Every finding on record at Grandview Nursing and Rehabilitation

Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and sanitary environment in resident areas on one of three resident units (Pavilion).Findings include: On September 1, 2026, at 10:45 AM, an observation of resident room [ROOM NUMBER] revealed a tan discoloration stain measuring 1 foot by 1 foot on the bottom of the door-side privacy curtain. A black liquid stain was observed running down the wall near the window, above the garbage can. The cover for the cooling/heating unit was observed to be falling off. On September 1, 2026, at 11:16 AM, an observation of resident room [ROOM NUMBER] revealed tan discoloration stains on the door-side privacy curtains. One stain in the middle of the curtain measured 4 inches by 2 inches, and a second stain at the bottom measured 12 inches by 8 inches. On September 1, 2026, at 11:32 AM, an observation of Resident 32's room revealed soiled bed linens. The top sheet had multiple brown stains in the center and along the left edge of the mattress, as well as multiple stains at the foot of the bed. The pillowcase was covered by a towel; when the towel was removed, the pillowcase underneath was observed to be yellow-stained. During an interview at the time of the observation, Resident 32 stated that it was common for his sheets not to be changed and reported that staff often did not change his sheets for weeks, despite his requests. On September 1, 2026, at 11:45 AM, an observation of Resident 160's room revealed soiled bed linens. The pillowcase had yellow and dark brown stains covering the entire pillow, and the fitted sheet had multiple brown stains in the center of the mattress. Follow-up observation on September 2, 2026, at 10:49 AM, and September 3, 2026, at 12:05 PM, revealed Resident 32's bed linens remained soiled in the same condition as previously observed on September 1, despite surveyor inquiry and staff acknowledgement of the soiled linens. During an interview on September 2, 2026, at 2:15 PM, Resident 160 stated her sheets are not routinely changed weekly or when they become soiled. During an interview on September 2, 2026, at 12:10 PM the Nursing Home Administrator acknowledged the facility is to be maintained daily to provide a clean and sanitary environment for the residents. 28 Pa. Code 201.18 (e)(2.1) Management.

Based on select facility policy, observations, clinical record review, and staff interviews, it was determined the facility failed to provide care and services in accordance with professional standards for the management and monitoring of a Peripherally Inserted Central Catheter (PICC) line for one resident out of 31 residents reviewed (Resident 54).Findings include: A review of nursing standards published by Lippincott Nursing Center (Picking Up on PICC Lines, Nursing Made Incredibly Easy) indicates that appropriate PICC line care (a peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for intravenous fluids, including antibiotics) includes obtaining and documenting a baseline external catheter length (the portion of the catheter visible outside the body) and ongoing comparison of that measurement to identify catheter migration (movement of the catheter inward or outward from its original position). These standards further indicate that arm circumference (measurement around the arm where the catheter is inserted) should be obtained and trended to monitor for complications such as edema (swelling caused by fluid accumulation), phlebitis (inflammation of the vein), infiltration (leakage of fluid into surrounding tissue), or deep vein thrombosis (a blood clot in a deep vein). According to the Infusion Nurses Society Infusion Therapy Standards of Practice (2021), vascular access devices must be routinely assessed for patency (the catheter remains open and able to infuse fluids), proper function, and signs of complications. These assessments include evaluation of the insertion site and surrounding tissue for erythema (redness), edema (swelling caused by fluid accumulation), warmth, pain, drainage, or induration (hardening of tissue), which may indicate phlebitis (inflammation of the vein), infiltration (leakage of fluid into surrounding tissue), or infection. Nursing standards further require that clinicians monitor the affected extremity for changes in arm circumference when clinically indicated, as increases may suggest edema or the development of a deep vein thrombosis (a blood clot in a deep vein). Ongoing comparison to baseline or prior assessments is necessary to identify clinically significant changes. A review of the facility policy titled Central Venous Catheter Dressing Changes, last reviewed by the facility on January 29, 2026, revealed that it is the facility policy to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings, and the dressings should be changed at least every five to seven days, and as needed. A review of the facility policy titled Central Venous and Midline PICC/Catheter Flushing, last reviewed by the facility on January 29, 2026, revealed that it is the facility policy to maintain patency of midline and central catheters, to prevent mixing of incompatible medications and solutions, and to ensure the dose of the solution or medication is administered in the venous system. Further review revealed the preferred choice for flushing and locking is single-use systems, such as single-dose vials or prefilled syringes, and to flush catheters at regular intervals to maintain patency and before and after the administration of medications. A review of clinical records revealed Resident 54 was admitted to the facility on [DATE], with diagnoses including osteomyelitis of the vertebra, thoracic region (a serious infection and inflammation of the middle to upper back). A review of Resident 54's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 24, 2026, revealed that Resident 54 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of hospital discharge instructions dated August 18, 2026, indicated the resident underwent placement of a PICC line for administration of intravenous antibiotics related to spinal osteomyelitis. A review of the facility's readmission evaluation dated August 18, 2026, indicated the presence of a PICC line in the upper left arm; however, there was no documentation of the external catheter length or arm circumference at the time of readmission. A review of physician orders dated August 18, 2026, directed staff to infuse Ertapenem Sodium (an antibiotic medication used to treat infections) 1 gram intravenously one time a day until September 26, 2026, for osteomyelitis. A review of the clinical record during the survey on September 2, 2026, revealed no documented evidence for physicians' orders to monitor and for the care of Resident 54's PICC line. Observation of Resident 54's PICC line on September 2, 2026, at 9:00 AM, in the presence of Employee 1, Licensed Practical Nurse, revealed a PICC line to the resident's left arm and had a documented date on the dressing of August 18, 2026. Employee 1 confirmed the date of August 18, 2026, and stated that registered nurses at the facility are responsible for changing the PICC line dressings. A comprehensive clinical record review of the Nursing admission Evaluation dated August 18, 2026, the Medication Administration Record and Treatment Administration Record for August and September 2026, nursing progress notes from August 18 through September 2, 2026, and physicians orders revealed no documented evidence that nursing staff recorded measurements for PICC line external length or arm circumference, performed dressing changes, monitored, and flushed the PICC line for patency. During an interview on September 2, 2026, at 9:30 AM, with the Director of Nursing, the above findings were reviewed, and it was confirmed the facility failed to provide care and services in accordance with professional standards for the management and monitoring of a Peripherally Inserted Central Catheter (PICC) line for Resident 54.28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on select facility policy, observations, and staff interview, it was determined that the facility failed to maintain acceptable practices for the labeling, service, and storage of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illnessFindings include: A review of the facility's food storage policy reviewed January 29, 2026, revealed that dry storage rooms will have a thermometer inside this area of food storage and that monitoring of this area will be completed on a regular basis. In addition, temperatures within this storage area will be maintained between 50 and 70 degrees Fahrenheit. An observation of the dry storage area in the basement on September 1, 2026, at 10:05 AM revealed two wall mounted thermometers. One was in place by the entrance door and one was on the opposite wall. Both thermometers indicated the room temperature was 78 degrees Fahrenheit. The room was noted to be warm and humid. There were no temperature logs or documentation of routine monitoring of this room's temperatures/humidity level noted in the room. During the observations multiple resident food items were being stored in the room such as cookies, juices, tomato soup, canned tuna and canned chicken, thickened dairy drinks, canned carrots, chili, peas, wax beans, beef stew, mayonnaise, chicken noodle soup, cream of mushroom soup, canned sauerkraut, canned mushrooms, canned beans, canned peppers, canned apples, and canned peaches. An observation of the dry food storage area on the second-floor east nursing unit on September 1, 2026, at 10:40 AM revealed the room had an air conditioning unit but was turned off. The room was noted to be warm and stuffy. There were no temperature/humidity logs or monitoring in this room, and the room did not have a thermometer. During the observation mutliple resident food items were being stored such as salad dressing packets, thickened dietary drinks, cookies, sandwich crackers, powdered sugar, cornstarch, powdered drink mixes, lemon juice, salt and pepper, granola bars, fruit snacks, and pudding packs An interview with the Nursing Home Administrator on September 1, 2026, at 11:35 AM revealed that the maintenance department evaluated the temperature of the second floor east dry food storage area 50 minutes after the air conditioning unit was turned on. The temperature inside this room was noted to be 77 degrees Fahrenheit. An observation on September 1, 2026, at 10:48 AM in the Pavilion nursing unit resident pantry revealed a freezer containing two Styrofoam containers with an ice-cream-like substance. The containers were unlabeled and lacked a date (one had only a first name and last initial). An open plastic bag of vanilla wafers was observed in the snack bin with no open date or identifying information. The interior of the microwave was heavily soiled with food pieces, debris, and stains. During an interview on September 1, 2026, at 10:50 AM, Employee 3, Nurse Aide, confirmed that opened food items should be dated and labeled. Employee 3, NA, confirmed the items in the Pavilion resident pantry freezer were not labeled or dated and acknowledged this storage method is not a facility procedure. During an interview on September 1, 2026, at 10:58 AM, Employee 4, Dietary Aide, confirmed that the opened plastic bag containing vanilla wafers was not labeled or dated. Employee 4 explained that it is the facility policy to label and date opened food. An observation on September 1, 2026, at 12:33 PM in the [NAME] Nursing unit resident pantry revealed the microwave heavily soiled with food debris stains, crumbs, and an unidentified substance inside and on the top of the appliance. An ice pack wrapped in a white cloth with stains and discolorations was observed stored inside the freezer. An interview with the Nursing Home Administrator on September 2, 2026, at 10:00 AM the above findings were reviewed and acknowledged the facility failed to maintain a sanitary environment and acceptable practices for the service, labeling, and storage of food. 28 Pa. Code 211.6 (f) Dietary services.28 Pa. Code 201.18(b)(1) Management

Based on select facility policy, observation, a review of clinical records, review of planned menus, and interviews with residents and staff, it was determined the facility failed to provide food that accommodated residents' preferences for one resident out of 31 residents reviewed (Resident 15).Findings include: Review of the facility policy titled Resident Food Preferences last reviewed by the facility on January 29, 2026, indicated that individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The policy stated that upon admission, dietary or nursing staff will identify a resident's food preferences. Staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. Clinical staff will document the residents' food and eating preferences in the care plan. Review of Resident 15's clinical record revealed admission to the facility April 20, 2026, with diagnoses to include cerebral palsy (a group of movement disorder that appears in early childhood and affect body muscle control, balance, and posture), and Type 2 diabetes (a chronic condition where the body either does not make enough insulin or it resists it). Review of Resident 15's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 2, 2026, revealed that Resident 15 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). During an interview on September 1, 2026, at 11:03 AM, Resident 15 stated she had never been interviewed by dietary or nursing staff regarding her food or beverage preferences. She reported she disliked scrambled eggs, sausage, carrots, lima beans and liver. She reported that she was consistently served scrambled eggs and carrots, despite disliking these items. Observation of Resident 15's breakfast tray at the time of the interview revealed she was served scrambled eggs, a food she disliked and was served multiple times a week. Review of her meal ticket (menu-based document that provides essential information about a resident ' s meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) showed no documented food dislikes or preferences. Review of the facility planned breakfast menu for September 2, 2026, indicated scrambled eggs as the entree. Observation on September 2, 2026, 9:55 AM again revealed Resident 15 was served scrambled eggs, despite her stated dislike. Review of the Resident 15's care plan dated April 29, 2026, showed no documentation of any food preferences or dislikes. During an interview on September 3, 2026, at 1:45 PM, the Corporate Dietary Manager confirmed that Resident 15's food preferences, including her dislikes, had not been obtained upon admission or any time thereafter. The facility failed to follow its own policy requiring assessment and documentation of food preferences and failed to ensure that Resident 15 received meals consistent with her stated dislikes. 28 Pa. Code 211.6 (a) Dietary services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on a review of clinical records, facility-provided investigative documentation, and staff interviews, it was determined that the facility failed to ensure effective fall-prevention interventions were implemented and maintained for one resident out of 31 residents reviewed (Resident 65).Findings included: A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), muscle wasting and atrophy (the shrinking and loss of muscle mass and strength), and difficulty in walking. A review of Resident 65's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2026, revealed that Resident 65 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment), required extensive assistance from staff for bed mobility and moderate assistance from staff for transfers and ambulation. Section P: Restrains and Alarms, indicated the use of a bed alarm. A review of Resident 65's fall risk assessment dated [DATE], indicated the resident was a high fall risk (very high chance of falling and getting injured because of physical weakness, medical conditions, or confusion). A review of resident 's care plan dated October 10, 2025, revealed the resident was at risk for falls due to decreased mobility. Planned interventions included a bed alarm to be in place and functioning properly and with the alarm box to be out of reach, bathroom door alarm in place and functioning properly, and a personal safety alarm to her chair. A review of facility provided investigative documentation revealed the resident experienced two unwitnessed falls on June 4, 2026, and July 29, 2026, and one witnessed fall on August 11, 2026. All three falls occurred when the resident was attempting to get out of bed or rise from her wheelchair without staff assistance. Investigative documentation indicated that during the June 4 and July 29 falls, the resident's bed alarm was plugged in and attached to the bed but did not sound to alert staff that the resident was attempting to get out of bed without assistance. During the August 11 fall, the clip alarm on the wheelchair (consists of a garment clip where one end of the cord or magnetic strap attaches to the resident's clothing. The other end of the cord is attached to the alarm box) also did not sound. During an interview on September 3, 2026, at 11:10 AM, Employee 8 (nurse aide) reported that she witnessed the August 11 incident and saw the resident remove the alarm box from the wheelchair, preventing the clip alarm attached to the resident's clothing from activating. During an interview on September 3, 2026, at 12:05 PM, the Nursing Home Administrator confirmed that the planned intervention of a functioning bed alarm was not in place during the resident's attempted self-transfers on June 4 and July 29, 2026. She further confirmed that on August 11, 2026, the alarm box was not out of the resident's reach as required by the care plan, allowing the resident to disable the alarm. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on select facility policy, observations, clinical record review, and staff interviews, it was determined that the facility failed to consistently implement preventive interventions to avoid the development of pressure injuries for one of 31 residents reviewed (Resident 8). Findings include: A review of the facility policy titled Pressure Ulcers/Skin Breakdown Clinical Protocol, last reviewed by the facility on January 29, 2026, revealed it is the facility policy to assess and document an individual's significant risk factors for developing pressure ulcers. The interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. The practitioner will order pertinent wound treatments, identify medical interventions related to wound management, and characterize the likelihood of wound healing. A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that include acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2026, revealed that Resident 8 was moderately cognitively impaired with a BIMS score of 11 (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 08 through 12 indicates cognition is moderately impaired). A clinical record review revealed a care plan indicating Resident 8 is at risk for alteration of skin integrity and pressure-related issues related to decreased mobility initiated on January 5, 2026. The care plan indicates Resident 8 developed a wound to his left ear from oxygen tubing on July 31, 2026. Interventions implemented to ensure Resident 8's skin remains free of breakdown within limits of the disease process include administering preventative skin treatment per the physician's orders, observing for changes in skin condition, and monitoring the effectiveness of treatments. A progress note dated July 31, 2026, at 2:54 PM revealed Resident 8 has a wound on his left ear due to oxygen tubing. A (protective) cushion was placed on the tubing. A review of a quarterly skin evaluation dated August 7, 2026, revealed Resident 8 is occasionally moist, chairfast, has very limited mobility, currently has skin breakdown conditions, and requires moderate to maximum assistance when moving, indicating he is at risk for developing pressure injury. A progress note dated August 28, 2026, at 11:07 AM revealed Resident 8 presents with blanchable redness (skin or redness that temporarily turns white or pale when you press on it and then returns to its color when you release the pressure) to the back of both ears. He denies pain. Protective covering to oxygen tubing is present. A physician's order for skin prep (a liquid skin protectant that dries quickly to form a clear, waterproof barrier) to the back of both ears and red areas daily until resolved was initiated on August 28, 2026. During an observation and interview on September 3, 2026, at 9:38 AM, Resident 8 was complaining of right ear pain related to his oxygen tubing lying across the top of his ear. Employee 1, Licensed Practical Nurse (LPN), removed the oxygen tubing resting on Resident 8's ear and confirmed the presence of an open skin wound measuring 0.5 cm by 0.2 cm by <0.1 cm. Employee 1, LPN, confirmed there was a protective sheath covering the tubing on Resident 8's left ear, but there was no protective sheath covering the tubing where the tubing contacts his right ear. Resident 8 indicated he did not know where the padding was for his right ear. A wound evaluation form dated September 3, 2026, at 10:55 AM revealed Resident 8 has a new open wound on his right ear measuring 0.2 cm by 0.1 cm by <0.1 cm (an open wound presenting with partial-thickness skin loss involving the dermis with superficial depth featuring a viable pink/red wound bed and defined margins is considered a Stage II pressure injury). The wound is described as slightly red granulation tissue without drainage, and no sign of infection is noted. The wound has a defined margin with erythema (redness of the skin) tissue surrounding the wound. The resident indicated pain of two out of ten related to the wound. During an interview on September 3, 2026, at 1:30 PM, the above information was reviewed with the nursing home administrator (NHA) and director of nursing (DON). The facility failed to implement effective interventions to prevent the development of a pressure injury for a resident at risk and with a history of similarly acquired wounds (left ear wound on July 31, 2026). The facility failed to implement interventions to prevent Resident 8's skin breakdown due to medical equipment (oxygen tubing) to his right ear, resulting in an open wound presenting with partial-thickness skin loss measuring 0.2 cm by 0.1 cm by <0.1 cm.28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to implement physician orders for one resident out of 31 reviewed (Resident 171).Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: AssessmentsClinical problemsCommunications with other health care professionals regarding the patientCommunication with and education of the patient, family, and the patient's designated support person. A review of the facility policy titled Medication and Treatment Physician Orders, last reviewed by the facility on January 29, 2026, revealed that it is the policy of the facility that orders for medications and treatments will be consistent with principles of safe and effective order writing. A review of the clinical record revealed Resident 171 was admitted to the facility on [DATE], with a diagnosis to include anxiety (a mental condition that causes a feeling of worry, nervousness, or unease). and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A clinical record review of a BIMS assessment (Brief Interview for Mental Status, a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information) dated July 21, 2026, revealed that Resident 171 had moderately impaired cognition with a score of 11 (a score of 8 through 12 indicates moderate cognitive impairment). A review of a psychiatric/psychological services consultant note dated July 29, 2026, revealed Resident 171 was being seen due to reports of being unstable and required psychiatric assessment due to symptoms of depression. The consultant recommended initiation of Sertraline 50 mg (a medication used to treat depression) daily for treatment of depression. A review of a nursing communication form to the resident's primary care physician dated July 29, 2026, revealed a recommendation to start Sertraline 50 mg daily, and the resident's primary physician signed off and was in agreement. The form was also signed off by a nurse and dated for July 29, 2026, at 6:00 PM. A review of a psychiatric/psychological services consultant note dated July 31, 2026, revealed that Sertraline 50 mg daily had been started since the last visit for treatment of depression and that the resident still presented with depression and also anxiety. A review of a psychiatric/psychological services consultant note dated August 6, 2026, mentioned that Sertraline 50 mg daily had been started for treatment of depression and that the resident still presented with depression and anxiety. A review of Resident 171's physician orders during the time of the survey revealed facility staff failed to implement and administer the physician approved medication of Sertraline to help with the resident's depression. An interview with the Director of Nursing on September 3, 2026, at 10:15 AM, confirmed the facility failed to provide nursing care consistent with professional standards of practice and failed to implement orders for Resident 171. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records, and staff interviews, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one out of 31 residents reviewed (Resident 171).Findings include: A review of a facility policy for Acute Change in Condition last reviewed January 29, 2026, revealed the purpose of the policy is to ensure that the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status or when there is a need to alter treatment significantly. Further review of the policy defines an acute change in condition as a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains, and without intervention, may result in complications or death. A review of the clinical record revealed Resident 171 was admitted to the facility on [DATE], with a diagnosis to include vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A clinical record review of a BIMS assessment (Brief Interview for Mental Status, a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information) dated July 21, 2026, revealed that Resident 171 had moderately impaired cognition with a score of 11 (a score of 8 through 12 indicates moderate cognitive impairment). A review of an admission agreement revealed Resident 171 revealed had a responsible party listed. A review of Resident 171's clinical record of a nurse progress note dated August 9, 2026, at 1:41 AM, revealed the resident had shortness of breath, their oxygen level was 71% on room air (normal 92-100%), and that oxygen at 3 L was applied, and the resident's oxygen levels improved to 98%. There was no documented evidence at the time of the survey the resident's responsible party was notified of the acute change in condition on August 9, 2026, at 1:41 AM. An interview with the Director of Nursing and Nursing Home Administrator on September 3, 2026, at 10:20 AM, confirmed the facility failed to notify the resident's responsible party of the acute change in condition for Resident 171. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10 (c) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records, and resident and staff interviews, it was determined the facility failed to afford residents the right to refuse a resident's room change for two residents out of 31 residents reviewed (Residents 133 and 148). Findings include: A review of the facility policy entitled Room Change Policy, last reviewed by the facility on January 29, 2026, revealed it is the facility policy to ensure that all residents have the most comfortable and pleasant stay, that room changes can be an inconvenience, and that the facility will therefore try to avoid making unnecessary changes whenever possible. A review of the clinical record revealed Resident 133 was admitted to the facility on [DATE], with diagnoses that included hypertension (blood pressure that is higher than normal) and weakness. A review of Resident 133's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 11, 2026, revealed that Resident 133 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of a progress note from the social services director dated August 28, 2026, at 9:49 AM, revealed they contacted the resident's daughter to discuss a room change per their request. A review of a nurse progress note dated August 28, 2026, at 3:22 PM, revealed Resident 133 transferred out of the west wing with all their belongings and medications. A review of a nurse progress note dated August 29, 2026, at 2:48 PM, revealed the resident was visibly upset due to a recent room change and questioned why she had a room change. A review of a progress note from the social services director dated August 31, 2026, at 11:55 AM, revealed she met with the resident and her daughters regarding recent behaviors after a room change. It was noted the resident was unhappy with a room change and requested to return to the old room; however, the old room was unavailable at that time. An interview with Resident 133 on September 1, 2026, at 12:15 PM, revealed they were very unhappy with a recent room change and stated they never agreed to the room change. Resident 133 stated that her daughter requested a room change, and the facility then moved her to a different unit. Resident 133 expressed that she was perfectly happy in her old room and conversed with a lot of other residents, including her old roommates. Resident 133 also expressed that she was very familiar with the staff on her old unit and missed having them care for her. An interview with the social services director on September 2, 2026, at 12:45 PM, revealed that the family requested Resident 133 to be moved into a two-bed room versus a four-bed room and the resident did not want to be moved. A review of the clinical record revealed no documentation that written notice, including the reason for the room change, was provided to the resident prior to the relocation. A review of the clinical record revealed Resident 148 was admitted to the facility on [DATE], with diagnoses that included anxiety (a mental condition that causes a feeling of worry, nervousness, or unease) and weakness. A review of Resident 148's admission MDS, dated [DATE], revealed that Resident 148 was cognitively intact with a BIMS score of 13 (a score of 13 through 15 indicates cognition is intact). A review of a progress note from Employee 7, social worker, dated August 28, 2026, at 11:53 AM, revealed they called the resident's family to notify them of a room change due to the extended length of stay. An interview with Resident 148 on September 1, 2026, at 12:00 PM, revealed they recently had a room change and stated the facility told her she had to move because she was staying longer than expected at the facility and was no longer considered short-term. Resident 148 stated she did not want to move and didn't know she had the option of staying in her old room. Resident 148 stated she enjoyed the view of her old room because she would often see deer outside of her window, and now the deer are unable to be seen from her current view due to location. A review of the clinical record revealed no documentation that written notice, including the reason for the room change, was provided to the resident prior to the relocation. The facility provided no evidence that the floors maintain different staffing patterns, specialized training, or distinct clinical services that would necessitate moving a resident based on a transition from short-term to long-term care status. During an interview on September 2, 2026, at 1:00 PM, the above information was reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA and DON were unable to provide clinical justification, necessitating moving Resident 133, despite her refusal to change rooms, and necessitating Resident 148's room change due to extended stay. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on observations and resident and staff interviews, it was determined the facility failed to provide a dignified dining experience for one of (Resident 32) out of 31 residents sampled. Findings include:An observation conducted on September 2, 2026, at 12:10 PM, revealed that Residents 139 and Resident 32 shared a room. At that time, Resident 139 was served his lunch meal and began eating. Resident 32 remained without a meal tray. Staff continued delivering meals to other residents in their rooms while Resident 32 did not receive any information or assistance regarding his missing tray. At 12:24 PM, Resident 32 exited his room and stated to the surveyor I have to go check and see if I get a tray today. Resident 32 walked down the hallway toward the nurses' station and asked about receiving a lunch tray. Employee 6 (nurse aide) stated he did not know where Resident 32's tray was and reported it had not been delivered on the meal cart. No staff provided follow-up information or assistance, and Resident 32 stood waiting in the hallway without direction. He returned to his room. At 12:30 PM, Resident 32 again exited his room and walked down the hallway to the kitchen to inquire about his lunch tray. Upon returning, he stated, Sometimes this happens and I need to go looking for my tray. At 12:36 PM, Resident 32's lunch tray was delivered, 26 minutes after his roommate received his meal. During an interview on September 2, 2026, at 12:49 PM, Employee 6 reported that Resident 32's lunch tray had not been placed on the meal cart sent from the kitchen. During an interview on September 3, 2026, the Food Service Director confirmed that Resident 32's lunch tray was delayed on September 2, 2026, due to his meal ticket (a menu-based document that provides essential information about a resident's meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) being misplaced. The kitchen was only notified when Resident 32 personally approached dietary staff to report he had not received his lunch. The facility failed to ensure that meal service was provided in a dignified manner, resulting in Resident 32 experiencing an extended delay in receiving lunch and requiring him to leave his room multiple times to inquire about his meal.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of the facility assessment, facility-provided training documentation, and staff interviews, it was determined the facility failed to ensure an effective behavioral health care and services training program was provided for employees for 12 out of 12 months reviewed (May 2025 through April 2026).Findings include: A review of the facility assessment (a mandated, comprehensive, and recurring evaluation designed to determine the necessary resources such as staffing, equipment, and services needed to care for residents competently during daily operations and emergencies) last reviewed by the facility on January 29, 2026, revealed that the facility identified that it manages the medical conditions and medication-related issues causing psychiatric symptoms and behaviors and identifies and implements interventions to help support individuals with issues such as dealing with anxiety, caring for someone with cognitive impairment, caring for individuals with depression, trauma, post-traumatic stress disorder, or other psychiatric diagnoses, or intellectual or developmental disabilities. The assessment indicated that, on average, 90 residents receive psychiatric services (treatment provided by a qualified practitioner for mental health conditions such as mood disorders, anxiety, or psychosis), and 99 residents receive psychological services (therapeutic interventions such as counseling or behavioral therapy to address emotional and mental health needs) each month. The assessment indicated staff education is a key component to assuring that residents receive quality care. The facility assessment failed to identify or include a structured or ongoing staff training program specific to behavioral health care and services, despite the identified resident population requiring these services. A review of the facility's annual staff training modules for the period of May 2025 through April 2026 failed to reveal evidence that staff received training related to behavioral health care and services, including the identification of behavioral symptoms, implementation of non-pharmacological interventions (approaches that do not involve medications, such as redirection, environmental modification, or de-escalation techniques), or appropriate response to residents with psychiatric or psychological needs. During an interview conducted on April 17, 2026, at 11:30 AM, the Director of Nursing and Nursing Home Administrator were unable to provide documentation demonstrating that staff received training in behavioral health care and services during the review period. During the same interview, both confirmed the facility provides care to residents with varying and complex behavioral health needs, including those requiring psychiatric and psychological services. The facility failed to ensure the development and implementation of a behavioral health care and services training program for staff, consistent with the needs identified in the facility assessment and the resident population served. 28 Pa. Code 201.20(a)(b)(d) Staff development. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, Medication Administration Records (MARs), facility policy, and staff interview, it was determined the facility failed to ensure pain was managed in accordance with professional standards of practice by not consistently attempting or documenting non-pharmacological (non-medication) interventions prior to the administration of as-needed (PRN) opioid pain medications for two of 33 residents reviewed (Residents 3 and 78).Findings include: A review of the facility policy titled Pain Assessment and Management, last reviewed January 26, 2026, indicated non-pharmacological interventions may be appropriate alone or in conjunction with medications. The policy identified interventions such as environmental adjustments (for example, changing room temperature), repositioning, pressure-reducing mattresses, application of ice or heat, exercise including range of motion (movement of joints to prevent stiffness), and cognitive or behavioral approaches such as relaxation or music. The policy further indicated pharmacological interventions (medications used to treat pain, such as analgesics) may be prescribed; however, these medications may not address the underlying cause of pain and may result in adverse effects, including drowsiness, increased fall risk, and decreased appetite. A review of Resident 3's clinical record revealed the resident was admitted on [DATE], with diagnoses including peripheral vascular disease (a condition involving narrowed blood vessels that reduce blood flow) and chronic left hip pain. A review of Resident 3's clinical record revealed the resident was admitted on [DATE], with diagnoses including peripheral vascular disease (a condition involving narrowed blood vessels that reduce blood flow) and chronic left hip pain. A review of physician orders dated October 31, 2025, at 3:30 PM, revealed an order for oxycodone HCl (an opioid pain medication used to treat moderate to severe pain) five milligrams by mouth every six hours as needed for pain levels four through ten (pain scale is a standardized tool used to measure a resident's level of pain, typically ranging from zero-no pain to ten-worst possible pain, to guide treatment decisions The order directed staff to offer non-pharmacological interventions prior to medication administration, including repositioning, toileting, backrub, dimming lights, food, fluids, or other measures. A review of the MAR (Medication Administration Record, a legal document that records medications administered to a resident) revealed the opioid medication, oxycodone HCL, was administered without licensed nursing staff attempting non-pharmacological interventions prior to administering the medications as follows: MAR dated November 1, 2025, through November 30, 2025, indicated oxycodone HCL was administered eleven (11) times out of one hundred and twenty (120) opportunities. MAR dated December 1, 2025, through December 31, 2025, indicated oxycodone HCL was administered twenty-three (23) times out of one hundred and twenty-four (124) opportunities. MAR dated January 1, 2026, through January 31, 2026, indicated oxycodone HCL was administered twenty-two (22) times out of one hundred and twenty-four (124) opportunities. MAR dated February 1, 2026, through February 28, 2026, indicated oxycodone HCL was administered twenty-three (23) times out of one hundred and twelve (112) opportunities. MAR dated March 1, 2026, through March 31, 2026, indicated oxycodone HCL was administered thirty-one (31) times out of one hundred and twenty-four (124) opportunities. The facility was unable to provide consistent documented evidence that licensed nursing staff attempted non-pharmacological interventions prior to administering the PRN opioid medication, oxycodone HCL as ordered. A review of Resident 78's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included a left femur fracture (a break in the thigh bone, the longest and strongest bone in the human body, usually caused by high-impact trauma). A review of Resident 78's physician's orders revealed an order for oxycodone HCl five milligrams, give one-half tablet by mouth every four hours as needed for pain levels four through seven, with direction to attempt non-pharmacological interventions first, including repositioning, toileting, food, fluids, back rub, dim lights, or other measures. A review of Resident 78's MAR dated March 12, 2026, through March 31, 2026, indicated oxycodone HCL was administered twenty-one (21) times out of one hundred and fourteen (114) opportunities. A review of MAR dated April 1, 2026, through survey ending on April 17, 2026, indicated oxycodone HCL was administered ten (10) times out of seventy-eight (78) opportunities. The facility was unable to provide consistent documented evidence that non-pharmacological interventions were attempted prior to administering Resident 78 a PRN opioid pain medication, oxycodone HCL. During an interview conducted on April 15, 2026, at 1:33 PM, the above findings were reviewed with the Director of Nursing, who confirmed the facility could not provide documented evidence that non-pharmacological interventions were consistently attempted prior to administering PRN opioid pain medications to Residents 3 and 78. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement nutritional interventions for 3 of 33 residents reviewed (Residents 146, 84, and 161).Findings include: A review of the facility policy titled Weight Assessment and Interventions, last reviewed by the facility on January 29, 2026, indicated each resident's weight would be monitored by the interdisciplinary team and staff would intervene for undesirable weight loss. The policy indicated any weight change of 5 percent or more since the last weight assessment would be reweighed for confirmation and, if verified, nursing would immediately notify the Registered Dietitian. The policy further indicated that 5 percent weight loss in 1 month is significant, 7.5 percent weight loss in 3 months is significant, and 10 percent weight loss in 6 months is significant for unplanned and undesired weight loss. A review of the facility policy titled Nutritional Assessment, last reviewed January 29, 2026, indicated the dietitian, in conjunction with nursing staff and healthcare practitioners, would conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that placed the resident at risk for impaired nutrition. A clinical record review revealed Resident 146 was readmitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle wasting with atrophy (wasting or thinning of muscle mass and can be caused by disuse of muscles). A review of a readmission nutrition evaluation completed by the Registered Dietitian on December 25, 2025, at 11:23 AM, indicated the resident's height was 59 inches and weight obtained on December 22, 2025, at 1:48 PM, was 91.2 pounds. The Registered Dietitian documented that the resident's ideal body weight was 123 pounds, the resident's weight had trended downward from 96 pounds on November 26, 2025, to 91.2 pounds on December 22, 2025, and the resident was underweight. The Registered Dietitian further documented the resident met criteria for malnutrition related to a mechanically altered diet, low body mass index (BMI, a measurement using height and weight to estimate whether body weight is low, normal, or high), compromised skin, variable oral intake, and a history of protein calorie malnutrition (poor nutrition caused by inadequate intake of calories and protein, which can result in weight loss, muscle loss, and impaired healing). The Registered Dietitian documented a goal for weight stability with gradual gain and recommended Med Pass 2.0, a liquid high calorie, high protein oral supplement, 120 milliliters three times daily. The note indicated staff should monitor weight trends and the resident should consume 75 percent or greater of most meals and supplements, show no signs or symptoms of malnutrition, and maintain weight without significant changes through the next review period, with weight gains favorable. A review of the resident's five day Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 27, 2025, revealed that Resident 146 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognitively intact). The assessment coded the resident's height as 59 inches and weight as 91 pounds. Section K0300 was coded to indicate the resident had a significant weight loss of 5 percent or more in the last month or 10 percent or more in the last 6 months that was not physician prescribed. Section K0520 indicated the resident required a mechanically altered diet and did not have a therapeutic diet in place. A review of Resident 146's weight record revealed the resident weighed 91.2 pounds on December 22, 2025, at 1:48 PM, and 82.2 pounds on January 5, 2026, at 11:35 AM. This reflected a 9-pound weight loss, or 9.8 percent, in approximately 1 week. A review of a nutrition progress note completed by the Registered Dietitian on January 12, 2026, at 2:20 PM, 7 days after the January 5, 2026, weight was obtained, indicated the current weight was 82.2 pounds on January 5, 2026, compared to 96.1 pounds on December 3, 2025, for a 14-pound loss, or 14.5 percent, in 1 month. The note described the weight loss as unfavorable, documented that the resident remained underweight, and indicated oral intake was mostly 50 to 75 percent of meals with oral supplementation in place. The note indicated staff would continue the current plan of care and monitor weekly weights to follow up for further nutritional interventions. Further clinical record review failed to reveal a reweight was obtained after the January 5, 2026, significant weight loss, as required by facility policy. The clinical record also failed to reveal timely identification of the significant weight loss or timely development and implementation of additional interventions to address the resident's ongoing nutritional decline. After the January 12, 2026, nutrition note, the clinical record did not include further nutrition monitoring related to the significant weight loss. During an interview on April 16, 2026, at 10:45 AM, the Nursing Home Administrator reviewed the above findings. A review of Resident 84's clinical record revealed admission to the facility on March 19, 2025, with diagnoses to include major depressive disorder, and cerebral infarction (stroke which occurs when blood flow to part of the brain is blocked or interrupted). A review of Resident 84's weight record revealed the resident weighed 105 pounds on February 4, 2026, and 94 pounds on March 1, 2026. This reflected an 11-pound weight loss, or 10.5 percent, in less than 1 month. Clinical record review failed to reveal the facility immediately reweighed Resident 84 after this significant weight loss. Clinical record review also failed to reveal documented evidence that the facility notified the Registered Dietitian, physician, or resident representative of the significant weight loss. During an interview on April 16, 2026, at 9:40 AM, the Nursing Home Administrator reviewed the above findings and was unable to provide documentation showing staff had timely notified the dietitian and physician of the resident's significant weight loss or obtained and recorded a reweigh to support an accurate assessment of the resident's nutritional status and needs. Clinical record review revealed that Resident 161 was admitted on [DATE], with diagnosis of major infection, major depression and diabetes. A review of Resident 161's quarterly Minimum Data Set assessment MDS dated [DATE], revealed that Resident 161 was moderately cognitively impaired with a BIMS score of 10; a score of 8 through 12 indicates moderate cognitive impairment. Review of Resident 161's weight record revealed that the resident weighed 133.6 lbs. on February 5, 2026, and as of March 1, 2026, weighed 126 lbs. representing a 7.6 pound weight loss in 24 days. A review of dietary notes and physician orders revealed the facility did not complete a dietary assessment and intervention until February 15, 2026, at which time the note indicated the weight loss was unfavorable and a dietary supplement was added. The clinical record failed to reveal the facility implemented timely follow-up monitoring after the identified weight loss. A review of the weight record revealed Resident 161 weighed 126.4 pounds on April 9, 2026. Clinical record review failed to reveal more aggressive monitoring, such as weekly weights, or timely reassessment before April 9, 2026, to assure reasonable measures were implemented to assure that the resident's nutritional needs and goals were being met. During an interview on April 17, 2026, at 12:30 PM, the Director of Nursing reviewed the above findings and was unable to provide documentation showing re-evaluation of dietary goals, care plan revisions, or ongoing aggressive weight monitoring by dietary services after the February 15, 2026, dietary note. These findings showed the facility failed to consistently reweigh residents after significant weight changes, failed to timely notify appropriate clinical staff, and failed to implement and monitor nutritional interventions to identify and address changes in nutritional status for Residents 146, 84, and 161. 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, review of Minimum Data Set (MDS) assessments, and staff interview, it was determined the facility failed to ensure the MDS assessments accurately reflected the residents' status for six of eight residents reviewed for MDS accuracy (Residents 2, 4, 6, 7, 14, and 39).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (October 2025), which provides instructions for completing the Minimum Data Set (MDS, a federally required standardized assessment used to evaluate resident status and develop care plans), indicates the assessment must accurately reflect the resident's functional status and be completed with participation from appropriate health professionals. The RAI Manual defines the Assessment Reference Date (ARD) as the last day of the observation period used to determine the resident's status. Information collected during the assessment period associated with the ARD must include direct observation of the resident, communication with the resident, and communication with direct care staff across shifts. The RAI Manual instructs that Section GG Functional Abilities must reflect the resident's usual performance, meaning the level of assistance the resident typically requires for activities such as eating, hygiene, toileting, bathing, and mobility, based on documentation and observation of the resident's actual performance during the assessment period. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with cerebral infarction (brain damage caused by interrupted blood flow to the brain, which may affect movement and ability to perform daily activities). A review of Resident 2's Annual MDS assessment dated [DATE], revealed Section GG Functional Abilities indicated Resident 2 required partial or moderate assistance with personal hygiene (activities such as combing hair, shaving, applying makeup, and washing and drying the face and hands). However, documentation in the clinical record during the assessment period associated with the ARD indicated Resident 2 was dependent on staff for personal hygiene on five of nine documented occasions, required substantial or maximal assistance on three of nine occasions, and required partial or moderate assistance on one of nine occasions.Section GG also indicated Resident 2 required partial or moderate assistance to roll left and right in bed. However, documentation during the assessment period associated with the ARD indicated Resident 2 was dependent on staff for bed mobility on three of nine documented occasions, required substantial or maximal assistance on five of nine occasions, and required partial or moderate assistance on one of nine occasions.Section GG also indicated Resident 2 required partial or moderate assistance to roll left and right in bed. However, documentation during the assessment period associated with the ARD indicated Resident 2 was dependent on staff for bed mobility on three of nine documented occasions, required substantial or maximal assistance on five of nine occasions, and required partial or moderate assistance on one of nine occasions. A clinical record review revealed Resident 14 was admitted to the facility on [DATE], with Alzheimer's disease (a progressive brain disorder that affects memory, thinking ability, and the ability to perform daily activities). A review of Resident 14's Quarterly MDS assessment dated [DATE], revealed Section GG indicated Resident 14 required partial or moderate assistance with eating (the ability to use utensils to bring food or liquid to the mouth). However, documentation during the assessment period associated with the ARD indicated Resident 14 was dependent on staff for eating on five of six documented occasions and required substantial or maximal assistance on one of six occasions. Section GG also indicated Resident 14 required substantial or maximal assistance with personal hygiene. However, documentation during the assessment period associated with the ARD indicated Resident 14 was dependent on staff for personal hygiene on nine of nine documented occasions. Section GG indicated Resident 14 required substantial or maximal assistance with bed mobility. However, documentation during the assessment period associated with the ARD indicated Resident 14 was dependent on staff for bed mobility, rolling left and right in bed and returning to a back lying position, on nine of nine documented occasions. A clinical record review revealed Resident 6 was admitted to the facility on [DATE], with dementia (a condition characterized by decline in memory and thinking skills that interferes with daily functioning). A review of Resident 6's Annual MDS assessment dated [DATE], revealed Section GG indicated Resident 6 required substantial or maximal assistance with toileting hygiene (cleansing oneself and adjusting clothing before and after toileting). However, documentation during the assessment period associated with the ARD indicated Resident 6 was dependent on staff for toileting hygiene on nine of nine documented occasions. Section GG also indicated Resident 6 required substantial or maximal assistance with showering and bathing (washing, rinsing, and drying the body). However, documentation during the assessment period associated with the ARD indicated Resident 6 was dependent on staff for bathing on two of two documented occasions.A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses including acquired absence of the left leg below the knee and right hip joint (surgical removal of the lower portion of the left leg and right hip joint). A review of Resident 4's Quarterly MDS assessment dated [DATE], revealed Section GG indicated Resident 4 required substantial or maximal assistance with showering and bathing. However, documentation during the assessment period associated with the ARD indicated Resident 4 was dependent on staff for bathing on four of four documented occasions. Section GG also indicated Resident 4 required partial or moderate assistance with personal hygiene. However, documentation during the assessment period associated with the ARD indicated Resident 4 was dependent on staff for personal hygiene on five of seven documented occasions and required substantial or maximal assistance on two of seven occasions. Section GG indicated Resident 4 required partial or moderate assistance with bed mobility. However, documentation during the assessment period associated with the ARD indicated Resident 4 was dependent on staff for bed mobility on five of eight documented occasions and required substantial or maximal assistance on three of eight occasions. A review of Resident 39's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A review of Resident 39's Quarterly MDS assessment dated [DATE], revealed Section GG indicated Resident 39 required substantial or maximal assistance with showering and bathing. However, documentation during the assessment period associated with the ARD indicated Resident 39 was dependent on staff for bathing on one of one documented occasion. Section GG also indicated Resident 39 required partial or moderate assistance with personal hygiene. However, documentation during the assessment period associated with the ARD indicated Resident 39 was dependent on staff for personal hygiene on four of four documented occasions. Section GG indicated Resident 39 required supervision or touching assistance to wheel 50 feet in a wheelchair and complete two turns. However, documentation during the assessment period associated with the ARD indicated Resident 39 was dependent on staff for wheelchair mobility on two of two documented occasions. Resident 39 was dependent on staff to wheel 50 feet and make two turns in a wheelchair on two of two occasions documented. Review of Resident 39's Quarterly MDS assessment dated [DATE], revealed Section J Health Conditions indicated Resident 39 had no falls within the month prior to admission and no falls within the prior two to six months. However, documentation in the clinical record indicated Resident 39 sustained a fall at the facility resulting in an acute right femoral intertrochanteric fracture (a break in the upper portion of the thigh bone near the hip joint). A clinical record review revealed that Resident 7 was most recently admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and hemiplegia (paralysis on one side of the body). A review of Resident 7's admission MDS assessment dated [DATE], revealed Section GG indicated Resident 7 required partial or moderate assistance with personal hygiene. However, documentation during the assessment period associated with the ARD indicated Resident 7 was dependent on staff for personal hygiene on five of seven documented occasions and required substantial or maximal assistance on two of seven occasions. During an interview on April 15, 2026, at 1:30 PM, the above findings were reviewed with the Registered Nurse Assessment Coordinator. The Registered Nurse Assessment Coordinator acknowledged the MDS assessments for Residents 2, 4, 6, 7, 14, and 39 did not accurately reflect the residents' status documented in the clinical record. The facility failed to ensure the Minimum Data Set assessments accurately reflected the status of Residents 2, 4, 6, 7, 14, and 39.Refer F94028 Pa. Code 211.5(f)(ii) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, staff interview, manufacturer guidelines, and review of select facility policy, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications and failed to maintain proper refrigeration temperatures for medications used in resident treatment on one of two nursing units (West), involving 10 residents (Residents 2, 4, 6, 22, 39, 56, 87, 90, 93, and 123).Findings include: A review of manufacturer guidelines for injectable agents used to lower blood glucose (blood sugar), including insulin products such as glargine, lispro, Lantus, and Novolog, as well as non-insulin injectable agents such as Trulicity, indicated that these medications must be stored under controlled temperature conditions to maintain effectiveness (potency, meaning the medication's ability to produce the intended therapeutic effect). Manufacturer guidance indicated that when refrigerated, these medications are to be maintained between 36 and 46 degrees Fahrenheit and must not be frozen, as freezing or exposure to temperatures outside the recommended range may alter the medication's stability and effectiveness.A review of the facility policy titled Storage of Medications, last reviewed January 29, 2026, indicated medications are to be stored in accordance with manufacturer recommendations and under proper temperature controls. The policy indicated refrigerated medications are to be maintained between 36 and 46 degrees Fahrenheit and that refrigerator temperatures are to be recorded daily. The policy also required staff to promptly report any refrigerator malfunction for emergency repair or replacement. Observation of the [NAME] nursing unit medication room on April 15, 2026, at 9:30 AM revealed a medication refrigerator containing multiple injectable blood glucose-lowering medications. A thermometer inside the refrigerator registered 30 degrees Fahrenheit. Review of the posted temperature log revealed that staff had not documented the refrigerator temperature for April 15, 2026, as of 9:30 AM. Posted parameters for acceptable refrigerator temperatures indicated a range of 36 to 40 degrees Fahrenheit, which was inconsistent with the facility policy range of 36 to 46 degrees Fahrenheit. A review of recorded refrigerator temperatures from January 1, 2026, through April 14, 2026, revealed repeated temperatures below acceptable ranges. Specifically, temperatures of 35 degrees Fahrenheit were documented on January 2, 7, 11, 17, 20, 22, 24, 27, and 30; February 6, 18, 22, 25, and 27; March 3, 11, 16, 19, 21, and 27; and April 5, 2026. Temperatures of 34 degrees Fahrenheit were documented on January 19 and March 22, 2026. These findings indicate ongoing storage of medications outside of manufacturer-recommended temperature ranges. Observation confirmed that the following residents had injectable medications stored in the refrigerator requiring strict temperature control: Resident 2 (Lantus), Resident 4 (Novolog), Resident 6 (Glargine), Resident 22 (Lispro), Resident 39 (Lispro), Resident 56 (Trulicity), Resident 87 (Novolog), Resident 90 (Glargine), Resident 93 (Novolog), and Resident 123 (Novolog). Failure to maintain appropriate storage temperatures placed these medications at risk for reduced potency, which may impact blood glucose control. Observation of the same refrigerator on April 15, 2026, at 9:30 AM revealed an opened multi-dose vial of tuberculin (a solution used for tuberculosis screening) that was not labeled with a date of opening. Dating medications upon opening is necessary to ensure compliance with manufacturer guidelines, which commonly require multi-dose vials to be discarded after a specified period, often 28 days, due to the risk of contamination (introduction of microorganisms) and reduced effectiveness over time. During an interview on April 15, 2026, at 9:30 AM, the Director of Nursing confirmed that injectable blood glucose-lowering medications are to be stored between 36 and 46 degrees Fahrenheit and that medications are to be dated when opened. The Director of Nursing confirmed that an opened tuberculin vial should be discarded 28 days after opening. Despite repeated documentation of temperatures below acceptable ranges, there was no evidence the facility implemented or sustained corrective actions to ensure refrigerated medications were consistently maintained within manufacturer-recommended temperature parameters to preserve medication potency and ensure safe administration. 28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies.

