand. The soft palm roll was lying on the left side of the bed next to the resident. The resident did not answer when asked why she was not wearing the soft palm roll. An interview with Employee 1 (LPN) on September 19, 2025, at 10:00 AM confirmed that Resident 44 is frequently non-compliant with care. Employee 1 (LPN) confirmed that Resident 44 can use her right hand to remove the soft palm roll after it is placed by staff to the resident's left hand. An observation with the director of nursing (DON) of Resident 44 on September 19, 2025, at 12:00 PM revealed the soft palm roll was on the left side of the bed next to the resident. During an interview with Resident 44 at this time the resident refused to allow the DON to reposition the soft palm roll on her hand. Resident 44 held her hand in a fisted position and would not answer if she had the ability to open and close her hand.Review of the resident's care plan initially dated April 20, 2021, did not address Resident 44's concern with limited range of motion of the left hand and non-compliance with wearing soft palm roll to the left hand. During an interview on September 19, 2025, at 11:00 AM the Nursing Home Administrator (NHA) failed to provide documented evidence the facility developed a plan of care to address Resident 44's limited range of motion to the left hand and non-compliance with wearing the physician prescribed soft palm roll to maintain skin integrity and prevent a further range of motion decline to the resident's left hand. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to obtain physician orders and develop and implement a person-centered comprehensive care plan in accordance with standards of practice for one resident out of 22 sampled residents (Resident 15). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: AssessmentsClinical problemsCommunications with other health care professionals regarding the patientCommunication with and education of the patient, family, and the patient's designated support person. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and hypertension (blood pressure that is higher than normal). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 31, 2025, revealed that Resident 15 had moderately impaired cognition with a BIMS score of 12 (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 8-12 indicates cognition is moderately impaired). A review of Resident 15's clinical record revealed a physician's order, dated August 25, 2025, for Eliquis (a blood thinner), 5 milligrams (mg), one tablet every morning and at bedtime related to atrial fibrillation. A review of a nurse's progress note dated September 1, 2025, at 10:05 AM, revealed that Resident 15 was experiencing uncontrollable bleeding from the bilateral nares (nostrils). Further review of the note revealed the resident's morning dose of Eliquis was held due to the bleeding, and the resident was transferred to a local emergency room for evaluation and treatment. A review of a nurse's progress note dated September 1, 2025, at 4:30 PM, revealed a report from the emergency room that stated that dissolvable fibrinogen (a protein that is made by the liver that is essential for blood clotting) was placed in the resident's nares, and if bleeding were to occur, then apply ice and hold the pressure for ten minutes. Further review revealed that if Resident 15 was still bleeding, repeat the process and check for bleeding, and if bleeding was to still occur after two rounds of ice and pressure, then return the resident to the emergency department. A review of a nurse progress note dated September 1, 2025, at 6:15 PM, revealed that Resident 15's nose was dripping blood, and it was noted that a small amount of the fibrinogen was in the left nostril and none in the right nostril and Resident 15 was refusing ice and pressure and was sent back to the emergency room for evaluation and treatment. A review of a nurse's progress note dated September 1, 2025, at 7:50 PM, revealed they received a report from the emergency room nurse, and it was advised for Resident 15 to see an ENT (a medical specialist who is focused on the ears, nose, and throat). A review of a nurse's progress note dated September 3, 2025, at 7:49 PM, revealed that Resident 15 was experiencing a lot of bleeding from the nose, despite efforts that included holding pressure and applying ice, and the resident was sent to the emergency room for evaluation and treatment. A review of emergency room department discharge instructions for Resident 15 dated September 3, 2025, revealed instructions for Resident 15 to sneeze with their mouth open for two weeks, to not blow their nose for two weeks, to not pick their nose, and to not bend over. Further instructions for Resident 15 to use saline nasal spray every two hours while awake and to apply Ayr Saline gel (prevents drying and crusting) to the inside of the nostrils twice per day, especially before bed. It was advised to consider using a humidifier, especially at night. It was instructed that if Resident 15's nose began to bleed, to give two generous sprays of Afrin into the affected nostril and pinch the soft parts of the nose together for a minimum of fifteen minutes without releasing, and to not put anything inside the nose to stop the bleeding. It was noted that Resident 15 was provided with Afrin spray (nasal spray used to constrict blood vessels in the nasal passages) to take back to the facility. There was a discharge order noted for an ENT referral as an outpatient for persistent left-sided epistaxis (nosebleed), as resident 15 was seen three times in the emergency department for the same complaint. A review of Resident 15's physician orders failed to identify the emergency room doctor's medication recommendations and interventions to help prevent Resident 15's nose from further complications and bleeding. A review of a nurse's progress note dated September 7, 2025, at 3:15 PM, revealed that Resident 15's nose was actively bleeding, and the resident was evaluated by an outside medical group after hours, and there were new orders noted for Afrin nasal spray every six hours as needed for epistaxis. A review of Resident 15's clinical record revealed a physician's order, dated September 7, 2025, at 9:31 P.M., to consult ENT for recent episodes of epistaxis. A clinical record review on September 17, 2025, revealed that Resident 15 did not yet have a follow-up ENT appointment made. An interview with the Director of Nursing (DON) on September 18, 2025, at 11:45 AM, revealed the referral was faxed over on September 8, 2025, for the ENT consultation, but the resident had not received an appointment date. A review of Resident 15's plan of care, in effect at the time of the survey, identified that Resident 15 had potential for bleeding due to being on an anticoagulant and was to avoid strain on blowing the nose and observe for signs and symptoms of bleeding, including nosebleeds. The care plan failed to identify all the interventions provided by the emergency room to help prevent further complications and bleeding for Resident 15 and did not reflect that they were having episodes of nosebleeds. An interview with the Nursing Home Administrator and DON on September 18, 2025, at 11:45 AM, confirmed the facility's failure to identify interventions and recommendations provided by the emergency room to help prevent further complications and bleeding for Resident 15, obtain appropriate physician orders, and implement a person-centered comprehensive care plan for Resident 15's nosebleeds. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f) Medical records.

Based on observation, clinical record review, select policy review, and staff interviews, it was determined the facility failed to ensure enteral feeding syringes in use were labeled and dated, and failed to provide direction on the maximum time such syringes may remain in service, to prevent contamination and other complications, for one resident receiving enteral nutrition out of 22 residents sampled (Resident 40).Findings include: Review of the facility policy titled Checking Gastric Residual Volume (GVR) Policy last reviewed by the facility January 24, 2025, indicated that nurses should assess tolerance of enteral feeding (any method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories) and minimize the potential for aspiration (when material such as gastric contents, saliva, food, or nasopharyngeal secretions are inhaled into the airway or respiratory tract). The policy did not address the labeling, dating, rinsing, or disposal timeframes of syringes used for enteral administration. According to the CMS Tube Feeding Status Critical Element Pathway (Form CMS-20093), when feeding syringes are reused, they must be:Stored in a clean area.Labeled with the resident's name and the date opened.Rinsed with hot water after each use; andDisposed of within 24 hours.Failure to ensure syringes used for enteral nutrition were labeled, dated, and discarded within an appropriate timeframe created the potential for syringes to be reused beyond their safe period, increasing the risk of bacterial contamination, gastrointestinal infection, or other complications related to compromised enteral administration. Clinical record review revealed Resident 40 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing) and non-traumatic intracerebral hemorrhage (bleeding into brain tissue). Resident 40 required a PEG tube (percutaneous endoscopic gastrostomy, a tube placed through the abdominal wall into the stomach to deliver nutrition). A review of the clinical record revealed Resident 40 had a physician order, dated September 15, 2025, for continuous enteral feeding with Glucerna 1.5 at 70 ml/hour (a liquid high calorie enteral feeding formula) from 8:00 PM to 8:00 AM. Further review revealed a physician order dated September 18, 2025, to directed staff to check PEG placement prior to each use via auscultation (method of listening for air blown into the gastrointestinal tract via enteral syringe) and aspiration, administer 30 mls of water before and after medications and 5 mls of water between medications. Observation of Resident 40 on September 16, 2025, at 1:08 PM revealed a 60 mL enteral syringe (a syringe used to deliver medications, flushes or feedings directly into the gastrointestinal tract via the PEG tube) lying on the room windowsill with a clear plastic bag beneath it containing tan residue. Neither the syringe nor the bag was labeled or dated. Interview with Employee 4 on September 16, 2025, at 1:12 PM, confirmed that the enteral syringe was opened but was not labeled or dated. An interview with the Director of Nursing on September 19, 2025, at 12:00 PM revealed it was the expectation that supplies used for enteral feeding, flushes, and medications be labeled and dated upon opening. However, review of the facility's written policy revealed no such requirement. An interview with the Nursing Home Administrator on September 19, 2025, at 12:15 PM confirmed the expectation that syringes should be labeled and dated, although the requirement was not reflected in facility policy. