Every finding on record at Gino J Merli Veterans Center

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen four employees out of five newly hired employees to ensure they were eligible for employment in a long term care facility. (Employees 1, 2, 3, and 4).Findings include: According to regulatory requirements, the facility must have written procedures for screening prospective employees to include, but are not limited to, review of the applicant's employment history (e.g., dates of employment and position or title), particularly where there is a pattern of inconsistency; obtaining information from former employers, whether favorable or unfavorable; and obtaining documentation regarding licensure status and any disciplinary actions from licensing or registration boards and other registries. A review of the facility's policy titled Resident Abuse, last reviewed by the facility on August 27, 2025, revealed the facility is required to screen potential employees to determine their appropriateness for working with individuals who have specific conditions and needs. The policy included obtaining references from previous and current employers. A review of employee personnel files revealed the following: Employee 1 (Licensed Practical Nurse): Hired on March 16, 2026. The employment application listed previous employers; however, there was no documentation to show the facility contacted any former employer to screen the individual and ensure the individual was eligible for employment in a long term care nursing facility. Employee 2 (Nurse Aide): Hired on March 16, 2026. The employment application listed previous employers; however, there was no documentation to show the facility contacted any former employer to screen the individual and ensure the individual was eligible for employment in a long term care nursing facility. Employee 3 (Licensed Practical Nurse): Hired on March 30, 2026. The employment application listed previous employers; however, there was no documentation to show the facility contacted any former employer to screen the individual and ensure the individual was eligible for employment in a long term care nursing facility. Employee 4 (Nurse Aide): Hired on March 30, 2026. The employment application listed previous employers; however, there was no documentation to show the facility contacted any former employer to screen the individual and ensure the individual was eligible for employment in a long term care nursing facility. During an interview conducted on April 9, 2026, at 1:15 PM, the Director of Nursing (DON) was unable to provide evidence that prior employers were contacted to verify past work history for four of five newly hired employees. The facility failed to follow its abuse prohibition policy, which required verification of previous employment. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.19 (1) Personnel records.