Based on a clinical record review and staff interview, it was determined the facility failed to ensure that the required resident information was communicated to the receiving health care provider for three out of 33 residents reviewed (Residents 7, 39, and 108).Findings include: A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], and transferred to the emergency department on February 4, 2026. A review of Resident 7's clinical record revealed there was no documented evidence the facility communicated the required information to the receiving health care provider, including contact information of the physician responsible for the care of the resident, resident representative information, including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information. A review of Resident 39's clinical record revealed the resident was admitted to the facility on [DATE], and transferred to the community hospital on March 9, 2026. A review of Resident 39's clinical record revealed there was no documented evidence the facility communicated the required information to the receiving health care provider, including contact information of the physician responsible for the care of the resident, resident representative information, including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information. A review of Resident 108's clinical record revealed the resident was admitted to the facility on [DATE], and transferred to the community hospital on February 10, 2026. A review of Resident 108's clinical record revealed there was no documented evidence the facility communicated the required information to the receiving health care provider, including contact information of the physician responsible for the care of the resident, resident representative information, including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information. During an interview on April 17, 2026, at 11:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide documented evidence the facility communicated residents' required clinical information to receiving health care providers to ensure a safe and effective transfer of care on February 4, 2026, for Resident 7, on February 10, 2026, for Resident 108, or on March 9, 2026, for Resident 39. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice to promote healing of existing pressure injuries for two of 33 residents reviewed (Residents 7 and 75).Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines, indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility policy titled Pressure Injury Prevention and Management, last reviewed by the facility on January 29, 2026, revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure injury, prevent infection, and prevent the development of additional pressure injuries. The facility defines avoidable as the resident developed a pressure injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Clinical record review revealed Resident 7 was admitted [DATE], with diagnoses including diabetes (a chronic disease affecting the body's ability to regulate blood sugar levels) and hemiplegia (paralysis affecting one side of the body), both conditions that increase risk for impaired mobility and skin breakdown. A care plan initiated February 4, 2026, identified risk for impaired skin integrity (damage to skin tissue) related to decreased mobility. Interventions included use of a pressure reduction mattress, monitoring and measuring wounds, and providing treatments as ordered. An admission evaluation titled Skin Evaluation, dated February 12, 2026, revealed Resident 7 was at risk for alteration in skin integrity related to impaired mobility with open skin areas identified.An external wound clinic report dated March 31, 2026, documented a Stage 3 left heel pressure injury (a deep wound involving loss of skin layers and exposure of underlying tissue caused by prolonged pressure) measuring 3.5 centimeters (cm) by 1.8 cm by 0.3 cm. The wound contained yellow fibrinous slough (dead tissue that can delay healing) covering 26 to 50 percent of the wound bed and red granulation tissue (new healthy tissue indicating healing) covering 26 to 50 percent of the wound bed. The wound exhibited mild serous drainage (clear or light yellow fluid from a wound) and no odor was indicated. Recommendations included use of a low air loss mattress (a specialized medical support surface mattress designed to prevent and treat severe pressure injuries by combining pressure redistribution with moisture management; this device provides alternating air pressure in accordance with a resident's weight) Resident 7 was scheduled for a follow-up appointment in five weeks. Clinical record review from March 31, 2026, through April 17, 2026, revealed no documented evidence the facility monitored or measured the Stage 3 left heel pressure injury during this period. Clinical record review indicated Resident 7 weighed 222 pounds (lbs.) on April 9, 2026. Observation on April 17, 2026, at 9:37 AM revealed Resident 7 resting on a low air loss mattress set to 275 lbs. During the observation, the regional nurse consultant confirmed the mattress setting was not adjusted to the resident's current weight. An observation on April 17, 2026, at 9:39 AM revealed Resident 7's stage 3 left heel injury measured 3.0 cm x 1.5 cm x 0.2 cm. The wound presented without odor, 20 percent slough, 80 percent granulation, and with moderate serosanguineous drainage (a thin, watery, pale pink, or light red fluid commonly seen during the early inflammatory phase of wound healing).Clinical record review revealed Resident 75 was admitted [DATE], with diagnoses including osteomyelitis of the vertebra, sacral, and sacrococcygeal region (infection of bone tissue in the lower spine and tailbone area often associated with skin breakdown and pressure injuries). Resident 75's wound care consultant report dated April 10, 2026, documented treatment for a right buttock end-of-life skin failure wound (skin breakdown occurring as body systems decline near end of life due to decreased blood flow to tissues) measuring 4 cm by 3.5 cm by 0.1 cm and a left heel end-of-life skin failure wound measuring 1 cm by 1 cm by 0 cm. Treatment recommendations included use of an air mattress. A care plan initiated November 14, 2025, For Resident 75, identified risk for impaired skin integrity related to inadequate nutrition (insufficient intake of nutrients needed to maintain skin health) and immobility (limited ability to reposition independently). Interventions included use of a pressure reduction mattress on the bed (with staff to check placement and function every shift), and chair, repositioning with two staff assistance while in bed, weekly skin audits (routine skin inspections), and treatments as ordered. A physician order dated February 19, 2026, directed staff to apply an air mattress to the resident's bed and to check the placement and function on every shift. An observation on April 13, 2026, at 11:21 AM revealed Resident 75 asleep and lying in bed on an air mattress. The air mattress pump was set for a resident that weighed 148 lbs. A clinical record review revealed that on March 31, 2026, Resident 75 weighed 97.8 lbs. Review of the air mattress manufacturer's operating instructions indicated in Step 6: Determine the patient's weight and set the control knob to that weight setting on the control unit. The mattress should be set according to the resident's current weight to ensure appropriate pressure redistribution. During an interview on April 17, 2026, at 8:45 AM the Director of Nursing confirmed Resident 75's air mattress was not set for the resident's current weight. During an interview on April 17, 2026, at 11:30 AM, the above findings were reviewed with the Director of Nursing. The Director of Nursing was unable to provide documented evidence the facility monitored or measured Resident 7's left heel pressure injury between March 31, 2026, and April 17, 2026. The Director of Nursing further confirmed low air loss mattresses should be set according to the resident's weight and manufacturer instructions. The facility failed to ensure Residents 7 and 75 received necessary treatment and services consistent with professional standards of practice to promote healing of pressure injuries, including ongoing wound monitoring and implementation of pressure redistribution interventions adjusted according to resident-specific clinical needs. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical review and resident and staff interviews, it was determined the facility failed to ensure a resident with limited mobility received appropriate equipment necessary to maintain or improve mobility with the maximum practicable independence for one of 33 residents reviewed (Resident 4).Findings include: A clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included acquired absence of the left leg below the knee and right hip joint (the left leg and right hip joint were removed, either partly or entirely, due to injury, illness, or surgery, rather than being born without it). Review of the care plan initiated July 17, 2025, indicated Resident 4 had a self-care deficit related to decreased mobility (reduced ability to move independently). Interventions included getting the resident out of bed to a Geri-chair (a supportive medical chair designed for individuals with mobility limitations) or personal chair as tolerated, and use of back support in the wheelchair to promote positioning and comfort. An occupational therapy Discharge summary dated [DATE], indicated recommendations for Resident 4 to utilize a high-back reclining wheelchair with elevating leg rests (adjustable supports that raise the legs to improve positioning and circulation), a foot buddy (a positioning device used to help maintain proper foot alignment and prevent slipping), and a cushion (a pressure-relieving support surface intended to reduce the risk of skin breakdown). The discharge summary indicated Resident 4 was able to maintain upright positioning in the high-back reclining wheelchair for four hours and was able to safely propel (move) the wheelchair independently within the facility. A physician's order dated January 21, 2026, directed Resident 4 to utilize a high-back reclining wheelchair with elevating leg rests, foot buddy, and cushion for appointments. A review of Resident 4's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 28, 2026, revealed that Resident 4 was 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 through 15 indicates cognition is intact). A progress note dated April 6, 2026, at 1:00 PM indicated Resident 4 was awaiting a new wheelchair in order to get out of bed. Resident 4 reported weak abdominal muscles (reduced core strength affecting the ability to sit upright) and inability to sit upright in a standard wheelchair. The note indicated a recliner chair had been obtained but required repair as per resident. During an interview conducted April 14, 2026, at 11:30 AM, Resident 4 indicated he had not had a wheelchair he could use independently for several months. Resident 4 stated his reclining wheelchair broke in January 2026 shortly after discharge from occupational therapy services and he had been waiting for the facility to repair or replace the wheelchair so he could independently move throughout the facility. An occupational therapy note dated April 15, 2026, indicated out-of-bed seating options were discussed with Resident 4. Resident 4 indicated a desire to independently propel himself throughout the facility. The note indicated the newly ordered high-back wheelchairs were not able to recline and no available high-back wheelchair appropriately met the resident's needs at that time. During an interview conducted April 16, 2026, at 12:20 PM, Employee 1, Registered Occupational Therapist (OTR), stated she could not recall the exact date Resident 4's high-back reclining wheelchair became unusable. Employee 1, OTR, indicated an order of wheelchairs was delivered after Resident 4's wheelchair broke; however, none met Resident 4's clinical needs. Employee 1, OTR, explained Resident 4 requires a high-back reclining wheelchair to allow for pressure relief (reduction of prolonged pressure on body areas that may lead to skin breakdown) and due to limited abdominal strength affecting ability to maintain upright positioning. Employee 1, OTR, was unable to provide documented evidence the facility provided or was actively attempting to provide Resident 4 with a wheelchair that supported the resident's highest practicable level of physical well-being and independence prior to surveyor inquiry. During an interview conducted on April 17, 2026, at 11:30 AM, the above findings were reviewed with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON and NHA were unable to provide documented evidence explaining why Resident 4's identified need for a high-back reclining wheelchair had not been met since the prior wheelchair became unusable in January 2026. The facility failed to ensure Resident 4 received appropriate equipment necessary to promote mobility, maintain functional ability, and support the resident's highest practicable level of independence. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(3) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined the facility failed to provide care and services in accordance with professional standards and physician orders for the management and monitoring of a Peripherally Inserted Central Catheter (PICC) line and subsequent midline catheters for one resident out of 33 residents reviewed (Resident 75).Findings include: A review of nursing standards published by Lippincott Nursing Center ( Picking Up on PICC Lines, Nursing Made Incredibly Easy) indicates that appropriate PICC line care (a peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for intravenous fluids, including antibiotics) includes obtaining and documenting a baseline external catheter length (the portion of the catheter visible outside the body) and ongoing comparison of that measurement to identify catheter migration (movement of the catheter inward or outward from its original position). These standards further indicate that arm circumference (measurement around the arm where the catheter is inserted) should be obtained and trended to monitor for complications such as edema (swelling caused by fluid accumulation), phlebitis (inflammation of the vein), infiltration (leakage of fluid into surrounding tissue), or deep vein thrombosis (a blood clot in a deep vein). Accepted standards of nursing practice for midline catheter care (a peripheral intravenous catheter inserted into a vein of the upper arm with the tip remaining in a peripheral vein and not extending into the central circulation) require ongoing assessment, monitoring, and documentation to ensure safe administration of intravenous therapy and early identification of complications. According to the Infusion Nurses Society Infusion Therapy Standards of Practice (2021), vascular access devices, including midline catheters, must be routinely assessed for patency (the catheter remains open and able to infuse fluids), proper function, and signs of complications. These assessments include evaluation of the insertion site and surrounding tissue for erythema (redness), edema (swelling caused by fluid accumulation), warmth, pain, drainage, or induration (hardening of tissue), which may indicate phlebitis (inflammation of the vein), infiltration (leakage of fluid into surrounding tissue), or infection. Nursing standards further require that clinicians monitor the affected extremity for changes in arm circumference when clinically indicated, as increases may suggest edema or the development of a deep vein thrombosis (a blood clot in a deep vein). Ongoing comparison to baseline or prior assessments is necessary to identify clinically significant changes. A review of clinical records revealed Resident 75 was initially admitted to the facility on [DATE], with diagnoses including osteomyelitis of the vertebra, sacral, and sacrococcygeal region (a serious infection and inflammation of the tailbone area, often originating from adjacent pressure ulcers). A review of the resident's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 20, 2026, revealed that Resident 75 was severely cognitively impaired 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 0 through 7 indicates severe cognitive impairment). A review of the hospital Discharge summary dated [DATE], indicated the resident underwent placement of a PICC line (a peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for intravenous fluids, including antibiotics) for administration of intravenous antibiotics related to sacral osteomyelitis. A review of the facility's readmission evaluation dated March 19, 2026, indicated the presence of a PICC line in the upper left arm; however, there was no documentation of the external catheter length or arm circumference at the time of readmission. A review of physician orders dated March 20, 2026, included a directive for nursing staff to measure the resident's arm circumference (measurement around the upper part of arm, performed to monitor for potential complications like blood clots or swelling) on admission and every 72 hours thereafter, to measure the PICC line external length (portion of the catheter remaining outside the body. It is crucial for detecting migration of the PICC line (movement of the tip of the catheter from its intended, documented position) on admission and every 7 days, and to document all measurements in the progress note. Nursing documentation dated March 23, 2026, at 5:10 PM indicated the resident removed (pulled out) the PICC line. On March 24, 2026, at 3:33 PM a new midline catheter (soft plastic tube inserted into a peripheral upper arm vein with the tip resting near the armpit) was inserted in the left upper arm by an outside consultant. The procedure note documented an external catheter length of 0 cm and a mid-arm circumference of 25 cm at the time of the insertion. Nursing documentation dated March 24, 2026, at 6:59 PM indicated the resident pulled out the newly inserted catheter again. On March 27, 2026, another midline catheter was inserted in the right upper arm. The procedure note documented an external catheter length of 0 cm and a mid-arm circumference of 21 cm at the time of the insertion. A physician's order dated March 26, 2026, directed nursing staff to measure and document the midline external catheter length on admission and weekly thereafter (every Thursday on day shift). A physician's order dated March 26, 2026, directed nursing staff to monitor the midline site every shift for infection, line fracture, breakage, dislodgement, pain, or swelling. Staff were to document the findings in the progress notes. The physician's order from March 20, 2026, for staff to measure the arm circumference every 72 hours and document the measurement in the progress note, remained in effect. A comprehensive review of the Nursing admission Evaluation dated March 19, 2026, the Medication Administration Record and Treatment Administration Record for March and April 2026, and nursing progress notes from March 19 through April 17, 2026, revealed no documented evidence that nursing staff consistently completed or recorded the required measurements for PICC line external length, midline catheter length, or arm circumference on admission, every 72 hours, or weekly as ordered. During an interview on April 17, 2026, at 10:45 AM the Director of Nursing confirmed that there was no documentation to support that nursing staff consistently followed physician orders for monitoring and documenting catheter length and arm circumference for Resident 75. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to provide food and beverages in accordance with residents' documented allergies, intolerances, and stated food preferences for two residents of 33 residents reviewed (Residents 188 and 167).Findings include: A review of Resident 188's lunch meal ticket (a menu-based document that provides essential information about a resident's meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) indicated the resident had an allergy to lactose, and a dislike to pineapple and raw tomatoes. Observation of Resident 188's lunch meal on April 15, at 1:18 PM revealed the resident was served a side salad containing raw tomatoes and a cup of white whole milk. At that time, the resident stated she is allergic to raw tomatoes, pineapple, and milk. During an interview on April 15, 2025, at 1:25 PM, in the presence of Resident 188, Employee 4 (Regional Dietary Director) and Employee 5 (Regional Dietary Manager) confirmed the resident was served raw tomatoes despite the meal ticket identifying tomatoes as a dislike. Observation of the drink cart on the resident's unit on April 15, 2026, at 1:33 PM revealed no lactose-free milk available. During an interview at the time of the observation, Employee 3 (nurse aide) stated that drink carts are delivered from the kitchen and do not include lactose-free milk. Observation of the kitchen walk-in refrigerator on April 15, 2026, at 1:37 PM in the presence of Employee 5 revealed an unopened 1/2 gallon of lactose-free white milk on the shelf. Employee 5 stated that nursing staff must request or obtain lactose-free milk from the kitchen, as it is not provided on the unit drink carts. Clinical record review revealed a Certified Registered Nurse Practitioner (CRNP) progress note dated April 7, 2026, documented the resident had dietary allergies to chocolate (tongue blisters), raw tomatoes (nausea, vomiting, and rash), pineapple (swollen tongue), and was lactose intolerant (diarrhea). Review of the resident's allergy list in the medical record included pineapple and lactose but failed to include raw tomatoes, despite documentation in the CRNP's note identifying this allergy. A review of Resident 167's lunch meal ticket indicated documented dislikes of tomatoes and cucumbers. Observation of the resident's lunch meal on April 15, 2026, at 1:37 PM revealed the resident was served a side salad containing tomatoes and cucumbers. At that time, the resident stated he frequently receives foods identified on his dislike list. During an interview on April 16, 2026, at 9:35 AM with the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure accurate transcription of dietary allergies in the medical record and failed to ensure residents received meals consistent with their documented allergies, intolerances, and preferences. 28 Pa. Code 211.6(a) Dietary services. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on observation, staff interviews, review of facility policies, manufacturer instructions for use (IFU), clinical record reviews, and facility investigative documentation, it was determined that the facility failed to ensure residents were protected from potential hazards in the environment by failing to implement safe and sanitary food handling practices in the facility kitchen. Specifically, the facility failed to ensure that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used in accordance with manufacturer instructions and facility policy. This deficient practice resulted in a corrosive sanitizing chemical being mistaken for a beverage, prepared and served to ten residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) out of 57 residents who resided on the East unit of the facility. The failure created a condition of Immediate Jeopardy to resident health and safety by exposing residents to a poisonous chemical substance capable of causing burns to skin and mucous membranes, poisoning, and potentially life-threatening illness.Findings include: A review of the facility policy titled Chapter 3: Food Production and Safety, last reviewed and revised by the facility on July 7, 2025, revealed it is facility policy to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. The policy indicated chemicals must be clearly labeled, kept in original containers, when possible, kept in a locked area, and stored away from food items. Further review of this policy's subsection titled Sanitation Buckets revealed the objective of the document is for participants to learn the guidelines for different sanitation solutions and their proper use in sanitation buckets. The policy's subsection titled Hazardous Chemicals revealed the objective of the document is for participants to learn to identify hazardous products in the workplace and follow directions on labels to protect themselves. A chemical is classified as hazardous if it can damage an employee internally, changes or damages the surface it contacts, causes an allergic reaction with repeated use, is poisonous or causes cancer, or causes chemical reactions, fires, or explosions. Employees will read Safety Data Sheets (SDS- document provided by chemical manufacturers that detail the properties and potential hazards of a chemical substance) on five key chemicals used in the department. The policy's subsection titled Chemical Safety Chart revealed that all chemicals and cleaning products are not stored near food and are labeled so that staff know what chemical they are using. An observation and an interview October 3, 2025, at 10:00 AM with the corporate dietary manager verified that the liquid sanitizing/disinfectant/virucide solution utilized by the facility kitchen was Knoxville solution. A review of a Manufactures Minimum Safety Data Sheet (MSDS-a document that provides detailed information about the risks and safety precautions and safe-handling instructions of a hazardous chemical) revealed that the product Knoxville, a disinfectant/sanitizer/virucide (kills viruses) and the container label revealed, Danger, this chemical is a hazard to humans and animals. Keep out of reach of children. Corrosive: causes irreversible eye damage and skin burns. Do not get in eyes, on skin, or clothing. Wear goggles or face shield, rubber gloves and protective clothing. Harmful if swallowed. If swallowed, call poison control center or doctor immediately for treatment advice. Have person sip a glass of water if able to swallow. Do not induce vomiting unless told to do so by the poison control center or doctor. A review of facility investigative documentation dated September 22, 2025, at 1:00 PM revealed that staff notified facility administration that the pink juice served at lunchtime on the East unit tasted odd. Upon examination of the liquid, no odor was noted; however, when tasted, it did not taste like pink lemonade, which the facility served on a regular basis. Further investigation revealed that the contents in the pitcher was kitchen sanitizer. The pitcher with the pink liquid was placed on the beverage cart served to residents on the East wing that day. At the time of discovery, the food trays and beverage cups had already been gathered and returned to the kitchen. Investigation and interviews with nursing staff (as noted below) confirmed that 10 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) were served the liquid. The facility was not able to determine the amount of liquid that may have been consumed by each resident as the trays had been removed from the residents' rooms and washed. Ten residents were confirmed to have received the liquid and immediately assessed for any symptoms of adverse reactions. The Physicians were notified. The MSDS sheets were reviewed, the poison control center contacted, and recommendation was made to encourage fluid consumption. Physicians' orders were obtained for all residents on the east unit for nursing staff to administer 240 cc of water every hour for 4 hours, vital sign monitoring every 2 hours for 8 hours, then every shift for 24 hours and an oral evaluation for all residents on the east unit for any redness, pain or open lesions. Families of the affected residents were contacted. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that interferes with daily life). A review of a quarterly Minimum Data Set (MDS, a federally mandated standardized assessment conducted periodically to plan resident care) dated September 8, 2025, revealed that Resident 7 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS, a cognitive tool used to assess attention, orientation, and ability to register and recall new information) score of 03 (a score of 00-07 indicates cognition is severely impaired). A progress note dated September 22, 2025, at 3:25 PM revealed that Resident 7 experienced two episodes of emesis (vomiting) after eating lunch. New orders were noted for vital signs and fluid administration. A subsequent progress note dated September 22, 2025, at 4:08 PM revealed that Resident 7 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders directed that vital signs be monitored every two hours for eight hours and then each shift for 24 hours; an oral evaluation be performed for redness or irritation; and 240 cc of fluid be administered immediately and 240 cc every hour for four hours. A review of the clinical record revealed no documentation that the ordered vital signs or fluid administration were completed as directed. There was no evidence that an oral cavity assessment was performed at the time of the incident. Nursing notes revealed that an oral assessment was documented on September 23, 2025, at 1:27 PM. A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease. A review of a quarterly MDS dated [DATE], revealed that Resident 1 was cognitively intact with a BIMS score of 14, (a score of 13-15 indicates cognition is intact). A progress note dated September 22, 2025, at 4:04 PM revealed that Resident 1 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were received as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluid administration were completed as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. During an interview conducted on October 3, 2025, at 11:46 AM Resident 1 stated that he had not been made aware that he had been served and may have consumed kitchen sanitizer. Resident 1 stated that no facility employee had discussed the incident or the potential health risks associated with ingestion of the chemical. A clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to brain tissue due to interruption of blood flow). A review of a quarterly MDS dated [DATE], revealed that Resident 2 was severely cognitively impaired with a BIMS score of 03. A progress note dated September 22, 2025, at 4:07 PM revealed that Resident 2 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were received and noted as above. A review of the clinical record revealed no documentation that the ordered vital signs or fluid administration were completed as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to an extent that it interferes with daily life). A review of a quarterly MDS dated [DATE], revealed that Resident 3 was severely cognitively impaired as documented in Section C1000 Cognitive Skills for Daily Decision Making. Sections C700 and C800 revealed that Resident 3 had problems with short-term memory (information retained for seconds to a few minutes) and long-term memory (information or skills retained from the past). A progress note dated September 22, 2025, at 4:08 PM revealed that Resident 3 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were received as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung condition that blocks airflow and makes breathing difficult). A review of a quarterly MDS dated [DATE], revealed that Resident 4 was severely cognitively impaired with a BIMS score of 02. A progress note dated September 22, 2025, at 4:08 PM revealed that Resident 4 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were received as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with a diagnosis of chronic kidney disease (gradual loss of kidney function). A review of a quarterly MDS dated [DATE], revealed that Resident 5 was severely cognitively impaired with a BIMS score of 03. A progress note dated September 22, 2025, at 4:09 PM revealed that Resident 5 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were received as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to brain tissue caused by interruption of blood flow). A review of a quarterly MDS dated [DATE], revealed that Resident 6 was severely cognitively impaired as documented in Section C1000 -Cognitive Skills for Daily Decision Making. Sections C700 and C800 revealed that Resident 6 had problems with short-term and long-term memory. A progress note dated September 22, 2025, at 4:09 PM revealed that Resident 6 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were received as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses that included dementia. A review of a quarterly MDS dated [DATE], revealed that Resident 8 was severely cognitively impaired with a BIMS score of 05. A progress note dated September 22, 2025, at 4:10 PM revealed that Resident 8 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders were noted as above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 9 was admitted to the facility on [DATE], with diagnoses that included peripheral neuropathy (nerve damage that interferes with the function of the peripheral nervous system). A review of a quarterly MDS dated [DATE], revealed that Resident 9 was severely cognitively impaired with a BIMS score of 06. A progress note dated September 22, 2025, at 4:09 PM revealed that Resident 9 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. A clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a condition caused by abnormal brain development or brain damage that affects movement and coordination). A review of a quarterly MDS dated [DATE], revealed that Resident 10 was cognitively intact with a BIMS score of 15. A progress note dated September 22, 2025, at 4:08 PM revealed that Resident 10 was served and possibly consumed an unknown amount of kitchen sanitizer. The physician, resident representative, and poison control center were notified. New physician orders as noted above. A review of the clinical record revealed no documentation that the ordered vital signs or fluids were provided as directed, or that an oral cavity assessment was performed at the time of the incident. Nursing documentation revealed that an oral assessment was completed on September 23, 2025. During an interview on October 3, 2025, at 12:30 PM Resident 10 indicated that staff checked on him after the incident a few weeks ago. He recalled staff asking him if the pink juice tasted funny but explained that he had no knowledge that he was served and may have consumed kitchen sanitizer. He indicated that no facility employee reviewed the dangers or risks associated with ingesting the chemical. Resident 10 expressed frustration that additional information about the incident had not been provided. A review of an interview statement dated September 22, 2025 (no time indicated) revealed that Employee 13 NA (Nurse Aide) reported, I was doing the assisted feed with Resident 11 and noticed that Resident 6 was not drinking his juice. Then Resident 3 made a nasty face after she took a sip of her juice, and Resident 4 refused to drink hers. Resident 7 'downed' two cups of the juice by this time while waiting on her tray. Employee 13 explained that residents in the dining room were served beverages prior to meal delivery. She stated, I figured it didn't have no taste that no one would drink it, meaning, Resident 6 drinks anything and everything. I poured a cup and tried it. I spit it out all over. It tasted chemically, with no flavor. Employee 13 stated that she then took the pitcher to the Director of Nursing (DON), who also noted the same taste. She reported, We, (me and the DON) took the pitcher to dietary, same outcome. At this time, Resident 7 started throwing up. Interviews and documentation reviewed during the investigation revealed the following information regarding the circumstances leading to residents being served sanitizer instead of a beverage. An interview with Employee 14 (Licensed Practical Nurse, LPN) revealed that Employee 13 NA informed her that the red or pink beverage on the drink cart appeared to cause residents to make faces while drinking it. Employee 13 reported tasting the beverage and stated it had a chemical flavor. Employee 14, LPN, directed Employee 13 NA to remove the beverage from the residents' possession and notify the DON. Employee 14, LPN, stated that staff were informed of the concern and that residents were encouraged to drink fluids and were monitored. A review of a written witness statement by Employee 1 (cook) no date or time indicated revealed, Last night (September 21, 2025), I, Employee 1 (cook) used a pitcher for sanitizer to clean the kitchen. As I finished, I placed the pitcher in the sink and left. During a telephone interview on October 3, 2025, at 2:08 PM, Employee 1, cook, explained that on September 22, 2025, he was tired after working multiple hours (a review of the facility's dietary department assignments for September 22, 2025, revealed Employee 1, Cook, began his shift at 5:00 AM, and the incident occurred at approximately 11:00 AM). He indicated that he began his normal responsibility of cleaning and disinfecting the food prep areas of the kitchen. Employee 1, cook, explained that there were no available sanitation buckets for mixing the sanitizing solution. Instead, he used a dirty clear plastic gallon drink pitcher to mix the red sanitizer agent with water, then proceeded to clean the kitchen surfaces. When he finished cleaning, Employee 1 explained he put the drink pitcher with the remaining pink/red liquid in the dirty compartment of the sink. He indicated that he was wrong to use the clear pitcher as a cleaning bucket. Employee 1, cook, explained he was suspended and then fired from the facility after the incident. He confirmed that he had never received any education regarding his job in the facility kitchen. A review of Employee 1's personnel file, maintained by the contracted dietary company, revealed he was hired on July 20, 2025, and terminated on September 22, 2025. The file contained no evidence of a written job description or documentation of orientation or training related to his position as cook. A review of written documentation dated September 21, 2025, with no time indicated, revealed that Employee 5 (Assistant Dietary Manager) stated, I completed the drink cart for lunch. The Kool-Aid tub we generally use to make the drink was full of the same pink lemonade we use for drinks. Employee 5 explained that the Kool-Aid tub referred to a five-gallon, covered plastic container kept in the kitchen refrigerator and used to prepare and store beverages prior to meal service. The beverage from this container was routinely poured into clear plastic pitchers that were placed on drink carts for delivery to resident dining areas. Employee 5 further stated, I automatically assumed that someone pre-made the Kool-Aid (in the pitcher) and I used it. I did not know it was sanitizer. The investigation determined that the facility's kitchen utilized a three-compartment sink system for manually washing, rinsing, and sanitizing cookware and utensils. The sanitizing step required the use of a red chemical sanitizer solution (a concentrated cleaning agent formulated to kill bacteria and viruses on food-contact surfaces). The solution was prepared by mixing the sanitizer with water in accordance with manufacturer instructions and was intended only for use within the sanitizing sink compartment. Based on staff interviews and documentation reviewed, it was determined that sanitizer prepared for the three-compartment sink had been placed into a clear plastic drink pitcher rather than an appropriately labeled container, resulting in the chemical solution being mistaken for pink lemonade and subsequently served to residents. Employee 5 (assistant dietary manager) resigned his position at the facility prior to the survey on September 30, 2025, and was not available for a telephone interview at the time of the survey. A review of Employee 5's personnel file revealed that he was hired on July 20, 2025, and voluntarily terminated employment on September 30, 2025. The file contained no documentation of a job description or evidence of education or training provided by the contracted dietary company or the facility. Interviews conducted on October 3, 2025, with current dietary staff revealed the following: Employee 15, dietary aide, stated that she had been employed in the kitchen for a few months. She reported that she received education regarding labeling drink pitchers only after the September 22, 2025, event and stated that she had not received any prior education regarding her kitchen duties. Employee 16, dietary aide, stated that he had worked in the kitchen for a few months and had not received any education or training related to kitchen operations. Employee 17 (cook) stated that she had been employed in the kitchen for several months and had never received any education or training regarding her job responsibilities in the kitchen. During an interview conducted on October 3, 2025, at 3:30 PM the facility's Dietary Manager stated that most of the kitchen staff were newly hired and had been employed for only a few months. She confirmed that the kitchen was operated under contract with an outside food-service agency and that she was employed by that agency. The manager stated that education and training for dietary employees were completed upon hire and annually but described the process as informal, consisting of being walked through the job duties on the first day of employment. She confirmed that there were no written competencies or job descriptions available for staff reference. Immediate Jeopardy was identified and declared on October 3, 2025, at 3:30 PM due to the facility's failure to properly label and identify a pitcher that contained a sanitizing solution used in the three-compartment sink. The unlabeled solution was mistaken for pink lemonade and subsequently served to approximately ten residents. This failure resulted in the exposure of residents to a hazardous chemical substance and placed them in a condition of Immediate Jeopardy to health and safety. The facility was notified of the Immediate Jeopardy findings at 3:30 PM on October 3, 2025, and the Immediate Jeopardy Template was provided to the Nursing Home Administrator at that time. In response, the facility submitted a written Immediate Jeopardy action plan at 7:30 PM on October 3, 2025. The plan included the following corrective actions:A root-cause analysis was completed, which determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen. All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring. All chemicals in the kitchen were reviewed for proper labeling and storage. Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies. All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area. Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised. Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures. Verification of implementation of the Immediate Jeopardy action plan was completed, and the Immediate Jeopardy was determined to have been removed on October 4, 2025, at 11:30 AM, after it was verified that the corrective actions had been fully implemented and were effective in removing the immediate threat to resident health and safety.28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) (2.1) (3) Management 28 Pa. Code 211.6 (f) Dietary services 28 Pa. Code 211.10 (d) Resident care policies

Based on a review of select facility policies, clinical records, investigative reports, and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care according to professional standards of practice, which included a failure to implement necessary interventions after a fall, such as close supervision and neurological assessments for one of two residents reviewed for falls resulting in actual harm with a subdural hematoma (brain bleed). Resident CR1.Findings include: A review of a select facility policy for Anticoagulation, last reviewed [DATE], revealed it is the policy of the facility that some medications, including anticoagulants (blood thinners), are associated with greater risks of adverse consequences (increased risk of bleeding and hemorrhage) than other medications. Further review revealed the resident's plan of care should alert staff to monitor adverse consequences risks associated with anticoagulants, which include bleeding and hemorrhage. A review of the facility policy titled Neurological Testing, (include, at a minimum, pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength)last reviewed [DATE], revealed it is the policy of the facility to identify and treat suspected head injury promptly, and if a resident is suspected of having a head injury, has an unwitnessed fall and it is unclear if they hit their head, or a resident has a change in mental status, a full neurological exam will be performed and any abnormal results will be provided to the physician immediately. Neurological testing will be completed immediately and at specified intervals over a 72-hour period (every 15 minutes x 4 days, every 30 minutes x 2 days, every hour x 2 days, every 4 hours x 5 days, then every shift x 6 days), and that abnormal findings are to be reported to the physician immediately. A review of a facility policy titled Assessing Falls and Their Causes, last reviewed [DATE], revealed it is the policy of the facility to provide guidelines for assessing a resident after a fall, to assist staff in identifying causes of the fall, and that falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Further review revealed that after a fall, if a resident has just fallen or is found on the floor without a witness to an event, evaluate for possible injuries to the head, neck, spine, and extremities, and observe for delayed complications of a fall for 48 hours after an observed or suspected fall. Professional literature and national emergency care guidance support that anticoagulated patients who sustain head trauma should undergo prompt evaluation, including initial neuroimaging and close monitoring. According to the Centers for Disease Control and Prevention (CDC), referencing the American College of Emergency Physicians (ACEP) 2023 Clinical Policy, advises that for patients on anticoagulation or antiplatelet therapy (other than aspirin), clinicians should highly consider imaging and not use clinical decision rules to exclude the need for head CT. (CDC 2023 Mild Traumatic Brain Injury Management Guideline). The Eastern Association for the Surgery of Trauma (EAST) Practice Management Guideline likewise recommends that clinicians perform a brain CT scan on patients presenting with suspected brain injury in the acute setting and cautions that those on anticoagulation require heightened vigilance and observation when coagulopathy is present. Falls are the leading cause of injury among people 65 and older. The CDC recommends that injured older persons be triaged to trauma centers whenever possible. Following traumatic brain injury (TBI), older individuals had greater rates of morbidity and death than younger patients due to changes in brain structure, a higher burden of comorbidities, and more frequent use of anticoagulants and antiplatelet medications. Some of the factors that can affect the accuracy of prehospital triage in older adults include frailty, age-related physiological reactions to injuries, polypharmacy (concurrent use of multiple medications), major trauma from low-energy impact mechanisms (low-level falls) that are not detected by the current triage tools, and the use of anticoagulants and antiplatelet medications. Anticoagulated patients are more likely to experience intracranial hemorrhage, or brain bleeding, hence early CT scanning (computed tomography scan, a medical imaging technique that uses X-rays and a computer to create detailed cross-sectional images of the body) may be utilized more frequently in these patients. Traumatic intracranial hemorrhage has been documented to occur at an epidemic rate in patients [AGE] years of age or older who are taking anticoagulants. Compared to younger patients with comparable injuries, older adults who present with polytrauma are at risk for more serious injuries, longer hospital stays, and a higher chance of death. Closed clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include muscle weakness and cervical (bones at the top of the spine) fracture due to a fall at home prior to admission, which required surgical intervention of a cervical fusion (a procedure that joins two or more vertebrae, the bones in the spine, in the neck) on [DATE], and was to wear a cervical collar (neck brace to support the neck and spine to stabilize an injury/surgery to promote healing) at all times. A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that Resident CR1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A physician's order dated [DATE], prescribed enoxaparin (blood thinner) 40 milligrams (mg) every 12 hours to prevent blood clots (anticoagulation) related to cervical fracture, and an order dated [DATE], prescribed Dilaudid (a high-alert Schedule II opiate narcotic medication) 8 milligrams (mg) every 6 hours for pain related to cervical fracture and chronic pain. A review of the resident's fall-risk care plan, initiated on [DATE], revealed the resident was identified as being at risk for falls related to a history of falls at home and unsteady gait, with the goal to minimize the risk for injury related to falls. Interventions included keeping the call bell within reach, ensuring non-skid footwear, and reinforcing the need for the resident to request assistance for mobility or transfers.A review of a nurse's progress note documented by Employee 6, Registered Nurse (RNS) Supervisor dated [DATE], at 11:15 a.m. revealed Resident CR1 slid from her recliner chair onto her buttocks and was assisted back into the recliner. The immediate post-fall intervention included placement of a Dycem (a brand of a non-slip material used to stabilize seating surfaces) on the recliner to prevent further sliding. A review of a nurse's progress note from Employee 7, RN, dated [DATE], at 4:10 p.m. revealed that Resident CR1 was found seated on the floor in an upright position in front of her wheelchair, located next to her bed. Documentation reflected that a new intervention was added to offer the resident the opportunity to rest in bed after meals. A review of a nurse's progress note from Employee 8, RN, dated [DATE], at 10:10 p.m. revealed that Resident CR1 was found on the floor near her bathroom after attempting to ambulate independently, lost balance, and fell. An abrasion measuring 4.5 centimeters (cm) in length and 0.2 centimeters (cm) in width was noted on her back. New interventions implemented after the fall included a therapy referral and direction that the resident wear non-skid socks instead of slippers. A review of a nurse's progress note written by Employee 7, RN, dated [DATE], at 12:15 p.m. revealed Resident CR1 was found on the floor beside the bed after attempting to self-transfer from her wheelchair to the bed following a self-transfer to the toilet. Documentation indicated that she was assisted to the bedside for assessment, and that her cervical collar was in place at the time of evaluation. A review of the corresponding facility provided investigative documentation for the [DATE], 12:15 p.m. fall revealed the intervention entered following this fall was to schedule toileting upon rising, before and after meals, and at bedtime. Review of the resident's electronic task record (an electronic record that summarized planned resident centered tasks completed by nursing) dated [DATE], revealed this intervention had already been initiated prior to the fall. There was no documentation that any new or revised interventions were developed to address the resident's continued pattern of falls. A review of the clinical record revealed a physician's order entered on [DATE], at 9:48 p.m. directing staff to perform 15-minute safety checks following multiple falls within a 24-hour period.Further review of a nurse's progress note from Employee 9, RN, dated [DATE], at 9:51 p.m. revealed that at approximately 7:40 p.m. that evening, Resident CR1 sustained an unwitnessed fall and was found lying on her left side at the foot of the bed with her head positioned under the bed frame after reportedly attempting to reach for an item on the bedside table and sliding off the bed. The resident's cervical collar was noted to be in place, and the on-call physician was notified. The physician ordered safety checks every 15 minutes due to two falls within a 24-hour period. Documentation indicated that neurological checks were initiated and recorded as within normal limits at the time of this assessment. A review of the neurological assessment flow sheet documented assessments at 8:00 p.m., 8:15 p.m., 8:30 p.m., 9:30 p.m., 10:00 p.m., 10:30 p.m., 11:00 p.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., and 4:00 a.m. There were additional times written on the neurological sheet for assessments and vitals to be completed at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM remained blank. The facility was unable to provide documentation that 15-minute checks for safety were completed due to two falls in 24 hours, as ordered by the physician. An interview with the Director of Nursing (DON) on [DATE], at 4:00 p.m., revealed that Employee 9, RN, did not relay to other staff members that Resident CR1 was ordered 15-minute checks, so they were unaware that the resident was on every 15-minute safety checks. The DON stated it is not their normal protocol at the facility to put someone on 15-minute checks after a fall, unless ordered by the physician. There was no evidence that the facility modified the plan of care to include heightened monitoring or further assessment following repeated falls, despite the resident's anticoagulation therapy, unsteady gait, and history of head and neck injury.A review of a medication administration note from Employee 10, LPN, dated [DATE], at 7:09 AM revealed Resident CR1's Dilaudid 8 mg for 6:00 AM administration was held because the resident could not be awakened to take the medication, and the vital signs recorded at that time were identical to those documented during the 4:00 a.m. neurological check., blood pressure of 128/64 (normal is 120/80), pulse of 94 (normal is 60-100), and respirations of 18 (normal is 12-20) completed at that time by Employee 10, LPN.A review of a nurse's progress note written by Employee 11, RN, dated [DATE], at 9:00 a.m. revealed that Resident CR1 was not responding to verbal stimulation (spoken words) or to touch. The resident's vital signs at that time were a temperature of 97.6 degrees Fahrenheit, pulse of 60 beats per minute (BPM), respirations of 16 per minute (normal range 12-20), blood pressure of 142/85 millimeters of mercury (mm Hg; normal 120/80), and oxygen saturation of 88 percent on room air (normal is above 90 percent). The record showed that oxygen at 2 liters per minute was applied to the resident, and the on-call physician was notified. The physician ordered that the resident be transferred to the emergency department for evaluation. Further review of the same progress note revealed that on [DATE], at 9:15 a.m., staff called 911 emergency medical services. At 9:33 a.m., documentation indicated that Resident CR1 had no spontaneous respirations (stopped breathing) and staff began assisting with breathing using an Ambu bag (a hand-squeezed device that delivers air and oxygen into the lungs). Oxygen flow was increased to 10 liters per minute. It was noted that the resident had a pulse in the 70s (BPM) at that time, oxygen saturation improved to 99 percent, and the resident's pupils were dilated (enlarged) and unresponsive to light (a sign of neurologic impairment). Upon the arrival of paramedics, the resident was intubated (a breathing tube was inserted into the airway to provide mechanical ventilation) and transported to the emergency department.A review of the clinical record further revealed that five hours had elapsed between the last documented neurological assessment (4:00 a.m.) and the time the resident was found unresponsive at 9:00 a.m. on [DATE]. At that time, the resident was noted to be unresponsive to verbal and tactile stimulation. The on-call physician was again notified, and emergency medical services were called. The resident was subsequently transferred to the hospital for evaluation, 13 hours after the fall occurred. A review of a nurse's progress note documented by Employee 12, LPN, dated [DATE], at 5:42 p.m. revealed that Resident CR1 was admitted to the hospital for evaluation of brain bleeding. A review of outside hospital documentation provided by the facility, dated [DATE], revealed that a computed tomography (CT) scan of the brain (a diagnostic imaging test that uses X-rays and computer processing to create detailed cross-sectional images) showed a large left subdural hematoma (a collection of blood between the brain surface and its outer covering), a substantial midline shift (movement of brain structures away from their normal position due to pressure from bleeding), and multi-compartmental intracranial hemorrhage (bleeding in multiple areas within the skull). A CT scan of the abdomen and pelvis also showed a left lateral thigh subcutaneous contusion (a bruise under the skin). Hospital records indicated that the resident underwent further neurological evaluation and was pronounced deceased on [DATE].An interview with the Director of Nursing (DON) on [DATE], at 5:00 p.m. confirmed that Resident CR1 had a history of falls in the facility. The DON stated that documentation of the 15-minute safety checks ordered on [DATE], following the fall at 7:40 p.m., and documentation of completion of all required neurological assessments, were not present in the resident's medical record. The record and documentation reviews revealed that after an unwitnessed fall with possible head impact Resident CR1, who was receiving anticoagulation therapy, was not transferred for immediate medical evaluation or diagnostic imaging. Neurological assessments and safety monitoring were not completed as ordered after the fall. The resident was found unresponsive 13 hours later and was transferred to the hospital, where diagnostic imaging identified multiple areas of brain bleeding. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a review of clinical records, select facility policy, and facility provided investigative documentation, the facility displayed past non-compliance by failing to protect one of 32 sampled residents (Resident 25) from neglect by not implementing the individualized care plan intervention for transfers, resulting in actual harm in the form of a left tibial periprosthetic fracture.Findings include: A review of the facility policy titled “Abuse Prevention Program,” last reviewed by the facility in January 2025, revealed it is the facility’s policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicates that as part of abuse prevention, the administration shall protect the residents from abuse from anyone, including but not limited to facility staff and other residents. Also, the policy indicates the facility will implement measures to address factors that may lead to abusive situations, for example, providing staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that include chronic heart failure (a condition that occurs when the heart can't pump enough blood to the body) and polyosteoarthritis (a condition when at least five joints are affected with inflammation). Further clinical record review revealed Resident 25 had a care plan to address activities of daily living (ADLs fundamental care tasks such as bathing, dressing, and transferring) initiated on January 17, 2025. Interventions implemented to assist Resident 25 with her goal of receiving assistance necessary to meet her ADL needs specifically required use of a Hoyer lift (a mechanical device used to transfer persons with limited mobility) with two staff to complete all transfers. A physician’s order also confirmed this requirement as of January 17, 2025. A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 19, 2025, revealed that Resident 25 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13–15 indicates cognition is intact). A witness statement dated June 12, 2025, provided by Employee 1, Nurse Aide (NA), revealed that on June 12, 2025, Employee 1 was transferring Resident 25 when she heard a crack and reported it to the nurse. Employee 1, NA, explained when she repositioned Resident 25’s legs, she heard the crack. Employee 1, NA, documented that “I transferred her myself because I couldn’t find anyone. I know you’re supposed to have two people for the lift. I feel really bad for what I did. I wouldn’t ever hurt any residents on purpose.” A witness statement dated June 12, 2025, provided by Employee 2, Licensed Practical Nurse (LPN), revealed that on June 12, 2025, at approximately 2:45 PM, Employee 1, NA, made her aware that during a transfer she heard the resident’s knee “pop.” Resident 25 initially presented with no swelling, pain, or discoloration. Employee 2, LPN, indicated that on a follow-up observation on June 12, 2025, at 3:20 PM, Resident 25 presented with swelling to the left knee and reported pain. The RN supervisor was made aware for further evaluation. A progress note dated June 12, 2025, at 8:12 PM revealed Employee 13, Registered Nurse (RN) was called to the resident's bedside by Employee 2, LPN following an injury. At the time of the assessment, Resident 25 appeared to be exhibiting facial cues and verbal indicators of pain. Resident 25 was able to repeat back the events that had occurred. Resident 25 stated she was being transferred by a Hoyer lift, and her leg got caught, and that was when she heard a crack. The resident continued to mention having pain. Pain medication and ice applied. Physician extender notified. It was determined to get quick, appropriate care for the resident, the best course of action was to send her to the emergency room for evaluation. A progress note dated June 12, 2025, at 3:55 PM revealed Resident 25 was transferred to the emergency department at the hospital. A review of hospital emergency department documentation dated June 12, 2025, at 7:41 PM revealed Resident 25 had a history of bilateral total knee arthroplasty (surgical reconstruction or replacement of a joint) as well as a right total hip arthroplasty done in 2019. She had her bilateral distal femur fixed in 2021. The assessment indicated Resident 25's status post-incident with the Hoyer lift was a left tibial periprosthetic type 2 closed fracture (a break in the tibial bone occurring around a knee joint replacement). The plan indicated compressive wraps (elastic bandages to reduce swelling, offer support, and help with pain relief during recovery) for tibial hematoma, maintaining the knee immobilizer, pain control per the primary physician, and a plan pending consultation. A review of the hospital after-visit summary dated June 17, 2025, revealed Resident 25 was seen by orthopedics for her left tibial periprosthetic fracture. She did not require surgery. She cannot walk on her leg, and she should wear a knee immobilizer at all times. Follow-up appointments were scheduled with an orthopedic surgeon. The document indicated new medication, including oxycodone (a narcotic pain medication). A progress note dated June 17, 2025, at 2:12 PM revealed Resident 25 returned from the hospital at 10:45 AM with a diagnosis of a periprosthetic fracture around the internal prosthetic left knee joint and a closed fracture of the proximal end of the left tibia. She had an immobilizer to remain on at all times. The resident was alert and oriented with a pain level 3 out of 10 (0 being least amount of pain and 10 being the worst amount of pain). A physician’s order for a knee immobilizer on Resident 25’s left knee at all times was initiated on June 17, 2025. A physician’s order for Oxycodone HCI Oral Tablet 5 mg with directions to give 2.5 mg by mouth every 4 hours as needed for moderate pain levels 4 through 6 was initiated on June 17, 2025. A physician’s order for Oxycodone HCI Oral Tablet 5 mg with directions to give 5 mg by mouth every 4 hours as needed for moderate pain levels 7 through 10 was initiated on June 17, 2025. A review of the Medication Administration Records dated June 2025 and July 2025 revealed Resident 25 received Oxycodone HCI Oral Tablet 2.5 mg for pain 38 times from June 17, 2025, through July 18, 2025. A review of the Medication Administration Records dated June 2025 and July 2025 revealed Resident 25 received Oxycodone HCI Oral Tablet 5.0 mg for pain 59 times from June 17, 2025, through July 18, 2025. During an interview on July 17, 2025, at 11:05 AM, Resident 25 explained that last month when she was being transferred from her chair to the bed, she was injured. Resident 25 indicated that a female aide with dark hair was helping her to get to bed. She indicated the nurse aide was the only staff present when she was transferred to bed that day. During the transfer, the nurse aide attempted to reposition her, and they both heard a crack. Resident 25 explained that her leg did not hurt at first, but it became painful a little while later. Resident 25 indicated the nurses and physician were in to see her, then sent her to the emergency department for further evaluation. Resident 25 indicated t she has had to wear an immobilizer as her leg heals and described her pain as intermittent at about a level of 6 out of 10 when it is the worst. Resident 25 indicated she takes medication when the pain is bad, and it seems to help. During an interview on July 17, 2025, at 1:15 PM, Employee 1, NA, indicated that on June 12, 2025, at about 2:30 PM, she used the mechanical lift to transfer Resident 25 without the help of any other staff. Employee 1, NA, explained that Resident 25 wanted to get into bed and there were no other staff around, so she hooked her up to the lift and raised her a bit. When she was attempting to adjust the resident’s legs, she heard a “pop” and a “crack.” Employee 1, NA, indicated she went to get the nurse immediately after she heard the crack. Employee 1, NA, explained that she knew that two staff were required to transfer Resident 25, but there were no other staff at that moment. During an interview on July 17, 2025, at approximately 11:15 AM, the Nursing Home Administrator (NHA) indicated the facility identified through their investigation that Employee 1, NA, failed to follow Resident 25’s care plan and physician’s orders, which state she requires an assist of two for all transfers, resulting in serious physical injury (a closed left tibia fracture). This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: Nurse Aide involved in transfer with Resident 25 was suspended pending investigation for neglect on June 12, 2025. Identify all residents who require the assistance of a Hoyer lift for transfer. Review documentation related to staff assistance with the Hoyer lift transfer and ensure the transfer status is correct to the plan of care. Immediate education provided for all working nursing staff on Hoyer lift transfers. Education continued with nursing staff prior to the start of their next shift. Education completed on June 16, 2025. Audits will be completed weekly for eight weeks to ensure that Hoyer lift transfers are completed per the plan of care. Results of audit findings will be reviewed through the Quality Assurance Performance Improvement Committee. The facility's compliance date was June 21, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, a review of clinical records, manufacturer's product information, video surveillance footage, employee personnel files and select facility reports, resident, and staff interviews, it was determined that the facility failed to ensure staff properly utilized an assistive device to prevent a serious injury, a major burn, to one resident (Resident A1) and failed to provide required staff supervision of one resident with dysphagia while eating to decrease the risk of a choking episode, which resulted in the resident's death for one resident (Resident B3) out of 17 residents sampled. Findings include: A review of Resident A1's clinical record revealed that the resident was admitted to the facility [DATE], with diagnoses to include muscle weakness, chronic respiratory failure, convulsions, and obesity. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 15, 2024, revealed that the resident was cognitively intact with a BIMS score of 13 ( Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The resident had functional limitations in range of motion (ROM) on one side of his body in both his upper, and lower extremity. The assessment noted that during eating, the resident had the ability to use suitable utensils to bring food and /or liquid to the mouth and required supervision or touching assistance. A review of the resident's care plan, initially dated, [DATE], revealed that the resident had an activity of daily living (ADL) self-care deficit with planned intervention for eating to provide partial/moderate assistance. The resident had a current physician order, initially dated [DATE], for supervision with all PO (by mouth) intake and the use of a Kennedy cup (a lightweight spill proof drinking cup that is used with a straw) at all meals and bedside, date-initiated [DATE]. An Occupational Therapy treatment encounter note dated [DATE], identified precautions required due to the resident's left sided hemiplegia (paralysis on one side of the body). The resident was able to drink coffee from a Kennedy cup with straw with moderate assistance to manage. A nurses note dated [DATE], at 1:00 PM, indicated that at 12:57 PM the nursing supervisor was called to the resident's room, The resident had spilled hot coffee on himself. The resident's left side was noted to be erythematosus (red) with small blisters forming, with area of redness noted on his forearm. The on-call provider was made aware, and staff were awaiting call back. Cool compress were applied. A nurses note dated [DATE], at 1:14 PM, indicated that at 12:57 PM the MD was made aware of coffee spill. A new order was noted to apply cool compresses to left forearm (LFA) and left side as tolerated. Skin prep to blisters every (Q) shift. Monitor q shift for opening of blisters and notify MD when open. A nurses note dated [DATE], at 1:33 PM, indicated that a coffee cup was on left side of the resident. On his side he was also noted to have a small burn on his left arm that he is not able to use. On the left side of resident was a bigger burn (no measurements noted). Nursing noted that the resident was in distress and visibly upset. Resident was calmed down according to the entry. A review of a Wound Evaluation, dated [DATE], at 1:47 PM, completed by Employee 8, a licensed practical nurse (LPN), revealed that the resident's left front iliac crest burn measured 12-centimeter (cm) x 14 cm width x 0 depth, without exudate, or odor. The resident was experiencing pain rated at 4 on the scale from ,d+[DATE]. The wound was warm to touch with epithelial tissue. The wound bed was pink with scattered white blisters. The peri wound margins were defined, and the surrounding tissue is warm. Treatment was a cool compress as needed and skin prep to blisters. A review of a Wound Evaluation, dated [DATE], at 1:53 PM, completed by Employee 8, (LPN), indicated that the resident's left antecubital (the crook of the elbow) burn measured 5 cm x 3 cm x 0 depth, without exudate, or odor. The resident was experiencing pain rated at a 4. The wound was warm to touch, and the skin was closed. The wound bed was dark pink with one white blister. The peri wound margins were defined, and the surrounding tissue was warm. Treatment was cool compress as needed and skin prep to blisters. A nurses note dated [DATE], at 2:50 PM, indicated new telephone verbal order was noted to discontinue skin prep and cool compresses. The new order was to apply Silvadene (treatment cream used for wound infections in patients with second- and third-degree burns) and dry dressing to burn areas and blisters to left side and left forearm burn areas and blisters twice a day (BID). At 3:35 PM on [DATE], oxycodone (a narcotic pain medication) HCL 5 mg tablet was given, and was effective for the resident's increased pain due to the burn. A nurses note dated [DATE], at 9:13 PM, revealed reddened areas with blisters, left forearm 4 centimeter (cm) x 6 cm with multiple blisters, left lower quadrant of abdomen 25 cm x 26 cm with multiple blisters and left thigh 4 cm x 5 cm with one blister. A review of facility incident report (IR) completed by Employee 8, a licensed practical nurse (LPN), dated [DATE], at 1:00 PM, revealed that Resident A1 sustained a burn while reaching for his coffee as described above. Review of witness statement Employee 1, nurse aide, dated [DATE], revealed that at lunch time, she delivered Resident A1 tray and set him up to eat. Employee 1 offered to assist the resident to eat and the resident said to let him eat. A review of facility follow up witness statement Employee 1, nurse aide, dated [DATE], revealed there was an empty cup on the resident's tray, and he wanted coffee. Employee 1 stated that the resident's coffee was put in a cup with a handle and lid with a straw ([NAME] Cup). The lid was well closed according to the employee. During an interview on [DATE], at approximately 3: 40 PM, Employee 3, (Therapy Director) confirmed that Resident A1 has minimal function of his left side and requires assistance. She further indicated the resident should not be left alone to eat. During an interview on [DATE], at approximately 4:25 PM, with the alert and oriented Resident A1, he stated that on [DATE], his lunch tray was delivered without coffee. He requested coffee, and his nurse aide, Employee 1, obtained some, and placed it on his overbed table. After Employee 1 exited the room, when resident reached over with his right hand to grab the coffee he spilled onto his left abdomen and ran down his waist to his buttocks. On [DATE], at approximately 5:20 PM, with the resident's permission, an observation of the resident's burn was conducted in the presence of Employee 2, LPN. The resident's burn was visible on his bottom left abdomen, which extended around his back to his buttocks. The burn appeared clean, and measured 24.2 cm x 24.6 cm as measured by Employee 2, LPN. The burn was triangular in shape and appeared slightly red, with scattered areas of purple, and white. Numerous blister like clusters remained, with an open red area in the center that measured 9.8 cm x 5.0 cm as measured by Employee 2, LPN. There was no drainage, or odor. An observation of the left forearm burn revealed a red, open area without drainage or odor, measuring 2.4 cm x 0.5 cm as measured by Employee 2, LPN. An interview with Employee 1, nurse aide, on [DATE] at 9:38 AM revealed that Resident A1 requested coffee with his lunch meal on [DATE]. She stated his Kennedy cup was on his lunch tray when she served his meal tray, but it was empty. She stated that she went to the dining room and obtained coffee from the dispenser. She stated she then provided the coffee to the resident, placed the lid on the Kennedy cup and put in a straw. She asked the resident if he needed help and he stated he did not. Interview with Employee 20, nurse aide, on [DATE] at 10:27 AM revealed that on [DATE], she assisted Employee 21, nurse aide, to help change the wet sheets from under Resident A1 after the coffee had spilled. Employee 20 stated she was sure the lid was still on the Kennedy cup because she saw it laying along side of the resident when she helped to change him after the spill. During an observation in the facility's kitchen on [DATE] at 9:15 AM, Employee 22, a dietary aide, provided a Kennedy cup, the type Resident A1 used, for inspection. The cup was a frosted white color but clear enough to see the liquid it contained. She stated that the liquid should only be filled to the fill line. An observation of the cup revealed raised letters on the bottom half of the cup which read Fill Line. The lid of the cup also read Spill Proof. The surveyor proceeded to fill the cup above the fill line with coffee, a straw was placed inside the cup and the cup was then tipped over, which caused the liquid to spill out of the cup around the straw until it reached the fill line and then the spillage stopped. Manufacturer information for the Kennedy cup indicated eliminates leaks and spills. The cup is dishwasher safe up to 180 degrees Farenheit and holds up to 7 ounces of liquid. A review of the facility's video footage from [DATE]. 2024, conducted on [DATE] at 10:05 AM revealed that on [DATE], at 12:15 PM Employee 1 was observed carrying a meal tray to Resident A1's room. An empty Kennedy cup was visible on its side on the tray. At 12:19 PM Employee 1 was observed leaving resident's room with the empty Kennedy cup and a styrofoam cup in her hand. Employee 1 headed toward the main dining room. She shortly left the dining room and went to the side of the nursing station. Her back was toward the camera and her actions not visible. She turned towards the camera and she had a Styrofoam cup in her hand and the Kennedy cup containing a dark liquid (coffee) at 12:20 PM as she walked towards the camera. The footage revealed that the dark colored liquid (confirmed by Employee 1 to be coffee) in the Kennedy cup was over the fill line. During an interview with Employee 1 on [DATE] ar 9:56 AM she confirmed that the coffee in the Kennedy cup was filled above the fill line, and demonstrated by pointing to the amount she filled the cup as being over the fill line. During interview with Employee 1 on [DATE] at 9:56 AM, while presenting the [NAME] Cup and fill line Employee 1 confirmed that she filled the coffee above the fill line. She pointed at the area of the cup to which she filled the cup with coffee on [DATE], which was above the spill line. Employee 1, was unaware the Kennedy cup would no longer be spill proof if the cup was filled above the designated spill line. A review of the employee's personnel file revealed that Employee 1 was a newly hired nurse aide as of [DATE], and was currently on orientation at the time of the incident. Employee 1 was under the guidance of another nurse aide, Employee 23, who had been employed by the facility as a nurse aide since [DATE]. On [DATE], the surveyor team requested to review any food and beverage temperature logs maintained by the facility at resident meal service but the facility did not provide them on [DATE], when requested. There were no logs available for review on [DATE], to show that the facility consistently obtained the temperature of the coffee after brewing, and at point of service to residents. The facility, subsequently provided temperature logs to the surveyors on [DATE]. The food/beverage temperature record was dated [DATE], and did not include beverage temperatures at breakfast, but noted that the coffee temperature at the lunch meal was 136 degrees Farenheit. Interview with the NHA on [DATE] at approximately 2:00 PM confirmed, after reenactment observation of the Kennedy cup, that the cup would spill out its contents if filled above the line, The facility failed to ensure Employee 1 was knowledgeable on the correct use of the [NAME] Cup before providing a hot beverage to Resident 1 in that adaptive eating device. As a result of Employee 1 overfilling the Kennedy cup with coffee, the cup was no longer spill proof and the resident spilled the hot coffee on himself sustaining significant and painful burns. Resident B3 was admitted to the facility on [DATE], with diagnoses of unspecified convulsions (medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body), dysphagia ( a condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and abnormality of gait (difficulty walking). The resident's plan of care, revised February 6, 2023, indicated that the resident required close supervision with all oral intake secondary to dysphagia. The care plan, dated as created on [DATE], indicated a restorative nursing program for dysphagia 6 to 7 days a week. The resident's care plan, initiated [DATE], included interventions to monitor for signs and symptoms of swallowing dysfunction, coughing/choking during eating, pocketing of food in mouth, inability to control saliva or drooling, which remained in effect at the time of a choking episode the resident experienced on [DATE]. A speech language pathologist assessment of the resident dated [DATE], revealed that to promote safe oral intake the following strategies and/or maneuvers were to be used: alteration of liquids and solids, rate modification, bolus size modifications and general swallowing techniques/precautions in an upright position. The speech language pathologist recommended a mechanical soft texture diet (a mechanical soft diet consists of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor. These processes break down the structure of foods to make them soft and easy to eat without biting or chewing) with thin liquids and close supervision for oral intake. An evaluation of oral and pharyngeal swallowing (the mass of chewed food transitions from the area behind the mouth into the esophagus (tube to the stomach) function was completed by speech therapy on [DATE], in response to nursing's report that the resident had increased difficulty with chewing. The same recommendations were provided, as noted during the assessment of [DATE], alternate liquids and solids and for the resident to sit upright with close supervision during oral intake. Observation of facility surveillance video camera footage, conducted on [DATE], revealed that on the evening of [DATE], Resident B3 was observed seated in the hallway on the [NAME] side of the facility near the feeding room. The resident was seated upright in a geri-recliner with a tray table in front of him. Staff were observed removing meal trays after the resident meal service, and returning them to food delivery truck in the hallway. At approximately 6:13 PM Employee 17, a nurse aide, was observed to provide Resident B3 with a sandwich. There was no one directly supervising the resident while he was eating the sandwich, nor were any liquids present. Multiple staff members were in the hall cleaning up the evening meal, but were not observed closely monitoring or supervising Resident B3 while he was eating his sandwich. The video footage showed the resident bringing the sandwich to his mouth multiple times. There was no one directly supervising the resident while he consumed the sandwich. At approximately 6:20 PM Employee 18, a nurse aide, walked by Resident B3 who appeared to raise his right hand to which Employee, 18, waved at the resident, walked through the nursing station, went into the backroom and immediately came back out. She stopped at the desk pulled her cellphone out of her pocket and looked at her phone. She then looked up and saw the resident was in distress. She alerted staff. By 6:30 PM, Employee 19, an LPN, came running and initiated the Heimlich Maneuver (emergency procedure that is used to dislodge foreign bodies from the throats of choking victims, abdominal thrusts for conscious victims), which was not successful. Staff brought the resident to the floor since a thready pulse was still palpable and abdominal thrusts continues according to the clinical record). The facility contacted 911 emergency services and the ambulance arrived at 6:37 PM and the paramedic and EMT (emergency medical technician) began CPR (since the resident no longer had a pulse according to facility documentation). Video footage revealed that on [DATE], a 6:38 PM resuscitation efforts were terminated by EMS. Clinical record review revealed that nursing staff determined that the resident was a DNR (do not resuscitate- a physician's order directing a clinician to withhold any efforts to resuscitate a patient in the event of a respiratory or cardiac arrest). Resuscitation efforts were discontinued by the EMT at 6:38 PM. According to the facility investigation the resident was pronounced deceased at 6:40 PM on [DATE]. At 7:00 PM the police arrived to speak with EMS and the coroner arrived at 7:30 PM. The body was released to the funeral home at 7:50 PM. A review of a statement written by Employee 17 dated [DATE], confirmed that the resident requested a peanut butter and jelly sandwich, which Employee 17 provided to the resident. Employee 17 stated he cut the sandwich in four pieces. Employee 17 indicated the resident was not on his assignment however, he was familiar with the resident and had provided him with sandwiches in the past. An interview conducted with Employee 17 on [DATE] at approximately 11:30 AM, revealed that the employee confirmed that he provided the resident with a peanut butter and jelly sandwich. He stated that he couldn't remember if he cut the sandwich into three pieces or four pieces. He said he placed it on the table in front of the resident and left to continue his duties. Interview with Employee 19, LPN, on [DATE] at 11:20 AM, the nurse who initiated the Heimlich Maneuver to Resident B3 on [DATE], stated she heard staff scream and ran to assist, she stated she was not assigned to the resident but arrived to help. She stated the resident was choking and she began the Heimlich Maneuver. Employee 19 stated that there was no sandwich on the resident's tray table when she arrived. The facility failed to provide the close supervision the resident, with dysphagia, required while while he was eating the peanut butter and jelly sandwich, which was confirmed upon review of the video surveillance footage. The resident was observed consuming the sandwich for approximately 7 minutes, and appeared to be consuming it in its entirety. Staff were observed to be conducting their duties after the dinner meal. Although this resident was in the hallway he was not being directly supervised while eating this sandwich. There was also no evidence the resident had liquids provided to him in order to alternate between solid food items and liquids as indicated by speech therapy. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services