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on a review of select facility policy, observation, and staff interview, it was determined the facility failed to maintain respiratory equipment in a manner to promote optimal functioning for one resident out of 22 sampled residents. (Resident 9). Findings include:A review of facility policy entitled Equipment Management Policy last reviewed on January 24, 2025, revealed the nebulizer machine tubing and masks are to be changed weekly and as needed to ensure sanitary conditions and safe function. A nebulizer machine is a device that converts liquid medication into a fine mist for inhalation to treat respiratory conditions. A review of Resident 9's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis affecting one side of the body), hemiparesis (weakness affecting one side of the body), and aphasia (a communication disorder resulting from damage to the language areas of the brain). An observation conducted on September 17, 2025, at approximately 12:15 PM revealed a clear plastic bag attached to Resident 9's nebulizer machine containing a tubing and mask without any dating to identify when it was last changed. Further observation revealed the nebulizer bowl (the medication chamber) was labeled with the date June 16, 2025, and the nebulizer tubing was wrapped with a piece of nursing tape also marked with June 16, 2025. An interview with Employee 3 confirmed that the nebulizer mask and tubing had last been dated as June 16, 2025, and had not been replaced according to policy. A review of Resident 9's clinical record revealed no current physician's order for nebulizer treatments. An interview conducted with the Director of Nursing (DON) on September 18, 2025, at 1:00 PM revealed that Resident 9 had received nebulizer treatments earlier in the year, but when the treatments were discontinued, the nebulizer machine was not removed from the resident's room. A subsequent interview with the DON on September 19, 2025, at approximately 9:00 AM confirmed that the respiratory equipment remained in the resident's room and had not been maintained in accordance with the facility's policy. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one out of two nursing units (West Unit), including issues reported by two of seven sampled residents (Residents 5 and 6) and one resident representative (Resident 2's representative). Findings include: An observation conducted on June 4, 2025, at 10:45 AM in Resident 2's bathroom revealed a strong, musty urine odor. During an interview at that time, Resident 2's representative expressed concerns regarding the persistent smell of urine in the resident's bathroom. She reported that although the odor subsides temporarily following cleaning, it returns shortly thereafter. The representative stated that the recurring odor is unacceptable and affects the living experience of her family member. A follow-up observation at 1:20 PM that same day confirmed that the strong, musty urine odor remained present in Resident 2's bathroom. During a facility tour on June 4, 2025, live and dead insects were observed throughout the [NAME] Nursing Unit, including common areas, hallways, and resident rooms. At 11:05 AM, observation in Resident 5's room revealed several large black ants actively crawling on the bedside table, including on personal items such as tissues, papers, and an open orange beverage. Resident 5, who was seated at his bedside, stated the ants had been present for several weeks and continued to appear on his bed and table. He expressed frustration and distress about their ongoing presence. At 11:10 AM, Employee 1, a Licensed Practical Nurse (LPN), confirmed the presence of ants in Resident 5's room. Employee 1 removed the resident's drink from the bedside table and placed it, along with visible ants, into a trash receptacle. Employee 1 acknowledged that ants had been a recurring issue over the past week due to recent changes in weather. At 11:15 AM, observation of the long hall west exit area revealed several large, slender spiders with webs extending several feet from floor to ceiling in the corner near the exit. Numerous dead black ants were trapped in the webs. A thumbnail-sized flying insect was observed on the upper left corner of the exit door, and a half-inch spider was visible on the exit window glass. Additionally, a 2-inch dead worm was seen lying on the hallway floor several feet from the exit. During an interview at 11:20 AM, Resident 6 indicated that she often see ants crawling on the floor in her room. She explained she has killed several ants and throws them in the toilet after she kills them. Resident 6 indicated that ants are the bigger black ants. At 11:25 AM, observation in the [NAME] Unit dining room revealed a dead centipede approximately two inches in length on the heating unit. During a subsequent tour at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed the presence of live spiders, flying insects, and multiple dead pests in the [NAME] Nursing Unit. The NHA acknowledged that it is the facility's responsibility to ensure the environment remains clean and homelike for all residents. 28 Pa. Code 201.18 (e)(1)(2.1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of clinical records and select facility investigation reports and staff interviews, it was determined that the facility failed to timely review and revise a resident's fall prevention plan and provide necessary staff supervision and individualized person-centered approaches to maintain resident safety for a resident identified at risk for falls and known unsafe behaviors to prevent a fall with serious injury, a subarachnoid hemorrhage, for one resident out of 10 residents reviewed (Resident CR1). Findings include: A review of the Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with heart failure, [CONDITION(S)], and [CONDITION(S)] (temporary loss of consciousness caused by a fall in blood pressure) and collapse. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 2, 2021, revealed that the resident's BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) was a 12, indicating that the resident was moderately cognitively impaired. The resident required limited assistance of one staff member for transfers and extensive assistance of two staff members for bed mobility. A review of an incident/accident report dated October 2, 2021, at 2:30 a.m. indicated that the staff heard moaning coming from the resident's room. Staff responded and observed the resident lying on the floor flat on his back. The resident stated he was trying to get his [NAME] Cups from the closet. According to the facility's incident/accident investigation dated October 2, 2021, the resident sustained abrasions to his right ear, right knee, and a lump and abrasion to his right back as a result of the fall. Further review of the facility's investigation revealed that the resident's call bell was not on and that the resident's bed alarm was not sounding. The report noted that the, resident turns alarm off and the resident had admitted to turning off his alarm prior to getting out of bed prior to the fall. The facility recommended that staff encourage the resident to get out of bed for bathing after breakfast and morning/daytime activity since he habitually sleeps throughout the day and is up at night. Further recommendations included that the nursing supervisor follow-up with the physician regarding an increase in [MEDICATION(S)] and/or question need for new sleep aide, as appropriate. The resident was also educated with importance stressed on using call bell for assistance and not manipulating personal safety alarms. A review of Resident CR1's physician orders dated October 2021, revealed that on October 4, 2021 the resident's [MEDICATION(S)] was increased from 5 mg daily at bedtime to 6 mg daily at bedtime. A review of an incident/accident report dated October 21, 2021, at 1:20 a.m. indicated that the resident was found and observed by another resident, lying on the floor in the resident's room next to his bed. According to the facility's investigation dated October 21, 2021, the resident was attempting to reach his urinal when he slid out of bed. The investigation revealed that the resident did not use his call bell for assistance and he again turned off the bed alarm intended for personal safety. The facility again educated the resident regarding adherence with safety measures in place, relocated the bed sensor alarm box to the foot of the bed, staff to ensure urinal is at bedside, and a low-bed was implemented. A review of an incident/accident report dated November 13, 2021, at 10:15 p.m. indicated that the resident had fallen in the hallway near the nurse's station, in short hall, after turning off his chair alarm and using his walker to ambulate into the hallway. According to the facility's investigation dated November 13, 2021, Resident CR1 lost consciousness for one minute, with sonorous respirations (producing a sound when struck) and full body extension. A hematoma (a collection of blood outside of blood vessels. Most commonly, hematomas are caused by an injury) was present to his left forehead and the resident sustained a skin tear to his left elbow, earlier during the shift, while agitated. Further review of the investigation dated November 13, 2021, revealed that prior to the resident's fall in the hallway, he had removed the alarm box from the back of the wheelchair and turned the seat alarm off. According to the documentation in the investigation, the alarm in the resident's doorway (mini motion sensor: MMS) that was functioning at 5:30 p.m. also did not function properly and the resident was described as agitated prior to the fall. Resident CR1 was transferred to the emergency room for evaluation. Review of the Resident CR1's hospital record dated November 14, 2021, revealed that the resident was found to have a traumatic ICH {intracerebral brain hemorrhage: bleeding in the brain} prompting admission to the TICU (trauma intensive care unit) along with a left frontal cephalohematoma (accumulation of blood under the scalp), and a left hip hematoma. The resident was assessed as moderately cognitively impaired and identified at risk for falls due to impaired mobility with risks for falls due to unstable health condition, [CONDITION(S)] and collapse, history of falls and actual falls dated September 13, 2020, November 25, 2020, April 16, 2021, April 22, 2021, April 28, 2021, August 27, 2021, September 14, 2021, October 2, 2021, October 21, 2021, and November 13, 2021 as per his care plan dated June 3, 2019. The facility planned approaches that included educating resident on importance {of} remaining compliant with fall interventions, educate/offer reminders to use RW (rollator walker) with transfers and ambulation and to wear nonskid footwear at all times, keep call bell and personal belongings in resident reach at all times, and MMS in doorway of room to alert staff to resident exiting room. There was no evidence that the facility had timely reviewed and revised the resident's safety plan and had addressed the resident's known behavior of turning off the bed and chair alarms prior to his fall on October 21, 2021. The facility was also aware of the resident's unsafe behaviors, particularly late in the 3 PM to 11 PM and 11 PM to 7 AM shifts, and had identified the resident's habit of turning off personal alarms on the bed and chair planned to prevent fall. The facility failed to review and revise the existing fall prevention and safety measures for adequacy in preventing falls and develop and implement necessary supervisory approaches and alternative measures to maintain the resident's safety and prevent another fall on November 13, 2021, resulting in serious injury. Resident CR1 was readmitted to the facility on [DATE], with diagnosis of subarachnoid hemorrhage and urinary tract infection. According to nursing documentation dated November 16, 2021 at 2:15 p.m., the resident was verbally reminded not to transfer or ambulate independently, but to ask staff for assist, and all alarms were checked for function and working properly. However, there was no documented evidence that additional safety interventions or supervision were implemented upon his return from the hospital. The resident had been displaying repeated instances of unsafe behaviors, self-transfers and turning off alarms that had been implemented for resident safety, but the facility failed to timely provide necessary staff supervision and interventions, at the frequency and level required, to prevent a fall, which resulted in a subarachnoid hemorrhage. 28 Pa. Code 211.11(d) Resident care plan Previously cited 3/6/20, 6/29/21 28 Pa. Code: 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 3/6/20, 6/29/21