Based on clinical record review, information submitted by the facility, and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect the resident's current needs and services required for one of 35 residents reviewed (Resident 25). Findings include: Review of the clinical record of Resident 25 revealed the resident was admitted to the facility on December1, 2022, with diagnoses to include Parkinson's disease (a progressive neurological disorder that affects movement, cognition, and behavior). A quarterly Minimum Data Set Assessment (MDS, federally mandated assessment of a resident's functional abilities and care needs) of Resident 25 dated February 17, 2026, indicated the resident was moderately cognitively impaired with a BIMS (brief interview for mental status) score of 9 (8-12 represents moderately, cognitively impairment). The MDS indicated the resident exhibited verbal behavioral symptoms directed toward others on 1 to 3 days during the assessment look-back period. A review of facility investigative documentation dated January 13, 2026, indicated staff identified Resident 25's lower dentures were missing during care. The investigative documentation indicated nursing and social services staff searched the resident's room and wheelchair, checked the clean utility room, and contacted the outside laundry service; however, the dentures were not located. The investigative documentation further noted Resident 25 had a history of placing personal items in tissues and discarding them, placing items on his lunch tray and placing items in food containers such as cereal or milk cartons. The facility replaced the missing dentures. A review of Resident 25's comprehensive care plan revealed a focus area for Activities of Daily Living (ADLs, routine daily care activities such as eating, dressing, and personal hygiene) initiated December 1, 2022, and reviewed December 1, 2025, documented the resident was edentulous (without natural teeth) and used upper and lower dentures. Interventions included removing dentures in the evening, applying dentures in the morning, and cleansing and storing dentures according to resident preference. A review of the care plan focus area for behaviors, initiated December 2, 2022, and revised February 17, 2026, documented behaviors including poor impulse control, throwing objects, activating alarms, kicking staff, grabbing staff hands, attempting to strike staff, and interfering with care. The care plan did not include individualized interventions addressing the behavior identified in the January 13, 2026, investigative documentation related to placing personal items in tissues or food containers, which created a risk for loss of dentures. There was no documented evidence that the interdisciplinary team reviewed or revised the comprehensive care plan after the January 13, 2026, investigative documentation to evaluate whether interventions were needed to address the identified behavior affecting denture management. During an interview on April 10, 2026, at approximately 11:00 AM, the Director of Nursing confirmed the facility had not revised the resident's care plan to address the behavior identified in the investigative documentation related to denture loss. 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 the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and implement nutritional interventions for one resident out of 3 residents reviewed for nutrition (Resident 63).Findings include: A review of a facility policy entitled Weight Monitoring last revised by the facility August 27, 2025, indicated each residents' weight will be monitored by the interdisciplinary team and residents with patterned or significant weight changes will be assessed as indicated. Interventions to address nutritional issues will be initiated and incorporated into the residents' care plan and re-evaluated on a timely and periodic basis. Monthly weights will be obtained by the nursing team during the first 5 business days of the month. Any resident, weighing 100 pounds or greater, with a weight change of greater than or equal to 5 pounds or more will be re-weighed the same day for verification of weight change.The Registered Dietitian (RD) will document any significant monthly weight changes with appropriate interventions and update care plans as appropriate and re-evaluate and reassess as needed. Any significant weight changes (gain or loss) will be conveyed to provider. A review of the clinical record revealed Resident 63 was admitted [DATE], with diagnoses including chronic heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's oxygen and circulation needs), vitamin B12 deficiency anemia (a condition in which the body does not have enough healthy red blood cells due to lack of vitamin B12), and adjustment disorder with depressed mood (a mental health condition characterized by emotional or behavioral symptoms in response to a stressful event). A review of the resident's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 4, 2026, revealed that Resident 63 had severe cognitive impairment with a BIMS score of 6 (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 zero (0) through 7 indicates severe cognitive impairment). Section K0200 (Height and Weight) documented a height of 65 inches and weight of 173 pounds. Section K0300 (Weight Loss) documented that the resident experienced a significant weight loss of five percent or more in one month or ten percent or more in six months that was not physician prescribed. The facility identified a significant weight change on February 3, 2026. The Registered Dietitian completed a comprehensive nutrition evaluation on February 10, 2026, which included assessment of the resident's nutritional status and recommendations to address the identified weight loss. A review of the resident's weight record revealed that on January 3, 2026, the resident weighed 186.4 pounds, and on February 3, 2026, the resident weighed 172.8 pounds, representing a 13.6 pound (7.3 percent) significant weight loss within one month. A review of an annual comprehensive nutrition evaluation completed by the facility's Registered Dietitian (RD) on February 10, 2026, at 11:52 AM, seven days after the identified significant weight loss, documented a summary of clinically significant weight changes as follows: January 3, 2026, weight was 186.4 pounds, reflecting a 13.6 pound (7.2 percent) loss in 30 days. November 5, 2025, weight was 188 pounds, reflecting a 15.2 pound (8 percent) loss in 90 days. and August 4, 2025, weight was 193.6 pounds, reflecting a 20.8 pound (10.7 percent) loss in six months. The RD documented the resident's diet consistency had been downgraded during the previous quarter and identified a nutrition diagnosis of increased calorie and protein needs related to variable dietary intake ranging from 0 percent to 100 percent of meals consumed, slight congestion (mucus accumulation that may affect appetite or breathing), and increased lethargy (fatigue or decreased energy level). A review of the comprehensive nutrition evaluation revealed the RD recommended liberalizing Resident 63's diet (removing dietary restrictions to encourage improved intake), discontinuing the consistent carbohydrate diet (a diabetic diet used to manage blood glucose levels), initiating Boost Glucose Control (a high calorie, high protein oral nutritional supplement used to improve nutritional intake and assist with blood sugar control) twice daily at afternoon and bedtime snack, and implementing weekly weights to monitor for additional weight changes. During an interview with the Food Service Director/Registered Dietitian on April 9, 2026, at 11:26 AM, the above findings were reviewed. No explanation was provided as to why Resident 63's significant weight loss identified on February 3, 2026, was not addressed until February 10, 2026, seven days after the weight was obtained and recorded. During an interview with the Director of Nursing on April 9, 2026, at 1:00 PM, the above findings were reviewed. The Director of Nursing reported the facility weight team (nurse aides and licensed nurses) obtains resident weights and the Registered Dietitian reviews weights for significant changes and communicates concerns to the interdisciplinary team during morning meeting. The Director of Nursing was unable to provide an explanation for the seven-day delay in implementing nutritional interventions following identification of significant weight loss and confirmed the findings. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on clinical record review, facility policy review, resident observation, and staff interviews, it was determined that the facility failed to ensure residents' drug regimens were free from unnecessary medications by administering duplicate antipsychotic therapy without documented clinical justification, and by failing to attempt gradual dose reductions where appropriate, for two residents (Residents 9 and 38). Findings include: A review of the facility policy titled Behavior Management Program, last reviewed in September 2024, revealed that the facility recognizes the importance of ensuring each resident's drug regimen is free from unnecessary medications. Accordingly, the interdisciplinary team will evaluate the resident's response to psychotropic medications on an ongoing basis. This evaluation will include, but is not limited to, monitoring the resident's mood and behaviors, assessing for side effects, and reviewing the outcomes of both pharmacological and non-pharmacological interventions. Mood and behavior monitoring will be documented in the resident's electronic medical record by nursing staff, and additional clinical progress notes will be entered by other interdisciplinary team members as needed. A review of Resident 9's clinical record revealed admission to the facility on [DATE], with diagnoses to include schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 20, 2025, revealed the resident was moderately cognitively impaired with a BIMS score of 12 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information a score of 08-12 indicates moderate cognitive impairment). Physician's orders dated January 14, 2025, revealed the resident was prescribed: Ativan (an anti-anxiety medication) 0.5 mg three times daily, Fluvoxamine (an antidepressant) 50 mg at bedtime, Seroquel (an antipsychotic) 400 mg at 8:00 a.m. and 425 mg at 4:00 p.m., and Haldol (an antipsychotic) 5 mg at bedtime. Review of the resident's clinical record revealed an antipsychotic medication review dated March 6, 2025, listing all four medications above. The review included a checked box stating that a dose reduction was contraindicated because the benefits outweighed the risks and that a reduction would likely impair the resident's function and/or cause psychiatric instability. However, the review lacked resident-specific documentation to support this assertion. There was no individualized clinical rationale provided to explain why a GDR had not been attempted for either Seroquel or Haldol, nor was there justification for the concurrent use of two antipsychotic medications. At the time of the survey ending June 6, 2025, there was no documentation from the physician to support the absence of a GDR attempt, nor any rationale substantiating the need for ongoing duplicate antipsychotic therapy in Resident 9's drug regimen contained in the clinical record. An interview with the Director of Nursing (DON) on June 6, 2025, at 9:30 a.m., confirmed the facility was unable to provide evidence the physician had documented a resident-specific justification for continued antipsychotic use at current dosages or for the necessity of prescribing both Seroquel and Haldol concurrently. The DON also confirmed that no GDR had been attempted. Clinical record revealed that Resident 38 was admitted to the facility on [DATE], with diagnosis to include Alzheimer's disease/Dementia (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks. It is the most common cause of dementia), anxiety, and the resident was also receiving hospice care. The documented hospice admitting diagnosis was end stage heart failure (heart failure occurs when the heart cannot pump enough blood to meet the body' s needs). A quarterly Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], identified the resident as severely cognitively impaired and noted behavioral symptoms including fidgeting, restlessness, and difficulty concentrating. Admission Physicians orders dated December 30, 2024, included Seroquel (an antipsychotic medication) 25 mg by mouth at night for dementia. A review of the Abnormal Involuntary Movement Scale (AIMS) assessment, dated December 30, 2024, revealed that Resident 38 did not exhibit any extrapyramidal symptoms upon admission to the facility. The AIMS is a 12-item, clinician-rated tool used to assess the severity of dyskinesia in patients taking neuroleptic (antipsychotic) medications. It specifically evaluates involuntary movements such as oral-facial tics (e.g., lip smacking, tongue thrusting), extremity and truncal movements (e.g., abnormal posture, pill-rolling with fingers, shuffling gait), and includes ratings for overall severity, level of incapacitation, the patient's awareness of the movements, and any distress they may be experiencing as a result. Between January 1 and February 4, 2025, nursing documentation described behavioral expressions such as throwing dishes, attempting to exit her Broda chair, and verbal outbursts during care. The record noted that Resident 38 sustained two falls from bed in early January. On February 4, 2025, a hospice nurse and the facility's LPN (Employee 1) discussed the resident's behaviors, resulting in a request by the facility LPN for Haldol 1 mg twice daily. A facility Certified Registered Nurse Practitioner (CRNP) subsequently ordered Haldol 1 mg twice daily for dementia. A hospice nursing note dated February 11, 2025, documented that Employee 1 (LPN) requested an increase in Haldol to three times daily. The CRNP issued a new order on February 11, 2025, for Haldol 1 mg three times daily. Behavioral documentation on and after that date noted persistent agitation throwing the blanket off of her, covering her face with her hands and repetitive verbalizations about her husband, but no objective evidence was provided to support the escalation. On February 13, 2025, despite no documented behavioral episode, hospice recommended increasing Seroquel to 50 mg twice daily, more than double the original dose, resulting in duplicate antipsychotic therapy. Resident 38 sustained another fall on February 15, 2025, after attempting to exit her Broda chair unsafely. Nurses' notes continued to reflect persistent behaviors despite the increased psychoactive medications. On February 20, 2025, the CRNP doubled the Haldol dose to 2 mg three times daily. However, documented behaviors persisted without documented evidence of benefit or clinical reassessment. Nursing documentation continued to reflect persistent behavioral symptoms, including restlessness, throwing blankets, and calling out, through the date of survey. There was no evidence of hallucinations, delusions, or other psychotic symptoms that would warrant the use of antipsychotic medications as a treatment modality. Observation of the resident on June 6, 2025, at 10:00 AM revealed extrapyramidal symptoms, specifically pill-rolling movements of the fingers, which are known adverse effects of antipsychotic drugs. There was no evidence in the clinical record that the resident's medication regimen was reassessed in response to these symptoms. Despite the use of antipsychotic medications, the clinical record lacked evidence that the facility attempted behavioral strategies to address the resident's symptoms prior to initiating or escalating pharmacologic treatment. There was no documentation indicating that nonpharmacological approaches were trialed or considered and determined to be ineffective or inappropriate. In the absence of such efforts, the facility did not demonstrate that medication was necessary to manage the resident's condition. Furthermore, there was no clinical rationale provided by the prescriber explaining why alternative, less restrictive measures were not suitable. Without documentation supporting that behavioral interventions were ruled out as ineffective or clinically inappropriate, the facility failed to justify the necessity of the antipsychotic medication regimen. During an interview on June 6, 2025, at 11:00 AM, the Director of Nursing confirmed that there was no physician documentation supporting the clinical need for duplicate antipsychotic therapy or the repeated increases in dosage for Resident 38. Despite the resident's hospice status, the increased use of Haldol and Seroquel was directed at managing behavioral expressions of cognitive impairment rather than addressing terminal agitation or psychiatric symptoms, without evidence of individualized assessment or consideration of alternative strategies. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.2 (3) Medical Director 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, a review of clinical records, select facility policies, documentation provided by the facility, and resident and staff interviews, it was determined that the facility failed to adequately assess a resident's safety needs and implement adequate safety measures for a resident identified as at risk for falls, including a fall with multiple abrasions and a cervical spine fracture for one out of three residents sampled (Resident 1) which caused actual harm. Findings include: A review of the facility policy titled Fall Prevention Program, last reviewed by the facility June 4, 2024, revealed it is the policy of the facility to assist in fall management and prevention, reducing the risk of serious injury from falls while in conjunction optimizing each resident's freedom of mobility and/or using the least restrictive method supporting resident mobility and quality of life. The policy indicated the falls prevention program is a full-facility program including active engagement by all disciplines 24 hours a day, seven days a week. Also, the policy indicated therapy will screen all residents upon readmission to review for fall risk factors. The policy indicated a fall risk acuity observation will be completed in the electronic health record (EHR) by the licensed staff nurse upon resident readmission for all nursing care residents. Furthermore, the policy indicated an individualized, person-centered nursing care plan will be initiated and/or updated by the interdisciplinary team upon readmission. A review of the facility policy titled Wheelchair Use, last reviewed by the facility on November 4, 2024, revealed it is the facility's policy to support residents in achieving or maintaining their highest practicable physical, mental, and psychosocial well-being by encouraging their independence and assisting them with their mobility and seating needs. The policy indicated occupational therapy will determine if leg rests (support devices on wheelchairs that support the lower legs/feet and prevent slipping) are required at all times during transport on or off the unit and will determine if one or two leg rests are required for all residents utilizing a wheelchair. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (gradual loss of kidney function), dependence on renal dialysis, and an acquired absence of the right leg below the knee. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2025, revealed that Resident 1 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A physician's order for Resident 1 to receive Acetaminophen 325 mg with directions to administer two tablets (650 mg) as needed for mild pain 1 through 4 initiated on July 19, 2022. A physician's order for Resident 1 to receive Tramadol (an opioid pain medication used to treat moderate to severe pain) tablet 50 mg with directions to give as needed for pain or discomfort level 4 through 10 initiated on July 1, 2024. A care plan indicated Resident 1 is at risk for injury from falls initiated on June 24, 2019. Interventions implemented to assist Resident 1 to be free from injury include a wheelchair with leg rests for transportation and PRN (as needed) implemented on March 10, 2023. During an interview on May 13, 2025, at approximately 12:55 PM, the Director of Rehabilitation Services explained the intervention for as-needed leg rests: leg rests should be utilized when being pushed by facility staff and not self-ambulating on and off the nursing unit. An external hospital discharge document dated April 26, 2025, at 3:10 PM, revealed Resident 1 was admitted to the hospital on [DATE], with shortness of breath. He was diagnosed with acute hypoxic respiratory failure (lungs are unable to adequately transfer oxygen into the blood, resulting in low blood oxygen levels), likely secondary to heart failure exacerbation. The resident underwent a bilateral thoracentesis (a medical procedure where a needle is inserted into the area between the lungs and the chest wall to remove fluid) on April 25, 2025. Two liters of fluid was drained from the right side of his lungs, and one and a half liters of fluid was drained from the left side of his lungs. Resident 1 was to be discharged back to the facility according to this hospital record review. The external hospital discharge document dated April 26, 2025, indicated, Special Instructions: Use caution when standing or walking since you are at an increased risk for falls. A review of a progress note dated April 26, 2025, at 5:15 PM, revealed that Resident 1's vital signs were recorded as follows: temperature 98.4°F, pulse 60 beats per minute, and respirations 20 per minute. The note documented that the resident had multiple discolored areas on both the right and left arms, which were noted as possibly resulting from intravenous access sites and blood draws during his recent hospital stay. The resident denied experiencing pain to those areas. Two dressings were observed to be intact on the right and left back. The note indicated that the Certified Registered Nurse Practitioner (CRNP) had been made aware and would assess the resident on April 28, 2025. Additionally, the resident was noted to have an 8.2 cm x 4.0 cm bruise on the left abdomen and a 15.2 cm x 6.0 cm bruise on the right abdomen, with no reported pain. The note documented that a call was placed to the discharging hospital to obtain discharge orders and a summary. The resident was documented as being in bed and resting, with a weight to be obtained. A review of the clinical record revealed no other documented evidence of a comprehensive assessment of Resident 1's care needs upon return from the hospital, including any evaluation of fall risk or the need to update the resident's care plan. During an interview conducted on May 13, 2025, at approximately 1:45 PM, the Director of Nursing (DON) stated that she was unable to provide any documentation reflecting that the facility assessed Resident 1's clinical status or fall risk upon his return from the community hospital on April 26, 2025. A review of a progress note dated April 26, 2025, at 7:00 PM, indicated that Resident 1 sustained a fall from a wheelchair while being weighed. The note documented that the resident sustained a 0.1 cm x 0.1 cm area to the right pinky. The area was cleansed with normal saline and left open to air. Additional open areas were documented as follows: Left knee: 1.5 cm x 1.0 cm Left wrist, outer aspect: 2.5 cm x 1.5 cm Left hand, posterior aspect above right finger: 1.0 cm x 1.0 cm Right hand: 2.0 cm x 1.5 cm Right elbow: 2.0 cm x 1.5 cm Forehead: 0.1 cm x 0.1 cm Treatment orders included cleansing the areas with normal saline, patting dry, applying wound dressing and gauze, and wrapping the affected areas daily until healed. Two blood blisters noted on the mid-forehead were to be left open to air. The note further indicated that the resident's power of attorney and the Certified Registered Nurse Practitioner were notified of the event. Employee 1, Nurse Aide (NA), in a signed statement dated May 4, 2025, stated that on April 26, 2025, at approximately 6:45 PM, she was instructed by Employee 3, LPN, to weigh Resident 1 because he returned from the hospital. She stated she transferred him into the weighing chair, and he leaned forward and fell. Staff assisted him back to his personal wheelchair. During a telephone interview conducted on May 19, 2025 (completed on this date due to the inability to contact the employee during the survey), Employee 1, Nurse Aide (NA), stated that on the day of the incident, she transported Resident 1 from his bedroom to the facility's scale room. She reported that she and Employee 2, NA, utilized a sit-to-stand mechanical lift to transfer Resident 1 from his wheelchair into the scale chair. Employee 1 noted that Resident 1 was wearing his prosthetic leg at the time. She stated that safety devices, such as leg rests, were not transferred from the resident's personal wheelchair to the weight chair and confirmed that the weight chair did not have leg rests in place. Employee 1 explained that while she was pushing Resident 1 forward onto the wheelchair scale, his leg did a flop on the scale and he suddenly leaned forward and fell. She stated the incident occurred too quickly for her to stop him. Although she was unsure whether he struck the wall, she recalled seeing him on the floor asking for help. Employee 1 stated that following the fall, she observed skin tears on Resident 1's arms and a scrape on his forehead. She reported that nurses assessed the resident and that she assisted other staff in transferring Resident 1 back into his wheelchair. A witness statement dated April 26, 2025, provided by Employee 2, Nurse Aide (NA), revealed that on the evening of April 26, 2025, a nurse requested assistance in weighing Resident 1. Employee 2 stated that she assisted another nurse aide (Employee 1) in the process. After Resident 1 was placed on to the scale wheelchair, the other aide pushed him forward onto the scale. At that time, Resident 1 leaned forward and fell out of the chair. Employee 2 reported that she immediately left the room to seek additional help. During an interview conducted on May 13, 2025, at 10:41 AM, Employee 2, NA, stated that Resident 1 returned to the facility at approximately 6:00 PM on April 26, 2025, following a recent hospital stay. She reported that Resident 1 appeared weaker than usual and did not seem himself. Employee 2 stated that she and her coworker, Employee 1, NA, got Resident 1 out of bed and brought him into the designated weighing room. She confirmed that they transferred him from his personal wheelchair into the facility's designated weight chair, which did not have any safety features such as leg rests. Employee 2 stated the facility does not routinely transfer leg rests or other safety devices from residents' personal wheelchairs to the weight chair. She recalled that as Employee 1 pushed the resident forward onto the scale, Resident 1 fell forward and struck his face against the wall. According to Employee 2, Resident 1 then called out, Get me up. I'm okay! She stated that she left the room to get help, while Employee 1 remained with the resident until licensed staff arrived to assess him. A witness statement dated April 26, 2025, provided by Employee 3, Licensed Practical Nurse (LPN), revealed that on April 26, 2025, she was called into the scale room while Resident 1 was being weighed as per protocol, following his return from the hospital. Upon entering the room, Employee 3 observed Resident 1 lying on the floor. She noted several areas of injury, including bleeding to the left wrist, left hand, right hand, right elbow, left knee, and forehead. Two blood blisters were also observed on the mid-forehead. Employee 3 stated that she notified the Registered Nurse Supervisor (RNS) and the Certified Registered Nurse Practitioner (CRNP) immediately. She indicated that the registered nurse assessed the resident at the scene, and Resident 1 was then assisted back into his wheelchair. Employee 3 reported that treatments for the injuries were initiated and in progress at the time of her statement. A witness statement dated April 26, 2025, provided by Employee 4, Nurse Aide (NA), revealed that while returning from the scale room, she heard another nurse aide calling for assistance. Upon entering the room, she observed Resident 1 rolling on the floor from front to back. She confirmed that two other nurse aides and an LPN were already present in the room. Employee 4 stated that Resident 1 was lifted from the floor and transferred back into his wheelchair using a mechanical lift. No additional details regarding the cause of the fall or the specific circumstances prior to her arrival were provided in her statement. A witness statement dated April 26, 2025, provided by Employee 5, Registered Nurse (RN), revealed that she was called to the unit by a nurse aide who reported that Resident 1 had fallen. Upon entering the scale room, Employee 5 observed that multiple nursing staff, including nurse aides and an LPN, were present. She noted that the weight scale had been moved forward by a nurse to create space for a full-body mechanical lift. Employee 5 reported that Resident 1 was lying on his back and partially on his right side on the window side of the bathroom, which is where the scale is typically stored. She observed multiple skin tears on both arms and the left knee. A bump was also noted on the mid-forehead. Resident 1 stated that he had leaned forward and fell. A neurological assessment was completed and found to be within normal limits. All visible wounds were treated with ointment and dressings. Employee 5 stated that the Assistant Director of Nursing (ADON) and the CRNP were made aware of the incident, and that the resident was assisted back into his wheelchair without any further complaints. A review of the facility's closed-circuit video footage on May 13, 2025, at approximately 1:30 PM, revealed that on April 26, 2025, Employee 1, NA, and Employee 2, NA, were observed entering the scale room with Resident 1. Resident 1 was being transported in his personal wheelchair into the scale room. Resident 1's personal wheelchair was observed with the safety leg rest attached. The resident transfer as described by Employee 2, NA, from his personal wheelchair to the facility weight chair was not observable in the video footage because the door to the scale room was closed. The fall event as described in the above witness statements was not observable because the door to the scale room was closed. Employee 2, NA, was seen exiting the room gesturing for assistance. When the shower room door was opened, Resident 1 was observed on the floor, and staff were seen entering and exiting the room. A review of post-incident documentation revealed that the resident sustained a cervical fracture due to the fall. A review of care plan interventions and physician orders did not include a directive to transfer the resident into an alternate chair for weighing, nor was there documented justification for not utilizing the resident's personal wheelchair during the use of the scale. No individualized safety measures were identified specific to the use of a scale in combination with his prosthetic limb. The facility utilized a [NAME] Lake 350-10-7 Single Ramp Wheelchair Platform Scale, a medical-grade device specifically designed to comply with accessibility standards under the Americans with Disabilities Act (ADA). ADA Accessibility Guidelines for Medical Diagnostic Equipment (MDE) require that such equipment accommodate individuals who use mobility devices, including wheelchairs and prosthetics, without necessitating an unsafe or burdensome transfer. The scale features a wide, low-profile platform with an integrated access ramp, enabling direct roll-on entry using the resident's own personal wheelchair. Maintaining the resident in their personal wheelchair is essential to prevent disruption of individualized positioning supports, such as properly adjusted backrests, lateral supports, and leg rests. These features are particularly critical for residents with lower-limb prosthetic devices, where improper seating or limb stabilization can lead to imbalance, shifting of the prosthesis, and increased fall risk. The use of an unfamiliar chair-such as a scale-assigned weight chair lacking individualized safety devices, such as leg rests, contradicts best practices for accessibility and resident safety, and violates the intended use of ADA-compliant scale equipment. Weighing procedures must ensure wheelchair brakes are engaged, prosthetic limbs are stabilized, and staff remain in attendance throughout the process. Failure to implement these precautions and utilize the scale as designed exposed Resident 1 to a preventable accident hazard. A progress note dated April 27, 2025, at 3:45 AM indicated resident complaints of 8 out of 10 generalized body pain unrelieved with rest, repositioning, or fluids. As needed, Tramadol (an opioid pain medication) was administered, and additional fluids provided. Resident repositions with head of bed elevated and all safety measures in place. A review of Resident 1's medication administration record (MAR) revealed he was administered Tramadol 50 mg at 3:34 AM on April 27, 2025, for a pain level 8 out of 10. A progress note dated April 27, 2025, at 5:33 AM indicated the as-needed Tramadol was effective for generalized body pain. Resident 1 had no complaints of pain or discomfort. Resident in bed, all safety measures in place. A review of Resident 1's medication administration record (MAR) revealed he was administered acetaminophen 650 mg on April 27, 2025, at 12:39 PM for a pain level 3 out of 10. A progress note dated April 27, 2025, at 1:09 PM indicated the Certified Registered Nurse Practitioner (CRNP) was made aware of resident complaints of pain. New physician's orders were indicated for an X-ray of the skull and neck, a complete blood count, and a basic metabolic panel. The note indicated the power of attorney was made aware. A progress note dated April 27, 2025, at 1:34 PM indicated as-needed Tylenol was ineffective. Resident 1 had complaints of pain on a rated 8 out of 10. Nonpharmacological interventions were also ineffective. The resident was administered Tramadol at this time. A review of Resident 1's medication administration record (MAR) revealed he was administered Tramadol 50 mg at 1:31 PM on April 27, 2025, for a pain level 8 out of 10. A progress note dated April 27, 2025, at 4:32 PM indicated x-ray results of the head and neck were received by the facility. A CT scan (computed tomography scan - a medical imaging technique that uses x-rays to create detailed, cross-sectional images of organs, bones, and soft tissue) is recommended for skull x-rays. No acute fracture or subluxation (a partial or incomplete dislocation of a joint, where the bones forming the joint are still partially in contact) by plain radiography (x-ray). Moderate cervical (related to neck or spine) degenerative changes on cervical x-ray. The CRNP was made aware, and a new physician order was noted to send Resident 1 for a CT scan. The note indicated the power of attorney was made aware. The resident indicated he had no pain while lying down but indicted he had pain on his left side when moved. The note indicated the resident had no pain or discomfort in his head or neck at this time. A progress note dated April 27, 2025, at 5:10 PM revealed Resident 1 left via stretcher to the community hospital. A review of community hospital documentation revealed a neurological consultation dated April 28, 2025, indicating the cervical spine CT imaging confirmed a Type 2 odontoid fracture (a bony extension on the C2 bone in the neck) with some posterior angulation (a bending or tilting of a bone or fracture fragment towards the back side) and also what appears to be a chronic [NAME] type fracture of C1 (a non-acute fracture in the C1/first bone in the neck). His neurologic examination was grossly normal. A community hospital consultation note dated April 28, 2025, at 10:20 AM, indicating impressions following CT imaging of spine included: 1. C1 anterior (front) arch fracture (C1 is a bone in the neck). Bilateral C1 posterior (back) arch fractures, which involve the expected bilateral vertebral artery course (path or trajectory of the vertebral arteries). 2. Type 2 odontoid process fracture (a bony extension on the C2 bone in the neck) with displaced/angulated fracture fragment. 3. No additional cervical spine fracture. The community hospital consultation note dated April 28, 2025, at 10:20 AM indicated Resident 1, a [AGE] year-old male, presented after a fall yesterday, striking his head. CT head showing a likely chronic [NAME] fracture and a Type 2 odontoid process fracture. Recommendations include no acute neurosurgical intervention required at this time, a soft collar (a soft cervical collar or neck brace is a device used to support the neck and limit movement) for three months, and follow-up outpatient 6-8 weeks with flexion-extension x-rays. A community hospital Discharge summary dated [DATE], indicated Resident 1 presented for evaluation following a fall from a chair to the scale. The summary included a report that the resident was dropped during this event. (It is unclear from the discharge summary where the allegation the resident was dropped originated. Documentation provided by the facility, interviews with Resident 1 and employees, and a review of clinical records regarding the incident revealed no clear evidence the resident was dropped. Instead, the investigation revealed the resident fell out of a wheelchair while being pushed on to a scale.) The discharge summary further noted the resident struck his forehead on a concrete wall, mostly landing on his right side. As per neurosurgery findings documented in the summary, a CT of the cervical spine showed a likely chronic [NAME] fracture and a Type 2 odontoid process fracture, with no neurological deficit. Recommendations from neurosurgery included a soft collar for 3 months and outpatient follow-up in 6-8 weeks with flexion-extension x-rays prior to the visit, with a follow-up visit scheduled for June 23, 2025. During a resident interview on May 13, 2025, at 1:20 PM, Resident 1 indicated on April 26, 2025, he returned from the hospital and needed to be weighed. He explained when the staff pushed him to the scale, he fell forward and hit his head off the wall. Resident 1 was not able to recall what wheelchair he was in when he was weighed that day. He was not able to identify any other factors that may have resulted in him falling. Resident 1 explained that ever since the fall, he has had neck pain. He described the pain as jolting and rated it as 10 out of 10. During an interview on May 13, 2025, at approximately 1:45 PM, the Director of Nursing (DON) confirmed is the facility's policy to adequately assess a resident's safety and care needs and implement adequate safety measures for a resident identified as at risk for falls. The DON confirmed that upon re-admission on [DATE], Resident 1's care needs should have been reassessed, including any changes to his fall risk acuity. The DON confirmed that upon readmission on [DATE], there was no documented evidence the facility assessed Resident 1's safety and care needs prior to his fall resulting in a cervical fracture and pain. The DON also confirmed the wheelchair from which the resident fell did not have a leg rest in place at the time of the fall. The facility's failure to reassess the resident following a significant change in condition, failure to ensure the use of appropriate assistive equipment consistent with the resident's physical needs, and failure to supervise the weighing procedure in a manner consistent with safe practices and the intended use of the ADA-compliant platform scale resulted in an avoidable fall and actual harm. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to include the resident's discharge planning in the comprehensive care plan of four residents out of 35 reviewed (Residents 6, 150, 11, 107). Findings include: A review of the clinical record revealed Resident 6 was admitted to the facility April 3, 2019, with a diagnosis to include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), diabetes )(body has trouble controlling blood sugar and using it for energy), and acquired absence of the right leg, above the knee (right lower leg amputation). Review of the quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 29, 2023, Section Q: Resident's Overall Goal for discharge: the resident expects to remain in this facility as per information provided by the resident. A review of Resident 6's comprehensive care plan conducted on August 14, 2024, revealed that the resident's current care plan did not address a discharge plan for the resident to remain in the facility for long term placement. A review of the clinical record revealed Resident 150 was admitted to the facility June 20, 2023, with a diagnosis to include atherosclerotic heart disease (build-up of plaque in the artery walls causing obstruction of blood flow), and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe). Review of the Significant Change in status MDS dated [DATE], Section Q: Resident's Overall Goal for discharge: the resident expects to remain in this facility as per information provided by the resident. A review of Resident 150's comprehensive care plan conducted on August 14, 2024, revealed that the resident's current care plan did not address a discharge plan for the resident to remain in the facility for long term placement. A review of the clinical record revealed Resident 11 was admitted to the facility June 29, 2018, with a diagnosis to include neurocognitive disorder with Lewy bodies (disease associated with abnormal deposits of protein in the brain), Parkinson's disease and schizophrenia. Review of a quarterly MDS dated [DATE], Section Q: Resident's Overall Goal for discharge: the resident expects to be discharged to the community as per information provided by the resident. A review of Resident 11's comprehensive care plan conducted on August 14, 2024, revealed that the resident's current care plan did not address a discharge plan for the resident to be discharged to the community. A review of the clinical record revealed Resident 107 was admitted to the facility April 20, 2021, with a diagnosis to include bipolar disorder, and atherosclerotic heart disease. Review of a quarterly MDS dated [DATE], Section Q: Resident's Overall Goal for discharge: the resident expects to remain in the facility as per information provided by the resident. A review of Resident 107's comprehensive care plan conducted on August 14, 2024, revealed that the resident's current care plan did not address a discharge plan for the resident to remain in the facility for long term placement. Interview with the Director of Nursing on August 15, 2024, at approximately 11:15 AM, confirmed the absence of discharge planning on Resident 6, 150, 11, and 107's care plan. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function and fecal continence to the extent possible for two out of 32 sampled residents (Resident 9 and 114). Findings include: A review of facility policy entitled Bowel and Bladder Management Program last reviewed on June 26, 2023, indicated the facility will assist the residents in maintaining their highest practicable level of independence and dignity. Further it is indicated all residents' bowel and bladder habits will be patterned for three days to establish potential patterns on admission and with a change in their bowel and bladder patterns. The staff nurse will initiate a three day bowel and bladder patterning and observation log in the electronic health record. The nurse aides will document in the electronic health record the residents' bowel and bladder habits for three days. This will provide documentation of toileting schedule and continence or incontinence status for the restorative nurse to accurately evaluate, create, and care plan the bowel and bladder management program. The restorative nurse completes the bowel bladder observation form using the information collected during the evaluation as well as the information gathered in the three day bowel and bladder patterning and observation log period. The residents plan a care will be updated in accordance with their care needs. A review of Resident 9's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and diabetes. A review of the resident's admission bowel and bladder assessment dated [DATE], indicated the resident was always continent of bowel. A review of the resident's clinical record revealed a three day bowel and bladder log was not completed on admission to determine the resident's bowel habits as noted in facility policy. A review of the resident's quarterly bowel and bladder assessment dated [DATE], indicated the resident had a decline in fecal continence and was now always incontinent of bowel. The facility failed to initiate a three day bowel log in response to the resident's decline in bowel continence in an effort to identify any patterns or habits and conduct an accurate assessment of the resident's bowel function and provide appropriate treatment and services to restore as much normal bowel function as possible, unless it is not clinically possible. A review of the resident's current plan of care, in effect at the time of the survey, did not address the resident's bowel incontinence. A review of Resident 114's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia (late on-set), hypothyroidism, depression, and hypertension. A review of Resident 114's quarterly bowel and bladder assessment dated [DATE], at 12:46 PM, indicated that the resident required assistance of one-person for toilet use, for example - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages and adjusts clothes. The assessment indicated that a toileting program was not being used to manage the resident's bowel continence. The assessment noted that the resident had cognitive impairment, however, was sometimes aware of her toileting needs. The current care plan action was noted to continue with the current plan of care and no referral needed. A review of a Quarterly MDS assessment dated [DATE], indicated that the resident required extensive assistance with support of one-person physical assist for bed mobility, transfers, toileting, and personal hygiene. Section H Bladder and Bowel H0400. Bowel Continence was coded that Resident 114 was always continent and Section H0500 was coded no that the resident was not on a toileting program. A review of the resident's quarterly MDS dated [DATE], indicated that the resident required extensive assistance with support of one-person physical assist for bed mobility, transfers, toileting, and personal hygiene. Section H Bladder and Bowel H0400. Bowel Continence was coded that Resident 114 was now frequently incontinent and Section H0500 was coded no that the resident was not on a toileting program to manage the resident's incontinence. Resident 114 had a decline in her bowel continence from the January 31, 2023, quarterly MDS and the April 28, 2023, quarterly MDS. The facility failed to initiate a three-day bowel log with the change in bowel continence to accurately assess the resident and plan care and treatment based on the resident's identified needs related to decline in bowel function to the extent practicable. A review of Resident 114's current plan of care, conducted during the survey ending September 1, 2023, failed to address the resident's decline in bowel continence and current needs related to fecal incontinence. During an interview on August 31, 2023, Employee 2, RN, stated that they don't have anyone on a bowel retraining program due to the comorbidities and age of the population residing in the facility, and the need to use mechanically lifts for some of the residents to transfer, and related to the use of bowel management medications. Interview with the Director of Nursing on August 31, 2023, at 2:23 PM confirmed that the facility failed to act upon declines in residents' bowel continence, failing to thoroughly assess bowel function and provide appropriate treatment and services to restore as much normal bowel function as possible, unless it was not clinically possible. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of the Resident Assessment Instrument Manual and clinical records and staff interviews, it was determined that the facility failed to timely submit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, for three out of 32 residents reviewed (Resident 35, 114, and 129). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, that assessments must be submitted within 14 days of the MDS Completion Date (Section Z0500B + 14 days). An Annual MDS assessment of Resident 35 with an ARD (Assessment Reference Date) of July 3, 2023, was not submitted/transmitted as of August 31, 2023, and was noted to be 45 days overdue. Interview with the Employee 1 (Registered Nurse Assessment Coordinator) on August 31, 2023, at approximately 10:15 AM, confirmed that the Resident 35's Annual MDS Assessment was not submitted timely. A review of Resident 114 's Annual MDS with an ARD of July 27, 2023, annual MDS status indicated validated and was not submitted/transmitted as of August 31, 2023, and was noted to be 34 days overdue. Interview with Employee 1 on August 31, 2023, at approximately 10:20 AM, confirmed that Resident 114's Annual MDS assessment was not submitted timely. A review of Resident 129's Annual MDS with an ARD of July 20, 2023, indicated that it was validated This MDS was not submitted/transmitted within 14-days of the MDS Completion Date. Interview with Employee 1 on August 31, 2023, at approximately 10:21 AM, confirmed that Resident 129's Annual MDS assessment was not submitted timely. During an interview with the Nursing Home Administrator (NHA) on August 31, 2023, at 1:30 PM, confirmed that the annual MDS assessments for Residents 35, 114, and 129 were not submitted/transmitted within 14-days of the MDS completion date and were overdue.