Based on a review of clinical records and facility investigative reports and staff and family interviews it was determined the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to promptly identify and act upon ongoing signs and symptoms of a change in resident condition, and evaluating current resident care needs, which resulted in a delay in treatment of a serious injury, a comminuted impacted hip fracture for one resident (Resident B1), and to maintain the safety of one cognitively impaired resident with behavioral symptoms (Resident A8) out of 22 residents reviewed. Findings include: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling. The resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function, a score of 13 to 15 indicates the resident is cognitively intact) according to a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2023. The resident required the assistance of staff for activities of daily living, including bathing, toileting, bed mobility and transfers and ambulated with assistance with a rollator walker. The resident had current physician orders, initially dated September 18, 2023, for Acetaminophen ER (extended release,Tylenol, a non narcotic pain medication) 650 mg, take 1 by mouth every 12 hours for pain management and Tylenol 325 mg, give 2 tabs by mouth every 4 hours as needed for mild to severe pain level 1-10. A facility investigation report and nursing documentation dated January 1, 2024, at 1:41 PM revealed that staff found Resident B1 on the floor in her room, between her bed and the wheelchair, after the resident attempted to self transfer. Nursing noted that the resident sustained no apparent injury, denied discomfort and was able to move all extremities without discomfort. It was noted that the resident's non-skid socks had been applied incorrectly. Staff reapplied the socks. The resident was referred to therapy for evaluation and treatment. A physical therapy evaluation dated January 2, 2024, revealed that the resident had unspecified abnormalities of gait and mobility, muscle weakness and pain. The assessment summary noted that the resident was evaluated and treated after a fall on January 1, 2024. It was noted that the resident presented with a decline in functional ability, increased low back pain and was at risk for falls. A review of a physical therapy service note dated January 12, 2024, indicated that nurse aides alerted therapy that they were having difficulty transferring Resident B1 off the toilet. Therapy assisted the nurse aides into the wheelchair with the assistance of another therapy staff member. The task was completed with dycem (a non-slip surface) placed under the resident's feet to ensure that her feet remained on the floor. The resident's transfer status was changed to transfer assistance of two staff with a rollator walker and the use of a hoyer (mechanical lift) lift as needed. The resident's care plan was updated at this time with this change in transfer status. A facility investigation report and nursing documentation dated January 15, 2024 at 6:45 AM revealed that staff lowered the resident to floor during a transfer to the bathroom. The resident was then seated on the floor with her legs extended in front of her. She was able to move all extremities without pain or limiting range of motion. Resident B1 stated that her knees gave out. The nurse practioner was notified. The resident was placed into her wheelchair via a mechanical lift. A request for another physical therapy screen was sent to therapy for evaluation and treatment. The report indicated that the resident's transfer status was changed on January 12, 2024, indicating that the resident required the assistance of two staff with transfers, and, as needed, use of the hoyer lift for transfers. Employee 12, a nurse aide admitted that she did not review the resident's care card (kardex) prior to starting her shift and transferred the resident by herself. A review of an employee witness statement dated January 15, 2024, revealed that Employee 12 stated, I was walking Resident B1 to the bathroom and had to lower her to the floor so I slid her down my legs. She didn't hit anything. Physical therapy was notified after this fall for an additional evaluation. The evaluation, dated January 17, 2024, indicated that the resident needs extensive assistance for sit to stands from the wheelchair. The resident tends to have extensive toe out of the right lower extremity, unable to weight shift to correct. A review of an interviewer statement (between nursing administration and Employee 12) dated January 15, 2024 revealed, Resident B1 is an assist for transfers/ambulation. On January 15, 2024, approximately 6:45 AM Employee 12, nurse aide, stated that she lowered the resident to the floor. Employee 12 transferred Resident B1 as a one assist. Employee 12 stated that she did not check the communication book at the beginning of the shift to see if there were any changes for the resident's ADL status. During an interview March 12, 2024, at approximately 3 PM the Director of Nursing (DON) confirmed that Resident B1 required the assistance of two staff members for transfers and on January 15, 2024, Employee 12 transferred the resident by herself The DON stated that Employee 12 was interviewed regarding the incident, and Employee 12 stated that she did not check Resident 2's care card to ascertain the resident's transfer status prior to transferring her. Employee 12 was suspended pending investigation. A review of an employee disciplinary record dated January 18, 2024 revealed that Employee 12's work performance was not up to established professional standards. The employee was reeducated and returned to work. A facility incident report dated February 4, 2024 at 12:45 AM revealed that staff identified a dark purple bruise was on the resident's left inner thigh measuring 10 cm x 5 cm. Resident B1 reported pain rated at a 4 out of 10 pain scale rating. The intervention planned was to monitor the site until resolved. The resident was also noted to be receiving daily anticoagulant therapy, Coumadin (dose dependent on lab results). A review of nursing documentation dated February 4, 2024 at 05:40 AM Dark purplish bruise remains to mid left thigh inner aspect. Denies pain at this time. No further bruising noted at this time. A review of a therapy progress note dated February 5, 2024, revealed that the resident was seen on this date, seated in her wheelchair complaining of pain rated at an 8 out of 10 pain in her hernia (a hernia usually happens in your abdomen or groin, when one of your organs pushes through the muscle or tissue that contains it. It may look like an odd bulge that comes and goes during different activities or in different positions. It may or may not cause symptoms, such as discomfort or pain) area, the left lower quadrant. Therapy noted that the medical team was made aware. Seated bilateral lower exercises were limited due to the resident's left lower quadrant pain which also affected her lower back. The resident was returned to her room. Therapy notes dated February 8, 2024, revealed that the resident was hesitant to participate in physical therapy session, repeatedly stating that she does not feel like herself, unable to tolerate activity to be able to pivot and walk. Physical therapy notes dated February 12, 2024, revealed the resident is reluctant to trial stands from the wheelchair due to overall decreased motivation and complaints of back pain stating, it hurts pretty bad. A review of physical therapy notes dated February 13, 2024 revealed that the resident requires maximum assistance for toileting. The resident not appearing appropriate for consistent transfers with assistance of 2 staff. Nursing staff was educated on orders for the use of the hoyer lift for all transfers. Physical therapy notes dated February 14, 2024 revealed that due to complaints of pain, fear of falling and overall muscle weakness, {Resident B1} was unable to complete therapy session. She reports pain in her back area as an 8 out of 10 scale. A nursing note dated February 18, 2024 at 6:15 P.M. revealed that the resident complaining of left knee pain stated she bumped it while at an activity yesterday, resident does not want to move it or allow nursing staff to move it, resident requested a warm compress for her knee and nursing staff provided the compress, resident stated it was feeling better with the warmth. asked resident if she would like to elevate it and she said no it hurts to move, offered resident Tylenol and she wanted to see if the warm compress would work or not before taking Tylenol. resident also refused to get into bed at this time. RN supervisors notified and RN supervisor assessed knee. The nurse practioner was notified and ordered a left knee x-ray. The x-ray of the knee was completed February 19, 2024 and negative for a fracture. A review of physical therapy notes dated February 20, 2024, revealed that the resident had limited standing tolerance due to complaints of left knee pain. Physical therapy notes dated February 21, 2024, revealed that Resident B1 remained in bed throughout the morning, declining to get out of bed due to fatigue and left extremity pain. Bed exercises were attempted. The resident was not helping during mobility, and was described as anxious and resistive due to complaints of lower extremity pain and fatigue. The resident did not give specific description of the pain and then begins to state she was not fell ing well. Physical therapy notes dated February 23, 2024, revealed that The resident was approached in the morning and again in the afternoon for PT services. She is hesitant and resistive to PT services, complaining of fatigue and left extremity pain at rest. She is becoming behavioral with even the attempt to move the wheelchair. She begins to yell that she is having pain in her left extremity. The resident was yelling in pain when the therapist was moving her feet on the wheelchair rests. Therapy services were discontinued at this time due to not making progress. A review of the resident's February 2024 medication administration record (MAR) revealed that staff administered the prn (as needed) Tylenol 325 mg, two tabs, to Resident B1 on February 4, 2024, at 11:22 AM and 6:05 PM and February 17, 2024, at 5:11 PM for complaints of pain. A review of the resident's March 2024 MAR revealed that staff administered the as needed Tylenol 325 mg tabs, to Resident B1 on March 6, 2024 at 2:32 PM A review of nursing documentation dated March 7, 2024 at 11:33 AM revealed a physician order for x-ray of left hip due to the resident's complaints of left hip pain. Prior to the notation of this physician order for an x-ray of the resident's left hip, there was no documented evidence in the clinical record of an assessment of the resident's ongoing pain by licensed professional nursing staff. Since the resident's falls on January 1, 2024, and January 15, 2024, the resident had been complaining of pain in left side and left extremity and decreased participation in physical therapy and ADLs. According to the resident's January 2024 and February 2024 MAR nursing was medicating the resident with Tylenol for complaints of left sided pain. However, there was no documented evidence that the facility's licensed professional nursing staff had consulted with the physician regarding the resident's ongoing signs and symptoms of potential injury and the potential need for further diagnostics and treatment. A review of an x-ray report of the resident's left hip and pelvis dated March 7, 2024 for Resident B1 revealed an acute fracture of the femoral neck. The physician was contacted and the resident was sent to the hospital for evaluation and treatment. A review of hospital documentation dated March 7, 2024 revealed that {Resident B1} presented to the emergency department after she was found to have a left femoral neck fracture at her nursing home. Resident reportedly had her last known fall in January and had been complaining of significant left leg pain since that time. They had previously only x-rayed her femur and knee and did not x-ray of the left hip. This is a [AGE] year-old woman presenting with several weeks of left leg pain and difficulty ambulating patient has had multiple falls in the month of January {'24} and has been having left leg pain and requiring a Hoyer lift. Physical exam did not show any other obvious injuries or tenderness does have significant tenderness of the left hip. X-rays confirmed the left femoral neck fracture. Orthopedics and Trauma Surgery consulted Trauma Surgery admitted the patient plan for likely operative intervention of the hip by Orthopedics. A review of a CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated March 8, 2024 revealed the following: 1. A mildly comminuted fracture (a comminuted fracture refers to a bone that is broken in at least two places. Comminuted fractures are caused by severe traumas) of the left femoral neck is present with 1/2 bone width lateral displacement, impaction and various angulation. 2. Focal hematoma (A collection of blood outside the blood vessels) in the left iliacus (The iliacus is a flat, triangular muscle which fills the iliac fossa) to the fracture, measuring up to 3.6 cm. Orthopedics was consulted by the emergency department and the resident was to proceed to OR (operating room) within 24 hours. Left leg held in shortened and externally rotation position compared to contralateral leg, (+) pain with log roll. The resident had surgery March 8, 2024. The orthopedic surgical report revealed that {Resident B1} with several months of decline in ambulatory status and ongoing pain. She was found to have a chronic left femoral neck fracture. It was believed that this occurred approximately 3 months ago. Prior to her decline in ambulation she was a limited ambulator with the use of a walker. Options which include nonoperative treatment as well as [NAME] ([NAME] procedure, the orthopedic surgeon removes the hip bone and ball, leaving patients without a hip joint) and close. versus hemiarthroplasty. We discussed that due to this being a chronic fracture as well as her health status both cognitively and physically she may do better with a [NAME] procedure. After discussion with the family the decision was made to proceed to a [NAME] they are aware that she will not have a hip but we will be able to be a limited ambulator with bed-to-chair transfers and short ambulation with the help of her walker. During a telephone interview March 12, 2024 at 12 PM, the resident's representative stated that her mother has had a steady decline in her health since her first fall on January 1, 2024. She stated that her mother was in constant pain that was not addressed by the facility. By the time of the second fall on January 15, 2024, the resident's ambulation and transfer abilities had decreased. The resident's representative stated that she reported her concerns regarding her mother's ongoing pain to the facility nursing staff, but those reports were most mostly ignored by the facility. During a telephone interview March 14, 2024 at 10 A.M. the resident's other daughter stated that she lives locally and visited her mother daily. She stated that since her mother's falls in January 2024 her mother's ADL abilities declined. She stated that after the falls her mother could no longer stand and ambulate by herself. The resident's daughter stated that her mother complained about pain and nursing staff said they could not do anything about it. The facility failed to ensure that Employee 12, a nurse aide, demonstrated knowledge of the resident's individual needs and used techniques and skills to maintain resident safety identified on the resident's care plan for providing assistance with transferring. The facility failed to ensure that licensed professional nursing staff consistently assessed the resident's health status, including her ongoing complaints of pain and declines in functional status and ADL abilities, after two falls, to timely identify potential signs and symptoms of injury, and coordinate with other members of the interdisciplinary team, including the physician, to ensure that the resident received timely treatment at the level required for the resident's serious injury. A review of the clinical record of Resident A8 revealed admission to the facility on [DATE], with diagnoses of a psychotic disorder (conditions that affect the mind, where there has been some loss of contact with reality) with delusions (a false belief or judgment about external reality) dysphagia (difficulty swallowing food or liquid), and dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with agitation. A review of the resident's quarterly MDS dated [DATE], revealed that the resident was severely cognitively impaired with a BIMS score of 3. A review of the resident's current comprehensive plan of care, which was not dated when reviewed during the survey ending March 12, 2024, indicated that Resident A8 was at risk for elopement due to wandering behaviors. The resident self-propelled in the wheelchair was noted to display fidgety and restless behaviors. The resident had a history of wandering into other resident rooms. The care plan noted that if the resident wanders into other resident rooms she is to be assisted toward her room and placed back to bed and provided an activity bag that contained magazines and word search books. A review of Resident A8's clinical record revealed nursing note dated March 3, 2024, at 9:53 PM written by Employee 15, LPN, indicating that staff witnessed the resident drinking from a bottle of aloe peri wash while in the hallway of the [NAME] wing. A written report entitled Unusual Event, written by Employee 15, indicated Employee 16, an LPN, witnessed the resident drinking aloe peri wash. The resident was sucking at the end of the container like a bottle. The peri wash was taken from the resident. The physician assistant was made aware and poison control was contacted. Poison control advised to have resident drink water and observe the resident for any nausea or vomiting. A review of the MSDS (material safety data sheet) for the periwash indicated that if swallowed call physician immediately and rinse mouth and throat with water. A statement written by Employee 16, LPN indicated This nurse was walking towards the nurses station when witnessing resident attempting to drink out of a peri wash bottle. This nurse immediately took bottle from resident. The spray mechanism on the bottle was missing but screw on cap was on the bottle. A nurse aide provided the resident with water to drink. This nurse provided the LPN assigned to the resident with information and immediately alerted the RN supervisor. A telephone interview conducted with Employee 16, LPN, on March 12, 2024, at 5:30 PM revealed that Employee 16 stated that the resident obtained the peri wash bottle from the linen cart that was located in the hallway. She stated they looked but never found the spray mechanism from the bottle. Clinical record documentation from the facility's behavior management team dated March 4, 2024, revealed a note written by the DON which indicated the new intervention developed in response to this incident, was to attach a cup holder to the resident's wheelchair so the resident may have access to drinking while self-propelling in the hallway. A note written by Employee 17, LPN, also indicated that a cup holder would be added to the resident's wheelchair to provide more beverages. It was determined through interview with the facility's DON and corporate nurse on March 12, 2024, at 6:30 PM that nursing staff had left the personal care item, periwash on the linen cart, where it was accessible to the resident self-propelling in the corridor. Following the incident, the facility provided education to nursing staff, on March 5, 2024, to ensure that personal care items are stored in the resident's room and not on the linen cart where they may be accessible to residents and mishandled or consumed. The facility was aware that Resident A8 self-propelled about the facility and displayed restless and figidity behavioral symptoms but nursing staff failed to secure personal care supplies to prevent this cognitively impaired wandering resident from accessing and drinking periwash. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.5 (f) Medical records

Based on a review of clinical records, select facility incident reports and policies, and American Heart Association guidelines and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident (Resident CR1) out of three residents sampled. This failure placed 93 facility residents, desiring cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to their advanced directive, out of the 169 resident census in the facility, in immediate jeopardy to their health and safety with the potential for death as a result of a similar occurrence. Findings include: Review of the facility's policy and procedure titled Emergency Procedure - Cardiopulmonary Resuscitation last reviewed by the facility [DATE], revealed that if an individual (resident, visitor, staff) is found unresponsive and not breathing normally a licensed/certified staff member shall initiate CPR (Cardiopulmonary Resuscitation) unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exist for that individual or there are obvious signs or irreversible death. According to American Heart Association guidelines presumptive Signs of Death are as follows: The patient is unresponsive; The patient has no respirations; The patient has no pulse; The patient's pupils are fixed and dilated; The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature; The patient has generalized cyanosis (Bluish skin color due to decreased amounts of oxygen). AHA guidelines for Conclusive (irreversible) Signs of Death are as follows: There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body); decomposition (decay or putrefaction of the body); rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop) A review of Resident CR1's clinical record revealed admission to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, heart failure, and diabetes. Review of Resident CR1's clinical record revealed a physician order dated [DATE], identifying that the resident was to receive CPR (emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac arrest. Review of the Resident CR1's vital signs record revealed that the resident's blood pressure on February 9, 2024, at 1:26 PM was ,d+[DATE] mmHg and temperature on February 9, 2024, at 3:38 PM was 97.6 degrees Fahrenheit. A nurses note dated February 10, 2024, at 7:52 AM indicated that this nurse, Employee 4 (RN Supervisor) was called to assess Resident CR1. The RN noted No heartbeat, no lung sounds auscultated (examine patient by listening to sounds from the heart, lungs, or other organs, typically using a stethoscope). Death pronounced at 6:28 AM, but resident appeared to have been deceased for some time (no signs or description documented). Employee 5 (CRNP) called and made aware of death at 6:33 AM. Received new order to 'Release body to mortician.' POA and emergency contact #1(name mentioned), was notified of the death at 6:37 AM. Review of the facility incident report dated February 10, 2024, indicated that at 3:50 AM on February 10, 2024, Employee 6 (nurse aide) was in Resident CR1's room with Employee 7 (LPN working as nurse aide), had pulled the resident up in bed, changed her, and noted the resident was fine at that time. Interview with Employee 3 (an agency LPN) on February 12, 2024, at 12:45 PM confirmed that she was the assigned nurse to Resident CR1's unit and had found the resident unresponsive on the morning of February 10, 2024. Employee 3 confirmed that she was CPR and AED certified. Employee 3 stated that it was an overwhelming night and she was the only LPN on the [NAME] Wing and that there were two nurse aides. Employee 3 stated there were two falls with no injuries that night, along with Resident CR1's death. Employee 3 stated that on the morning of February 10, 2024, she entered Resident CR1's room at approximately 6:20 AM to obtain a blood sugar. Employee 3 called the resident's name, and the resident did not respond. Employee 3 stated that the resident had no pulse, her hands were cold, and the resident's chest was not rising. She called a nurse aide (Employee 3 was unsure of the aide's name) into the room. Employee 3 (LPN) saw on the computer that resident desired CPR. The nurse aide went to get Employee 4 (RN Supervisor). Employee 3 (Agency LPN) stated that she did not start CPR and was waiting for Employee 4 (RN Supervisor) to get instructions. Employee 3 stated she did not know the facility policy for starting CPR, was never trained on the facility's policy, and had never been in the situation before. Employee 3 (Agency LPN) stated that Employee 4 (RN Supervisor) arrived within two minutes and checked the resident. Interview with Employee 4 (RN Supervisor) on February 12, 2024, at 1:20 PM confirmed that she arrived in Resident CR1's room at approximately 6:28 AM on February 10, 2024. At the time she arrived in the room, Resident CR1's one eye was a quarter opened and the other eye was closed, and blue stuff was running out of the side of her mouth which she thought was a candy of some sort. Employee 4 stated that, using a stethoscope, she auscultated the resident's chest and found no breathing and no heartbeat, the resident's face and body were yellow and arms were very cool. Employee 4 stated that she felt the resident was gone for a while. Employee 4 stated that she was not CPR certified and was unaware of who, on duty on that shift was CPR certified. Employee 4 stated that she then called Employee 5 (Certified Registered Nurse Practitioner) who asked Employee 4 if CPR was started and Employee 4 informed the CRNP that CPR had not been initiated. Interview with Employee 8 (LPN) on February 12, 2024, at 2:45 PM revealed that on February 10, 2024, she arrived for work at 6:50 AM to do a double shift. Employee 8 stated that Employee 3 (LPN) told her that she had a rough night, explaining to Employee 8 that when she {Employee 3} went in to Resident CR1's room to check her blood sugar the resident was still warm. Employee 8 (LPN) stated that she did not know why, based on what she heard from Employee 3, that CPR was not started for Resident CR1. Interview with Employee 9 (PA-C Physician Assistant) on February 12, 2024, at 12:20 PM revealed that although she was not at the facility when the incident happened upon reviewing the incident post-occurrence, she was upset because Resident CR1 was a full code and CPR was not started when staff initially found the resident without no pulse and respirations. The facility failed to provide cardio-pulmonary resuscitation (CPR) to a resident who had requested this emergency care and was identified as a full code status. On the morning of February 10, 2024, nursing staff found the resident unresponsive, and described the resident with no heartbeat and no lung sounds auscultated but did not initiate CPR. According to interview with the RN Supervisior, Employee 4, and documentation in the clinical record, the RN did not to perform CPR based on presumptive signs of death and not conclusive irreversible signs of death. The facility's licensed and professional nursing staff did not document specific irreversible signs of death in the resident's clinical record. Interview with Employee 3 (Agency LPN) on February 12, 2024, at 12:45 PM who found the resident, stated that she was aware the resident had an order for CPR, but was unaware of facility procedures for initiating CPR. Employee 4 (RN Supervisor), when interviewed on February 12, 2024, at 1:20 PM was unaware of which staff member during the shift was certified to provide CPR. These failures placed residents who desired CPR in the event of cardiac arrest in immediate jeopardy. The facility was notified of the Immediate Jeopardy on February 12, 2024, at 2:20 PM and the IJ template provided to the facility at 2:30 PM. An immediate plan of correction was requested and received on February 12, 2024. 2024. The plan included: Employee 3 (Agency LPN) and Employee 4 (RN Supervisor) have been re-educated concerning the facility Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes. Licensed staff education-initiated immediately concerning the Cardiopulmonary Resuscitation policy, the Obvious Clinical Signs of Irreversible Death, nursing documentation related to these signs will continue to be completed with licensed staff prior to their next shift starting on [DATE] with 3 PM to 11 PM shift. Starting with 3 PM -11 PM shift on [DATE] Licensed staff education will be completed regarding the need to initiate CPR immediately in accordance with resident wishes, the location of facility crash carts and AED's (Nursing Supervisors office on East and Pavilion Nursing desk) and where staff can locate the code status for each resident [in Point Click Care(PCC) on the resident face sheet and in the orders]. Facility will designate on the deployment shift each staff member who is certified in CPR. Education will continue prior to each licensed staff member's next shift. Residents code statuses are reflected in PCC on the resident's face sheet and in the resident's orders. Completed [DATE] Director of Nursing or designee will complete an audit of EMR (electronic medical record) code status by [DATE] to validate consistency of records for staff reference. DON or designee will complete an audit of CPR certification on Licensed Facility staff [DATE]. The Immediate Jeopardy was lifted on February 12, 2024, at 5:15 PM upon receipt of the facility's immediate action plan and evidence of its implementation was verified. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 201.18 (e)(1) Management.