Based on employee training and nursing competencies, select incident/accident reports and clinical records and staff interviews, it was determined that the facility failed to assure the proficiency of nurse aides in demonstrating the necessary skills and competencies to perform safe transfers using a mechanical lift to prevent injuries to a resident, fractured ribs, during the transfer of one out of five residents reviewed (Resident 25). Findings include: A review of the clinical record revealed that Resident 25 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated December 10, 2020, revealed that Resident 25 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 8-12 indicates moderate cognitive impairment), required extensive assistance of two persons for bed mobility, transfers, toileting, and bathing. The resident was assessed to require the use of a sit to stand lift for transfers (STS - mechanical lifting device used to assist mobility patients when they are unable to transition from a sitting position to a standing position on their own). A review of the facility's Nursing Competency Check List - Total Mechanical Lift Safety review revealed that the nurse aides are required to demonstrate competency in lift safety procedures that included, staff member checked lift & sling was in good condition (no rips, tears, mechanical issues) prior to use; staff checked to be sure all loops were secure & evenly placed so resident was well-balanced. A review of facility provided document entitled, Physical Therapy Treatment Encounter Note(s) dated March 25, 2021, indicated that Resident 25 demonstrated that she is safe to transfer bed to WC (wheelchair) with STS (sit to stand) lift A X 2 (Assist with 2 staff). A review of a facility investigation report dated April 2, 2021, revealed that Employee 5, a Temporary Nurse Aide (TNA) and Employee 6 (TNA), were in Resident 25's room. Resident 25 was seated in her wheelchair. These two TNAs transferred the resident from the wheelchair to her bed using a sit to stand lift as planned for the resident's transfer. During this transfer from the wheelchair to the bed, one of the straps (right) came off the lift causing Resident 25 to fall onto the floor on her right side. A nursing note dated April 3, 2021, at 9:05 AM revealed that the resident complained of right sided rib pain. The resident was medicated for pain, the MD was notified, and X-rays were ordered. Review of the radiology report dated April 3, 2021, at 1:35 PM indicated Resident 25 sustained an acute nondisplaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture of the right posterior lateral eighth and ninth rib. Review of Employee 5's (TNA) witness statement dated April 2, 2021, indicated that Resident 25 had been seated in her wheelchair. Both Employees 5 and 6 placed the sling around the resident and attached it to the sit to stand lift and visually acknowledge that the sling was on the hooks. Employee 6 (TNA) manned the STS and Employee 5 was behind Resident 25, and as the lift rose, the resident stood up and the sling on the right side detached causing the resident to fall onto the floor. Review of Employee 6's (TNA) witness statement dated April 2, 2021, indicated that both employees had hooked the resident to the STS lift and that the right side slipped off as they were moving her into position thus causing her to fall. The employee noted, hooked her to the sit to stand, the right side slipped off as we were moving her into position to get into bed and she fell on her hindquarters. A review of a nursing note in Resident 25's clinical record dated April 2, 2021, at 7:33 PM revealed that the resident fell out of the STS lift when the right strap came off the lift while being transferred to bed. Nursing noted that the resident was observed on her right side laying at the foot of the bed in front of the STS lift. At present no injuries were noted and the MD and family were notified according to the entry. An Incident Note dated April 2, 2021, at 7:35 PM indicated that after the incident both staff members, Employees 5 and 6, were educated on how to properly connect the straps to the hook of the lift and to double check for safety. A review of Employee 5's (TNA) training record revealed a, Nursing Competency Checklist, for mechanical lift safety review, dated October 20, 2020, and February 4, 2021, indicating that the employee was found to have satisfactory performance. Employee 5's training record revealed a form entitled Staff Education Record dated April 2, 2021, the date of the resident's transfer with injury, indicating that the education provided/plan of correction was to triple check to ensure safety and secure of lift straps before transferring residents. A review of Employee 6's (TNA) training file, revealed a, Nursing Competency Checklist, for mechanical lift safety review, dated December 1, 2020, and February 4, 2021, revealed satisfactory performance. Employee 6's training record revealed a form entitled, Staff Education Record, dated April 2, 2021, the day of the resident's transfer with injury, indicating that the education provided/plan of correction was to, triple check to ensure safety and secure of lift straps before transferring residents. A review of the facility provided report entitled, Fall Investigation, dated April 2, 2021, at 7:00 PM indicated that it was unsure whether proper technique was used to transfer the resident via the sit the stand lift. The report concluded that the cause of the accident was, unsure, aides said it was hooked properly, when she (resident) stood up they think it pushed the right strap off. The facility failed to ensure that the temporary nurse aides had used safe and correct technique and had demonstrated competency in the skills and techniques necessary to transfer Resident 25 using the sit to stand lift as planned for the resident to prevent this incident resulting in rib fractures. Interview with the Nursing Home Administrator on June 28, 2021, at approximately 11:30 AM confirmed that the resident had been injured while being transferred with the mechanical lift and there was no evidence to support that the temporary nurse aides had used appropriate technique and had adequately performed safety checks on the lift straps. The employees indicated that they had visually acknowledged the straps were secure, but there was no evidence that the aides had physically assured the security/placement of straps and positioning of the resident prior to transferring the resident as indicated in the facility competency for mechanical lift transfers. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing Services

Based on review of clinical records, staff interviews and observations it was revealed that the facility failed to timely identify the development of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) and failed to demonstrate the consistent and appropriate use of interventions designed to address the resident's contributing factors for skin breakdown, evaluate the effectiveness and use of these planned measures and monitor the resident's wound healing to prevent infection and promote the healing of pressure sores for one of four residents reviewed (Resident 1) Findings include: A review of the clinical record revealed that Resident 1 had physician's orders [REDACTED]. Nursing progress notes dated (MONTH) 30, 2019, revealed that the the resident's right thumb was noted to be red, warm and swollen when the lambswool was removed from between the resident's right thumb and index fingers. When the rolled wash cloth, used to treat the contractures, was removed from the resident's right hand, a 1.5 cm x 1.4 cm x 0.1 cm pressure area to the resident's inner thumb was identified. Nursing noted that the area was was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture. Maceration is caused by excessive amounts of fluid remaining in contact with the skin or the surface of a wound for extended periods) with slough (the yellow/white material in the wound bed; it is usually wet, but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound. It consists of dead cells that accumulate in the wound exudate) present. A review of the resident's Occupational Therapy (OT) Evaluation and Plan of treatment dated (MONTH) 30, 2019, the resident's short-term goal was to safely wear the most appropriate splint on his right hand for up to two hours with minimal signs and symptoms of redness, swelling or discomfort and to decrease the risk of further breakdown. The long-term goal was to eventually achieve these factors within six hours. To assess the appropriateness of the splinting/pressure reducing device, occupational therapy routinely checked the placement, tolerance and appropriateness of the device according to OT documentation. A review of a wound evaluation flow sheet dated (MONTH) 30, 2019, revealed that the pressure area was unstageable, which according to this facility assessment tool, was a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black in the wound bed). Nursing noted that there was a scant amount of foul smelling sanguineous (bloody) drainage, which was described as thick and tenacious in consistency. The wound margins were macerated/soft. There was no identification of the percentage of slough in the wound or any additional description of the wound bed. There was no documented evidence that facility staff had identified any impairment or declines in the resident's skin integrity in this area prior to (MONTH) 30, 2019, unstageable pressure area identification. The physician ordered [MEDICATION NAME] (antibiotic) 125 mg one, twice daily was ordered for seven days on (MONTH) 30, 2019, with a completion date of (MONTH) 6, 2019. Orders also included the application of rolled cloths to the right hand at all times, with no pressure to the medial aspect of the right thumb and two hour checks to ensure proper placement of the cloths were to be completed. On (MONTH) 2, 2019, the physician order [REDACTED]. The wound was evaluated by a wound care specialist on (MONTH) 5, 2019. The area was described as being located on the right ulnar aspect of the right thumb, a Stage IV pressure area (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) with moderate serous exudate (exudate is a liquid produced by the body in response to tissue damage; serous drainage is clear, thin, watery plasma) due to a severe contracture. According to the wound care specialist the area measured 1.5 x 1.5 cm x 0.3 cm with a 2.25 cm surface area and 40% slough and granulation and 20% viable tissue (muscle.) During this evaluation, a surgical excisional debridement procedure was completed to remove necrotic (dead) tissue and establish the margins of viable tissue. A review of occupational therapy notes completed on (MONTH) 5, 2019 revealed that observation of the resident's right hand revealed that the carrot splint was observed in the resident's