Based on clinical record review, observation, and staff and resident interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet the current individual needs of one of 32 residents reviewed (Resident 147). Findings include: Clinical record review revealed that Resident 147 was admitted to the facility on [DATE], and had diagnoses that included heart failure. Resident 147's Quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) dated August 18, 2023, revealed that the resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status Score - a tool to assess cognitive function). Review of Resident 147's nursing progress notes dated August 11, 2023, and August 17, 2023, revealed a new concern with potential auditory hallucinations. Resident 147's significant other informed staff of this concern. A review of Resident 147's current care plan conducted on August 31, 2023, revealed that the new concern of potential auditory hallucinations was not included on the care plan. During an interview on August 31, 2023, at 10:46 a.m., the Director of nursing confirmed there was no documented evidence that concern with potential auditory hallucinations were addressed in Resident 147's current care plan.

Based on clinical record and select policy review and staff interview, it was determined that the facility repeatedly failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 38) of 27 residents reviewed. Findings include: Review of facility policy entitled Pain Evaluation and Management, last reviewed by the facility August 2022, indicated that they policy purpose is to help the staff identify pain in the resident, evaluate the resident's level of discomfort and provide optimal comfort through a pain control plan that is mutually established with the resident, family and interdisciplinary team. According to the policy, at least one documented non-pharmacological approach must be attempted prior to administration of a PRN {as needed} pain medication. A review of Resident 38's clinical record revealed current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's August 2022 Medication Administration Records (MARs) revealed that staff administered this pain medication 11 times during the month of August 2022. Of the 11 doses given, 9 were administered without evidence of non-pharmacological interventions attempted prior to administration of the opioid pain medication. A review of the resident's September 2022 MARs revealed that staff administered the pain medication 15 times during the month of September 2022. Of the 15 doses given, 14 were administered without evidence that non-pharmacological interventions were attempted to alleviate pain prior to administering the pain medication. A review of the resident's October 2022 MARs revealed that staff administered the pain medication 2 times during the month of October 2022. Of the 2 doses given, all were administered without evidence of non-pharmacological interventions being attempted prior to administering the pain medication. Interview with the DON (director of nursing) on October 14, 2022, at approximately 2:30 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of prn pain medication. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.5(f)(g) Clinical records 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing Services

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptom of aggressive behaviors for one out of 27 residents reviewed (Resident 67). Findings include: A review of the clinical record revealed that Resident 67 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician order's revealed and active order for [MEDICATION(S)] 25mg (an antipsychotic) to be provided by mouth at 8:00 AM and 8:00 PM for unspecified dementia with behaviors dated September 22, 2022. Review of the Resident 67's Behavior Monthly Flow Sheets for the months of August 2022 through the time of the survey ending on October 14, 2022, revealed that the resident was prescribed an antipsychotic medication ([MEDICATION(S)]) for behaviors related to dementia. However, review of the behavior monthly flow sheets failed to identify the Target Behavior requiring treatment with the antipsychotic drug. The behavior flow sheets revealed that the resident did not display any behaviors. Interview with the Director of Nursing on October 13, 2022, confirmed the targeted behavior was not identified and that Resident 67 was to be monitored for aggressive behaviors. The resident's current care plan, in effect at the time of the survey ending October 14, 2022, identified the resident's dementia diagnosis, but the resident's specific dementia-related behaviors, aggressive behaviors, were not identified on the plan of care. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for behavioral symptoms failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage the resident's dementia-related behavioral symptoms. Interview with the Director of Nursing on October 14, 2022 at approximately 1:00 PM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related aggressive behaviors. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan

Based on a review of clinical records and select facility incident reports, and staff interview it was determined that the facility failed to maintain an environment free of accident hazards on one of four nursing units (2 North) by failing to secure treatment carts to prevent unintended resident access. Findings include: A review of Resident 1's clinical record revealed admission to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of a progress note dated August 29, 2022, at 8:30 PM, revealed Resident 1 had a pair of scissors in his hand in the common area, threatening staff that he was going to get them. A review of a facility incident report dated August 29, 2022, at 9:36 PM revealed that staff were walking up the hall with a resident. Resident 1 walked over to staff, pulled a pair of scissors out of his back pocket, and began making stabbing motions towards staff. Staff were able to remove the scissors from the resident and the resident was transferred to the hospital for an evaluation. Further review of the incident report revealed that facility staff reviewed the camera footage to determine a timeline of the incident. It was noted on August 29, 2022, at 7:23 PM Resident 1 approached a treatment cart. The cart was not locked, and the resident went through the drawers, obtained a pair of red handled scissors, and placed them in his pocket. Interview with the director of nursing and nursing home administrator on September 22, 2022, at approximately 1:15 PM revealed that the treatment carts should be locked at all times and confirmed that the facility failed to maintain an environment free of accident hazards. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: Resident 1 was transported to the hospital for evaluation. All residents with behaviors rooms were checked for harmful objects and removed . All treatment carts were checked for proper working locks, and all were immediately locked Education were completed with all staff to ensure all treatment and medication carts are locked when not in use. The nurse sign out sheet will include check for scissors. Audits will be completed on all nursing units every shift for one month to ensure all carts are locked when not in use. The facility's compliance date was August 30, 2022. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.12(c) Nursing services

Based on observations, a review of clinical records, a facility investigation report and manufacturer's directions and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the skills and competencies to assure resident safety and perform emergency operation of a mechanical when necessary as evidenced by one resident out of six residents reviewed (Resident CR1). Findings Include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set Assessment ( MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 7, 2022, revealed that Resident CR1 was severely cognitively impaired and totally dependent on two person physical assist for toileting, and required extensive assistance of two person physical assistance for dressing and bed mobility. The resident was totally dependent for transfers with two persons assistance and not steady during surface to surface transfers. A review of the resident's comprehensive plan of care dated June 21, 2021, indicated that the resident was assessed to require the use of an Arjo Hoyer lift (mechanical device used to transfer residents between surfaces) for all transfers with two person physical assistance. A review of information submitted by the facility dated June 3, 2022, revealed that staff placed Resident CR1 in the mechanical lift and transferred the resident into the bathroom for incontinence care. Employee 1 a licensed practical nurse (LPN) and Employee 2 a nurse aide (NA) transferred the resident into the bathroom via the mechanical lift. A documented statement from Employee 1 indicated that resident was raised up in lift (from his Broda chair) to be transferred to a shower chair for incontinence care. When these staff members were lowering the lift, the resident appeared to be turning red in his face and he became unresponsive. Staff then attempted to lower the resident from the lift back into his chair, but lift had become lodged into the ceiling soffit. The lift started beeping and it would no longer function. As a result, the staff were unable to lower the resident from the lift. Employee 4, a Registered Nurse (RN), was summoned to the bathroom and attempted to pull the pin to release the lift in order for it to be lowered. However, the lift continued to beep and would not lower. Employee 3, LPN, arrived and was able to pull the lift from underneath the shower ceiling soffit. A review of the facility's timeline and observation of video footage revealed the following; Ar 7:06 PM on June 3, 3022 Resident CR1 was observed being transferred to the bathroom with Arjo lift by Employee 1, LPN, and Employee 2, nurse aide. Three minutes later at 7:09 PM Employee 3, RN, was observed to enter the bathroom then leaves the room and returns at 7:10 PM with a battery pack. At 7:12 PM Employee 3, RN, left the bathroom and returned with a step stool. At 7:16 PM Employee 3 brought oxygen. At 7:20 PM the Resident was transferred out of the bathroom in his Broda hair accompanied by Employee 1 LPN, Employee 4, RN and Employee 5, RN. Interview with the NHA on June 16, 2022, and review of facility's investigation determined that the resident remained suspended in the lift for approximately 10-11 minutes. Through investigation and interviews it was determined facility's nursing staff had difficulty releasing the emergency release on the mechanical lift in order to safely lower the resident back into his chair. According to manufacturer's directions if electrical power fails due to battery power loss or any other electrical malfunction the jib (an extension of the arm, operation arm of the mechanical lift) can be lowered by first raising the red colored emergency lowering level found on the rear section of the mast (actual mechanical structure that allows the lift to reach to specified heights). The the locking pin is to removed from its location beneath the red colored emergency lowering level. Then using the red lever as a crank it is to be turned clockwise rotation one full clockwise turn. One full clockwise rotation of the shaft will lower the mast by 3/8 of an inch. A warning note in the manufacturer's recommendations indicate if the mast is in a high position and the wind down function must be used ensure that suitable and safe measures are taken to gain access to the cover. It was determined that the mast of the lift where this emergency equipment was located was wedged underneath the ceiling making it difficult for the operator to access the emergency lowering function. It caused the electrical buttons not to function electrically to automatically lower the lift. An interview with Employee 3, RN, on June 16, 2022 at 10:41AM indicated that it was not until other nursing staff arrived in the room and physically pulled the lift out from underneath the ceiling that they were able to use the lift and lower the resident into his broda chair. She stated she knew that there was an emergency release on the top of the mast but could not reach it. Employee 6, LPN, who was in the room at 7:11 PM stated during telephone interview on June 16, 2022, at 11:30 AM that she and other staff were trying to get to the red handle to turn it, but they were unable to reach it. Employee 6 stated that the lift was stuck on the ceiling and they tried desperately to operate the lift, but it failed. At the time of the survey the facility had a total of 10 Arjo maxi lifts. According to facility documentation there were 37 residents in the facility that utilized this specific lift. Multiple interviews conducted with nursing staff on the day of the survey of June 16, 2022, revealed that not all nursing staff interview were knowledgeable in the use of the emergency function of the lift. Interviews with Employee 7, nurse aide, Employee 8, nurse aide, and Employee 9, nurse aide, were unaware how to properly release the lift if the battery power failed. An interview with the nurse educator on June 16, 2022 at 1:00PM revealed she does explain the process of releasing the lift in the event of an emergency to staff. However she stated she did not have each of them practice the task or return demonstration on the lift and physically show her they are able to release it properly. The facility failed to ensure that all staff operating a mechanical lift were trained and competent in the use of the mechanical lift in an emergency situation. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.10(a)(d) Staff development 28 Pa Code 201.19 Personnel policies and procedures

Based on review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined that the facility failed to ensure that four residents (Resident 48, Resident 22, Resident 122 , Resident 17 ) were free from physical and/or verbal abuse, which resulted in physical injuries, a fractured finger, lacerations and contusion to one resident (Resident 22) out of 26 sampled residents Findings include: Review of facility policy titled Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property that was last reviewed by the facility November 15, 2021, revealed that the facility will provide protections for the health, welfare, and rights of each resident residing in the facility. The facility shall prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. A review of Resident 22's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)] (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 22's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 7, 2021, revealed that the resident was severely cognitively impaired. A review of Resident 131's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dementia. A review of Resident 131's Quarterly Minimum Data Set assessment dated [DATE], revealed the Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being Cognitively Intact) that the resident scored a 15, which indicated that he was cognitively intact. A review of Resident 22's clinical record revealed a nursing progress note dated October 27, 2021, at 7:15 AM noted that at 1:20 AM on that date, staff were called to the C lounge where a resident was on the floor and bleeding. Resident 22 was found in his wheelchair, lying on right side, on the floor. Resident 22 had a laceration to the top of left lip, measuring 3 cm x 0.5 cm, his right elbow was skinned and swollen, and had a right dorsal hand skin tear 0.5 cm x 0.5 cm. When asked what happened, Resident 22 stated I was punched in the face by a man with white hair, my wheelchair fell over with me in it. A nursing progress note dated October 27, 2021, at 4:32 PM revealed Resident 22 returned from an evaluation at the emergency room in good spirits with no complaints of pain or discomfort. Resident 22 received 3 sutures to the linear laceration to his left upper lip. The resident had swelling in the right dorsolateral hand and 5th metacarpal (the little finger or pinky finger) due to a fracture and right elbow swelling with redness. The resident had no complaints of pain or discomfort. A review of a progress note dated October 27, 2021, at 7:15 AM revealed an interview with Resident 131 related to the morning's incident. Resident 131 stated that he went into the C lounge with Resident 97 to play cards when Resident 22 came over and grabbed the cards, so he pushed Resident 22 and he fell over in his wheelchair. A review of a facility investigation, which included video footage dated October 27, 2021, at 7:37 AM revealed that Resident 131 struck Resident 22, which caused Resident 22 to fall over in his wheelchair to the floor. Resident 22 sustained a laceration to his left upper lip, skin tear to his left hand, and fracture to his right 5th metacarpal (little finger/pinky finger). The facility failed to ensure that Resident 22 was free from physical abuse perpetrated by Resident 131. A review of Resident 48's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)] disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and the elderly) and unspecified dementia [chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] without behavioral disturbances. Review of the resident's quarterly MDS assessment dated [DATE], indicated that the resident had severe cognitive impairment and did not display any behaviors. A review of Resident 72's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included unspecified dementia with behavioral disturbance, impulse disorder (is a condition in which a person has trouble controlling emotions or behaviors), and generalized anxiety. Review of the resident's Admission MDS dated [DATE], indicated that the resident had severe cognitive impairment and displayed behaviors of wandering occurred four to six times per week. Nursing progress notes dated July 11, 2021, at 4:48 PM, revealed that Resident 72 approached Resident 122 in the hallway near the nurse's station and said get the f*** out while making gestures towards the door. Space/distance was provided between the residents and redirection was met with negative comments. Every 30-minute visualization of Resident 72 and documentation was initiated according to nursing progress notes. Review of Resident 122's Progress Notes - Social Services dated July 12, 2021, at 3:50 PM, revealed that the resident was pleasant and friendly and could not identify any concerns related to peer relationships and stated that he did not remember any problems. Nursing progress notes dated August 4, 2021, at 4:38 PM, revealed that Resident 72 approached Resident 17 and pointed his index finger towards his peer's face and told him in a loud voice to shut the f**k up. Staff separated both residents. Resident 72 continued to curse at staff but returned to his room. Every 30-minute visualization documentation related to aggressive behaviors was initiated. Review of Resident 17's Progress Notes - Social Service dated August 5, 2021, at 3:20 PM, revealed that the resident presented in pleasant mood and could not recall the interaction with Resident 72 and no distress observed. Nursing progress notes completed by Employee 1, LPN (licensed practical nurse), dated August 29, 2021, at 4:35 PM, revealed that Resident 72 came out of resident room [ROOM NUMBER] (his room) and struck Resident 48 with closed fists multiple times to the right top of head in which caused Resident 48 to fall out of his wheelchair. Resident 48 had been seated in his wheelchair by the nurse's station to the left side of Resident 72's room (room [ROOM NUMBER] ) prior to being physically abused by Resident 72. Both residents were separated and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 72 was transferred to an acute care facility for a Geropsychiatric evaluation. However, returned to the facility later that evening and was immediately placed on one-to-one observation. A review of the facility's serious incident report dated August 29, 2021, at 3:54 PM, revealed video footage showing Resident 48 seated in a wheelchair in the hallway when Resident 72 walked up to him, pulled his wheelchair back and positioned it against the wall, pointed his finger near Resident 48's face and begun to strike him in the head/face with a closed fist approximately five times, while wearing a winter glove. Resident 72 turned and entered his room briefly, and then returned to the hall, and reapproached Resident 48 and struck him several more times in the head/face while wearing his gloves, which caused Resident 48 to fall out of his wheelchair onto his knees. Staff immediately responded and separated the residents and assessed Resident 48 with no evidence of injuries noted. A review of Employee 1 witness statement dated August 29, 2021, at 4:00 PM, indicated that she was down hallway E passing medications when she heard residents yelling and when she came around the corner, Resident 48 was getting back into his wheelchair and Resident 72 was in his doorway when she arrived. When Employee 1 arrived, both residents were immediately separated. Review of Resident 48's Progress Notes - Social Services dated August 30, 2021, at 1:15 PM, revealed that the resident presented as alert and appeared comfortable and did not recall interaction with Resident 78 that occurred on August 29, 2021. The facility failed to ensure that Resident 48 was free from physical abuse perpetrated by Resident 72. An interview with the nursing home administrator (NHA) on December 3, 2021, at approximately 2:30 PM, confirmed the facility failed to ensure that these residents were free from physical and verbal abuse perpetrated by other residents. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(1) Management Previously cited 1/31/20 28 Pa. Code 201.29(a) Resident Rights Previously cited 1/30/20, 5/27/20 28 Pa. Code 201.29(c) Resident Rights Previously cited 1/30/20 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services Previously cited 1/30/20, 2/5/21

Based on observation, review of CMS guidance, select facility policy and documentation and interviews with residents, it was determined that the facility failed to allow residents to receive visitors of their choosing, at time desired by six of 26 residents reviewed (Residents 6, 126, 124, 131, 45, and 62). Findings include: Review of CMS (Centers for Medicare and Medicaid Services) Memorandum QSO-20-39-NH, Nursing Home Visitation - COVID-19 (Revised) dated revised November 12, 2021, revealed that, Visitation is now allowed for all residents at all times. Continued review revealed, Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations . Facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Further review revealed Effective Date: Immediately for this Memorandum. During observations in the facility on November 30, 2021, at approximately 8:00 a.m., signage was observed outside of elevators dated August 23, 2021, stating that due to local positivity rates all visits are restricted to the MPR (Multipurpose Room) or the patio and there will be no visits on the unit. Review of the facility's current visitation policy revealed it had not been updated to reflect the most recent QSO memorandum revised 12, 2021. During an interview with Resident 6, he stated he was tired of not being allowed to have visitors in his room. The resident stated I miss my friends and family. I feel like a prisoner. During a group meeting held on December 1, 2021 at 10:00 a.m., with five alert and oriented residents (Residents 126, 124, 131, 45, and 62) all residents in attendance stated they were not allowed to have visitors in their rooms and they wanted visits at locations of their choosing. Interview on December 1, 2021, at 2:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility had not updated the facility policy regarding visitation based on the updated guidance issued by CMS (Memorandum QSO-20-39-NH Revised November 12, 2021). 28 Pa Code 201.18 (e)(1)(2) Management 28 Pa Code 201.29 (a)(d) Resident rights

Based on review of select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by five of five residents attending a group meeting (Residents 126, 124, 45, 131, and 62) Findings include: Review of the facility's current Grievance policy indicated that it is the facility's policy to provide an opportunity for residents to express concerns at any time. The facility's goal is to resolve resident and family concerns in a timely basis. Review of the minutes from the Resident Council meetings held between June 4, 2021 through November 3, 2021, revealed that residents in attendance at these resident group meetings voiced their concerns regarding their care and facility services during the meetings. During the August 4, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system, snack delivery, and visitation limitations. During the September 1, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system, and snack delivery. During the October 6, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system. During the November 3, 2021, Resident Council meeting the residents relayed concerns with the timeliness of staff response to their requests for assistance via the nurse call bell system. During a group meeting held on December 1, 2021, at 10:00 a.m., with five (5) alert and oriented residents, 4 residents (Residents 126, 124, 45, and 62) stated that untimeliness of staff response to their call bells and meeting their needs for assistance in a timely manner remains a problem for them. Five of five residents (Residents 126, 124, 45, 131, and 62) at this meeting stated they are still unsatisfied with visitation limitations in place at the facility due to COVID-19 pandemic. The residents stated that they have repeatedly brought these particular complaints to the facility's attention without resolution to date. The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints/grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding untimely staff response to call bells and delays in meeting residents' needs for assistance, snacks and visitation. During an interview with the Assistant Nursing Home Administrator (ANHA) on December 3, 2021, at 11:00 a.m. the ANHA was unable to provide documented evidence that the facility had followed-up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding facility services and resident care. 28 Pa. Code 201.18(e)(1)(3)(4) Management 28 Pa. Code 201.29(i)(j) Resident Rights

Based on a review of clinical records and staff interview it was determined the facility failed to provide medically-related social services to assure coordination of necessary communication regarding the resident's care and facility services to promote the resident's physical and psychosocial well-being for one resident out of three sampled (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with multiple diagnosis including dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) hypertension (high blood pressure) and [CONDITION(S)] (chronic [CONDITION(S)] disease that affects the joints. This results in painful joints, swelling and stiffness in the joints). The resident expired on [DATE] under Hospice services. A review of the resident's clinical record revealed an entry dated [DATE], at 3:49 PM written by the social worker which read Received call from the resident's daughter this date regarding concerns brought to her attention by the hospital emergency department staff. Discussed these with her and she asked that administration contact her to further discuss. Administration made aware of above. There was no documented evidence of the follow up to the concerns the resident's daughter reported to the Social Worker and how they were resolved. A review of the clinical records from the resident's visit to the emergency department dated [DATE] indicated that the emergency department nurse reported a bruise on the resident's back and the resident's daughter was concerned about the possibility of abuse at the skilled nursing facility. Social Service documentation in the resident's clinical record failed to identify the resident's daughter's concerns regarding the bruise and potential abuse at the skilled nursing facility and the facility's response and/or resolution of her concerns. Interview with the Nursing Home Administrator (NHA) on [DATE], at 1:30 PM confirmed that the facility's Social Worker failed to convey the specific concerns from the resident's daughter regarding an injury and potential abuse to the facility's nursing home administrator. 28 Pa Code 201.29(a)(f) Residents Rights 28 Pa. Code 211.16(a) Social Services

Based on clinical record review and staff and resident interview it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and/or grooming of residents dependent on staff for assistance with these activities of daily living for four out of six residents reviewed (Resident 66, Resident 71, Resident 127, and Resident 137). Findings include: A review of the clinical record revealed that Resident 66 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 66's Quarterly MDS Assessment (Minimum Data Set-a federally mandated standardized assessment process completed periodically to plan resident care) dated August 8, 2020, section G Functional Status indicated that the resident required physical assistance of one person with bathing and showers. A review of the The MDS assessment dated [DATE], indicated under Section G Functional Status that bathing/showering activity did not occur. A review of Resident 66's clinical record revealed an order dated March 12, 2020, for skin checks on shower days, which were scheduled twice a week during the evening shift on Sundays and Thursdays. During group meeting conducted on February 4, 2021 at 1:30 PM, Resident 66 reported that he was not aware that he would only be receiving bed baths instead of showers. Facility provided education dated December 23, 2020 through December 30, 2020, to show that staff was educated on giving bed baths when a resident unit is under transmission-based precautions. However, the facility was not able to provide evidence that the residents were notified of changes to bathing procedures and the rationale. Interview conducted with the nursing home administrator on February 4, 2021, at 2:45 PM, confirmed that residents were not made aware that bed baths were replacing showers on select units related to COVID status. A review of the clinical record revealed that Resident 71 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 71's Admission MDS Assessment (Minimum Data Set-a federally mandated standardized assessment process completed periodically to plan resident care) dated November 16, 2020, section G Functional Status indicated that he required extensive assistance of two plus person support for transfers, toileting, and dressing. Bathing activity was coded as did not occur during that assessment period. A review of Resident 71's clinical record revealed an order dated November 10, 2020, for skin checks on shower days, which were twice a week on evening shift Sundays and Thursdays. Skin check on shower day orders was changed on November 24, 2020, to twice a week on evening shift Tuesdays and Fridays. A review of the Resident 71's bathing records revealed that from November 22, 2020 through February 2, 2021, Resident 71 received only four showers during that time period. Bathing records revealed that the resident had received some bed baths. The facility was unable to provide documentation of the resident's bathing activities from November 10, 2020 through November 21, 2020. A review of the clinical record revealed that Resident 127 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 127's Quarterly MDS Assessment (Minimum Data Set-a federally mandated standardized assessment process completed periodically to plan resident care) dated July 9, 2020, section G Functional Status indicate she required physical help in part of bathing and showers with two plus person support. The MDS assessment dated [DATE], indicated under Section G Functional Status that bathing/showering activity did not occur. A review of Resident 127's clinical record revealed an order dated March 12, 2020, for skin checks on shower days, which were twice a week on day shift, Tuesdays and Fridays. A review of the Resident 127's bathing records revealed that from November 1, 2020 through November 30, 2020, Resident 127 received one shower out of eight scheduled showers. From December 1, 2020 through December 31, 2020; and Resident 66 received two out of nine scheduled showers and from January 1, 2021 through January 31, 2021. The resident received some bed baths. A review of the clinical record revealed that Resident 137 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 137's Quarterly MDS assessment dated [DATE], section G Functional Status indicated that the resident required staff assistance of two persons for bathing and showers. The MDS Assessments dated July 13, 2020, October 9, 2020 and January 6, 2021, all indicated under Section G Functional Status that bathing/showering activity did not occur. A review of the resident's clinical record revealed an order dated October 3, 2018, and renewed January 9, 2021, for skin checks to be conducted on shower days twice a week. (Originally shower days were Tuesday and Saturday and at the time of the survey ending February 5, 2021, were Wednesday and Saturday). A review of the residents' bathing records revealed that from April 7, 2020, through September 29, 2020, this residents received only one shower a month during April 2020, May 2020, June 2020, July 2020, August 2020, and September 2020. The residents received bed baths in lieu of showers during this time frame. Interview with the assistant nursing home administrator (ANHA) on February 4, 2021 at 3:00 pm rvealed that the residents did receive bedbaths and were not receiving showers due to the transmission based precautions related to the COVID-19 pandemic. However, the facility did not implement transmission based precautions until October 2020, and only on select resident areas. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services. 28 Pa. Code 211.10(a)(d) Resident care policies

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. 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 during the initial tour of the food and nutrition services department on February 3, 2021, at 9:15 AM, revealed that the following deficient sanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified: In a walk-in freezer, identified as Freezer #2, an opened plastic bag of frozen chicken was found not labeled or dated. The food service director stated at the time of the observation that it was a bag of chicken cordon bleu. Several cardboard boxes were observed stacked around the perimeter of the freezer in close contact with ceiling and freezer fan potentially inhibiting proper air circulation required to temperature of frozen foods. On a shelf in the dry storage area, there was two opened undated gallon containers of snow cone syrup. The pumps and gallon containers were sticky on the outside. Inside the walk-in cooler that was identified as Cooler #5 (top left shelf), two large clear tote bags were observed on top of shelf above the resident food for tray line. The food service director stated that the bags were staff's lunches and personal belongings. Observation on the receiving dock area, the location food orders are received, revealed two wet cardboard boxes of resident personal belongings on the floor of the loading dock along with two wheelchairs covered in snow. During an interview with the assistant nursing home administrator (ANHA) on February 4, 2021, at 9:45 AM, identified that the boxes on the loading dock as resident personal belongings, one box, contained adult disposable briefs belonging to a resident transferred another facility that was admitted on [DATE] and the other box contained unwanted resident belongings to be discarded from October 21, 2020. The ANHA stated that the two wheelchairs were broken and needed to be discarded. Interview confirmed that the food receiving area should be kept clean and orderly to ensure food safety. 28 Pa. Code 211.6 (f) Dietary services. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for one of 27 residents reviewed (Resident 1). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a death in the facility was to be completed no later than 7 days (discharge date {death} + 7 calendar days) following admission and transmission date no later than discharge (death) date + 14 calendar days. A review of Resident 1's clinical record revealed that the resident ceased to breath in the facility on November 13, 2020 at 2:30 a.m. The clinical record revealed a Significant Change MDS assessment dated [DATE], but no additional MDS' assessment were available on the clinical record at the time of the survey ending February 5, 2021. An interview with the Employee 1, RNAC, on February 5, 2021, at 8:30 AM verified that the facility failed to timely complete an MDS assessment to reflect the death of this resident, 28 Pa. Code 211.5(f) Clinical records.

Based on a review of clinical records, information submitted by the facility and resident incident reports it was determined that the facility failed to provide timely and necessary assistance with activities of daily living as planned to prevent a fall with serious injury, a [MEDICAL CONDITION], for one of five residents (Resident 151) sampled for falls. Findings include: A review of the clinical record revealed that Resident 151 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the resident's care plan for ADL (activities of daily living) functioning and self-care deficit revealed an intervention dated November 20, 2018, indicating that the resident required the assistance of one staff member when dressing. A review of a fall risk assessment dated [DATE], revealed that the resident was assessed at a high risk for falling. A review of an annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated November 20, 2019, revealed that the resident was moderately cognitively impaired and required one person staff assistance for activities of daily living, including dressing, personal hygiene and using the bathroom. A planned intervention dated December 9, 2019, indicated that the resident required the assistance of one staff member when toileting (to include scheduled voiding, personal hygiene, adjusting clothing). Further review of the resident's care plan dated December 9, 2019, revealed that the resident was on a scheduled toileting program and was to be assisted to the bathroom [ROOM NUMBER] minutes prior to meals and up to an hour after meals, upon rising, during the night and when the resident requests. A review of progress notes dated December 14, 2019, at 8:09 AM indicated that the resident was observed lying on the floor in her bathroom. The resident at that time stated she was trying to get dressed. Non-skid socks were in place. The resident was encouraged to use the call bell. A review of a facility incident report dated December 14, 2019, at 8:08 AM revealed that Resident 151 was in the bathroom getting dressed and staff found her lying on the bathroom floor in her bedroom. A witness statement dated December 14, 2019, revealed Employee 11, RN (registered nurse) entered the resident's room to administer her medications. The employee observed the resident lying on the floor in her bathroom. The call bell was not activated. The resident was assisted off the floor to her recliner. A falls investigation form dated December 14, 2019, revealed Employee 12, nurse aide, did not witness the resident fall. Employee 12 stated that the nurse had informed Employee 12 that the resident was on the floor in the bathroom and that the resident fell when she was going to the bathroom. A review of the resident's Bowel and Bladder Detailed Entry Report dated December 14, 2019, revealed that the last time the resident was toileted prior to the fall was at 1:45 AM. A review of the resident's care plan revealed no new interventions were put in place after this fall to prevent falls and similar occurrences of the resident attempting to self-toilet and dress or evidence that the facility staff had toileted the resident upon rising as care planned on December 9, 2019. A review of a nursing note dated December 15, 2019, at 10:31 AM revealed that a nurse entered Resident 151's room and observed her lying on the floor in her room at the bottom of her bed. The resident's nightgown was partially removed, feces were observed on her non-slip socks and on the bathroom floor. Further review of nursing notes dated December 15, 2019, at 10:35 AM revealed that the resident was lying on the floor in her room. The resident was complaining of severe pain to the left hip and shoulder. The resident was transferred to the hospital for further evaluation. A review of the incident report dated December 15, 2019, at 10:18 AM revealed that the nurse entered the resident's room to obtain her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). The resident was observed to be lying on the floor in her room. The resident stated that she slipped when coming back from her bathroom. The resident had fecal matter on her socks and fecal matter was observed on the resident's bathroom floor. The resident was in severe pain and was transferred to the hospital for evaluation. A review of Employee 11, RN's witness statement dated December 15, 2019, revealed that the employee entered the resident's room and found her lying on her bedroom floor. Feces were observed on her socks and bathroom floor. The resident reported to the employee that she had discomfort in her left side and was transferred to the hospital. A review of a falls investigation form completed by Employee 12, nurse aide, dated December 15, 2019, revealed that the employee returned to the floor (nursing unit) from her break and was informed that the resident was on the floor in her room and being sent to the hospital. The employee was asked if the resident was toileted within the past two hours. The employee did not answer the question, but stated that the resident was independent with toileting. A review of a falls investigation form completed by Employee 13, nurse aide, dated December 15, 2019, revealed that the employee was also on break and when she returned to the nursing unit the employee was informed that the resident was on the floor in her room. The employee was asked if the resident was toileted within the past two hours. The employee did not answer the question, but also stated that the resident was independent with toileting. A review of the resident's Bowel and Bladder Detailed Entry Report dated December 15, 2019, again revealed that the last time the resident was toileted prior to the fall was at 1:45 AM. A review of an X-ray report dated December 15, 2019, at 11:49 AM revealed that Resident 151 had sustained a displaced left femoral neck fracture (one type of [MEDICAL CONDITION], which occurs just below the ball of the ball-and-socket hip joint, the region of the thigh bone called the femoral neck) as a result of the fall. An interview with Employee 11, RN, on January 31, 2020, at 9:00 AM revealed that the employee stated that the resident fell in her room coming back from the bathroom, but could not remember the exact details. The employee further stated the resident was independent with toileting herself. An interview with Employee 12, nurse aide, on January 31, 2020, at 11:00 AM revealed that the resident stated that she could not remember the exact time, but sometime after breakfast the resident tried to take herself to the bathroom and fell . The employee stated the resident was independent when using the bathroom. The employee stated the Kardex (a medical information system used by nursing staff to communicate important information on their patients) is kept at the nursing station with the resident's plan of care, so staff is aware of the resident's functional status. A review of the resident's Kardex that was in place at the time of the resident's fall on December 15, 2019, indicated that the resident required the assistance of one staff member when toileting and dressing. The facility failed to implement the resident's care plan dated December 9, 2019, to assist the resident to the bathroom [ROOM NUMBER] minutes prior to meals and up to an hour after meals, upon rising, during the night and when the resident requests. An interview with the director of nursing on January 31, 2019, at approximately 1:00 PM confirmed the facility failed to provide timely and necessary staff assistance to meet this resident's assessed and identified level of assistance with toileting to prevent a fall with serious injury. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services Previously cited 5/6/19, 12/7/18