right hand. It was described as ill fitting, as was the dressing. The areas between the resident's fourth and fifth digits were noted to be red and irritated. It was documented that nursing was made aware of the redness and irritation. On (MONTH) 6, 2019, Occupational Therapy (OT) documented that when staff assisted the resident to the therapy room the resident's Carrot splint was observed to be soiled with urine as well as drainage from the resident's pressure sore wound. OT documented that OT staff assisted the resident back to the resident's room and notified nursing staff on the resident's unit of the resident's urinary incontinence and issues related to moisture in his hand, which had the potential to cause additional skin breakdown. It was noted that there was redness between the resident's fourth and fifth fingers. Documentation noted that the resident's hands were patted dry with multiple cloths and left to air dry. The resident's Carrot splint was sent to the laundry and a rolled cloth was utilized until the carrot splint could be returned because another Carrot Splint was not available. A review of Occupational Therapy notes dated (MONTH) 7, 2019, revealed that when therapy was getting the resident ready for his session, the rolled wash cloth, which was to be used in place in of the Carrot Splint was observed placed on top of the resident's hand and was not positioned in the intended location (palm). Therapy documented that there was noticeable redness and irritation between the resident's fourth and fifth digits and that the nursing supervisor was made aware. On (MONTH) 8, 2019, OT documented that the the resident was observed in the hallway at approximately 8:10 a.m. with the Carrot splint placed on the resident's stomach and not in the proper place to the right hand. Therapy observed the resident at 9:53 a.m., with the Carrot splint laying on the resident's stomach. The dressing to the resident's thumb pressure sore was noted to be saturated with bloody discharge. When the COTA (Certified Occupational Therapy Assistant) checked the Point Click Care (electronic medical record ADL {activities of daily living} documentation used by direct care nursing staff to note the provision of resident care) documentation, the nursing staff had, however, documented at 9:35 a.m., on that date, that the Carrot device was in place as planned. OT noted that concerns regarding the placement of the splint were discussed with nursing staff following these observations. It was subsequently observed and documented by Occupational Therapy that the nurse on the resident's unit improperly replaced the wound dressing over the resident's index finger, thus not allowing web spacing for proper placement of the Carrot splint. According to nursing progress notes dated (MONTH) 9, 2019, the resident developed a pea sized small blanchable red area near the knuckle of the fourth finger to right hand. When the resident's contracture and Carrot Splint was checked for placement by Occupational Therapy on the morning of (MONTH) 13, 2019, the Carrot splint was not in place on the resident. When OT attempted to provide range of motion to the resident, the resident was pulling away and grimacing. On (MONTH) 14, 2019, the resident's wound dressing required changing when OT monitored the resident's splint on that date. OT documented that the resident was very sensitive to the Carrot splint that day. The resident was described as pulling away from the staff and an additional staff member was needed to assist in placing the splint. Nursing was informed that the resident might be having pain with the right thumb wound. According to OT dated (MONTH) 16, 2019, the Carrot splint was not in place when the Occupational Therapist came to check the placement of the device. It was confirmed with nursing at that time, that the use of the Carrot splint remained a current physician order. Occupational therapy applied the Carrot Splint. On (MONTH) 19, 2019, occupational therapy again noted observations that the Carrot splint had not been applied as ordered. Occupational therapy placed the Carrot splint in the resident's hand after searching the resident's room for the device. OT noted that the resident was continuing to demonstrate resistive tendencies with the splint. Occupational therapy again documented observations that the resident did not have the Carrot splint in place when they arrived to check tolerance of the device on (MONTH) 20, 2019. The nursing staff was educated on the importance of providing the splint to the resident. On (MONTH) 21, 2019, occupational therapy again documented that the Carrot splint was not in place in the resident's right hand. OT noted that nursing staff was unaware of where the device was located. Nursing was instructed to utilize wash cloths until the splint was located. Subsequently the Carrot splint device was located in the laundry. Although OT staff frequently documented their observations of finding the resident without the Carrot Splint in place as ordered on multiple occassions, a review of the resident's treatment records for (MONTH) 2019, revealed that facility nursing staff consistently documented the application of the Carrot splint, to the resident's right hand, at all times, with two-hour skin checks also conducted. A review of the resident's wound evaluation flow record completed on (MONTH) 20, 2019, revealed the pressure area was 1.1 cm length x 0.5 cm width x 0.3 cm depth with a scant amount of thick tenacious sanguineous drainage. The wound bed was tender to touch with 50% slough and granulation. On (MONTH) 22, 2019, the physician ordered another course of antibiotic therapy, Keflex 500 mg every eight hours for five days was ordered. A review of nursing progress notes dated (MONTH) 22, 2019, revealed that the resident's right thumb was red, swollen, tender and warm to touch. A review of the resident's wound evaluation flow record dated (MONTH) 26, 2019, the area remained unstageable and was 1.3 cm x 0.2 cm x 0.2 cm. No drainage was observed and the wound bed was described as 100% granulation (tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size). According to nursing progress notes dated (MONTH) 28, 2019, the resident's daughter asked nursing staff to look at her father's right thumb as it appeared red and more bent than usual. When the nurse examined the area on (MONTH) 28, 2019, nursing noted that the resident's thumb area was red, swollen and bent at the knuckle at an unusual angle. An X-RAY was ordered at that time and the results were documented as unremarkable. Nursing noted that the resident's daughter requested another X-RAY on (MONTH) 29, 2019. The facility emphasized with the resident's resident's daughter the resident's non -use of the splint because father not always cooperative in wearing and the resident's contractures, but the resident's family insisted on another X-RAY, which was completed on (MONTH) 29, 2019, and showed a dislocation (when the bones in a joint slip out of their normal position) of the interphalangeal joint of the first finger without a fracture. The resident's daughter requested the resident be sent to the hospital. A review of an orthopedic consultation requested by the emergency room physician, dated (MONTH) 30, 2019, revealed that the resident had a significant deformity on his right PIP joint (proximal interphalangeal joint - bones in the middle of the finger.) The resident was observed with a wound over the IP joint (interphalangeal joint-joint between fingers.) The IP joint dislocation was reduced, but further inspection of the wound revealed that it was deep and extended into the joint. It was noted that the resident's joint was unstable and required pressure to retain reduction. A right thumb digital amputation was completed on (MONTH) 31, 2019. Observation of the resident on (MONTH) 12, 2019, at 11:15 a.m., revealed that the resident was seated in his room. When the surveyor made attempts to observe either of the resident's hands he was resistive to allow observation. Interview with the facility's administrator on (MONTH) 12, 2019, revealed that the Administrator stated that the facility provided all prescribed and planned measures for the resident's contractures as evidenced by nursing staff documentation and that the resident's pressure sore could have developed in hours. The facility failed to demonstrate that consistent and effective measures to manage the resident's contracture, a risk factor for pressure sore development. The facility failed to identify the resident's pressure sore until an advanced stage and/or signs of wound infection were present and subsequently failed to provide the prescribed splinting device to prevent worsening of the pressure sore once identified. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records and staff interviews it was revealed that the facility failed to timely identify and act upon a change in resident condition, to assure the resident received timely and necessary treatment and prompt medical intervention at level required, which compromised the condition of one resident out of 24 sampled (Resident 358). Findings include: A review of clinical records revealed Resident 358 was admitted to the facility on (MONTH) 11, 2019, with [DIAGNOSES REDACTED].{dead} tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). An MDS (The Minimum Data Set - a comprehensive assessment of each resident's functional capabilities) dated (MONTH) 30, 2019 revealed the resident was frequently incontinent of bowel and bladder. A review of nursing documentation dated (MONTH) 10, 2019, 11:27 PM revealed that staff obtained a urine specimen via straight catherization (a way obtaining urine by placing a tube into the bladder) for a urinalysis. Nursing noted that the resident's urine was thick yellow and foul smelling, symptoms of a possible urinary tract infection. A report of a urinalysis dated (MONTH) 11, 2019, indicated a large amount of blood in the resident's urine. The facility noted that this report was faxed to urology on (MONTH) 11, 2019. A review of a laboratory report of the urine culture results dated (MONTH) 13, 2019, at 5:04 PM revealed the resident had abnormal laboratory results. The report indicated that the resident's urine contained more than 100,000 colonies/ml of Escherichia coli (E-coli - a bacterium commonly found in the intestines and feces of humans - urine cultures with greater than 100,000 colony forming units (CFU)/mL of one type of bacteria usually indicate infection). The sensitivity report identified select antibiotic drugs to which the bacteria was susceptible for treatment. A review of nursing documentation dated (MONTH) 14, 2019, at 7:52 AM revealed the resident's abnormal lab results were faxed to the resident's urologist (the branch of medicine concerned with the function and disorders of the urinary system). However, there was no documented evidence that the facility had notified the resident's attending physician regarding the resident's thick and foul smelling urine and the results of the resident's urinalysis. The facility further failed to follow-up with the urologist after 24 hours of faxing the physician the abnormal lab results, when the facility received no response to the faxed lab report. An interview with the DON (director of nursing) on (MONTH) 28, 2019, at 11:22 AM indicated that if the facility does not hear back from a physician, the facility staff should follow up within 24 hours. The DON confirmed that nursing staff failed to notify the resident's attending physician of the change in the resident's condition and failed to follow-up to ensure that the urologist was aware of the abnormal lab results to ensure that the resident received any desired treatment promptly. A review of nursing documentation dated (MONTH) 16, 2019, at 9:17 PM revealed that during assessment observed vaginal bleeding and small blood clots x 4 moderate amount. A review of nursing documentation dated (MONTH) 16, 2019, at 10:30 PM revealed that the resident continued to have large amounts of vaginal bleeding with blood clots. The resident saturated two incontinence briefs with blood. Further review of clinical documentation indicated that the resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED].{ part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection} of the urinary bladder due to an infection or resulting in bleeding from the bladder. The most common cause is bacterial infection). A review of hospital discharge instructions dated (MONTH) 20, 2019, revealed that the resident resident was transferred and admitted to the hospital on (MONTH) 17, 2019, at 12:10 AM at for bloody urine. While hospitalized the resident was treated for [REDACTED]. There was no documented evidence at the time of the survey ending (MONTH) 28, 2019, that the facility had timely acted upon the resident's signs and symptoms of a urinary tract infection and vaginal bleeding. The facility failed to ensure the attending physician was promptly made aware of the resident's change in condition and follow up with the urologist after 24 hours of faxing the physician the abnormal lab results. An interview with the DON (director of nursing) on (MONTH) 28, 2019, at 11:22 AM confirmed that the resident did not receive timely treatment and services from (MONTH) 11, 2019, when the abnormal lab results (blood in the urine) were received until she was admitted to the hospital on (MONTH) 17, 2019, with hemorrhagic [MEDICATION NAME]. Refer F580 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 7/13/18, 10/2/18, 3/5/19, 4/30/19 28 Pa. Code 211.10(a)(d) Resident care policies

Based on a review of clinical records, medication incident reports, select facility policy and information submitted by the facility and staff and resident interviews, it was determined that the facility failed to ensure that two residents were free of significant medication errors, which resulted in a dangerous complication of diabetes and hospitalization of one resident (Resident 5) and placed one resident at risk for clinical complications (Resident 77) out of 21 residents reviewed. Findings include: Review of the facility's policy titled, Transcribing Physician Orders, reviewed by the facility January 19, 2017, revealed that physician orders [REDACTED]. The facility will recognize physician orders [REDACTED]. Review of the clinical record of Resident 5 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 29, 2017, revealed that the resident did not receive insulin injections during this assessment period from May 25, 2017 through May 29, 2017. Review of a resident medication incident report (facility medication error report) and information dated May 29, 2017, submitted by the facility revealed that Employee 1, a Registered Nurse (RN), who had been responsible for the resident's admission process, had not clarified the physician's orders [REDACTED]. Review of nursing documentation dated May 29, 2017, at 3:22 PM revealed that a nurse notified the physician that the resident was lethargic (drowsy, sluggish). The resident's son was at the resident's bedside and was concerned about his mother's change in condition. An Accu-check (blood glucose (sugar) monitoring via finger stick blood sample) was performed with the results of 586 (normal blood glucose 70-100 milligrams{mg}/ deciliters {dl}). Upon notification at this time, the physician ordered [MEDICATION NAME] 9 units/sq at bedtime and [MEDICATION NAME] sq (short acting insulin), as per a sliding scale (amount of insulin administered is based on the resident's Accu-check blood sugar level) after Accu-checks were obtained before meals and at bedtime. This entry also indicated that the physician was informed that the resident was admitted to the facility without insulin orders. The resident's blood sugar was rechecked 40 minutes later on May 29, 2017, with a glucometer (a medical device for determining the approximate concentration of glucose in the blood) reading, which read Hi. According to an interview with Employee 2, a Licensed Practical Nurse (LPN), on June 15, 2017, at 11:15 AM the glucometers used by facility indicate Hi when the blood glucose levels are greater than 600. Further review of nursing documentation dated May 29, 2017, at 4:55 PM revealed that the resident was lethargic and had a blood sugar of 581 mg/dl. Nursing administered 30 units of [MEDICATION NAME]per the physician order. The resident's blood sugars were checked three more times on May 29, 2017, from 3:22 PM through 4:55 PM resulting in a Hi reading. The RN Supervisor was made aware at 4:55 PM and the physician was notified at 4:56 PM that the resident's blood sugar was rising despite the administration of two separate doses of 30 units of [MEDICATION NAME] insulin. The physician ordered that the resident be sent to the hospital. The resident was transferred to the hospital at 5:10 PM. Review of nursing documentation dated May 29, 2017, at 8:25 PM revealed that the facility had phoned the hospital to inquire about the resident's condition and was informed that the resident was admitted to the intensive care unit with non-ketotic coma unresponsiveness (a complication of diabetes in which high blood sugars cause severe dehydration and a high risk of complications, coma and death). Interview with the Director of Nursing (DON) on June 13, 2017, at 2:15 PM confirmed that Employee 1 had missed the admission insulin order and did not verify the order with the physician at the time of the resident's admission, which resulted in the significant medication error of omission. The resident did not receive insulin for a period of four days following admission. A review of the clinical record revealed that Resident 77 had [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. A review of the facility medication incident report dated April 12, 2017, indicated that Resident 77 received [MEDICATION NAME] 40 mg, in error, from April 1, 2017 through April 11, 2017. The report indicated that Employee 4, RN, took a physician's telephone order on March 31, 2017, for an additional one time dose of [MEDICATION NAME] 40 mg, on March 31, 2017. However, Employee 4 entered the order incorrectly into the facility's computer. Further review of the resident's March 2017 and April 2017 MARs revealed that the resident received an additional 40 mg dose of [MEDICATION NAME] from March 31, 2017 through April 11, 2017. The resident received 80 mg of [MEDICATION NAME] daily from March 31, 2017 through April 11, 2017. During an interview with the Director of Nursing (DON) on June 15, 2017, at approximately 1:30 PM the DON confirmed the medication error and that Resident 77 received 11 extra doses of [MEDICATION NAME] 40 mg. 42 CFR 483.45(f)(2) Residents Free of Significant Medication Errors. Previously cited 9/20/16. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. Previously cited 7/15/16, 9/20/16. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 9/20/16, 7/15/16, 6/18/15. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited 2/14/17, 9/20/16, 7/15/16, 6/18/15.

Based on a review of clinical records and staff interviews, it was revealed that the facility failed to ensure that residents were free of significant medication errors for one of 18 residents reviewed (Resident 11), resulting in the resident's hospitalization for the development of blood clots. Findings include: Resident 11 was admitted to the facility on [DATE]. review of the resident's medical record revealed [REDACTED]. to clot) lab tests to be drawn on July 13, 2016. A review of the resident's Medication Administration Record [REDACTED]. A review of a lab report dated July 13, 2016, revealed the physician ordered PT/INR blood test was completed that day with results: PT-16.2 seconds (normal 11.5-14.6 seconds) and INR-1.29 (normal 0.85-1.16. If PT/INR test results are too high, it means that the resident's blood is clotting too slowly and a person is at risk of increased bleeding). On July 13, 2016, Employee 3, a Registered Nurse (RN), called the resident's physician with the results of the above lab tests and received a physician's telephone order for [MEDICATION NAME] 2.5 mg daily and a PT/INR to be drawn the week of July 20, 2016. Employee 3, however, failed to transcribe this physician medication order onto the resident's Medication Administration Record [REDACTED]. These failures resulted in the resident missing six doses of [MEDICATION NAME] from July 13, 2016 through July 19, 2016. During a physician's physical exam of the resident conducted on July 19, 2016, the physician noted the presence of [MEDICAL CONDITION] (swelling) in the resident's right leg and also discovered that doses of the prescribed medication, [MEDICATION NAME], were missed. On July 19, 2016, the physician ordered a venous Doppler (a diagnostic study that uses sound waves to produce pictures of the body's veins. It is commonly used to search for blood clots) of the resident's right lower extremity. The Doppler test was completed on July 20, 2016, with results that were positive for deep venous thrombus (a blood clot) in the resident's right calf vein. The physician was notified and the resident was sent to the hospital for an evaluation on July 20, 2016. The resident returned to the facility that same day with physician's orders [REDACTED]. Nursing noted that on July 21, 2016, Resident 11 complained to the nursing staff of right sided rib pain. The physician was contacted and the resident was sent to the emergency room . A review of hospital emergency room (ER) physician's notes dated July 21, 2016, at 9:18 AM revealed that Resident 11 presented to the emergency room with pain and abnormal lab values. The ER physician noted that after a visit to the ER yesterday (July 20, 2016) Resident 11 had returned to the long term care facility and had developed increasing right sided pleuritic (chest pain that worsens when you breathe, cough or sneeze; shortness of breath) chest pain. Resident 11 informed the ER staff that the pain was on her right side, under the ribcage and is made worse by deep inspiration. A CT scan (CT-computerized tomography diagnostic imaging study) was completed at the hospital on July 21, 2016. The results revealed a [MEDICAL CONDITION] emboli within segmental and subsegmental branches of the right upper, middle and lower lobes of the resident's lungs (blood clots and pieces of clots in the resident's lungs). The resident was admitted to the hospital for two days and received anticoagulation therapy (a medication that reduces the body's ability to form clots in the blood ). During an interview on September 20, 2016, at approximately 1:00 PM the Director of Nursing confirmed the medication error, regarding Resident 11's [MEDICATION NAME] administration, resulting in the resident's hospitalization due to blood clots. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 7/15/16, 6/18/15

Based on a review of clinical records, select facility policy, resident incident reports and resident, family and staff interview, it was determined that the facility failed to consistently implement interventions and provide planned care and services to prevent pressure sore development for three of 23 sampled residents (Residents 27, 36, and 56). Findings include: The facility's policy entitled, "Skin Integrity and Wound Management," reviewed by the facility February 2014, revealed that the intent of the policy is to provide safe and effective care to prevent the occurrence of pressure ulcers (also called pressure sores, which are injuries to skin and underlying tissue resulting from prolonged pressure on the skin), manage treatments and promote the healing of wounds. Prevention protocols for residents at risk include: performing daily observation of skin, applying moisturizer daily to high risk areas such as heels, positioning of body with pillows and support devices, suspending heels off surface and individualizing positioning and repositioning schedules to prevent pressure sore development. A review of the clinical record revealed that Resident 56 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS - provides a comprehensive assessment of each resident's functional capabilities and helps nursing facility staff identify health problems) dated April 10, 2014, revealed that the resident was severely cognitively impaired (Brief Interview for Mental Status {BIMS} used to assess thinking, memory and recall score was 7 {0-7 indicates severe impairment}), was at risk for pressure ulcers, had a history of [REDACTED]. Review of a "Nursing Re-Admission Assessment" dated April 3, 2104, revealed that the resident scored an 8, greater than 10 indicates the resident is high risk for pressure ulcer development, in the Pressure Ulcer Risk Assessment section. Further review of the Re-Admission Assessment indicated that the resident had a history of [REDACTED]. Review of a care plan which was provided to the state surveyor on the morning of May 6, 2014, indicated that on August 28, 2012, a care plan was initiated for the resident's identified risk for pressure ulcers related to immobility. Interventions planned up until April 10, 2014, included the following: [MEDICATION NAME] (a protective skin ointment) to bilateral (both) lower extremities with a.m. and p.m. care, encourage the resident to turn and change position every two hours and to assist when needed, monitor skin with care each shift and notify nurse of changes and skin assessments per facility policy. Review of another care plan provided to the state surveyor on the morning of May 8, 2014, revealed the discontinuation of the use of heel suspension boots when in bed dated January 25, 2014, and the new approach to suspend the resident's heels on a pillow while in bed dated on the same date, January 25, 2014. A review of a physician's telephone order dated January 25, 2014, revealed that the order called for staff to discontinue the use of the suspension heel boots and to start suspending the resident's heels while in bed. Review of a resident "Incident/Accident Report" dated April 10, 2014, indicated that Resident 56 stated that his left heel had been hurting the past two days and that it only hurts when he is wearing his shoes. When the nurse asked, the resident stated that he had not told anyone about his pain prior. The report further indicated that an open pressure ulcer measuring 3 centimeter (cm) x 4.5 cm x 0.2 cm was found on the resident's left heel. The nurse also noted on the report that the resident had +2 [MEDICAL CONDITION] (accumulation of fluid characterized as a temporary depression in the skin The +2 indicates a detectable distortion of the skin measuring 2 to 4 millimeters with indentation). As a result of this pressure sore development, the new interventions and physician's orders [REDACTED]. Further review of the investigative report indicated that one nursing assistant who provided care for the resident, stated she had placed a pillow under his heels. Review of the facility's "Pressure Ulcer Management Report" revealed that on April 10, 2014, staff identified that Resident 56 had acquired an unstageable open pressure ulcer due to necrosis (a wound described as full thickness tissue loss at the base of the wound covered either by slough (dead tissue) and/or eschar (scab/dead tissue)), measuring 3 cm x 4.5 cm x .01 cm. Review of the wound consult dated April 16, 2014, indicated that the resident had an unstageable area due to necrosis of the left heel. Further review of the consultation revealed that the wound was related to pressure, measuring 1.9 cm x 2.9 cm with thick black necrotic tissue (eschar) at 100%. The physican's recommendations at the time included: off-load (alleviate pressure) wound, float heels and the use of a sponge boot. A review of print outs of two electronic care flow sheets presented at different times during the survey, revealed that on one care flow sheet, there was no planned intervention to, "suspend heels at all times in bed" and on the other care flow sheet print out provided to the survey team, the intervention to, "suspend heels at all times in bed" was present; however, the dates for the two months were blank, with no employee signatures and/or time when and if this preventative intervention was performed for this resident. A review of the nursing documentation on April 5, 2014, at 7:14 a.m., April 6, 2014, at 5:06 a.m., April 7, 2014, at 3:22 a.m., and April 8, 2014, at 12:16 a.m., all indicated that the resident was resting in bed. The nursing documentation did not note if Resident 56's heels were on pillows. In an interview with Resident 56 and his family member on May 6, 2014, at 1:15 p.m., and on May 7, 2014, at 10:15 a.m., they stated that they were unsure if staff routinely placed his heels on pillows as ordered by the physican. The family member also stated that the resident was unable to put on his own socks and shoes and that this task was done by staff. Further review of the clincal record revealed no documented evidence that the resident's heels were consistently placed on pillows as ordered or evidence that preventative interventions were in place when the resident was placed in his wheelchair prior to the development of the pressure sore. During an interview on May 8, 2014, at approximately 9:35 a.m., the Regional Nursing Consultant and Nursing Home Administrator were unable to state why staff obtained another physican's order on April 4, 2014, to raise the resident's heels on a pillow while in bed, when an order already existed for that measure. In addition, the monthly recapitulation of physican's orders did include the order from January 25, 2014, that the resident's heels were to be placed on pillows. The Regional Nursing Consultant and Nursing Home Administrator did state, when interviewed, that there were discrepancies in the electronic print outs that were provided to the surveyor due to the set up of the electronic programs, staff familiarity with entering and obtaining information and the retaining and retrieval of old information. There was no documented evidence that the physican-ordered intervention, to suspend the resident's heels on a pillow, was performed by staff, as ordered by the physican. The clinical record review revealed that Resident 36 had [DIAGNOSES REDACTED].{delusions} ; Seeing or hearing things that aren't there {hallucinations}). A quarterly MDS assessment dated [DATE], revealed that the resident required extensive assistance of two staff for most activities of daily living and was at risk for pressure ulcers. A nurses' note dated April 10, 2014, at 8:26 p.m., revealed that Resident 36's right ischium (The ischium forms the lower and back part of the hip bone) presented with a Stage II pressure sore. An Incident/Accident Report dated April 9, 2014, at 8:30 a.m., described the Stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) on the right ischium as in-house acquired and measuring 1.5 cm x 2.5 cm x 0.1 cm deep. Further review of this Incident/Accident Report failed to indicate that the facility had determined the frequency that the resident was repositioned and verified that the resident had been provided timely repositioning both in and out of bed. Review of Resident 36's care plan, in effect since March 25, 2014, revealed that the resident was to be assisted with turning and repositioning, but neither the frequency nor an individualized plan for the resident was noted. The Director of Nursing (DON) when interviewed, on May 8, 2014, at approximately 9:30 a.m., was unable to provide evidence to demonstrate that the resident had been turned and repositioned at an individually assessed frequency to prevent pressure ulcer development. The clinical record review revealed that Resident 27 had diagnoses, which included [MEDICAL CONDITION] (a condition in which the heart cannot pump enough blood to the rest of the body) and hypertension (high blood pressure). A quarterly MDS assessment dated , March 7, 2014, indicated that the resident was non-ambulatory (unable to walk) and required staff assistance for most activities of daily living and was at risk for pressure ulcers. The facility's "Skin Integrity and Wound Management" policy, reviewed by the facility February 2014, revealed that a complete skin inspection was to be completed on admission and weekly. The inspections are to be documented on the Treatment Administration Record (TAR). The appearance and condition of the wound is to be documented weekly and with deterioration in wound condition. Review of the facility's "Pressure Ulcer Prevention Protocol" reviewed February 2014, indicated that a daily observation of the skin was to be performed for all residents at risk for pressure ulcers. A nurses' note dated, April 7, 2014, at 6:43 a.m., noted that a water blister was discovered to the resident's left inner calf. The blister appeared to be the result of the TED stockings (compression stockings worn to reduce swelling in the legs) being too tight. The blister appeared on the line at the top of the calf where the stockings would be located. The blister measured 5.5 cm by 0.5 cm. The resident was to be resized for new TED stockings. A physician's orders [REDACTED]. The staff were to check placement every shift (there was no time frame included in the physician's orders [REDACTED]. Review of the resident's April 2014, TAR revealed no evidence that the physician's orders [REDACTED]. Review of the resident's Incident/Accident Report dated April 7, 2014, indicated that the blister was found while bathing the resident. The Incident/Accident Report failed to indicate if the facility had verified that the staff were consistently inspecting the resident's skin according to facility policy for residents at risk for pressure ulcers. A review of the resident's Weekly Skin Assessments, revealed that the last documented weekly skin assessment prior to finding the blister was March 26, 2014. There was no documented weekly skin assessment for April 2, 2014. Review of the resident's Weekly Skin Assessments dated April 8, 2014, and April 15, 2014, failed to indicate a description of the blister as per the facility policy. An interview with the DON on May 8, 2014, at 10:00 a.m., failed to provided documented evidence that skin checks were consistently conducted to promptly identify changes and prevent the development of a pressure ulcer. 483.25(c) Pressure sores Previously cited 1/9/14 28 Pa. Code 211.6 (f) Clinical records Previously cited 1/9/14 28 Pa. Code 211.6 (g)(h) Clinical records 28 Pa. Code 211.10 (a) Resident care policies Previously cited 1/9/14, 3/11/14 28 Pa. Code 211.10 (d) Resident care policies Previously cited 1/9/14 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 1/9/14, 3/11/14