Based on a review of information submitted by the facility, information from local law enforcement, clinical records and select facility policies, interviews with staff and law enforcement officials and observation of video surveillance footage it was determined that the facility failed to prevent the physical abuse of one resident (Resident CR1) perpetrated by another resident (Resident 2), which resulted in serious bodily and physical injury and subsequent death of one resident (Resident CR1) out of nine sampled. Findings include: Review of facility policy entitled Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated as reviewed (MONTH) 22, (YEAR) indicated the facility shall prevent abuse, neglect, exploitation and misappropriation of resident property, corporal punishment, involuntary seclusion and physical or chemical restraints not required to treat a resident's medical condition. The facility defines serious bodily injury as an injury involving extreme physical pain involving substantial risk of death; involving protracted loss or impairment of a body member, organ, or mental faculty; requiring medical intervention such as a surgery hospitalization or physical rehabilitation. The facility defines serious physical injury as an injury that causes a person severe pain or significantly impairs a person's functioning, either permanently or temporarily. A review of the clinical record revealed that Resident CR1, was [AGE] years old and admitted to the facility on (MONTH) 20, (YEAR), with diagnoses, which include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and anxiety. The resident was receiving [MEDICATION NAME] 75 mg (prevents platelets in the blood from sticking together) by mouth daily and Aspirin 81 mg (helps to prevent blood clots) by mouth daily. According to a quarterly MDS (minimum data set assessment -a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 25, 2019, with resident was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of ,[DATE] equates to severe cognitive impairment). The resident utilized a wheelchair for mobility and was not steady standing from a seated position or walking independently. Clinical record review revealed that Resident 2 was admitted to the facility on (MONTH) 5, (YEAR), and was [AGE] years old. This resident had diagnoses, which included [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder (a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body). A quarterly MDS assessment dated (MONTH) 6, 2019 indicated this resident had a BIMS score of 4 (severe cognitive impairment). This resident also utilized a wheelchair for mobility and was not steady when walking or moving from a seated to standing position. A review of information dated (MONTH) 8, (YEAR), submitted by the facility revealed that on (MONTH) 8, (YEAR), Resident 2's wife, Resident 3, who also resided at the facility, reported that Resident 2 became agitated and struck her in the left leg, while they were sitting next to each other in the 2 South d unit hallway. The residents were separated. Resident 3 was placed on every 15 minutes check by staff. Resident 3 wanted her husband Resident 2's room changed to another floor as she did not want to reside on the same floor as her husband. However, their son was able to convince both residents to remain on the same floor when he visited on (MONTH) 11, (YEAR). Clinical record documentation revealed that Resident 2 continued to be combative with staff and attempted self-ambulate. The resident remained on every 15 minute staff checks, until the facility discontinued the watches on (MONTH) 20, (YEAR). Nursing documentation dated (MONTH) 28, 2019, indicated that at 3:20 AM Resident 2 was redirected out of another resident's room. Staff directed Resident 2 back to the nurse's station in his wheelchair. Resident 2 began to stand up; when asked to sit down he became angry, slammed his hand down on the counter and yelled don't tell me what to do!. He then fell to the floor without injury. On (MONTH) 17, 2019, nursing documentation indicated that Resident 2 was involved in a verbal altercation with another resident (Resident CR2), but he was easily redirected. Nursing documentation of (MONTH) 18, 2019, at 3:15 AM revealed that Resident 2 was verbally aggressive with staff, pointing in their faces and had continuous attempts of self-rising out of his wheelchair and aimlessly wandering in the hallways attempting to open doors. Nursing documentation dated (MONTH) 25, 2019, revealed that Resident CR1 was attempting to enter the hallway bathroom and Resident 2 was seated outside of the bathroom. Resident 2 kicked Resident CR1's wheelchair, then the two residents began kicking each other. Resident 2 made a fist with his left hand and punched Resident CR1 on the right side of his face, with no injury. Nursing documentation of (MONTH) 26, 2019, indicated that Resident 2 was very resistant to care; raising his fists and yelling and cursing at staff. Nursing documentation dated (MONTH) 18, 2019, at 2:09 AM revealed that the resident was very agitated while using the bathroom with staff. When staff explained to the resident he was not in the sawmill, but that he was in the bathroom, he made a fist and and hit the assist bars on the side of the toilet. A review of nursing documentation and information provided by the facility dated (MONTH) 22, 2019, and observation of facility video footage revealed that on (MONTH) 22, 2019, at approximately 1:14 PM Employee 1, RN (registered nurse) heard an alarm (pad alarm on wheelchair which would sound to alert staff if resident arises from alarmed pad on chair) sounding in resident room [ROOM NUMBER] (A hallway). Employee 1 attempted to enter resident room [ROOM NUMBER], but she was unable to gain access through the doorway of this room. She then entered the resident room through the adjoining bathroom of resident room [ROOM NUMBER], which allowed her access to resident room [ROOM NUMBER]. Employee 1 found Resident CR1 lying on the floor out of his wheelchair. He was lying with his head towards the bathroom and his feet towards the foot of the bed. His wheelchair was against the door, which was the reason Employee 1 could not access the room through the door to room [ROOM NUMBER]. According to the facility's submitted information, Employee 1 observed Resident 2 to be at the side of Resident CR1's wheelchair. Resident 2 was bending at his waist stating 'I'm trying to help him. Resident CR1 stated at that time He just started hitting me, he came from behind, I tried to protect myself! Facility nursing staff noted that blood spatter was observed on the walls, door and doorway into bathroom. Blood spatter was observed on the pillow on the back of Resident CR1's wheelchair. Resident CR1 was observed to have an approximate 2 inch laceration to the left side of his temple area with large amounts of bloody drainage, his left cheek and eye were swollen and purple. His upper and lower lips were split and bleeding. He was sent to the emergency room for evaluation by 1:33 p.m. on (MONTH) 22, 2019. Resident 2 was observed to have dried blood covering the posterior aspect of both of his hands including his fingers. He complained of pain to his right hand. An ecchymotic area 9 bruise) was noted to his 4th right knuckle measuring 0.8 cm by 0.7 cm and a 2.2 cm x 1.7 cm ecchymotic area to the 5th knuckle on his right hand. Neither resident resided in room [ROOM NUMBER]. A review of hospital documentation dated (MONTH) 22, 2019, at 2:05 PM revealed that Resident CR1 was assaulted by another resident while in the nursing care facility or pushed into a wall. Resident CR1 presented with a 4 cm laceration to the left temporal (side of head) region and left periorbital ecchymosis (bruising around the eyes). His eye was swollen shut. Soft tissue swelling noted on the left cheek area. At 2:15 PM, (MONTH) 22, 2019, a CT Scan (A computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CT scan images provide more detailed information than plain X-rays do), was completed and indicated the resident had bleeding on the left side of his brain diagnosed with [REDACTED]. The outermost layer is called the dura. In a subdural hematoma, bleeding occurs between the dura and the next layer, the arachnoid). It was noted that the resident had been receiving [MEDICATION NAME] 75 mg (prevents platelets in the blood from sticking together) by mouth daily and Aspirin 81 mg (helps to prevent blood clots) by mouth daily at the time of the assault (both of which increase the resident's risk for bleeding). Hospital records indicated that the resident's neurological condition deteriorated overnight (compared to CT of (MONTH) 22, 2019) from (MONTH) 22, 2019, to (MONTH) 23, 2019. There was an increase in the midline shift from ,[DATE] mm to 4 mm (Midline shift refers to when a person's brain actually shifts beyond the center line of the brain. The shift is normally caused by a traumatic event involving the brain or head, and can indicate further problems with the brain, such as intracranial pressure or tumor growths) and notable increase in subdural blood products along the left frontal area of the brain On (MONTH) 23, 2019, after multiple discussions with family, it was determined that surgical intervention was not an option as per the resident's wishes and his advanced age. Resident CR1 was discharged to inpatient Hospice for end of life care. The resident expired in Hospice care on (MONTH) 26, 2019. A review of hospital records for Resident 2's ER evaluation following the incident of (MONTH) 22, 2019, revealed that Resident 2 was evaluated in the emergency room for aggressive behaviors and assaulting another resident. The resident was observed to have bruising of his right fouth and fifth knuckles. No fractures were identified. This resident was evaluated by psychiatry and was returned to the facility on (MONTH) 23, 2019 placed in a private room under a two person constant watch, which the facility later decreased to a continous watch by one staff member after seen by the psychiatrist on (MONTH) 25, 2019 at 8:50 AM. On the day of the survey ending (MONTH) 6, 2019, interviews were conducted with staff who were present during Resident 2's physical assault of Resident CR1 on (MONTH) 22, 2019. An interview with Employee 1, RN, at 9:50 AM on (MONTH) 6, 2019, revealed that she was administering medications that day and heard a wheelchair alarm sounding from behind a door. She realized that it was coming from room [ROOM NUMBER]; when she tried to open the door she could not and heard someone from inside the door yell I can't open the door! Employee 1 stated that she recognized Resident 2's voice. She then went through room [ROOM NUMBER]'s doorway through the adjoining bathroom and found Resident CR1 lying on the floor. Employee 1 stated that Resident CR1's wheelchair had been pushed up against the door. She stated that Resident 2 was reaching out to Resident CR1. She stated Resident CR1 stated He assaulted me. He attacked me! Employee 1 stated that Resident 2 stated that he was trying to help Resident CR1. An interview with Employee 2, nurse aide, at 9:45 AM on (MONTH) 6, 2019, revealed that she arrived in the room shortly after Employee 1 as she also stated she heard an alarm sounding. Employee 2 stated that Resident CR1 stated He tried to kill me, where is my brother, he was hitting me! Employee 2 stated that she ran for towels and washcloths. Employee 2 stated that there was blood everywhere. The RN supervisor, Employee 3, was also interviewed at 9:13 AM on (MONTH) 6, 2019. The RN Supervisor stated that neither resident resided in the room [ROOM NUMBER] where the assault took place. She stated that she was called to the scene at around 1:16 PM (MONTH) 22, 2019. She stated that Resident CR1 was soaked in blood and Resident 2 had blood on both of his hands. Observations during the survey ending (MONTH) 6, 2019, revealed that Resident CR1 had resided in room [ROOM NUMBER] on the B hallway. Resident 2 resided in room [ROOM NUMBER] in the A hallway. Resident CR1's brother, Resident 4, resided in room [ROOM NUMBER] in the A hallway directly across from room [ROOM NUMBER]. The facility provided video surveillance footage of the hallway for the date that Resident 2 physically attacked Resident CR1. Obseravtion revealed that at 12:51 PM Resident CR1 was sitting in the hallway, next to his brother Resident 4. At 12:51 PM Resident 2 was observed to pass by Resident CR1 in his wheelchair with no contact. At 12:53 PM Resident 4 went down A hallway, passed Resident 2 and went into his room, 219. At 12:55 PM Resident 2 went down A hallway and went into resident room [ROOM NUMBER] (not his room). At 1:03 PM Resident CR1 was observed to go down the A hallway and also entered room [ROOM NUMBER], the room which Resident 2 had entered. It was not until approximately 1:14 PM that Employee 1 heard Resident CR1's wheelchair alarm sounding indicating the resident was no longer in his chair. As per the video footage and staff interviews it was determined that Resident CR1 and Resident 2 were alone in room [ROOM NUMBER] for approximately 11 minutes, during which time Resident 2 had physically assaulted and seriously injured Resident CR1, resulting in Resident CR1's death. An interview conducted with the assistant nursing home administrator on (MONTH) 6, 2019 at 9:00 AM revealed and the Coroner's report noted that the cause of Resident CR1's death was [MEDICATION NAME] force head trauma and that the local police had determined it was homicide. The facility spoke with Resident CR1's son on (MONTH) 22, 2019, at 2:30 PM who declined to press charges against Resident 2 at that time. Interview with a representative from the county District Attorney's office on (MONTH) 13, 2019, at 11 AM revealed that the decision to file charges against Resident 2 remained under review at this time. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (e)(1)(2) Management 28 Pa. Code 211.5 (f)(g)(h) Clinical records 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited [DATE]

Based on a review of clinical records, select facility policy, reports and documentation and interviews with residents and staff it was revealed that the facility failed to provide adequate staff supervision to prevent an elopement by one resident (Resident 41) and failed to provide sufficient staff assistance with activities of daily living, as planned for each resident, to prevent accidents for three residents (Resident 133, 80, 99) with injuries (fractures) to two residents (Resident 133 and 99 ) out of 29 sampled residents. Findings include: A review of the facility policy entitled Policies and Procedures Related to Wandering and Elopement dated as reviewed by the facility May 20, 2014, revealed that the facility developed the a layered system of protection to prevent elopement. Once a resident is identified as being at risk, an individualized elopement/wandering care plan will be developed and implemented and interventions initiated. The system begins with a comprehensive resident assessment for elopement risk. The second layer is an ongoing facility assessment for elopement risk. The third layer is covered by our individualized interdisciplinary plan of care addressing each resident's elopement risk assessment. The fourth layer contains eyes on visual location check of each resident a minimum of every two hours. The fifth layer is to educate staff on the importance of elopement prevention through the monitoring of the facility exits and resident identification as well as elopement resolution. A review of the clinical record revealed that resident 41 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A physician order was noted October 30, 2017, for the use of a Wander Guard (a tracking device designed to prevent persons at risk from leaving a facility unless they are accompanied. The system tracks the person using a wrist or ankle band and automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person) and to check the function of the device every shift (day, evening and night). An admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 6, 2017, indicated that the resident was independent with transfers and ambulation, but required supervision, oversight, encouragement and cueing with locomotion off the unit. A Brief Interview of Mental Status (BIMS - a tool to assess cognitive function) was not conducted at this time to ensure dignity due to age (resident under 40) . An Elopement Risk assessment dated [DATE], revealed that Resident 41 was at risk of elopement and the interventions put in place to address this resident's risk was the use of a Wander Guard Review of a nursing progress note dated November 3, 2017, at 8:10 AM revealed staff presents concerns of observations to include multiple phone call to spouse, pacing while on the phone and repeated requests by the resident, while on the phone, to be taken out for a visit. The facility completed another Elopement Risk Assessment of the resident dated December 7, 2017, which indicated that the resident was now not at risk for elopement. Review of nursing progress note dated December 7, 2017, revealed new (physician) order noted to discontinue resident's Wander Guard. Discussed in morning meeting same. No behaviors noted. Resident capable, aware and in agreement. Will continue to observe. Review of the resident's clinical record and care plan revealed no documented evidence that the facility had planned and provided increased supervision of the resident following removal of the resident's Wander Guard on December 7, 2017. Review of facility reports revealed that on December 17, 2017, the resident signed himself out of the 2nd floor south nursing unit on movement sign out sheet at 4:00 PM, noting his documented destination as the facility's Multipurpose Room (MPR - activity room). A review of a facility report entitled Safety Events- Elopement dated December 17, 2017, revealed that Resident 41 eloped from facility at 4:17 PM on that date and was returned to facility by staff at 4:43 PM on December 17, 2017. A review an employee witness statement revealed that the last time staff had seen Resident 41 was at the beginning of the 3 PM - 11 PM tour of duty on December 17, 2017. An employee witness statement from Employee 4, Licensed Practical Nurse, revealed that while on break, she drove to Dunkin Donuts, located down the street from the facility. Employee 4 saw Resident 41 crossing the street. Employee returned the resident to the facility at 4:43 PM. At that time the resident stated that he wanted to go see his wife and wanted to see if he could do it. Resident was found to have no injuries. A BIMS completed December 19, 2017, indicated that the resident was cognitively intact with a score of 15 (a score of 13-15 indicates intact cognition). Review of the facility's video surveillance conducted on January 25, 2018, at 1:00 PM revealed that Resident 41 exited the MPR courtyard door on December 17, 2017 at 4:17 PM. The resident was wearing a coat. At 4:20 PM the resident was viewed on video surveillance to jump the fence by the ambulance exit. The resident then walked away from facility and out of video surveillance range. The resident's physician and wife were notified of incident on December 17, 2017. The physician ordered the application of a Wander Guard and to check its function and placement every shift. On December 17, 2017, at 4:57 PM the facility applied a Wander Guard to the resident's right ankle and initiated every fifteen-minute safety checks of the resident. Interview conducted with the resident on January 24, 2018, at 10 AM revealed that his bored in the facility at times. Interview with the Director of Nursing (DON) on January 25, 2018, at approximately 1:40 PM confirmed that the facility staff failed to adequately supervise this resident to prevent the elopement and failed to provide age appropriate diversional activities. A review of the clinical record of Resident 133 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance of two staff for bed mobility, dressing and transfers (moving to and from bed and chair). A review of the resident's current comprehensive plan of care indicated that the resident required assistance of two persons for bathing, dressing and all aspects of transfers. The resident was severely cognitively impaired with a BIMS of score of 5 (a score 0-7 indicates severe cognitive impairment). Further review of the clinical record revealed that on January 6, 2018, at 5:45 AM Employee 3, nurse aide, was dressing Resident 133 while the resident was sitting at the edge of the resident's bed. There was no other staff assisting Employee 3 with Resident 133's care. Employee 3 left the resident and walked to the side of the bed to adjust the height of the bed. At that time, the resident fell forward hitting the left side of his face and body on the floor. The resident was sent to the emergency room for evaluation on January 6, 2018 and was diagnosed with [REDACTED]. The resident also sustained a 5 cm laceration on the right side of his head with bleeding and bruising. Employee's 3's written statement noted that I lifted the resident to sit him on the edge of the bed. The foot of the bed was up so I couldn't sit him up properly, I then went to the other side of the bed to put the foot of the bed down to sit him up properly. He then leaned forward and went face first onto the floor. I couldn't prevent it. The statement indicated the resident stated My face hurts. The facility failed to ensure that sufficient staff assistance with activities of daily living was provided to Resident 133 to prevent this accident with minor injuries. A review of the clinical record revealed that Resident 80 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired with BIMS score of 5 and required assistance of two staff members for transfers and ambulation. A review of the resident's plan of care dated December 6, 2017, indicated that Resident 80 required the assistance of two persons with transfers. A review of a facility incident investigation dated January 18, 2018, at 1:47 PM revealed that Resident 80 was seated in a wheelchair in the hallway. Employee 1 (nurse aide) assisted him to a standing position. The resident became unsteady and Employee 1 lowered the resident to the floor. A review of an employee witness statement dated January 18, 2018 revealed that Employee 1 noted that I went to transfer Resident 80 to a standing position, he pushed his legs forward, he began to slide himself to the floor. A review of a facility documentation dated January 18, 2018, revealed that Employee 1 was removed from resident care areas and an investigation initiated. The facility determined that Employee 1 failed to follow Resident 80's plan of care for transfer assistance. During an interview on January 25, 2018, at 12:04 PM the Director of Nursing confirmed that Employee 1 failed to follow Resident 80's care plan for the amount of assistance necessary for transfers. A review of the clinical record revealed that Resident 99 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the resident's Fall Plan of Care initiated by the facility June 16, 2015, revealed that the resident was at risk for falls related to impaired physical status secondary to chronic underlying disease process. A review of a facility Fall Risk Assessments dated June 11, 2017, and August 21, 2017 revealed that Resident 99 was at high risk for falls. A review of an Annual Minimum Data Set assessment dated [DATE] and a Quarterly MDS dated [DATE], revealed that the resident was severely cognitively impaired, required extensive staff assistance for activities of daily living (routine activities that people tend do every day without needing assistance, such as eating, bathing, dressing, toileting, transferring (walking) and bladder and bowel continence), including staff assistance for bed mobility, transfers, moving in the room and off the unit. A review of an RN Supervisor Fall Investigation dated July 7, 2017, timed for 2:55 PM revealed that Resident 99 was seated in a wheelchair next to the clean utility room. An alarm sounded and the resident was found lying face down in front of his wheelchair on the floor. The resident was sent to the emergency room due to hitting his head during the fall. A review of an employee witness statement dated July 10, 2017, from Assistant Administrator indicated that video footage of the fall showed the resident sitting in the hallway of the nursing unit. The resident slowly began to doze with his head seen to fall forward onto his chest. The resident fall was seen appearing to fall asleep in the wheelchair and quickly landed on the floor of the hallway. The resident's plan of care was updated on July 8, 2017, to include an approach to offer the resident frequent rest periods. A review of an RN Supervisor Fall Investigation dated November 24, 2017, and timed for 5:05 PM revealed that Resident 99 was found lying on his right side on the floor infront of his wheelchair. A review of an employee witness statement dated November 24, 2017, revealed that when Employee 4, LPN, came back from her break Resident 99 appeared to be sleeping in his wheelchair. The resident was leaning to the right side with his right arm on chair arm rest resting and his hand on his head. As Employee 4 sat down at the nurses station the employee heard a thump and an alarm and saw Resident 99 lying on the floor. A review of a facility investigative form entitled Root Cause Analysis dated November 24, 2017, revealed that the facility reviewed the video footage of the above fall. The footage revealed that the resident was intermittently dozing in his wheelchair. At the time of fall resident was observed to fall asleep and fall out of wheelchair to the floor. A review of a nurses' note dated November 24, 2017, revealed blood was noted from the resident's right head area. The resident sustained [REDACTED]. The resident reported discomfort of right shoulder/upper back when the resident's arm ws raised above head. The Nurse Practitioner and the ADON were made aware. New orders were received for antibiotic ointment to the area on the resident's right head, offer frequent rest periods throughout the day, [MEDICATION NAME] (narcotic pain medication) 50 mg every four hours and [MEDICATION NAME] (narcotic pain reliever) 5/325 every 6 hours as needed for severe pain. Nursing documentation on November 25, 2017, revealed that the resident presented with blue/purple discoloration of the posterior (further back in position nearer the rear or hind end, of the body part) shoulder with swelling at site. The resident had decreased range of motion in the right upper extremity. The physician was notified and ordered an X-ray of the shoulder, which revealed an acute displaced fracture (bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the distal third (section of the bone situated away from the center of the body or from the point of attachment) of the right clavicle (collarbone). The physician ordered that the resident be transferred to the emergency room for evaluation on November 25, 2017. Resident 99 was identified at high risk for falls and had fallen asleep in the wheelchair, resulting in a fall on July 7, 2017. After that fall the planned to offer the resident frequent rest periods. The resident incurred a second fall under similar circumstances, falling asleep in the wheelchair, and sustained a fractured collarbone. There was no evidence that the facility had identified the resident's sleepiness/fatigue while seated in the wheelchair and implemented appropriate measures to maintain the resident's safety. The facility failed to demonstrate consistent implementation of the planned approach to offer rest periods in a safe setting to prevent this fall and injury. An interview with the Director of Nursing on January 25, 2018, at approximately 1:35 PM failed to provide evidence that the resident was offered frequent rest periods throughout the day and/or when staff observed the resident dozing while seated in the wheelchair. The Director of Nursing was also unable to provide evidence that the resident who was identified at risk for falls, which was known to the facility, was provided with adequate staff supervision and timely staff intervention to prevent this fall with serious injury. 483.25(d)(1)(2) Accidents previously cited 12/18/16 28 Pa. Code 211.10(a)(d) Resident care policies previously cited 12/18/16 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services previously cited 12/18/16