Based on observation, review of clinical records, an Event Report submitted to the State Agency, review of resident Incident/Accident Reports and staff interview, it was determined that the facility failed to provide adequate supervision and/or implement effective safety interventions to prevent falls and injury for two of 21 sampled residents (Resident 9 and 31) and failed to maintain the residents' environment free of potential accident hazards. Findings include: A review of the clinical record revealed that Resident 9 was admitted to the facility on [DATE], and had diagnoses, which included Diabetes Mellitus and anxiety. A review of an admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated, September 27, 2013, revealed that the resident was moderately cognitively impaired with evidence of disorganized thinking. The resident required staff assistance for transfers, toileting, and ambulation. The resident was assessed to be occasionally incontinent of bowel and bladder and had a history of [REDACTED]. A review of the resident's current care plan initially dated September 19, 2013, indicated that the resident required assistance related to decreased balance and a fall out of bed on September 24, 2013. The goal was to keep the resident free from falls. The interventions in place to prevent falls included a low bed. Every fifteen minute visual checks were added as an intervention to prevent falls on October 16, 2013. A Mini Motion Sensor (MMS - an alarm which is placed in a designated area and will sound when the path of the alarm is passed) to the door side of the resident's bed was added as an intervention to prevent falls on November 17, 2013. Review of an Event Report submitted to the State Survey Agency revealed that on November 22, 2013, at 3:15 a.m., the resident was seen falling to the floor outside of his room in the hallway. The resident's alarms were not sounding because the resident unclipped the Personal Body Alarm (PBA- an alarm which is clipped to the resident's clothing and alarms when a change in position occurs) and "stomped" on the mini-motions sensor alarm (MMS) that was on the floor near his bed because he "hated the sound." The resident urinated on the floor after arising from the bed (noted that the resident was last toileted at 2:00 a.m.) and then slipped on the floor bumping the left elbow against the hand rail and then falling to the floor onto his left side. Nursing noted that the resident was usually alert and oriented, but had been more confused lately. The resident sustained [REDACTED]. A STAT (immediate) X-Ray of the left hip was completed on November 22, 2013, and revealed a, "recent fracture neck of the left femur." The resident was admitted to the hospital with [REDACTED]. Further review of the clinical record revealed no documented evidence that every fifteen minute checks were completed as per the resident's care plan. Interview with the Assistant Director of Nursing on January 9, 2014, at 9:30 a.m., confirmed that every fifteen minute visual checks were to be documented on the designated form. Review of a nurse's note dated November 20, 2013, 5:15 a.m., indicated that the resident was rising without assistance two times and confusion was noted. The resident was assisted to the bathroom. An Occupational Therapy note dated, November 20, 2013, at 1:38 p.m., noted that the resident had increased agitation. A nurses' note dated, November 20, 2013, at 3:24 p.m., noted that the resident needs reminding to wait for staff before trying to get out of the wheelchair. An Occupational Therapy note dated, November 21, 2013, at 2:26 p.m., noted that the resident complained of difficulty seeing. The last nurses' note prior to the resident's fall on November 22, 2013, was at 11:40 p.m., on November 21, 2013, which noted that the resident was resting quietly in the recliner chair with his feet up per his request. The alarms were noted to be in place and working. Review of the facility Incident/Accident Report dated, November 22, 2013, revealed that the resident was last toileted at 2:15 a.m. The results of the toileting (which was to be filled in) was left blank on the form. The report noted that the resident was sleeping prior to the fall, rose without assistance, and stated that he was, "going to see mom." There was no indication on the report of what time the resident was last seen sleeping. A review of witness statements regarding the fall with injury revealed only one witness statement. There were no statements from staff who had actually provided care to the resident or actually observed the resident prior to the fall and at what time. The only attached statement was from Employee 3 (Registered Nurse) which noted that the resident was observed in the hall and Employee 3 started up the hall towards the resident, but the resident fell to the floor before the nurse was able to reach him. Employee 3 did not recall hearing an alarm and found the resident's MMS damaged and torn from the tape, which had been holding it in place, on the floor. The resident stated that he stepped on the alarm. Interview with Employee 3 on January 8, 2014, at 9:15 a.m., confirmed that the resident had intermittent confusion, was known to have behaviors which included attempting to transfer without assistance, and did not always sleep at night. Interview with the Director of Nursing on January 8, 2014, at 10:00 a.m., confirmed that the resident was at risk for falls and the resident's care plan was to be implemented to ensure resident safety. Observation of the East Nursing Unit on January 6, 2014, at 10:15 a.m., revealed that Resident 31 had a Mini Motion Sensor alarm on the door side of his bed. This surveyor accidentally tripped the alarm and the alarm sounded approximately five minutes with no staff responding to this alarm. The surveyor had to locate a staff member in the hallway to turn the alarm off. During an interview on January 8, 2014, at 10:00 a.m., the Director of Nursing was unable to explain why the staff did not respond to the resident's alarm in a timely manner. Observation of the West Nursing Unit on January 6, 2014, at 3:30 p.m., revealed that a wheelchair scale was left in the hallway and obstructed access to the handrail. Resident 50 was unable to access the handrail and was observed attempting to get around the scale to self-propel down the hall. Interview with Resident 50 on January 8, 2014, at 1:00 p.m., revealed that the resident enjoyed self-propelling his wheelchair and depended on the handrail to assist with propelling his wheelchair. An observation of the shower room on the West Nursing Unit on January 6, 2014, at 9:30 a.m., revealed a tube of skin protective ointment and a tube of Calmoseptine ointment on top of the back of the toilet. The labels on both of the ointments indicated that they are to be used for external use only. Interview with the Director of Nursing on January 8, 2014, at 10:00 a.m., confirmed that the ointment used for external use only, should be stored in a locked area and not accessible to residents. Refer to F520 483.25 (h) Free of Accident Hazards/Supervision/Devices Previously cited 2/14/13 28 Pa Code 207.2 (a) Administrator's responsibility Previously cited 2/14/13 28 Pa Code 211.11(d)(e) Resident care plan 28 Pa Code 211.12 (a)(c)(d)(5) Nursing services Previously cited 2/14/13, 3/16/12

Based on clinical record and Incident/Accident report review, resident and staff interview, and observation, it was determined that the facility failed to provide adequate supervision and/or implement effective safety interventions to prevent falls and injury for one of 21 sampled residents (Resident 72) and failed to maintain the residents' environment free of potential accident hazards. Findings include: A review of the clinical record revealed that Resident 72 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set Assessment (MDS - a standardized assessment completed at specific times to identify resident care needs) dated June 15, 2012, and a quarterly MDS assessment dated [DATE], revealed that the resident was cognitively impaired, required staff assistance for activities of daily living, including the assistance of one staff for transfers and ambulation. A review of the resident's initial care plan dated June 27, 2012, revealed that one of the problematic areas was her cognitive functioning, due to a deficit in memory, judgment, decision-making and thought process related to memory loss, confusion/disorientation, periods of restlessness and not responsive to alternate interventions. Another problematic area was her potential for elopement related to her exit-seeking behavior. A third area of concern was Resident 72's function for mobility related to her decreased balance. Interventions at the time of her admission for these at-risk areas included the following: allowing for periods of rest when fatigued, administering the medication Ativan as needed (an anti-anxiety medication prescribed for her periods of anxiousness and restlessness), providing her with word search puzzle books, redirection, safety interventions to include door alarms, 15 minute visual checks, anti-rollback system to wheelchair, bilateral mini-motion sensor alarms while in bed, right side floor fall mat, low bed, Velcro-alarmed seat belt (self-releasing belt) while in her wheelchair and recliner, and out of her room when in her wheelchair. A review of an initial "Fall Risk Evaluation" dated June 8, 2012, revealed that Resident 72 received a score of ten, which indicated that the she was at high risk for falls. Subsequent "Fall Risk Assessments" dated September 12, 2012, December 12, 2012, and January 30, 2013, all indicated that the resident's gait was unsteady, the resident lacked the awareness to use handrails or arm rests and, and could not transfer safely without assistance or supervision. A review a "Safety Interventions Not Classified as Restraints" form dated June 12, 2012, revealed that an alarm Velcro belt be attached to the resident while in her wheelchair and recliner secondary to her frequent independent transfers from her wheelchair. The form also indicated that the resident is confused and has no understanding of the call bell. A review of a "Therapy Needs Identification Checklist" dated June 21, 2012, identified that the resident "had many independent rising/ambulation attempts-safety issue. The checklist also indicated that the resident has now figured how to release the belt (alarmed Velcro seat belt), stand without assistance, reattach the belt, and ambulate before staff can get to her or even know she is getting up - question use of lap buddy (a type of preventative device positioned in a chair to prevent the person from rising)or sensor cushion." A review of a social worker's notes dated June 11, and 14, 2012, indicated that the resident is unaware of safety considerations and unable to remember to ask for assistance. "Safety interventions in place, plan continues to be developed with therapy." A review of the nursing documentation found in the "Nurses Record" from June 13, 2012, at 2:30 p.m. through February 9, 2013, at 4:15 p.m., indicated similarly documented behavior that included the following: "resident pulling on Velcro belt apart, attempting to stand....resident removing Velcro on wheelchair....continuously removing Velcro alarm and attempting to stand....resident noted to remove alarm belt, stand up and reattach alarm to wheelchair to turn off....removed alarm belt several times and said I have to get up....resident unhooking Velcro belt continually and trying to stand, one-to-one and redirect ineffective, Ativan given with effectiveness noted....standing