Based on review of the facility's abuse prohibition policy and procedures and clinical records and resident, family and staff interviews, it was determined that the facility neglected to provide one resident out of 31 sampled with planned services, which were necessary to avoid physical harm to the resident (Resident 140). Findings include: The facility policy entitled, Resident Abuse, last reviewed by the facility May 2015, revealed that the resident has the right to be free from abuse, mistreatment, neglect and misappropriation of property. The facility will take appropriate measures to prevent the occurrence of abuse, mistreatment, neglect and misappropriation of property by identifying residents at risk and those who by virtue of their personal histories render them at risk for abusing other residents, by developing interventions strategies to prevent occurrences, by monitoring for changes that would trigger abusive behavior, and finally by reassessing the interventions on a regular basis. A review of the clinical record of Resident 140 revealed readmission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 26, 2015, indicated that the resident had a BIMS score of 15 (BIMS - a brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and was totally dependent on the physical assistance of two plus persons for transfers (moving between surfaces from bed to chair etc.) A physician's orders [REDACTED]. Physical therapy evaluated the resident upon return from a hospital visit on April 21, 2015, and indicated that the staff should continue to use the ARJO lift for all the resident's transfers. The resident's care plan, with an approach start date of March 11, 2015, indicated that the resident was to be transferred by the ARJO lift for all transfers. The physician noted an order, dated April 18, 2015, for the use of the ARJO lift for all of the resident's transfers. The nursing documentation dated April 23, 2015, at 9:25 PM, indicated that the staff transferred the resident to bed and bumped the resident's right leg on the bed frame. The resident incurred an open area to the right leg measuring 4 cm (centimeter) by 1.5 cm by 0.75 cm (deep). The resident was transferred to the hospital for treatment on April 23, 2015. The hospital emergency room record dated April 23, 2015, indicated that the resident sustained [REDACTED]. The laceration was noted to be deep with skin tears and was actively bleeding. The wound was sutured (the process of joining two surfaces or edges together along a line by sewing with a nylon thread) using seven (7) sutures after the wound was cleaned. The emergency room report recommended that the resident continue to receive antibiotics (a type of antimicrobial used in the treatment and prevention of bacterial infection. They may either kill or inhibit the growth of bacteria), which he was receiving at the skilled nursing facility, prior to this ER (emergency room ) visit, for an ongoing blood infection. The resident was to return to the emergency room for a re-evaluation in two to three days. A review of the facility's investigative report dated April 23, 2015, revealed that the resident was injured when Employee 4, a Nurse Aide, was transferring this resident from his wheelchair to his bed with the assistance of Employee 5, a Nurse Aide. Employee 4's written statement dated April 23, 2015, noted, myself and another aide (Employee 5) were moving (Resident 140) from his power wheelchair to bed with a scoot board (a device used to bridge the space between a wheelchair and a bed, toilet, or car seat; used to facilitate independent or assisted transfer of the patient from one of these sites to another). In the middle of transporting, resident's right leg received a laceration from the bed. Employee 5's written statement dated April 23, 2015, noted, myself and another aide (Employee 4) were moving (Resident 140) from power chair to bed with scoot board. In the middle of transporting, resident's right leg received a laceration from the bed. The facility's investigative report included a written description of the event, written by Employee 9, a Registered Nurse (RN), which was reportedly obtained by interview with the resident. According to this description, I interviewed (Resident140) this morning 4/24/15 @ (at) 8:30. (Resident140) stated that while being transferred by 2 CNA's he bumped his leg on the frame of the bed causing a skin tear. However, interview with the Director of Nursing (DON) on September 23, 2015, at 2:00 PM, revealed that the DON also interviewed the resident on April 24, 2015, and when this interview was conducted with the resident, both Employees 4 and 5 were present in the room to perform a reenactment of the resident's transfer using the scoot board. The facility failed to utilize effective approaches to investigate this incident by failing to ensure that the resident was interviewed in a comfortable environment and without the presence of the specific staff members involved. The facility also failed to identify that the employees involved reported transferring the resident by means of a scoot board when the resident's plan of care and current physician's orders [REDACTED]. Following surveyor inquiry regarding the resident's injury during the survey ending September 25, 2015, the facility conducted second interviews with the two employees involved in the incident. When the facility interviewed Employee 5 on September 23, 2015, she stated that she and Employee 4 were moving the resident from the power chair to bed with a scoot board using a series of, up and putting down the resident (movements) in the middle of transporting the resident he received a laceration to his right leg. Employee 4's clarification statement indicated that he and Employee 5 were transferring the resident from his chair to the bed. He had the resident's right side and Employee 5 had the resident's left side. Employee 4 noted that, we in unison moved him inch by inch till he was in the bed. In the process the resident's leg got caught under the bed and received a laceration to his right lower leg. During an interview conducted on September 23, 2015, at 8:50 AM, Resident 140, revealed that on the night he sustained the injury to his leg, Employee 4 was transferring him from his chair into his bed. The resident stated that Employee 4 lifted the resident underneath his arm, while the resident was seated in the wheelchair. The resident stated that he told Employee 4 to use the ARJO lift because the resident was a, big guy and that the nurse aide should not attempt to transfer him by himself. Employee 4 replied, I am a big guy. Continued interview with Resident 140 revealed that he is 6' 5. The resident stated that Employee 4 caught the resident's leg under the bed then, rip, my leg was cut and bleeding. The resident firmly stated only one male nurse aide (Employee 4) was present during the incident on April 23, 2015, further stating that he, grabbed me underneath my arm and transferred me from the chair to the bed. The resident stated that no equipment, neither the scoot board or the ARJO lift, were used during this transfer. An interview conducted with the resident's daughter on September 23, 2015, at 10:15 AM, revealed that she knew that her father was to be transferred at all times with a mechanical lift because he could not be transferred safely with any other equipment. An interview conducted with Employee 5 on September 23, 2015, at 12:08 PM, revealed that Employee 5 stated that she was assigned to Resident 140 for care on April 23, 2015. She was preparing to assist the resident to bed by putting the supplies she needed in the resident's room, which included the sliding board (scoot board). She was not aware that the resident's plan of care indicated the use of an ARJO lift for all transfers. She further stated that she told the resident that she would return after she obtained assistance from another staff member to perform the transfer. She stated that she went into the bathroom next door where Employee 4 was assisting another resident and she asked him for assistance. Employee 4 told Employee 5 to take over for him and assist the resident he was caring for and he went to assist Resident 140. Employee 4 then entered Resident 140's room Employee 5 relayed that she was just finished dressing the other resident when Employee 4 returned to her and stated, we have a big problem. Employee 4 entered Resident 140's room and saw Resident 140 seated on the bed with his right pant leg up to his knee and a deep wound to the front of his leg. Employee 5 was asked why her statement changed from the date of occurrence and she replied, I lied for Employee 4. Employee 5 stated that Employee 4 asked her to, back him. Employee 5 stated that she was concerned about losing her job for lying about failing to provide proper care to Resident 140. Interview with Employee 4 on September 23, 2015, at 1:49 PM, revealed that the employee stated, How am I supposed to remember what happened in April? He then stated, Me and Employee 5 transferred the resident from the wheelchair to the bed with the slide board and his leg got caught. The surveyor shared the account of the incident as described by the resident and Employee 5 to which Employee 4 replied, That's all I know, there were two of us in the room. Employee 4 then rushed out of the room. An interview with the Director of Nursing (DON) on September 24, 2015, at 9:00 AM, confirmed that the statement Employee 5 shared during the survey was not consistent with the written statements the employee provided at the time of the incident. The DON was unable to verify that Resident 140 was provided with the necessary services, which included the transfer assistance of two staff persons and the use of an ARJO lift, to prevent injury to the resident. 28 Pa. Code 201.18 (e)(1) Management. previously cited 7/7/15, 4/16/15 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(c) Nursing services. previously cited 7/7/15, 4/16/15 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/7/15, 4/16/15

Based on clinical record and select facility policy review, observations and staff interviews, it was determined that the facility failed to provide necessary and individualized care and services to prevent the development of a pressure ulcer for one of 31 residents reviewed resulting in actual harm to the resident (Resident 51). Findings include: Review of facility policy entitled, Wound Prevention and Care dated as reviewed by the facility May 2015, indicated that it is the policy of the facility to utilize guidelines published by the National Pressure Ulcer Advisory Panel to identify those residents who have specific factors that place them at risk for impaired skin integrity. The guidelines are also used to maintain and improve tissue tolerance to pressure in order to prevent injury, to protect against the adverse effects of pressure and friction, and to reduce the incidence of pressure ulcers through educational programs. It is the goal of the facility that residents will not develop pressure ulcers. Review of Resident 51's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a physical therapy evaluation dated August 20, 2015, the resident had contractures (the loss of joint motion) to both his upper arms. Occupational therapy recommended a palmar guard (a mechanical or artificial aid to support weak or damaged parts of the hand) for his left hand and a resting hand splint (splint used to control the wrist hand and fingers in a contracted hand) to his right hand. A review of the resident's assessment for pressure sore risk dated August 4, 2015, revealed that the resident was at high risk for the development of pressure sores (Pressure sores, also known as pressure ulcers or bed sores, are caused long periods of uninterrupted pressure exerted on the skin, soft tissue, muscle, and bone). A review of nursing documentation dated September 11, 2015, at 10:04 PM, indicated that a nurse aide observed an open area to Resident 51's upper abdomen and reported it to the nurse. The nurse assessed the area as a 2.5 cm (centimeter) by 2. 5 cm scabbed area on the resident's upper middle abdomen. A facility investigative report dated September 11, 2015, indicated that the resident rests his hands on his abdomen and wears hand splints. The facility's Wound Care Nurse evaluated the resident on Monday September 14, 2015 and found the resident to have a 0.8 cm by 1.0 cm by 0.1 cm unstageable area (or Stage IV a full thickness loss with eschar {hard crust or scab} may be present) on the upper middle area of his abdomen. The wound base had 70% slough (mass of dead tissue) and 30% granulation (formation of new tissue growth) with a scant amount of serous (clear slightly yellow or colorless) drainage. According to documentation, the Wound Care Nurse concluded the pressure area lined up with the edges of the resident's hand splint. The wound care, Certified Registered Nurse Practitioner (CRNP) evaluated the pressure ulcer on September 16, 2015, noting that the resident had an unstageable pressure ulcer of the upper middle abdomen and made a recommendation to prop the resident's elbows with pillows to offload (remove pressure) the resident's arms from his abdomen. An observation of this resident conducted on September 25, 2015, at approximately 11:00 AM, revealed that the resident was seated in a chair in the hallway with his arms wrapped in front of him resting on his abdomen and the splints present to his left and right hand. There were no pillows observed to be propped under the resident's elbows to offload his arms from his abdomen as the CRNP had recommended on September 16, 2015. Observation of the resident's pressure sore conducted on September 25, 2015, in the presence of Employee 3, an RN, revealed an unstageable pressure ulcer on the resident's abdomen as well as an open area to the right of the pressure sore. Employee 3 stated that she was not aware of the open area because she had not been in the facility for a few days. The facility's Wound Care Nurse evaluated the newly identified open area on September 25, 2015, and assessed the area as a 0.2 cm by 0.2 cm open area, which she noted was caused by the dressing to the resident's abdominal pressure sore. An observation on September 25, 2015, of the resting hand splint the resident had utilized prior to the development of the abdominal pressure ulcer revealed that the splint was constructed of a hard material. An interview with the Director of Nursing (DON) on September 25, 2015, at approximately 1:00 PM, confirmed that following the identification of the unstageable pressure area, therapy changed the resting hand splint to another type of splint made of a soft material. The facility failed to timely identify and act upon the pressure to the resident's abdomen created by the use of the hard splint and the positioning of the resident's arm to prevent pressure ulcer development. 483.25(c) Pressure Sores Previously cited 4/16/15 28 Pa. Code: 211.5(f) Clinical records. Previously cited 4/16/15 28 Pa. Code: 211.5(g) Clinical records. 28 Pa. Code: 211.5(h) Clinical records. Previously cited 4/16/15 28 Pa. Code: 211.10(a) Resident care policies. Previously cited 4/16/15 28 Pa. Code: 211.10(c) Resident care policies. Previously cited 4/16/15 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 4/16/15 28 Pa. Code: 211.12(a) Nursing services. Previously cited 7/7/15, 4/16/15 28 Pa. Code: 211.12(c) Nursing services. Previously cited 7/7/15, 4/16/15 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 7/7/15, 4/16/15 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 4/16/15 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited 7/7/15, 4/16/15

Based on observation, review of clinical records, an event report and select facility policies and staff interview, it was determined that the facility failed to provide effective measures needed to address risk factors and prevent the development of a pressure sore for one resident at risk for skin breakdown out of 28 residents reviewed (Resident 60). Findings include: A review of the clinical record of Resident 60 revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 30, 2015, revealed that the resident was cognitively impaired, required staff assistance for activities of daily living, including the assistance of staff for personal hygiene and dressing. The MDS assessment also indicated that the resident had limited use, bilaterally (both sides), of his upper extremities that included the shoulders, elbows, wrists and hands, which placed the resident at risk of injury according to Section G0400. Further review of the MDS Assessment indicated the resident was at risk for developing pressure sores. On December 12, 2011, a physician's order was obtained for upper extremity passive range of motion (the therapist or equipment moves the joint through the range of motion with no effort from the patient) for strengthening and coordination per the recommendation of occupational therapy (OT). On December 25, 2012, OT recommended a restorative nursing program (RNP) for the resident that included bilateral upper extremity passive range of motion (PROM) exercises at each joint in all planes (abduction (the acting of turning outward) and adduction (the act of turning inward)) in the areas of the elbows, arms, wrists and fingers, five times a week to minimize contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a Restorative Nursing Evaluation Committee meeting held on May 16, 2013, the committee's discussion/action at that time was to continue the PROM. On June 19, 2013, the same committee recommended discontinuing the PROM exercises due to a decline in the resident's medical condition and to place the resident in a preventative program. However, no physician's orders were provided at the time of the survey verifying the physician's discontinuation of the PROM exercises. A review of the "IDCP" (interdisciplinary care plan) team meeting dated February 13, 2015, revealed that the resident was on the Preventative Restorative Program; however, there was no information regarding the resident's participation in the "comments" section. A review of the facility policy entitled, "Restorative Nursing Program" dated August 2014, indicated that the Preventative Restorative Program allows the resident the opportunity and encouragement to participate in the program with respect to Activities of Daily Living (ADL or basis self-care tasks) as performed with the assistance of nursing staff. Interview with the facility's Staff Educator on April 16, 2015, at approximately 11:15 AM, revealed that the expectation of the Preventative Restorative Program, is for staff to integrate aspects of care when providing assistance during ADLs that include, bathing, dressing and eating during AM and PM care. However, there was no formal or written instructions on which staff are educated, that was available for review at the time of the survey A review of a nursing progress note dated April 1, 2015, at 12:55 PM, revealed that Resident 60 was admitted to Hospice (end of life care) services. A revised plan of care dated April 4, 2015, identified the resident at risk for pressure sores related to chronic underlying diseases. Interventions at the time included, body checks performed by the nursing assistants (NA) every shift, weekly skin evaluations by the licensed nursing staff, keep areas clean, dry and minimize skin exposure to moisture and keep bony prominences from direct contact with one another. The revised plan of care also identified the resident as having limited abilities in maintaining personal hygiene related to chronic underlying diseases. Interventions called for the staff to provide washing and nail care to the hands and report any signs of skin breakdown. Review of a nursing progress note dated April 5, 2015, at 5:13 PM, revealed a 0.5 centimeter (cm.) by 0.5 cm. open area noted to the inside of the left thumb of the resident's contracted hand. Further review of the progress note indicated that the resident's spouse and physician were notified and orders were obtained. A review of a corresponding facility "Event Report" dated April 5, 2015, at 4:38 PM, indicated the development of an open area below the resident's left thumb. The physical observation of the wound revealed that it was a shallow laceration (a cut or tear of in skin or flesh) with a small amount of blood loss and the occurrence of the laceration was from the resident's contracted fingers. The treatment at the time called for staff to cleanse the area with soap and water, apply triple antibiotic ointment, affix rolled-up wash cloths to bilateral contracted hands and thumbs every shift and to check skin integrity every shift. A review of the April 2015 (Nursing Aide) Skin Check form revealed that on April 5, 2015, the 11:00 PM to 7:00 AM shift, the 7:00 AM to 3:00 PM shift, and the 3:00 PM to 11:00 PM shift nursing assistants failed to document that the resident had a skin alteration. A review of a nursing progress note completed on April 8, 2015, at 2:01 PM, revealed that the area on the resident's left thumb was reassessed and that the area was macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) now with a full-thickness wound-pressure area measuring 0.7 cm. x 0.8 cm. x 0.1 cm. Physical therapy and occupational therapy assessed the area and orders were obtained for a palm guard with finger separators. Also obtained on April 8, 2015, were instructions for staff to perform PROM to the resident's bilateral upper extremities every day. A review of the facility's "Event Investigation for Pressure Ulcers" dated April 8, 2015, revealed that the resident's hands were contracted and the pressure area was noted on the left thumb. A review of a nursing progress note dated April 9, 2015, at 2:56 PM, and a corresponding facility Weekly Skin Alteration Measurement Tool, dated April 9, 2015, revealed that the resident's full thickness wound was a Stage IV (a full thickness skin loss with damage to muscle, bone or supporting structures such as joints and tendons) measuring 1.5. cm. by 1.5. cm. by 0.1 cm. The wound was described as having scant serous (clear or straw colored fluid) drainage. New treatment orders were obtained for [MEDICATION NAME] Gel (a type of wound dressing used to provide moisture for the healing process and protection of the healing wound from contamination) and a dry dressing and to change twice a day. Observation of the wound treatment on April 14, 2015, at approximately 9:35 AM, revealed that when the nurse removed the dressing from the resident's wound, the tendon (a flexible but inelastic cord of strong fibrous collagen tissue attaching a muscle to a bone) was exposed. When asked at this time, the Treatment Nurse (Employee 3) confirmed that the resident's tendon was exposed. There was no documentation indicating if the resident's physician ordered the discontinuation of the bilateral PROM measures when the resident originally experienced a decline in health in 2013. In addition, the facility failed to assess and/or implement appropriate preventative and/or restorative measures for this resident with a history of contractures resulting in the development of a Stage IV pressure area. During an interview with the Director of Nursing (DON) on April 16, 2015, at approximately 10:50 AM, the DON was unable to provide information or explain why the resident, who was at risk for skin breakdown due to his contractures and recent decline in health, was not provided with applicable preventative measures to deter skin breakdown. 483.25(c) Pressure Sores Previously cited 1/27/15, 10/24/14 28 Pa Code 211.10 (a)(c)(d) Resident care policies. Previously cited 1/27/15, 10/24/14 28 Pa Code 211.11(a)Resident care plans. 28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited ending 1/27/15, 10/24/14

Based on observation, review of clinical records, event reports and resident accident/incident reports and staff interview, it was determined that the facility failed to consistently implement planned and/or necessary safety measures, including timely staff assistance, to prevent falls for two residents (Residents 149 and 172) and resultant serious injury to one resident out of 28 residents reviewed (Resident 149). Findings include: A review of the clinical record revealed that Resident 149 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 17, 2014, revealed that the resident was severely cognitively impaired. The resident required extensive assistance of two staff members for ambulating, transferring, bathing and toileting. The resident was assessed to be continent of bowel, occasionally incontinent (insufficient voluntary control over urination or defecation) of bladder and had suffered one previous fall in the past six months. A review of accident/incident reports revealed that the resident fell from the bed on June 18, 2014, and sustained a superficial laceration to her occipital area (back of the lower part of the skull). On June 20, 2014, the resident fell from the bed without injury. On June 21, 2014, the staff observed the resident fall from the bed without injury. A review of the resident's initial care plan dated June 25, 2014, revealed that one of the problematic areas was that the resident had the potential for injury related to falls. A fall risk assessment completed upon admission revealed that the resident had a score of 17 (a score of 9 or greater is at risk for falls). Interventions planned at the time of admission included ensuring that the resident is oriented to the environment with emphasis on the provision of physical needs including that assistive devices are within the resident's reach and functional status. On July 5, 2014, the resident fell out of the bed without injury. On July 10, 2014, the resident fell from a Broda chair (a tilt and reclining chair) and fractured her left hip. The resident was hospitalized from July 10, 2014, through July 16, 2014, for the surgical repair of the hip fracture. The resident's care plan regarding urination was updated on July 16, 2014, to include the intervention that, "Staff will assess toileting needs every two hours. The resident is able to make her needs known and verbalizes to the staff when she needs to use the bathroom. Check and change protocol in place." A three-day bladder diary assessment from September 18 - 20, 2014, revealed that the resident showed increased urinary incontinence. New interventions planned at this time were to assess the resident every two hours for wetness/toileting needs and to provide incontinence care every two hours and as needed. A review of a resident accident/incident report revealed that on November 10, 2014, at 11:45 PM, the staff heard the resident's bed alarm, went to her room and found her lying on the floor in the bathroom. The safety measures in place at the time of the fall were a bed alarm and floor mats. The accident/incident report noted that the resident stated that she had to go to the bathroom. Further review of the accident/incident report revealed no documented evidence of the last time that the resident was toileted prior to the fall. The field for this information was left blank on the accident/incident report. A review of a nursing progress note dated November 11, 2014, at 3:05 AM, revealed that the resident was assessed after the fall revealing skin tears to the left elbow and no other injuries or complaints of pain or discomfort. The resident was continent and barefoot and stated that she had to void. Nursing noted that, "after assessment resident was toileted and did void." A review of the resident's Bowel and Bladder Detail Report, revealed that the last time the resident was assessed for toileting needs prior to the fall on November 10, 2014, was at 8:46 PM, that evening at which time she was incontinent. A nursing progress note dated November 11, 2014, at 1:44 PM, revealed that the resident complained of pain in the pelvic area when she was assisted to the bathroom. The physician was notified and ordered an X-ray of the upper legs and pelvic area. Nursing noted at 6:30 PM, on November 11, 2014, that a new order was received from the physician for non-weight bearing until the physician evaluated the resident. A nursing progress note on November 11, 2014, at 7:36 PM, revealed that X-ray results indicated a fracture of the right inferior pubic ramus (pelvis). There was no documented evidence provided at the time of the survey that this resident was assessed for toileting needs every two hours as planned. The facility failed to timely address the resident's toileting needs to deter the resident's unsafe act of unassisted transfer and ambulation and subsequent fall with serious injury. Review of incident/accident report dated December 8, 2014, revealed that at 8:00 PM, the resident's bed alarm was sounding. A nurse aide responded and found the resident sitting on the floor in her room. The resident stated that she hit her head, but the assessment of her head was unremarkable. A body check revealed a 2 cm (centimeter) x 2 cm skin tear to her left elbow and a pink coccyx (tailbone). Interventions in place at the time of the fall included a scoop mattress, floor mats, and a bed alarm. A review of an accident/incident report dated January 8, 2015, at 9:00 PM, revealed that the resident was found lying on the floor behind the nurses' station with her Broda chair behind her. The accident/incident report revealed that there were no fall alarms in place at the time of the fall. Statements from the staff members included with the report revealed that they did not witness the fall or hear a chair alarm, but saw the resident lying on the floor. However, the nursing progress notes dated January 8, 2015, at 9:24 PM, noted that the, "resident slid to floor, alarm sounded staff responded to find resident had slid to floor causing a hematoma with abrasion to left side of forehead." It could not be determined if safety alarms were used as a fall prevention measure at the time of this fall although according to the resident's plan of care the use of a chair alarm to the Broda chair was added as an intervention on October 13, 2014, noting "chair sensor alarm to Broda chair." A review of accident/incident report dated February 14, 2015, revealed that at 4:00 PM, Resident 149's chair alarm sounded and she was found at the nurses' station lying across the foot rest of her Broda chair, with the left side of her head resting on the carpeted floor. A small amount of edema (swelling) was noted above the left eye and below the eye. An X-ray of the resident's facial bones performed on February 15, 2015, revealed no fractures. A review of the accident/incident report for this fall including staff interview forms revealed that three staff members reported that Resident 149: "1) Attempted to self transfer 2) Resident continues to try getting out of her chair and 3) Short staffing!/Resident persists to get out of chair." A comment to the follow-up investigation revealed, "As she places her legs to side - will try wings - Dycem (non-skid material) as applied" and "15 minutes while resident is in bed." Progress notes revealed that the Dycem was not ordered until February 16, 2015. Further review of the follow-up to the resident's fall on January 8, 2015, revealed that Dycem to chair was to be ordered as a new intervention following that fall, but there was no evidence that it was implemented until February 16, 2015. A review of Resident 149's quarterly MDS assessment dated [DATE], revealed that the resident's cognitive skills had further decreased, she was always incontinent of bowel and bladder (compared to always continent of bowel and occasionally incontinent of bladder on her June 17, 2014 MDS Assessment) and required increased staff assistance with transferring and ambulating. Treatment records for March 2015, for safety checks every 15 minutes while in bed were blank and the order was discontinued on April 2, 2015. On April 14, 2015, at 1:20 PM, Resident 149 was observed trying to climb out of the Broda chair while seated at the nurses' station. The resident was also observed sliding down to the bottom of the Broda chair three times within five minutes between 1:15 PM - 1:30 PM. There was no observable evidence that Dycem was in place to prevent the resident from sliding in the Broda chair. The staff then ambulated the resident to the bathroom. On April 15, 2015, between 2:00 PM - 2:15 PM, the resident was again observed seated at the nurses' station and was observed twice trying to climb out of the Broda chair. Observation of the resident on April 16, 2015, between 9:15 AM - 9:30 AM, revealed that the resident was very restless in the Broda chair and was observed attempting to climb out of it. The staff then ambulated her to the bathroom at 9:30 AM. On April 16, 2015, at 2:15 PM, the resident was sitting at the nurses' station and was observed trying to climb out of the Broda chair. The staff then ambulated her to the bathroom. The facility staff was not observed to provide the resident with diversion or forms of activities in an effort to decrease the resident's restless behavior and risk for falls. Interview with the Director of Nursing on April 16, 2015, at approximately 10:00 AM confirmed that the resident remained at risk for falls. A review of the clinical record reveals that Resident 172 was admitted to the facility on [DATE]. A review of a significant change MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired and required the extensive assistance of two staff members for transfers. The resident also required extensive assistance of one to two staff for bathing and dressing and the extensive assistance of two staff members for toileting. The resident was always incontinent of urine. Resident 172's care plan, with an initial date of February 3, 2013, identified a problematic area as, "potential for injury related to falls." The resident's fall risk assessment at this time resulted in a score of 10 (a score of 9 or greater is at risk for falls). Interventions instituted included: encouraging resident to rise slowly from lying to a sitting, to a standing position (especially in the morning); monitoring him for unsteady gait; assess resident for cognitive impairments which could present a serious problem to safety; and locating assistive devices within his reach. An update to the resident's plan of care on August 13, 2013, to address the problematic area of impaired urinary elimination included an approach of a three day bowel and bladder assessment, which resulted in a plan to toilet the resident (if awake) at 1:00 AM, 3:00 AM, and 5:00 AM, and regularly at 8:00 AM, 1:00 PM, 5:00 PM, and midnight. A fall risk assessment dated [DATE], now revealed a score of 20, which had doubled since he was admitted to the facility. Review of an accident/incident report revealed that on October 15, 2014, at 2:40 PM, the resident was seated at the nurses' station in a high-backed wheelchair with bilateral (both sides) foot rests when the staff observed him to stand up and fall onto his right side. The safety measures in place at the time of the fall included: proper footwear and bilateral leg rests. The resident was continent of bowel and bladder at the time of the fall and had been toileted an hour prior to the fall. After the fall new interventions ordered included, the application of a wheelchair alarm and the removal of the bilateral leg rests (except for transport only) to decrease tripping hazard. On October 23, 2014, a physician's orders [REDACTED]. The nursing notes revealed that on October 30, 2014, at 1:00 AM, the resident's bed alarm sounded and the staff found him attempting to crawl out of the bed. They assisted him to his highback wheelchair. On October 31, 2014, at 6:25 AM, the resident's bed alarm sounded and the staff found him attempting to get out of the bed. The resident was again placed in his high-backed wheelchair. On November 12, 2014, the resident was evaluated for a full length Broda chair to replace his high-backed wheelchair. On November 26, 2014, the resident's care plan for transfers was updated to include extensive assist of two staff along with a stand-up lift. Review of an accident/incident report dated December 7, 2014, revealed that at 7:30 PM, the staff found the resident lying on the right side of his body on the floor of his room. The report states that he had slid out of his Broda chair. The report did not indicate whether the resident's chair alarm was in place and/or sounding at the time of the fall. There were no new safety precautions or interventions listed on the resident's care plan following this fall. An occupational therapy evaluation was performed on December 9, 2014, at which time the resident was educated on using the Broda chair, although the resident was assessed as being severely cognitively impaired. Review of Resident 172's care plan and progress notes revealed that the chair alarm was discontinued on December 19, 2014. The fifteen minute safety checks were to continue due to the removal of the alarm, but were not identified on the resident's treatment record for the months of January 2015 or February 2015. Review of accident/incident report dated February 20, 2015, at 1:30 PM revealed that the resident was found on his bedroom floor with his buttocks resting on the footrest of his Broda chair. The staff interviews included with the accident/incident report revealed that the resident's roommate alerted staff to the fall. The report also revealed that the resident was last toileted at 10:00 AM, three and one half hours prior to the fall. The new safety measures instituted were to add Dycem to the Broda chair and initiate safety checks. A physical therapy/nursing fall team meeting was held on February 23, 2015, and no new orders were noted. Review of an Event Report dated March 13, 2015, at 6:01 AM, revealed that upon hearing Resident 172's bed alarm, the staff found him lying on his right side on the sensory mat with the call bell underneath him. The resident was transferred to the hospital emergency room for evaluation due to being on Coumadin therapy (anticoagulant drug that increases bleeding risk) and that the fall was unwitnessed. A fall team meeting was held on March 13, 2015, and new orders implemented were to use bilateral bed bolsters as a preventive safety measure. Review of an event report dated April 14, 2015, revealed that at 11:00 AM, the resident was observed sitting in front of the nurses' station when he suddenly attempted to stand up unassisted, resulting in a fall to his right side with a 3 cm x 0.5 cm superficial abrasion to his right eyebrow with surrounding tissue reddened, three superficial abrasions to the first three knuckles on his right hand measuring 1 round cm each and a small amount of sanguineous (blood like) drainage on his right eyebrow. The staff witness statements failed to reveal if the resident's chair alarm was in place at the time of the fall. There was no documentation on the treatment record regarding the use of the Dycem to the Broda chair during the month of April 2015 until the date of the fall. A new intervention put into place after this fall was the addition of a sensory clip alarm to the Broda chair. Interview with the Director of Nursing on April 15, 2015, at approximately 11:45 AM, failed to provide documented evidence that the facility consistently implemented safety measures and planned approaches, including adequate staff assistance/supervision, to prevent repeated falls. 28 Pa. Code 211.10 (d) Resident Care Policies Previously cited 1/27/15, 10/24/14 28 Pa. Code 211.11(d) Resident Care Plan Previously cited 1/27/15, 1/24/14 28. Pa. Code 211.12 (a)(c)(d)(5) Nursing services Previously cited 1/27/15, 10/24/14

Based on review of clinical records, select facility policy, resident Accident/Incident Reports, and resident and staff interviews, it was determined that the facility failed to accurately assess a pressure ulcer and provide prompt and necessary treatment and services to prevent worsening and promote healing of a pressure ulcer for one resident out of 29 residents sampled (Resident 62). Findings include: A review of the facility "Pressure Ulcer Treatment Policy" reviewed by the facility December 2013, revealed that the Licensed Nurse will document the status of the ulcer at the time of a dressing change. The Wound Care Nurse will recommend to the physician any changes to the wound treatments if the current treatment regimen does not appear to be effective in a timely manner. Every week, each pressure related area will be assessed by the Wound Care Team which is comprised of the physician, the Wound Care Nurse, a PT/OT representative, the Dietitian, and the Assistant Director of Nursing. A review of the clinical record revealed that Resident 62 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process of long term care residents) dated August 29, 2014, indicated that the resident was cognitively intact and required limited assistance (indicating the resident was highly involved in their activities and that the staff member provided guided maneuvering of limbs or other non-weight bearing assistance) of one staff member for bed mobility and transfers, and was not at risk for the development of pressure ulcers. A wound care progress note dated, September 18, 2014, noted that an abrasion (a scraping away of a portion of skin as a result of an injury) was reported to the Wound Care Nurse by a Licensed Practical Nurse. The abrasion was on the resident's left ischium (lower portion of the hip bone) and measured 1 cm (centimeter) x 1.2 cm. The physician was made aware of the abrasion and ordered a treatment consisting of [MEDICATION NAME] (an ointment used to promote wound healing) to the left ischium twice per day for seven days and then staff were to reassess the area. Review of an Accident/Incident Report dated, September 18, 2014, noted that the abrasion was found during the resident's shower. A review of the resident's Treatment Status Sheet (a form describing the status of the wound being treated) dated September 18, 2014, noted that the area was red with no depth. Further review of the Accident/Incident Report revealed no causative factor for the abrasion (to rule out pressure as a causative factor) was identified by the facility. A physical therapy/occupational therapy communication was sent to therapy for an evaluation of the resident's positioning. A review of a Rehabilitation Screening (a screening conducted by the specialized rehab department) dated September 19, 2014, indicated that the resident had an irritation to the coccyx (area at the base of the spinal column, despite the abrasion being noted on the left ischium). The recommendation was to continue using the two inch foam cushion to the resident's wheelchair. Review of the resident's September 2014 Treatment Administration Record (record of treatment prescribed and provided to the resident) revealed that the physician ordered [MEDICATION NAME] treatment was applied September 18, 2014 through September 24, 2014. Further review of the clinical record revealed no evidence that the area was reassessed after seven days as per the physician's orders [REDACTED]. A nursing note dated September 30, 2014, at 12:15 p.m., noted a recurrent area to the resident's left ischium. The area was noted to be reddened and measured 4.5 cm x 3 cm. A moistened Biostep (a wound dressing) was to be applied daily and covered with 4 x 4 gauze. A wound care progress note dated September 30, 2014, at 4:01 p.m., indicated that the area on the resident's left ischium was worse, presenting as a Stage II pressure area {partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (separating dead tissue). May also present as an intact or open/ruptured serum-filled blister} measuring 5 cm x 3 cm x 0.2 cm depth; the wound bed was red/hard, the surrounding tissue was white and macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) with no exudate (drainage). Review of the Incident/Accident Report dated September 30, 2014, indicated that the pressure area was recurrent. The action taken by the facility was the use of a Hillrom mattress (a brand name specialty pressure relieving mattress) and a physical therapy screen for positioning in the wheelchair. Review of a Rehabilitation Screening dated October 1, 2014, noted an order for [REDACTED]. A Weekly Wound Report dated October 9, 2014, indicated that the area on the resident's left ischium was greatly improved since October 1, 2014, and measured 4.5 cm x 3 cm, Stage II pressure sore with no depth. The wound bed was pink (no slough), the perimeter of wound flesh tone, and a scant amount of tan drainage was noted. The recommendation and order received was to change the current treatment to [MEDICATION NAME] with a dry dressing to be changed daily. A Wound Center consult dated October 14, 2014, indicated that the resident presented with a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) on the left ischium, which measured 4 cm x 3.5 cm x 0.2 cm depth. The wound bed was identified as 76-100% slough. A surgical debridement was performed by the Wound Center physician. This documented assessment and description of the resident's pressure sore differed from the facility's assessment of the wound as a Stage II without slough. An interview with the resident on October 21, 2014, at 11:00 a.m., confirmed that he requires staff assistance for bed mobility and transfers. The resident attributed the development of the pressure ulcer to his lying on the area. Review of the clinical record revealed no documented evidence of education to the resident regarding the importance of frequent repositioning to allow pressure relief. Review of the resident's current activities of daily living care plan dated June 9, 2014, indicated that the resident was unable to complete activities of daily living secondary to the underlying disease processes. The approach to meet the resident needs was to reposition the resident every two hours. Review of the clinical record failed to provide documented evidence that the resident was repositioned every two hours. An interview with the Wound Nurse on October 23, 2014, at 11:30 a.m., failed to explain the discrepancy between the assessment and staging conducted by the facility and the Wound Center. The facility had identified the wound as a Stage II pressure sore with a pink wound bed and no slough versus the Wound Center's assessment of the wound as a Stage III pressure sore with 76-100% slough prior to wound debridement. An interview with the Director of Nursing on October 24, 2014, at 9:30 a.m., failed to provide documented evidence that the pressure ulcer was identified and accurately assessed in a timely manner and that applicable interventions were implemented promptly to prevent the pressure ulcer from worsening. 483.25(c) Pressure sores Previously cited 6/20/14 28 Pa. Code 211.5(f)(g) Clinical records Previously cited 6/20/14 28 Pa. Code 211.5(h) Clinical records Previously cited 6/20/14, 9/18/14 28 Pa Code 211.10 (a)(c) Resident care policies Previously cited 6/20/14 28 Pa Code 211.10 (d) Resident care policies Previously cited 6/20/14, 9/18/14 28 Pa Code 211.11 (d) Resident care plan Previously cited 6/20/14 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 6/20/14, 8/26/14 `

Based on a review of clinical records, select facility policy and an investigative report, observation and staff interview it was determined that the facility failed to implement appropriate preventative measures in a timely manner to prevent pressure sore development and failed to accurately assess this area of skin breakdown for one resident out of 29 sampled (Resident 122). Findings include: A review of the facility policy for Pressure Ulcer Prevention reviewed by the facility May 2014, revealed that pillows or a foam wedge should be used as positioning devices to keep bony prominence's from direct contact with one another. A review of the facility policy for Investigation of Incidents of Unknown Origin reviewed May 2014, revealed all staff shall be responsible for promptly identifying injuries and reporting them to the nurse on duty. The nurse shall immediately evaluate the resident and provide any needed intervention. The description of the injury shall be documented in the nursing notes at the time of injury. A review of the clinical record revealed Resident 122 was admitted to the facility on [DATE], and was identified at risk for pressure sore development. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 7, 2014, indicated that Resident 122, was severely cognitively impaired, required maximum assistance for activities of daily living and was at risk for developing pressure sores. A monthly recap of the physician's orders dated June 1, 2014, revealed prescribed interventions to float the resident's heels when in bed (to relieve pressure), skin checks every shift, skin prep to the resident's heels every shift (topical skin protectant) and out of bed to Geri chair (cushioned reclining chair to maintain positioning and comfort) with calf pad (a pad placed under the calf to keep the heels off the chair for pressure relief). A review of the resident's care plan for the problem of a potential for impaired skin integrity secondary to immobility dated September 15, 2013, revealed that Resident 122 will be repositioned while in bed at least every two (2) hours. Pillows or foam wedge positioning devices will be used to keep bony prominence's from coming into direct contact with one another. A review of an incident report dated May 30, 2014, at 10:15 p.m., revealed that a nurse aide discovered an open area on Resident 122's right outer ankle. The registered nurse assessed the area, called the physician and a treatment and Comfy boots (preventive coverings for the feet) were ordered. The corresponding nursing documentation dated May 30, 2014, at 11:19 p.m., revealed that the nurse aide, while doing rounds, discovered an open area on Resident 122's right outer ankle. The physician was contacted and treatments were ordered. There was no description, including measurements or staging of the wound (a method by which the degree of damage to a skin area is measured) documented by the RN who had assessed the pressure sore upon initial discovery. There was no further nursing assessment of the right ankle wound noted until June 2, 2014. The facility wound nurse documented that there was a dark area on the resident's right outer ankle. The area measured 3 centimeters (cm) x 3 cm and in the center of the wound there was a dry dark scab noted. The wound round notes dated June 5, 2014, at 6:00 p.m., noted that Resident 122's right outer ankle site was dark red and scabbed. The next nursing note of an assessment of the pressure sore wound was dated June 11, 2014, at 2:30 p.m., noting that the resident's right ankle area was 1.1 cm x 1.3 cm with a dry, dark scab. During a tour of the nursing unit on June 17, 2014, at 10:00 a.m., Resident 122 was observed seated in the reclining Geri chair. The resident's legs were crossed at the ankles and she was wearing protective boots at that time. Employee 2 a Licensed Practical Nurse (LPN) stated, at this time, that Resident 122 had the habit of crossing her legs at the ankle all the time and had been doing so prior to the discovery of the pressure sore on the resident's ankle. There was no evidence that the facility had developed and implemented applicable preventative measures based on the resident's known habit of crossing her legs at the ankles, which placed direct pressure on the resident's ankle. The treatment records dated May 2014, indicated that staff floated Resident 122's heels off the bed, but there was no documented evidence of any measures to keep the resident's ankles apart. During an interview on June 19, 2014, at 11 a.m., the facility's Wound Nurse confirmed that upon discovery, a pressure sore or wound is to be measured and staged with a complete description. She further confirmed that when the pressure sore was first discovered it was covered with a dark scab and was unstageable. The wound care nurse stated that the pressure area was found on a Friday, but she did not work that weekend, so she assessed the wound the following Monday. The nurse on duty when the wound is found should assess the area in the absence of the Wound Nurse. The Wound Nurse further confirmed that there was no documentation from May 30, 2014, to the present, of a complete assessment or staging of this resident's skin breakdown. The Wound Nurse also confirmed that Resident 122 did not have a protective wedge or other preventative measure in place between her ankles to keep the ankles from touching as noted in the resident's plan of care related to boney prominences. During an interview June 20, 2013, at 11:10 a.m., the facility CRNP (Certified Registered Nurse Practitioner) confirmed that Resident 122's right ankle wound was caused by pressure. She further confirmed that the area was unstageable when first discovered. Observation on June 19, 2014, at 9:30 a.m., of Resident 122's right outer ankle wound revealed a round open area measuring 1.8 cm x 1.2 cm x 0.3 cm depth. The skin surrounding the wound was dark red. The interior of the wound was tan colored slough (dead skin or tissue that has fallen off). There was a scabbed area to the upper left of the wound measuring 0.3 cm x 0.3 cm., which was not noted in any of the nursing or wound care notes in the resident's clinical record. There was no documented evidence that the resident's plan of care was implemented for the use of pillows or foam wedge positioning devices to keep bony prominences from direct contact with one another prior to the discovery of Resident 122' s unstageable pressure sore on the right outer ankle. There was also no evidence of a complete and accurate description of the right outer ankle pressure area documented at the time of discovery and on a consistent basis. F 483.25(c) Pressure Sores Previously cited 5/2/2013 28 Pa. Code 211.5(f) Clinical records Previously cited 6/8/2012, 4/16/2013, 5/2/2013 28 Pa. Code 211.5(g)(h) Clinical records Previously cited 4/16/2013, 5/2/2013 28 Pa Code 211.10 (a)(d) Resident care policies Previously cited 4/22/2014 28 Pa Code 211.10 (c) Resident care policies 28 Pa Code 211.11 (d) Resident care plan Previously cited 6/8/2012, 5/2/2013 28 Pa. Code 211.12 (a) Nursing services Previously cited 6/8/2012, 4/16/2013, 5/2/2013, 1/22/2014, 2/4/2014 28 Pa. Code 211.12 (c) Nursing services Previously cited 6/8/2012, 4/16/2013, 5/2/2013, 1/22/2014, 2/4/2014, 3/13/2014, 4/22/2014 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 6/8/2012, 4/16/2013, 5/2/2013, 1/22/2014, 2/4/2014, 4/22/2014