up after removing alarm two times....resident awake at nurses station removing her belt and attempting to stand, all interventions ineffective Ativan given." Examples of these types of behavior were noted by nursing staff on 83 occasions and documented in the resident's clinical record. A review of a nurses' note dated January 19, 2013, at 7:30 p.m., and a corresponding I/A Report revealed that the resident was observed removing the sounding Velcro alarm belt, had made two attempts to stand up in the wheelchair and that the nurses aide were unable to get to the resident in time before falling in the hallway. Recommendations at the time included toileting the resident every two hours while awake and obtaining a urinalysis. A review of a nurses' note dated January 20, 2013, at 7:30 a.m., and a corresponding I/A Report revealed that the resident was found on the floor in the hallway in front of her wheelchair with the Velcro alarm sounding. The report indicated that the resident's was agitated and removing her seat belt prior to the event (fall). Recommendations at the time included starting an antibiotic for a urinary tract infection and hot rack charting for effectiveness (a method used to chart/document a specific infection, injury and/or unusual behavior for a designated time period). As a result of this fall a "Therapy Referral Form" dated January 20, 2013, was completed and sent to therapy. On the form, it was noted that the resident's family questioned if the belt (Velcro alarm belt) could be changed so the resident would not be able to take it off. A review of a nurses' note dated February 1, 2013, at 4:00 p.m., and a corresponding I/A Report revealed that the resident was observed sitting on the floor in the hall with her alarm sounding. She stated she had to go the bathroom. No new interventions were implemented at the time. A review of a nurses' note dated February 8, 2013, at 12:45 p.m., and a corresponding I/A Report revealed that the resident was observed in her room on her knees in front of her wheelchair with the alarm sounding. The resident was unable to verbalize what she was doing. Recommendations at the time included starting a bladder diary and checking with the physician for a treatment plan. A review of nurses' note dated February 8, 2013, at 9:25 p.m. that at 7:59 p.m., the resident was frequently removing the the alarm belt and looking for her husband. The resident was toileted, ambulated, given p.m. care and a snack - these interventions were ineffective and Ativan was given at the time according to nursing documentation. A review of a nurses' note dated February 9, 2013, at 4:15 p.m., and a corresponding I/A Report revealed that the resident was observed (by other residents) undoing her Velcro alarm belt while in the activity room and standing up to pick up a piece of paper on the floor and placing it on the table. She then took a few steps and fell backwards hitting her head on the stove. The incident/accident report revealed that another resident in the activity room pushed the call bell and then went out into the hall to alert staff that the resident had fallen. The report also indicated the resident was left unsupervised in the activity room with no staff supervision present. At the time of the fall, the nursing documentation indicated that the resident did not complain of pain and the only mark was a bruise on her right thumb. On a February 11, 2013, 2:44 p.m. a nurse noted that the resident complained of right hip pain. The doctor was notified and an order to x-ray the right hip, pelvis and lower back was obtained. At 6:06 p.m., Mobilex (mobile x-ray agency) arrived; however, resident was unable to lay flat for x-ray due to pain. Physician ordered resident to be transferred to the hospital emergency room . At 11:01 p.m., the hospital called to inform the facility that the resident was admitted to the hospital due to a fractured pelvis. Interview on February 14, 2013, from 9:05 a.m. through 9:18 a.m., with two alert and oriented residents (Residents 46 and 9) who were present at the time of Resident 72's fall, indicated that they had observed Resident 72 remove her Velcro alarm seat belt and that they had attempted to dissuade her from unbuckling it. The residents stated that Resident 72 was sitting alone at the table with no staff visible in the room. They also stated that the resident's alarm sounded. One resident (Resident 46) activated the call bell and then went out to the hall way to alert staff, since no staff responded to the call bell and/or alarm. The alert and oriented residents could not say how long it took for staff to respond; however, they said it was "a while." A review of the minutes from the May 25, 2012, Residents' Council Meeting, revealed that the residents in attendance had concerns with the untimely staff response times to the activity room call bell. Interview with the Activities Director on February 14, 2013, at 11:40 a.m., confirmed that on February 9, 2013, at 2:00 p.m., Resident 72 attended bingo. The activities director stated that the bingo activity probably concluded around 3:00 p.m. Nursing documentation indicated that the resident routinely displayed the unsafe behavior of attempting to or releasing the Velcro alarm seat belt to stand up and/or ambulate. The facility failed to adequately supervise the resident when exhibiting this behavior and/or consider an alternate intervention as a safety measure to prevent potential accidents. There was no evidence that the facility staff had insured the supervision of the resident when the activity had concluded on February 9, 2013. Interview with the nursing home administrator (NHA) and director of nursing (DON) on February 14, 2013, at approximately 9:40 a.m., confirmed that Resident 72 frequently exhibited unsafe behaviors and that the resident was uncooperative at times. The facility failed to provide evidence that this resident, identified at risk for falls and poor safety awareness, which was known to the facility, was provided with adequate staff supervision and timely intervention to prevent this fall with serious injury. During an observation and interview with Resident 102 on February 13, 2013, at 1:40 pm, the resident's motion sensor alarm was inadvertently activated by this surveyor when crossing the path of the alarm's range to speak with the resident. The alarm sounded for approximately 45 seconds and then stopped. No staff responded to the alarm. The alarm again sounded after interviewing the resident and again staff did not respond. The resident stated that it was not uncommon for staff to not respond to the alarm. Interview with the administrator on February 13, 2013, at 2:00 pm, confirmed that the resident was a fall risk and that staff were to timely respond to alarms. During initial tour on February 11, 2013 at 10:30 AM, of the facility's East side, revealed numerous potential accident hazards were found in the resident shower room. The potential hazards were found in an unlocked cabinet in an unlocked shower room across from the West side nurses station. They included a can of Tresemme hair spray, six bottles of McKesson shampoo and body rinse, a tube of Covilon cream, five tubes of McKesson ointment one tube of Tena protective cream, a can of shaving cream and a bottle of Frenze Breeze detergent disinfectant, all items were labeled for external use only. Other potential hazards included approximately 20 disposable razors and 40 wooden nail sticks. During an interview with the Nursing Home Administrator on February 12, 2013 at 9:00 AM confirmed that the above potential hazards should have been locked away for the residents' protection. 28 Pa code 211.12 (a)(c)(d)(3)(5) Nursing services Previously cited 3/16/12 28 Pa code 207.2 (a) Administrator's responsibility

Based on review of clinical records and select Incident and Accident Reports, and staff interviews it was revealed that the facility failed to provide safe individualized care in a manner and environment free of potential accident hazards, which resulted in an accident with significant injury to one resident out of 19 sampled (Resident 65) Findings include: Review of Resident 65's clinical record, revealed that the resident was admitted to the facility on [DATE], had multiple [DIAGNOSES REDACTED]. According to her admission Minimum Data Set (MDS) assessment dated [DATE], the resident was cognitively intact and required set up assistance with transfers and toilet use and one person physical assistance with bathing/hygiene and dressing. Review of an Incident/Accident Report, dated 11/29/10 at 9:50 AM, revealed that the resident was receiving morning care from a nurse aide in the resident's bathroom. The nurse aide was taking the resident's walker away when the resident went to reach for the safety bar, lost her balance, then grabbed for the overbed table (on wheels) which slid to the wall, causing the resident to fall. Further review of the Incident/Accident Report revealed that after the resident was transferred to the commode, she then complained of pain in her right hip area and at this time she was transported to the hospital. Review of the radiology report from the hospital, dated November 29, 2010, revealed that the resident sustained [REDACTED]. Interview with Employee 7 (nurse aide) on February 23, 2011, at 11:00 AM, stated that while she was providing AM care to the resident (which consisted of washing, toileting, dressing and dental care) and the resident stood from the commode, reached for the safety bar and missed. The resident then grabbed the wheeled bedside table that was in the bathroom; when the table slid away, that caused the resident to fall to the floor. Employee 7 stated that during AM care, she places the resident's supplies (body wash, washcloth, basin, deodorant and powder) on the bedside table (overbed table that is on wheels) and brings it into the bathroom while providing care. She stated that this method was the protocol while providing morning care to residents. When asked why the wheeled bedside (overbed) table was brought into the bathroom with the resident, she stated that she was trained to bring the table into the bathroom to hold the AM care supplies. The facility's policy, reviewed by the facility November 12, 2010, entitled, Bath, Partial, did not indicate that staff were to utilize wheeled bedside tables in the bathroom while providing care to residents. During an interview on February 25, 2011 at 10:00 AM, with the Administrator and Director of Nursing both acknowledged that the above practice is not in their policy, but that it was considered to be a past practice. Interview with Employee 8 (Certified Occupational Therapy Assistant) on February 25, 2011, at 11:10 AM, revealed that when she provides AM care to Resident 65, that the resident is able to sit at the edge of the bed while participating in AM care, for approximately 10 minutes, any longer than that, the resident complains of pain, at that time the resident is placed in her wheelchair to complete her care. Employee 8 stated that she would not recommend that the nurse aides provide daily care to the resident while she is on the edge of her bed or while on the commode nor would she recommend that the nurse aides bring a wheeled bedside table into the bathroom with the resident. Employee 8 stated that she recommends that the resident receive care while the resident is in her wheelchair and that she considered providing care while the resident was on the commode an unsafe act. 28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services. Previously cited 1/22/10