Based on review of clinical records, select facility policy, event reports and resident incident reports and staff interview, it was determined that the facility failed to provide adequate staff supervision to prevent an elopement by one resident (Resident 91), failed to implement planned safety interventions and provide sufficient ambulation assistance as needed to prevent an accident with injury for one resident (Resident CR2), failed to perform transfers as planned to prevent injury to one resident (Resident 150) and failed to maintain an environment free of potential accident hazards for one resident (Resident CR1) out of 29 sampled. Findings include: A review of the facility policy for Injuries of Unknown Origin reviewed by the facility [DATE], revealed that the nurse shall initiate and complete the appropriate investigation of unknown origin form. A review of the clinical record of Resident CR2 revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at established intervals to plan resident care) dated [DATE], revealed that the resident was severely, cognitively impaired, required assistance for activities of daily living, was at risk for falling and displayed wandering behavior. A review of the physician's orders dated [DATE] and [DATE], revealed that the resident was to ambulate with a seated rollator walker (assistive device) with supervision on the nursing unit. The resident's care plan for the problem of risk for falling, dated [DATE], revealed that Resident CR2 could ambulate after set up assistance with a seated rollator walker and supervision. A review of nurse aide assignment sheet dated [DATE], revealed that on the 7 a.m. to 3 p.m., shift Resident CR2 required the assistance of one staff member for the activities of daily living. However, the resident was noted as independent for transfers and activities of daily living on the 3 p.m. to 11 p.m. shift. During an interview with the Director of Nursing (DON) on [DATE], at 10 a.m., the DON was unable to explain the difference in the level of care required between the first and second shifts of nursing duty. A review of a resident accident/incident report and nursing notes dated [DATE], at 4:15 p.m., revealed that Resident CR2 was discovered lying on his right side on the floor outside of the unit dining room. The resident's walker was next to him on the floor. The resident was bleeding from his upper lip and had been incontinent of urine at the time of the fall. The resident was sent to the emergency room and returned to the facility the same night at 10:15 p.m., with a [DIAGNOSES REDACTED]. An arm splint, pain medication and an orthopedic appointment were ordered. The accident/incident report failed to provide evidence that at the time of the fall the resident's ambulation with the walker was supervised as planned. A review of a wandering monitoring system form (residents with wandering behaviors are monitored every 15 minutes by nursing staff) revealed that on [DATE], at 4 p.m., Employee 11 (a nurse aide) toileted Resident CR2 and at 4:15 p.m., the resident was noted to be out of bed, however, there was no reference to the resident being found on the floor outside the dining room at that same time at 4:15 p.m. A review of treatment records dated [DATE] and [DATE], revealed Resident CR2 may ambulate with a rollator walker with supervision on the nursing unit. During an interview on [DATE], at 1:00 p.m., the Director of Physical Therapy stated that ambulation with supervision indicates that a resident requires assistance of staff close by for ambulation. During an interview [DATE], at 10:00 a.m., the Director of Nursing (DON) confirmed that staff were not close by and were not monitoring this resident's ambulation at the time of the fall. Resident 150's quarterly Minimum Data Set assessment dated [DATE], revealed Resident 150 was severely cognitively impaired and required maximum assistance for the activities of daily living, transfers and ambulation. A review of a resident accident/incident report dated [DATE], at 7:00 a.m., revealed that Resident 150 was found with a reddened area to her left lateral (side) forearm wrist area, that was warm to the touch with slight swelling noted. She complained of pain in the same area. The physician was notified and an antibiotic drug was ordered. A nurse's note written the same day at 1:30 p.m., indicated that the resident's left forearm was slightly black and blue and edema (swelling) was present extending to the hand and fingers. The physician was again contacted and an x-ray and narcotic pain medication were ordered. The x-ray of the forearm dated [DATE], indicated that Resident 150 had a fracture of the distal ulna (wrist area, the longer of the two bones of the forearm) with mild displacement (the two ends of the broken bone are separated from one another). A review of the supervisor's section of the accident/incident report dated [DATE], indicated that the probable conclusion for the cause of the injury was a [DIAGNOSES REDACTED]. The employee witness statement's included as part of the facility's investigative report revealed that this resident complained to several nurse aides on [DATE], that her wrist hurt. These nurse aides noted that they reported the resident's complaints of pain to their charge nurse. There was no indication of any resistance to care displayed by the resident noted in any of the employee witness statements or nursing notes in the days preceding the finding of the fracture. The nursing documentation dated [DATE], at 12:15 p.m., indicated that physical therapy screened Resident 150 for a decline in transfer ability. A new physician's order dated [DATE], directed that staff discontinue the extensive assistance of two nurse aides for transfers and to begin using the stand up lift (a mechanical lift) for all transfers. The nurse aide assignment sheet dated [DATE] and 3, 2013, indicated that Resident 150 was noted as a "total assist" for transfers. There was no evidence that the facility began transferring the resident with the mechanical lift when ordered by the physician on [DATE]. During an interview [DATE], at 9:00 a.m., the DON confirmed that it could not be determined how the resident was transferred on the days immediately prior to the identification of the resident's fracture on [DATE]. A review of the facility's Elopement Policy and Procedure last reviewed by the facility [DATE], indicated that no nursing care residents would be outside without supervision of staff and/or facility representative. A review of the clinical record revealed that Resident 91 was [AGE] years old and had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated , [DATE], indicated that the resident was moderately cognitively impaired and was independent for ambulation. Review of the resident's Fall Risk assessment dated , [DATE], indicated that the resident had intermittent confusion and was at a high risk for falls. A monthly summary nursing note dated, [DATE], revealed that the resident was forgetful and ambulated independently "ad lib" (as much and as often as desired). Review of a resident accident/incident report dated, [DATE], at 11:30 a.m., revealed that the resident was observed ambulating away from the facility's front entrance at 11:03 a.m. At 11:16 a.m., according to the report, the resident was no longer in view of staff. The staff responded and observed the resident on the facility's sidewalk at 11:19 a.m. Upon return to the facility the resident stated that he went to the store (located approximately across the street from the facility at a heavily traveled busy intersection). The resident also stated that he had fallen (no injury noted) while ambulating back to the facility. Further review of the clinical record revealed no documented evidence that adequate supervision was provided to the resident, as per facility policy, to prevent this elopement. Interview with the Facility Safety Specialist on [DATE], at 1:00 p.m., confirmed that the facility failed to implement effective supervisory measures to prevent the resident's elopement. Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired and totally dependent on the assistance of two persons for transfers and dependent on staff for all activities of daily living. The resident also required extensive assistance of two persons for bed mobility and the resident had functional impairment of both lower extremities. A review of an event submitted to the State Survey Agency on [DATE], indicated that this resident utilized a (mechanical) lift for transfers and a splint and palm roll to his right hand to minimize contractures. The report indicated that on that evening the resident was given fluids at 10:25 p.m. and observed watching television in his room at 10:50 p.m. The resident was observed by a nurse aide lying on the floor of his room, on the left side of his bed, on a floor mat with the right side of his neck resting against the bed and grab bar (side rail) at 11:09 p.m. The resident's color was pale and a linear area of [DIAGNOSES REDACTED] (abnormal redness of the skin due to capillary congestion/pressure) was noted along the right side of his neck. The resident had no pulse or respirations. CPR was started and 911 was called. The resident was pronounced dead at 11:34 p.m. that night. A review of the facility's investigation revealed an incident/accident report dated [DATE], noting that on change of shift rounds a nurse aide found the resident unresponsive on the floor mat next to the resident's low bed and the supervisor was notified. CPR was initiated, and a code blue was called (medical emergency when a resident's heart stops beating or lungs stop functioning), the ambulance arrived at the facility and CPR ceased and the resident was pronounced dead at 11:34 p.m. Further review of the incident determined the resident had an air mattress on his bed at the time of the event. The resident also had grab rails on each side of the bed. There was no facility assessment to determine if the grab bars were appropriate for use by this resident based on the resident's dependence on staff for bed mobility. There was no evidence that the facility had accurately assessed this resident for the use of the grab bars in conjunction with an air mattress to ensure that the combination did not create an accident hazard and risk for entrapment of the resident. The statements from facility staff indicated the resident was not able to move on his own. A statement from Employee 17, an Licensed Practical Nurse, dated [DATE], indicated that the resident required assistance from staff with repositioning, utilized a right hand splint, was unable to make his needs known and was unable to use a call bell. This employee had observed the resident's lower extremities positioned off the bed during care in the past and also stated nurse aides have reported this to her in the past. A statement from Employee 14, a nurse aide, dated [DATE], stated that the resident could not move himself on his own and required assistance for moving and was unable to turn independently. A statement from the nurse in charge on the day of this incident, Employee 15, a Registered Nurse, noted that she found the resident on the floor at 11:09 p.m., on [DATE]. She noted the resident's history and his limited motion in his right hand and that he could grab the bar with his left hand, but not on his own. He rarely made his needs known and never rang his call bell. He could move his left arm, but his left leg had limited motion. The head of the resident's bed was always elevated. According to the statement, when Employee 15 arrived in the resident's room on [DATE], the resident was observed with his neck area between the grab bar and the air mattress and his body felt cold. A sheet partially covered him. The resident's pupils were fixed (did not react to light), his skin felt cool and he had no pulse or respirations at the time of discovery. The resident also had a mark on the right side of his neck. Employee 15 indicated the resident's privacy curtain was pulled closed and she was not aware of why it had been pulled closed. Three staff members assisted in placing the resident back to bed and CPR was initiated. Advanced Cardiac Life Support was initiated by paramedics at 11:17 p.m., the ambulance arrived at 11:19 p.m., a call to the emergency room at the hospital was placed and CPR was stopped at 11:34 p.m. The death certificate indicated the resident died of natural causes and (ASCVD) arteriosclerotic cardiovascular disease. A statement from Employee 16, a nurse aide, indicated he observed the resident on his left side with his feet on the floor and his head and neck in between the grab bar (and the mattress). He was gray in color. The employee stated the resident felt cold to touch and was unresponsive. The statement contained additional information written by this same employee, Employee 16, on [DATE], which indicated that approximately four weeks prior to this incident he observed this resident turned on his left side with his head and neck stuck between the grab bar and mattress and was blue in color and sputum (matter coughed up and usually ejected from the mouth, including saliva, foreign material) was coming from his mouth. Employee 16 indicated that he called for help. The resident was pulled from between the grab bar and mattress and he was placed on his back and his color returned to normal. Vital signs were obtained and the resident indicated he was okay. Review of the resident's clinical record failed to show evidence of the previous incident of entrapment described by Employee 16. However a review of an incident/accident report dated [DATE], indicated that the resident was observed with a 3 cm (centimeter) x 4 cm long ecchymotic (bruised) area to his right eyelid. The facility was unable to conclude how this injury occurred. The facility failed to ensure that the air mattress and grab bars were safe for use by this resident and continued to use the equipment without adequate assessment, including input from direct care staff on the resident's functional status and abilities, to ensure that the arrangement did not pose an accident hazard to the resident. On [DATE], at 10:00 a.m., the Nursing Home Administrator and the DON were interviewed and were unable to provide a documented assessment which indicated that the resident was able to utilize the grab bars for independent bed mobility. The DON stated there was no assessment for use of the grab bars (quarter side rails) prior to the incident on [DATE]. Telephone interview with a representative from the air mattress company on [DATE], revealed that they could not assure the use of rails on a bed not made by their company were safe for use with their air mattresses. The facility utilized a mattress from a different company than the company that supplied the beds. An interview with the Director of Maintenance on [DATE], at 11:50 a.m., failed to demonstrate that the facility air mattresses were compatible with the bed frame and grab bars in use. An observation of a bed in use with the air mattress and grab bars on [DATE], at 10:30 a.m., revealed that the area between the air mattress and the grab bar was approximately 2.5 inches. However, when pressure was applied to the end of the air mattress, the mattress compressed and the gap became as wide as 5 inches creating potential entrapment zone. 483.25(h) Accidents Previously cited [DATE], [DATE] 28 Pa. Code 205.71 Bed and furnishings 28 Pa Code 211.10 (c) Resident Care Policies 28 Pa Code 211.10 (d) Resident Care Policies Previously cited [DATE] 28 Pa. Code 211.12 (a) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12 (c) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records and select facility policy and staff interview it was determined that the facility failed to thoroughly assess, evaluate, and implement an individualized toileting program to improve/restore bladder function for two residents (Resident 44 and Resident 132) out of 26 sampled. Findings include: Review of the facility's policy and procedure entitled "Bowel/Bladder Incontinence Management Program " reviewed by the facility December 2010 revealed that it is the policy of the Gino J. Merli Veterans Center Nursing Department that residents who are incontinent of bowel/bladder as determined by the 96 hour Bowel and Bladder Management will receive the appropriate care and services to restore as much bladder/function as possible. The procedure states that all residents will be assessed via the 96-hour Assessment for Bowel and Bladder Management to determine presence and pattern of incontinence, to establish the cause of the incontinence, and to plan a program for the resident addressing the incontinence. Residents will be assessed utilizing this form upon admission, when a change in continence or overall condition occurs, and upon removal of a Foley catheter. Upon completion of the 96-hour assessment form , the Registered Nurse will then complete the Bowel and Bladder Retraining Assessment form. Based on the outcome of the assessment, the resident will be placed on an individualized toileting plan. Staff will document the results of each attempt at toileting in an effort to promote effectiveness and restore continence. Review of the clinical record revealed that Resident 132 had [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set Assessment (MDS) assessment dated [DATE], revealed that the resident was moderately impaired for decision making and required assistance with her activities of daily living. The MDS also indicated that the resident was frequently incontinent of bladder. Resident 132 had been hospitalized and returned to the facility on [DATE], at 11:15 a.m. with an indwelling urinary Foley catheter (tube into the bladder to drain urine). The Foley catheter was discontinued at 8:15 p.m. on August 2, 2010. Review of the resident's "96 hour assessment for Bowel and Bladder Management" dated August 2, 2010 through August 5, 2010 revealed lack of documented evidence that the resident's bladder diary was complete and accurate. Following the discontinuation of the Foley catheter, the 96 hour assessment was completed for only 70 hours. The bladder assessment further demonstrated incomplete documentation on August 4, 2010 from 8:00 a.m. through 3:00 p.m. and 12:00 a.m. through 6:00 a.m. Review of the "Bowel and Bladder Retraining Assessments" ( no date of completion) revealed that it did not identify any interventions that were to be put in place upon review of the "96 hour assessment for Bowel and Bladder Management." Review of the resident's care plan initiated June 28, 2010 indicated that staff will encourage and assist the resident to use the bathroom before and after each meal, immediately upon awakening, and at bedtime. Review of the facility's "Care Tracker" (computerized records used to record the resident's activities of daily living) from April 24, 2011 through May 24, 2011 failed to provide documented evidence that the resident was being toileted upon awakening,before and after each meal, and at bedtime. Interview with the Director of Nursing on May 24, 2011 at 11:15 a.m. revealed that "there is a problem with the bowel/bladder program" Clinical record review revealed Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an admission 96 hour assessment for bowel and bladder management dated September 1, 2009 through September 4, 2009 revealed Resident 44 to be continent of bladder. The next recorded bowel and bladder assessment was dated June 15, 2010 through June 18, 2010 and revealed that the resident was continent most times, with occasional bladder incontinence. The corresponding assessment stated the resident had urge ( the most common cause of urinary incontinence in the elderly: characterized by abrupt, frequency of urination) and functional incontinence (the loss of urine in residents whose urinary tract functions are intact but cannot remain continent because of external factors such as the inability to utilize the toilet facilities in time, the presence of confusion dementia or unwillingness). A review of the resident's plan of care for urinary elimination dated June 23, 2010, identified Resident 44 to have functional and urge incontinence and the plan of care was that the resident was to be toileted every 2 hours as per policy. A review of nursing, monthly summary notes dated from June 2010 through August 2010 revealed that Resident 44 was continent of bladder. Nursing monthly summary notes dated September 2010 through January 2011 indicated that the resident was frequently incontinent. A review of bladder records dated for November 2010 and December 2010 revealed that Resident 44 was always incontinent of urine on the 11 PM to 7 AM shift. The documentation indicated that the resident was frequently continent of urine during the 7 AM to 3 PM and 3 PM to 11 PM shift. There was no documented evidence that this resident was toileted every 2 hours as per the facility policy. A Quarterly Minimum Data Set assessment dated [DATE] revealed that the resident had severe cognitive impairment, required staff assistance for activities of daily living, was frequently incontinent of urine and not on a toileting program. A Quarterly Minimum Data Set assessment dated [DATE] indicated that Resident 44 required assistance for activities of daily living, was always incontinent of urine and not on a toileting program. A review of bladder records dated January 2011 revealed that Resident 44 had a few periods of urinary continence during the first 2 weeks of the month, but by January 14, 2011 was totally incontinent of urine. There was no documented evidence that this resident was toileted every 2 hours as noted on the resident's plan of care. A review of a 96 hour assessment for bowel and bladder management dated March 17, 2011 revealed Resident 44 to be mostly incontinent. There was no indication that the resident was assisted to the bathroom in an attempt to toilet him and decrease episodes of incontinence. During an interview May 23, 2011 at 9:25 AM the assistant Director of Nursing confirmed that there was no documentation that Resident 44 was toileted every 2 hours and that there was no assessment completed in January 2011 when Resident 44 urinary status went from frequently incontinent to totally incontinent of bladder. She confirmed that a 96 hour bladder assessment was not completed until March 17, 2011 for this resident with a noted decline in bladder function. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies Previously cited 6/18/10,10/1/10 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 6/18/10,8/11/10,10/1/10