Based on resident and staff interviews and a review of clinical records and select incident reports it was determined that the facility failed to consistently implement necessary precautionary measures and adequate staff assistance to maintain resident safety during transfers resulting in a serious injuries, a fractured humerus (arm), elbow and wrist, for one resident out of four sampled (Resident B1). Findings include: A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (brain damage that results from a lack of blood), muscle wasting and atrophy (significant shortening of the muscle fibers and loss of overall muscle mass) and hemiplegia (one-sided paralysis) affecting the left side. A review of an Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 5, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function; a score of 13-15 indicates intact cognition). A physician order, dated January 23, 2024, was noted for staff to transfer Resident B1 with the assistance of one staff and the use of a hemi-walker (one-arm walker). During an interview with Resident B1 on February 12, 2024, at 11:09 AM the resident was observed lying in bed with a soft cast applied to her left upper extremity from above her elbow to the end of her fingertips. She stated that she fell a few weeks ago and fractured her shoulder, elbow and wrist during a transfer from the bed to the wheelchair. The resident stated that a nurse aide was rushing her and when she turned to get out of bed, and get into her wheelchair, the aide never locked the wheelchair brakes and the wheelchair slid out from under the resident and she fell to the floor. Resident B1 stated that she does not understand why the facility keeps saying that she tried to get out of bed by herself when the nurse aide was with her the whole time. Review of the facility incident report dated January 26, 2024, at 4:15 PM described the incident as the PA (Physician Assistant) observed resident lying on the floor in her room on her buttock on the right side of her bed in front of her wheelchair. The PA assessed resident while on floor and noted only complaint at that time was discomfort in her left elbow. 2 staff members able to assist resident to a standing position and transfer her to her wheelchair and out to the nursing station. Resident reported that her shoulder was hurting. RN assessed vitals. X-rays ordered for elbow and shoulder. 'On question, resident related that she wanted to get up to her wheelchair and did not want to wait till help came. Nursing note dated January 26, 2024, at 6:47 PM revealed that staff observed Resident B1 observed lying on the floor in her room on her buttocks on the right side of her bed in front of her wheelchair. The physician assistant assessed the resident while the resident was on the floor and noted that the resident's only complaint at the time was discomfort in her left elbow. Two staff members assisted the resident into wheelchair and resident seated at nurses station. Resident reported her shoulder was hurting. RN assessed vitals: 173/113 (blood pressure), 97.9 (temp), 120 (heart rate), 16 (respirations), 96% (oxygen level) on RA (room air). On assessment, the resident had a complaint of pain in left shoulder with movement. Physician assistant present and orders received for x-rays to left elbow and shoulder. Mobile made aware of need for studies. According to this nursing documentation, when staff questioned the resident, she relayed that she wanted to get up into her wheelchair and did not want to wait till help came. Nursing noted that the resident requires frequent reminders of deficits due to CVA (stroke) and need for assistance with all transfer. Resident confirmed that she was aware of same. Neuro checks within normal limits for resident. Review of Employee 1 (nurse aide) witness statement dated January 26, 2024, indicated that at the time of the resident's fall at 4:15 PM on 1/26/24. Employee 1 reported that the nurse told her that Resident B1 needed to be changed. Employee 1 stated she changed Resident B1 and when she left her room, the resident was still in bed. Employee 1 was out of the room for 2-5 minutes when she heard a noise and went back into her room and saw her on the floor. Review of Employee 2 (Physician Assistant) witness statement dated January 29, 2024, indicated that the date of the incident was January 26, 2024, at 4:17 PM. Employee 2 stated that she was alerted that the resident was on the floor. When she entered the room, the resident was sitting upright on the floor on right side of the bed. She had complaints of elbow pain in her left elbow but was able to straighten it and raise her arm with help from her right arm. The wheelchair was in front of her. Employee 2's statement noted that the nurse aide had just turned around to get rid of her soiled linens and the resident attempted to self-transfer. Resident was wearing grippy socks and the wheelchair was locked when I moved it. A nursing note dated January 26, 2024, at 10:14 PM revealed Resident B1 was sent to the emergency department (ED) around 8:00 PM. A nursing note dated January 27, 2024, at 4:05 AM revealed Resident B1 returned from the ED at 5:00 AM with diagnosed fractures. In the emergency department, a splint was applied as well as a shoulder immobilizer. A New order to start oxycodone 5 mg every 4 hours as needed for pain. Orthopedics referral was requested. Review of the x-ray report dated January 26, 2024, at 10:30 PM revealed the resident sustained three fractures as a result of the fall: 1. Acute, comminuted (bone broken into more than two pieces), nondisplaced (bone stays aligned in an acceptable position for healing), mildly impacted (compressed) proximal left humerus (upper arm) fracture. 2. Acute, nondisplaced, impacted radial head (left elbow) fracture. 3. Acute, nondisplaced, mildly angulated (ends of broken bone are at an angle to each other) distal radius (left wrist) fracture. A second interview with Resident B1 on February 12, 2024, at 4:05 PM revealed that on the day of the resident's fall on January 26, 2024, Employee 1 came in to get me out of bed in my wheelchair so I could go to the dining room for dinner. She was helping me to get into my wheelchair. I told her my left foot doesn't work too well cause I'm paralyzed. She was kind of rushing me. Then I turned around to sit and she didn't lock the wheelchair brake. She was holding onto the back of the chair but didn't lock the brakes. When I sat down, it went out from under me, and I fell down on my elbow. The pain shot up my arm. I laid on the floor for quite some time. I don't know why they keep saying I tried to get up myself, it's not true. When the surveyor asked if the facility had obtained a statement from her for her account of the incident, Resident B1 replied oh gosh, I can't remember who they all were but a bunch of them came to ask me what happened, that's why I don't understand why they're lying about what happened. When asked if Employee 1 provided physical assistance during the resident's transfer from the bed to the chair at the time of her fall on January 26, 2024, and if the resident was using the hemi-walker, Resident B1 replied no, she just held the chair so it wouldn't move. She didn't help me. Therapy wants me to use that walker thing, but I forgot to use it, it gets in the way. A review of Resident B2's Admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14. Interview conducted with Resident B2, Resident B1's roommate, on February 12, 2024, at 4:20 PM revealed that Resident B2 was present in the room at the time of the fall and that she witnessed the incident. Resident B2 confirmed Employee 1 was helping Resident B1 get out of bed for dinner in the dining room. Resident B2 stated that Employee 1 was holding the wheelchair but didn't think of putting the locks on. When {Resident B1} turned to sit, she hit that floor! I felt so bad for her. Employee 1 stood there and froze. She left out of the room after the fall. When the surveyor asked if she was asked to provide a statement to the facility, Resident B2 replied do you know how many people came to ask us questions?! Honey, I lost track of how many came in. They even woke me up at midnight to ask me questions. Review of the facility provided nurse staffing deployment schedule for January 26, 2024, confirmed Employee 1 was assigned to Resident B1's unit during the day and time the incident occurred. Interview with the Director of Nursing (DON) on February 12, 2024, at approximately 4:45 PM revealed that the facility was unable to provide witness statements from Resident B1 or Resident B2 even though both residents reported multiple staff members interviewed them regarding the circumstances of the fall on January 26, 2024. The facility failed to conduct a thorough investigation into the circumstances of the fall by failing to obtain witness statements from two cognitively intact residents. The facility failed to demonstrate that staff applied preventative safety measures, locking the wheelchair brakes, to prevent a fall and failed to provide the required assistance for a transfer of a resident from the bed to the wheelchair resulting in a fractured arm, elbow and wrist. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policies, and information submitted by the facility, observation, and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident, with a known history of exit seeking behavior, and conduct planned monitoring of the resident's whereabouts to promptly identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy to his health and safety for one resident out of four residents sampled (Resident 146 ). Findings include: A review of facility policy entitled Elopement Policy and Procedure last reviewed by the facility March 29, 2023, indicated that the facility will provide a safe and secure environment with adequate supervision and assistive devices to prevent elopements and accidents. The definition of elopement is when the resident leaves the premises or a safe area without authorization. A review of the clinical record revealed that Resident 146 was admitted to the facility on [DATE]. The resident's diagnoses included severe protein - calorie malnutrition, fractures of thoracic vertebra, skull, face, ribs and sternum, underweight, fall, difficulty in walking, and dementia. An admission elopement assessment dated [DATE], indicated that the resident was not at risk for elopement at the time of admission. A review of an Admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 12, 2023, revealed that the resident was moderately cognitively impaired with a BIMS score (brief interview for mental status a tool that assesses cognition) of 11 (a score of 8-12 indicates moderately impaired cognition), and required limited assist of one staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. A review of Resident 146's plan of care revealed a planned intervention initiated July 27, 2023, to monitor for the resident's exit seeking behaviors. A social service note, dated July 27, 2023, indicated that a discussion was held with the resident's representative about the resident's past placements, social and behavioral history and that the resident was an elopement risk. A physician order was noted July 31, 2023, to conduct every 15 minute checks of the resident to monitor for exiting seeking behavior, and discontinued on August 2, 2023. A physician order was noted August 2, 2023, to conduct every 15-minute checks of the resident every shift to observe for the resident's exit seeking behaviors when outside of facility. The resident's August, 2023 Medication Administration Record (MAR), noted staff documentation indicating that on the 3 PM to 11 PM shift on August 3, 2023, staff had monitored and checked the resident every 15 minutes while outside for exit seeking behavior. A quarterly MDS dated [DATE], revealed that the resident was now severely cognitively impaired with a BIMS score of 6 (a score of 0-7 indicates severely impaired cognition). An Elopement Risk Form dated September 6, 2023, revealed that the resident is disoriented at all times, and exhibits impulsive behavior, but not at risk for elopement, despite the resident's exit seeking behavior and physician order for 15 minute checks while outside. A review of information dated September 22, 2023, submitted by the facility revealed that Resident 146 left the facility without knowledge around 1:30 PM, and at approximately 7:00 PM, the resident's responsible party (RP) called the facility reporting that the resident left the facility to visit friends. The resident's RP brought him back to the facility A nurses note dated September 22, 2023, indicated that around 4:20 PM the resident was identified as missing from the facility. According to the entry, the resident was last seen by staff and other residents at approximately 3:30 PM near the {outside} Gazebo during activities. A day shift nurse came to the nursing office to report that she found a walker laying on the grass near the parking lot. 911 was called around 4:45 PM to report the missing resident and assist with search. The resident's Responsible Party then called facility and notified the staff that resident was being brought back to the facility. The resident was assessed upon return and no injuries were noted. The resident was placed on 1:1 supervision when returned. Nursing documentation dated September 22, 2023, indicated the resident returned to the facility at 7:41 PM on September 22, 2023. A new physician order was noted for a wander guard placed on the resident's right wrist and 1:1 supervision. Documentation from a physician assistant indicated that the PA-C evaluated the resident upon the resident's return to the facility on the evening of September 22, 2023, and noted that the resident left the skilled nursing facility, walking through the local town, and getting a ride to a nearby town located approximately 16 miles away from the facility. The resident was gone approximately 6 hours without (facility) permission and was alone most of the time. The resident had no complaints of pain, no complaints at all, without injury or skin disturbance. Resident stated he was alittle tired and had left the facility to see friends in the nearby town. Review of witness statement provided by Employee 1, nurse aide, dated September 22, 2023, who was assigned to care for Resident 146 on day shift on September 22, 2023, revealed that she had not seen the resident exit seeking, and was not aware of him being outside the building. Employee 1, nurse aide indicated that she last saw the resident at approximately 12:20 PM. A witness statement from Employee 2, nurse aide, dated September 22, 2023, who was assigned to care for Resident 146 on the evening shift on September 22, 2023, revealed that she came to work at 2 PM, and had not seen the resident. A witness statement from Employee 3, Licensed Practical Nurse (LPN), dated September 24, 2023, revealed that she was outside the building on a break at approximately 1:30 PM, and saw Resident 146 walking through the parking lot in front of the facility and they spoke with each other. A witness statement from Employee 4, Licensed Practical Nurse (LPN), not dated, revealed that he did not see the resident during the 4:00 PM medication administration. He began to ask fell ow staff members about Resident 146's whereabouts, which initiated the search for the resident. During an interview with the Director of Nursing (DON) on October 18, 2023, at approximately 11:40 AM, the DON confirmed that the social service note dated July 27, 2023, stating that the resident was an elopement risk, was based on an interdisciplinary team (IDT) meeting with the resident's representative, who had informed the facility of the resident's history and behavior. The DON also stated during this interview that the nurses note, dated September 22, 2023, indicating that staff and other residents last saw Resident 146 at approximately 3:30 PM near the Gazebo during activities, was found to be incorrect. During an interview with the Nursing Home Administrator (NHA) on October 18, 2023, at approximately 1:30 PM, it was confirmed that the facility was aware that Resident 146's history of exit seeking behavior as reported by the resident's responsible party during the resident's care conference in July 2023 and was on physician ordered 15 minute checks while outside due to the resident's exit seeking behaviors. The facility staff responsible for conducting these 15 minute safety checks of the resident while outside the facility failed to conduct these checks as planned on September 22, 2023, failing to timely identify the resident's absence from the facility property. Staff had not observed the resident for approximately 3 hours. There was no evidence that staff began to search for the resident's location until approximately 4:20 PM when the medication nurse was unable to locate the resident. Observation of Resident 146 on October 18, 2023, at approximately 3:00 PM, in his room revealed that a right arm wanderguard was in place. The conclusion of the facility's investigation into the elopement was that the resident had hitch hiked a ride to a nearby town, located approximately 16 miles away from the facility. Employee 3, LPN, who on September 22, 2023, had observed and spoken to the resident outside the facility at approximately 1:30 PM, failed to communicate his location to other staff members, including Employee 1, the nurse aide assigned to care for the resident during day shift. Employee 2, the nurse aide on the evening shift September 22, 2023, assigned to the resident failed to conduct visual checks of the resident as assigned failing to follow physician orders for every 15 - minute safety checks for the resident while outside. The resident was missing from the facility for approximately 3 hours (1:30 PM to 4:30 PM) before the facility had recognized his absence and began a search. The facility failed to monitor the resident's whereabouts, every 15 minutes, for 3 hours (1:30 PM to 4:30 PM), when outside the facility, as ordered by the physician. As a result of the failure to adequately supervise a resident's whereabouts to promptly identify the resident's absence and implement procedures for a potential missing resident, Immediate Jeopardy to the health and safety of residents was identified. The Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) and provided the IJ Template on October 18, 2023, at 2:15 PM. This deficiency is cited as past non-compliance. The facility's corrective action plan was that resident 146 was assessed by the Physician Assistant (PA) with no findings. The resident was placed on a 1:1 supervision upon return to facility, was reassessed for wandering and his wandering/risk care plan was updated. He was placed on elopement precautions, and a wandering transmitter was applied. Day and evening shift nurse aides and day shift LPN assigned to resident on September 22, 2023, were suspended pending investigation for failure to fully implement Resident 146 care plan, including implementation of the 15 minute safety checks while outside. Reassess residents for wandering/elopement risk, which resulted without the identification of new residents at risk. Residents with current 15-minute check orders while outside of the building were re-evaluated, without the identification of new residents at risk. Facility initiated a visual check process for each resident assessed to be at risk for elopement by the oncoming nurse aides prior to first rounds, and a protocol that residents with BIMS of 12 or less must be supervised while outside. Facility expanded the reception hours to 8 PM, and modified the late smoking schedule time to 7:30 - 8:00 PM, which was communicated to resident council, staff and families (via call system), and that resident and visitor entrance/exit must occur through the main entrance. Nursing staff will be re-educated concerning the elopement policy and procedure and implementation of care planned wandering/elopement approaches. Nursing staff will be educated concerning the visual check process, which was completed on September 23 - 26, 2023. Director of Nursing (DON)/designee will conduct a random audit of visual check documentation three times weekly for three weeks and monthly for three months. Maintenance Director or designee conducted elopement drills on September 23, 24, and 25, 2023, weekly for four weeks, and monthly thereafter, on varies shifts. The NHA and DON will review facility policies concerning elopement, update as necessary by September 25, 2023, and initiate staff education. NHA revised wandering transmitter tracking system - central supply logs serial number and expiration date upon activation, assigned LPN checks place every shift, day shift unit manager - registered nurse checks function daily. Audit and drill results will be reported at ad hoc Quality Assurance Performance Improvement Committee meeting on September 25, 2023, and will continue at the regularly scheduled monthly meeting until the committee determines sustained compliance has been achieved. Corrective plan was verified as completed as by September 26, 2023. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing Services 28 Pa. Code 201.18 (e)(1) Management

Based on a review of select facility policy and clinical records, observations and staff and resident and family interviews it was determined that the facility failed to accurately assess, consistently provide planned and prescribed care and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing and prevent worsening of pressure sores for four out of 30 sampled residents (Resident 52, Resident 123, Resident 53 and Resident 254). Findings included: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of facility policy entitled: Pressure Ulcer and Skin Management Treatment Guidelines with a policy review date of January 20, 2021 indicates: All residents are assessed for risk factors upon admission and a complete skin assessment is completed by the LPN/RN (licensed practical nurse/ registered nurse) A computerized weekly/ongoing skin condition form (WSCNA) is completed in Point Click Care for the weekly/ongoing skin condition form. Care plans are implemented for all residents with pressure ulcers or deemed to be at risk for developing a pressure ulcer Wound measurements are completed for all wounds and skin tears on presentation of wound. Weekly measurements are done on the TAR (treatment administration record) and WSCNA form by the charge nurse for skin tear, pressure, surgical, diabetic, arterial, and vascular. All residents with skin integrity issues are assessed by the Registered Dietitian or Dietary Tech for any additional nutritional support. Review of Resident 52's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 52's Weekly/Ongoing Skin Condition Form dated August 13, 2021, revealed that the pressure ulcer to the back/sacrum was a Stage IV that measured 37 centimeters (cm) in length by 18 centimeters (cm) in width by 1.8 centimeters (cm) in depth. The appearance of the wound bed was described as macerated [softening and breaking down of skin resulting from prolonged exposure to moisture] with 100% granulation [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process] and bloody drainage. Review of Resident 52's Treatment Administration Record (TAR) for August 2021 revealed that wound measurements were not obtained weekly, as ordered by the physician. The facility failed to measure the resident's sacral wound on August 20, 2021 or on August 27, 2021. Physician ordered wound treatments were not completed on four of 25 occassions as ordered on day shift, not completed on four occassions out of 26 times on evening shifts, and staff documented that the resident refused the treatment on 19 ocassions out of 26 opportunities to perform the treatment on the night shift. Further review of TAR for September 2021 revealed that weekly wound measurements were not obtained on September 3, 2021 or on September 24, 2021. Review of wound care specialist Wound Outpatient Follow-Up Note dated September 7, 2021, revealed that resident's sacral wound measured 51.5 cm x 20.0 cm x 2.0 cm in depth, indicating that the resident's wound had increased in size and depth since last measured on August 13, 2021. Resident 52's sacral pressure sore increased in size and depth from August 2021 to September 2021. The facility failed to consistently provide physician prescribed wound treatments and obtain weekly wound measurements to consistently monitor and timely identify declines in wound appearance, and as a result, was unable to demonstrate that the decline in the resident's pressure sore was unavoidable. A review of the resident's October 2021 TAR revealed that weekly wound measurements were not obtained on October 1, 2021 and on October 15, 2021 as ordered. The physician ordered wound treatment was not completed 4 times out of 31 ordered on day shift, not completed twice out of 31 times on evening shifts, and staff documented that the resident refused 20 times out of 31 times, and not completed 9 times out of 31 as ordered on the night shift. Interview with the Director of Nursing (DON) on November 4, 2021, at 12:45 PM, revealed that Resident 52's wife was a registered nurse (not employed by the facility) and that she completed the resident's wound care treatments in the evenings and on the weekends when she visited the resident. The DON also stated the resident's wound usually did not change much from week to week, but that wound measurements should be obtained and documented weekly in the resident's clinical record. Observation of Resident 52's sacral pressure ulcer on November 4, 2021, at 1:40 PM, with Employee 2, LPN, and Employee 3, LPN, revealed a very large beefy red, stage IV pressure ulcer with a large amount of bloody drainage on ABD pads. The area measured 28 cm in length by 18.7 cm in width. There were two other pressure areas near the large pressure sore, one at the top of the ulcer that had no depth and another area mid-way that measured 0.5 cm in depth. Employee 2 reported that the resident's wound care dressing was changed approximately one-hour prior to this observation. During interview with Resident 52 at the time of this observation, he reported that, according to his physician orders, his sacral wound care was to be completed twice each day. Resident 52 stated that the facility's nurse staffing on 3 PM to 11 PM shift was not adequate to provide his wound care and the resident relayed the problem to his wife who is a registered nurse. The resident stated that in response, his wife came to the facility every evening and on the weekends at 6 PM to provide his wound care treatment. Resident 52 stated that if the staff don't perform his dressing change by 12 PM on the dayshift, he's sitting 18 hours on saturated ABD pads. Resident 52 stated that the facility nurse staffing was very poor on the weekends, especially on the weekend of October 30 and October 31, 2021. Interview with Resident 52's wife on November 5, 2021, 12:30 PM, revealed that she stated that the facility was very short staffed and that if she didn't come in to do the resident's wound care treatments, that they wouldn't get done. Interview with the nursing home administrator (NHA) on November 5, 2021, at 10:30 AM, confirmed that the facility failed to complete weekly wound measurements and consistently perform physician ordered wound treatments as prescribed to promote healing and prevent worsening of the resident's pressure sore. Review of Resident 123's clinical record revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 123' clinical record and admission MDS assessment dated [DATE], revealed that Resident 123's cognition was impaired. The resident's BIMS (brief interview for mental status, the cognitive portion of the assessment) score was 04/15. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, toilet use, personal hygiene and without pressure injuries at the time of admission, however noted at risk for the development of pressure injuries. The resident had functional limitation in range of motion in her lower extremity, impairment on one side. Review of Resident 123's Braden Scale Assessment (a standardized, evidence -based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated September 21, 2021, revealed that the resident scored an 11 (total score of 10-12 indicates the resident was at HIGH RISK). A review of Resident 123's current care plan revealed the resident was identified as having a potential for breakdown from pressure and the intervention to turn and reposition the resident every 2 hours around the clock, utilize protective/preventative skin creams to buttocks every shift and as needed, pressure relieving mattress to bed check every shift and 4 inch foam cushion to the wheelchair with dycem below check every shift. Review of documentation of staff performing the care planned task of turn and reposition around the clock from September 21, 2021 through the time of the survey ending November 5, 2021, revealed that the task was not consistently performed for Resident 123. A review of September 2021 Turn and reposition every 2 hours around the clock task completion revealed that staff failed to perform the task 74 times during September 2021. A review of October 2021 Turn and reposition every 2 hours around the clock task record revealed that staff failed to perform the task 260 times during the month. Review of Resident 123's clinical record revealed an initial wound assessment form entitled: INITIAL SKIN CONDITION NURSING FORM dated October 5, 2021 at 12:07 PM, indicating that the resident had a left heel stage one (I) pressure ulcers 1.5 centimeters x 2.5 cm x 0 cm. The left heel was described with discoloration of left heel, area oblong, purplish discolored. Surrounding skin soft & boggy with blanchable redness. Interventions identified to be implemented included: Pressure reducing mattress, pillows under calves and a protective boot. The resident's October 2021 Treatment administration record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This pressure relieving measure was initiated 19 days after the pressure area on the resident's left heel was identified. The order was then discontinued on October 28, 2021 at 5:48 AM. Resident 123's October 2021 Treatment administration record revealed an order dated October 12, 2021, for weekly wound measurement of the left heel pressure sore every Tuesday on the dayshift. Review of Resident 123's weekly wound form revealed that the wound measurement of the resident's left heel were not completed on October 12, 2021, October 19, 2021, or October 26, 2021. However, the resident's October 2021 Treatment Administration Record, indicated that staff signed the TAR (initials of facility staff) indicating that the weekly wound form with the measurements had been completed. On October 22, 2021 the WEEKLY/ONGOING SKIN CONDITION FORM was completed and indicated that there was a decline in the resident's pressure sore left heel pressure sore. Resident 123's October 2021 Treatment Administration Record revealed an order dated October 8, 2021, at 3:00 PM for Dermaseptin (skin protectant) to open excoriation on the resident's coccyx area every shift, and as needed, cover with abdominal dressing until resolved. Review of the Resident's clinical record revealed an initial wound assessment form dated October 8, 2021. The type of wound was identified as excoriation/[CONDITION(S)] with measurements of 3.2 centimeter x 2.5 cm x 0.1 cm. There was no further documentation regarding the status of the skin damage to the resident's coccyx available at the time of the survey ending November 5, 2021. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the November 2021 Turn and reposition every 2 hours around the clock task was not performed 42 times at the time of the survey ending November 5, 2021. Observation of Resident 123's coccyx and left heel on November 4, 2021 at 2 PM in the presence of Employee 2, LPN and Employee 3, LPN revealed that the wound on the coccyx measured 2.8 centimeters x 1.8 cm x 0.1 cm. Employee 2 did not measure the depth, but stated based on visual observation that the depth was 0.1 cm. Additionally, an open area was observed to the left of the existing open area on the coccyx at approximately 7 o'clock, which measured 0.4 mm x 0.4 mm. This area also presented with depth, but neither Employee 2 nor Employee 3 attempted to measure the depth. The larger area observed on the coccyx appeared crater like, a thin light tan film covered approximately half of the would bed, the wound bed edges appeared rolled (epibole) and lighter in color, no drainage was noted, the surrounding skin (periwound) was dark in appearance. This area on the coccyx was identified by the facility as excoriation /[CONDITION(S)], which according to the facility policy is open or closed reddened areas. However, according to the facility policy the presentation of the areas on the coccyx was consistent with a Stage III Pressure Ulcer ( a full-thickness skin loss. Subcutaneous fat may be visible but not bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. The ulcer presents clinically as a deep crater and may include undermining and/or tunneling). Employee 3 confirmed this skin injury was over a boney prominence and more consistent with a pressure area than excoriation/[CONDITION(S)]. Employee 3 confirmed that the wound's appearance was not consistent with the facility's documented description of the wound. Observation of Resident 123's left heel at this time revealed that the wound was not measured due to the resident's expressed discomfort. Employee 3 stated this pressure area was also not consistent with the documented description of the wound, which the facility identified as a Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence). The area on the resident's left heel was observed by the surveyor and the wound bed was covered in eschar (blackened dead tissue), the edges of the wound appeared reddened and dry, no drainage was noted, the periwound was reddened and was blanchable. Employee 3 stated that the appearance of wound on the resident's left heel was more consistent with a deep tissue injury and not a Stage I pressure as documented. However, based on the surveyor's observation and according the facility policy/protocol the presentation of this wound it was more consistent with an unstageable pressure ulcer- full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/ or eschar (tan, brown, or black). Resident 123 developed a pressure sore on the left heel and coccyx and both wounds worsened. The facility was unable to demonstrate that the development and worsening of these pressure sores was unavoidable due to the facility's failure to consistently implement preventative measures, turning and repositioning around the clock, and accurately assess and identify pressure sores according to facility policy to assure appropriate treatment. Interview with the Nursing Home Administrator on November 5, 2021, revealed that wound rounds are being completed, however documentation related to pressure ulcers is lacking. The NHA confirmed that the facility failed to prevent the development and worsening of pressure ulcers for Resident 123. A review of the clinical record revealed that Resident 53 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Quarterly Change Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired, required extensive assistance with the assistance of two people activities of daily living, and at risk for developing pressure sores. A review of the resident's plan of care for potential for breakdown from pressure, initiated December 20, 2017, revealed interventions to prevent skin breakdown that included turn and repositioning every two hours, air mattress to the bed and check placement every shift, gel cushion to the wheelchair, and preventative skin cream to the buttocks every shift. A review of tasks completed for April 2021, revealed turning and repositioning was not completed 14 times, air mattress to bed and check was not completed 9 times on the 11:00 PM to 7:00 AM shift and no documentation was present to demonstrate that it was checked on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift, protective skin cream was not applied nine times, and the gel cushion to the wheelchair was not checked nine times. A review of an initial skin condition nursing form dated May 19, 2021, revealed that the resident developed an unstageable (full thickness loss in which the base of the wound is cover in a slough {yellow material covering the wound bed} or eschar {dead tissue black or brown in color}) pressure wound (injury to the skin and underlying tissue due to pressure) on her right buttocks measuring 1.2 cm x 1.5 cm x 0.1 cm. A review of tasks completed for May 2021, revealed turning and repositioning was not completed 28 times, air mattress to bed and check was not completed 10 times on the 11:00 PM to 7:00 AM shift and no documentation was found that staff checked it on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift, protective skin cream was not applied 14 times, and the gel cushion to the wheelchair was not checked 14 times. A review of tasks completed for June 2021, revealed turning and repositioning was not completed 39 times, air mattress to bed and check was not completed eight times on the 11:00 PM to 7:00 AM shift and no documentation was found that it was checked on the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift, protective skin cream was not applied 15 times, and the gel cushion to the wheelchair was not checked two times. A review of a weekly/ongoing skin condition form dated June 23, 2021, revealed the pressure sore became larger and now measured 3 cm x 2 cm x 2cm. Slough (dead tissue shedding) and granulation (healing tissue) were present in the wound. A review of tasks completed for July 2021, revealed turning and repositioning was not completed 78 times, air mattress to bed and check was not completed 16 times, protective skin cream was not applied 22 times, and the gel cushion to the wheelchair was changed to an air cushion and was not checked 16 times. A review of a weekly/ongoing skin condition form dated July 14, 2021, revealed that the resident's pressure sore again worsened and measured 3.9 cm x 2.3 cm. The staff did not measure the depth of the wound. However, undermining (tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) was noted at the 9:00 o' clock position, but staff failed to measure the length of the undermining. At the time of the survey, there was no documented evidence that the facility had assessed the resident's wound on July 21, 2021. A review of a weekly/ongoing skin condition form dated July 28, 2021, revealed the wound declined further and now measured 4.7 cm x 5 cm. The staff did not measure the depth of the wound. Undermining was noted at the 1:00 o'clock and 9:00 o'clock, position but staff failed to measure the length the undermining. A review of tasks completed for August 2021, revealed turning and repositioning was not completed 86 times, air mattress to bed and check was not completed 27, protective skin cream was not applied 25 times, and the air cushion to the wheelchair was not checked 27 times. A review of a weekly/ongoing skin condition form dated August 4, 2021, revealed the wound declined further and now measured 6 cm x 5 cm. The staff did not measure the depth of the wound. Undermining was noted, but staff failed to assess and document the location or the extent of the undermining. A review of an outpatient wound care consult note dated August 23, 2021, indicated that the resident now had a stage IV pressure sore measuring 6.4 cm x 5 cm x 5.9 cm of the right buttocks. The wound contained 26% to 50% necrotic tissue (dead tissue), had a moderate amount of drainage, and the bone was exposed. A review of a nursing note date August 25, 2021, at 1:50 PM indicated the resident had returned to the facility after having surgery to debride (remove damaged tissue) the pressure wound. The facility failed to demonstrate the consistent implementation of measures to prevent development and promote healing of the resident's pressure sore. Resident 53's developed an unstageable pressure sore, which progressively increased in size to a Stage IV pressure sore requiring surgical debridement. The facility failed to consistently implement care planned measures to prevent pressure sore development, promote healing and prevent worsening and as a result of these failures was unable to demonstrate that the pressure sore development and deterioration was unavoidable. Review of Resident 254's clinical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An Admission MDS assessment dated [DATE], revealed that Resident 254's cognition was intact. The resident's BIMS (brief interview for mental status, the cognitive portion of the assessment) score was 14/15. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, toilet use, personal hygiene and was admitted with an unstageable pressure injury at the time of admission and was noted at risk for the development of pressure injuries. Review of Resident 254's Braden Scale assessment dated [DATE], revealed that Resident scored an 17 (total score of 15 to 18 indicates the resident was at LOW RISK). An initial wound assessment dated [DATE], revealed that the resident had an identified as unstageable wound on the sacrum with measurements of 1 centimeter x 1 cm x ? cm. Resident 254's clinical record revealed no documentation of the weekly wound monitoring for the week of October 21, 2021 A review of Resident 254's current plan revealed that the resident was identified with the potential for breakdown from pressure and was admitted with an unstageable on her sacrum, interventions prior to the development of a pressure area on the resident's left heel included turn and reposition the resident every 2 hours around the clock. Resident 254's clinical record revealed an initial wound assessment form dated October 30, 2021, at 3:15 PM, indicating that the resident had a left heel stage two (II) pressure ulcers 2.5 centimeters x 1.5 cm x fluid filled. The form noted that the resident's left heel presented as a small blood blister. Review of documentation related to turn and reposition around the clock from October 8, 2021 through the time of the survey ending on November 5, 2021, revealed no documented evidence that staff were consistently performing the task. A review of Resident 254's turn and reposition around the clock documentation revealed on October 30, 2021, the date the resident's left heel pressure injury was found, revealed no documented evidence that the resident had been repositioned from 2:00 AM until the finding of the area on the resident's left heel on October 30, 2021, at 3:15 PM. Interview with the director of nursing on November 5, 2021 at approximately 1:00 PM confirmed that the facility failed to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for a resident at low risk for pressure sore development and to promote healing of pressure sores for Resident 254. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/21, 1/22/21, 1/3/21, 8/30/19 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 8/24/21, 8/30/19 28 Pa. Code 211.12(a)(c) Nursing services Previously cited 10/14/21, 8/24/21, 6/24/21, 1/22/21, 9/29/20, 7/27/20, 1/3/20, 8/30/19 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 10/14/21, 6/24/21, 9/29/20, 1/3/20, 8/30/19 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 6/24/21, 1/22/21, 8/30/19 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 10/14/21, 8/24/21, 6/24/21, 1/22/21, 7/27/20, 1/3/20, 8/30/19

APPEAL FILED Based on a review of clinical records, select incident reports and clinical documentation and staff interview it was determined that the facility failed to provide sufficient staff supervision and implement effective safety interventions to prevent a fall resulting in a [MEDICAL CONDITION] for one resident (Resident CR1) and failed to consistently provide prescribed assistance devices during transport resulting in a fall with injury, increased pain and a decline in functional abilities for one of four residents reviewed (Resident 1). Findings include: A review of Resident CR1's clinical record revealed admission to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. The facility assessed the resident to be at a high risk for falls. A significant change Minimum Date Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 8, (YEAR), indicated that the resident was cognitively impaired with a BIMS score of 0 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to severe cognitive impairment). Nursing documentation dated (MONTH) 12, (YEAR), at 6:45 a.m. indicated that the resident was found on the floor in between the nurse's station and the kitchenette. Employee 1, an LPN (Licensed Practical Nurse), heard the resident's chair alarm, but was unable to stop the resident from falling. The resident complained of pain upon movement of her legs. An x-ray was ordered at that time. Results of the x-rays were obtained at 9:47 a.m. which revealed a slightly impacted acute subcaptial [MEDICAL CONDITION] left femur (broken hip), clinical correlation and orthopedic consultation was suggested. The resident complained of increased pain and was medicated. Interventions the facility developed after this fall were for the resident to wear hipsters (adapted briefs designed to minimize potential damage, including [MEDICAL CONDITION] that can occur from a fall) at all times except when receiving hygiene. The resident was ordered not to bear weight (stand up) on her legs until further evaluation. The resident was to be in a supervised (West Wing Lounge area) area in a recliner when out of bed except for meals and activities. Nursing documentation dated (MONTH) 13, (YEAR), at 9:29 a.m. revealed that the resident complained of left hip discomfort with care and transfers. A physician's orders [REDACTED]. A review of a physician's progress note dated (MONTH) 14, (YEAR), revealed that the resident's x-rays (following the fall on (MONTH) 12, (YEAR)) were reviewed by an orthopedic physician. The orthopedic physician indicated that the resident's fracture was largely non-displaced (crack in the bone not shifted from its regular place) and was operative. However, the resident's family wanted a non-surgical approach. A review of a resident incident accident report dated (MONTH) 24, (YEAR), indicated that staff placed the resident in the hallway at approximately 6:05 p.m. The resident was seated in a wheelchair waiting to be taken to the West Wing Lounge and placed into her personal chair (as planned for the resident after the fall on (MONTH) 12, (YEAR)). However, the resident's wheel chair alarm sounded, and staff found on the resident on the floor on her left side. A Nurse Aide, Employee 2, stated that she last saw the resident across from the nurse's station and the resident was last taken to the bathroom at 5:50 p.m. Nursing documentation dated (MONTH) 25, (YEAR), at 1:59 p.m. indicated that the resident had no adverse effects from the fall. Following the fall on (MONTH) 24, (YEAR), the facility educated Employee 2 to ensure that the resident was placed in her personal chair in the West Wing Lounge to prevent falls and be under increased supervision. Nursing documentation dated (MONTH) 25, (YEAR), at 3:46 a.m. indicated that the resident complained of pain when care was provided to both of her lower extremities. An x-ray was completed at 10:15 a.m. on (MONTH) 25, (YEAR), which indicated a new acute non-displaced vertical fracture involving the greater trochanter (break in top of the thigh bone). Probable subacute slightly impacted subcaptial fracture (the fracture line extends through the junction of the head and neck of femur or thigh bone) also again noted similar to prior study of (MONTH) 14, (YEAR). A review of the orthopaedic surgery consult dated (MONTH) 27, (YEAR), revealed a possible left greater trochanter fracture. This consult compared the results of the resident's prior studies dated (MONTH) (YEAR), which at that time indicated that the resident had [MEDICAL CONDITION] (wear and tear arthritis, [MEDICAL CONDITION] (OA) is the most common chronic condition of the joints. It occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness, swelling and pain) and an intact right hip hemiarthroplasty (replacement of hip joint). The (MONTH) 27, (YEAR), orthopaedic consult indicated that the resident was to be weight bearing as tolerated with the use of a mechanical lift for transfers. Nursing documentation dated (MONTH) 28, (YEAR), at 10:30 a.m. revealed that therapy relayed that the resident complained of pain when standing. The physician was updated and he stated to ensure therapy takes it easy on her and let her hip rest. A comparison x-ray was completed on (MONTH) 17, (YEAR), which indicated chronic fracture deformity on left femoral neck, unchanged from the prior exam. Mild left hip [MEDICAL CONDITION]. Review of an incident accident report dated (MONTH) 24, (YEAR), at 2:45 p.m. revealed that the resident's personal wheelchair alarm sounded. Staff found the resident on the floor of her bathroom (in the resident's room). The report indicated that the resident was last observed at 2:30 p.m. The interdisciplinary team reviewed this resident on (MONTH) 26, (YEAR), and the order was clarified to sit in a recliner in the West Wing Lounge to prevent a recurrence of falls. The resident had turned on the bathroom call light but removed her hipsters. Feces were found on the wheelchair. It was noted that the resident had received a laxative that morning (to stimulate bowel activity). No injuries were sustained after this fall. A review of an incident accident report dated (MONTH) 10, 2019, at 10:00 p.m. revealed that the resident was seated in her personal chair in the West Wing Lounge as ordered, but she began to become restless as per Employee 2, a nurse aide. It was noted that Employee 2 walked away from the resident (during this period of restlessness). While Employee 2 was walking to the nurse station, Employee 2 heard the resident's alarm sound and the resident attempted to stand and fell in front of her chair on to the floor mat. The resident' right foot was observed to be externally rotated away from her body. An x-ray was completed of the resident's right hip, which showed intact arthroplasty without hardware compromise (reconstruction of hip with plates or nails,) which was from (MONTH) (YEAR). However, the x-ray did show an acute (new) oblique spiral (break that is diagonal to the long axis of the thigh bone) [MEDICAL CONDITION] femoral shaft with mild displacement (separated) of the distal fragment (just above the knee). Moderate left hip [MEDICAL CONDITION]. The resident was admitted to the hospital for surgical repair on (MONTH) 11, 2019 and returned to the facility on (MONTH) 15, 2019. Interview with the Director of Nursing (DON) on (MONTH) 26, 2019, at 2:30 p.m. confirmed that on (MONTH) 24, (YEAR), Employee 2, a Nurse Aide failed to follow the resident's planned safety interventions by failing to place the resident in her personal chair in the West Wing Lounge for increased supervision. The DON further stated that the facility developed safety measures, but the resident's fracture was unavoidable due to the resident's [DIAGNOSES REDACTED]. The resident had fallen on four occasions since (MONTH) (YEAR). The facility was unable demonstrate that staff had consistently implemented planned safety interventions and provided adequate staff supervision to prevent repeated falls and serious injury to the resident. Resident 1 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A significant change MDS assessment dated (MONTH) 15, 2019, indicated that the resident had a BIMS score of 14, which indicated that the resident was cognitively intact. The resident utilized a wheelchair and a walker for mobility and required physical help with two persons for showering. The current physician's orders [REDACTED]. According to the resident's restorative nursing program (program that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) dated (MONTH) 14, 2019, the resident was ambulating 75 feet with her walker while being followed by staff pushing her wheelchair for safety. A review of a resident incident/accident report dated (MONTH) 9, 2019, at 7:30 p.m. indicated that Employee 3, a Nurse Aide, was pushing Resident 1 back to the resident's room from the shower room. The resident's room was the farthest room from the shower room; the last room in the hallway on which the shower room was located. Employee 3 stated that the resident's feet got caught underneath the wheelchair causing the resident to fall head first onto her forehead, landing on the floor. A review of Employee 4's, a Registered Nurse (RN), statement regarding the incident revealed that upon arriving to the resident's room she observed Resident 1 lying on her left side on the floor. The resident was found to have a large hematoma (a localized swelling under the skin that is filled with blood caused by a break in the wall of a blood vessel, as a result of trauma) in the middle of her forehead. Nursing documentation dated (MONTH) 17, 2019, at 2:24 p.m. revealed that the resident stated that her back hurts more than usual since her fall. The resident was receiving [MEDICATION NAME] 325 mg (pain reliever) two tablets by mouth at 9:00 a.m. and 5:00 pm. every day. On (MONTH) 18, 2019, additional [MEDICATION NAME] 325 mg two tablets by mouth was given at 10:31 p.m. due to the resident's complaints of pain. Nursing documentation dated (MONTH) 19, 2019, at 10:30 a.m. indicated that the resident's son was concerned because his mother was complaining of severe low back pain and he felt the bruising on her face was not resolving quickly enough. The resident's son stated that he wanted her sent to the emergency room for evaluation. The physician ordered a stronger pain medication, [MEDICATION NAME] 50 mg (narcotic-like pain reliever used to treat moderate to severe pain) by mouth at this time. [MEDICATION NAME] 50 mg by mouth was administered at 12:41 p.m. The physician also ordered an x-ray. The results of the x-ray were obtained at 8:47 p.m. which indicated a 10% compression (narrowing of the spaces between the vertebrae) of her L1 vertebra (bottom part of the spine). Physical therapy evaluated this resident on (MONTH) 20, 2019, noting that the resident had pain traveling into her right hip and groin area and would benefit from physical therapy. The resident required maximum assistance for transfers and ambulation with a walker. On (MONTH) 22, 2019, physical therapy attempted to ambulate the resident, but the resident required maximum assistance due to scissoring gait (crossing the legs with slow small steps) with her legs buckling. Physical therapy recommended the use of mechanical lift for transfers. Interview with Resident 1 on (MONTH) 26, 2019, at 1:10 p.m. revealed that the resident was observed to have fading purple bruising around both eyes, above and below her eye sockets. A deeper purple colored large round bruise was observed in the middle of her forehead. The resident stated that after her shower Employee 3 was wheeling her back to her room, she had no leg rests on her wheelchair and when she turned her left into her room she fell head first out of her wheelchair landing on her face. The resident stated that a few days after her fall her back started hurting. She stated that she was able to use a walker before she fell and now she cannot. The resident stated that she feels like she went backwards (in her functional abilities). The facility failed to ensure the proper transportation devices were in place, bilateral leg rests, when transporting a resident, a distance, which resulted in a fall from the wheelchair with injury, pain and a decline in the resident's functional status. Interview with the DON on (MONTH) 26, 2019, at 2:15 p.m. confirmed the facility failed to implement the proper devices when transporting Resident 1 to ensure safety. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 8/4/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 7/13/18 28 Pa Code 211.12(a)(d)(5) Nursing services Previously cited 12/15/18, 7/13/18, 4/11/18, 1/4/18, 8/4/17 28 Pa Code 211.12(c) Nursing services Previously cited 12/15/18, 7/13/18, 4/11/18, 1/4/18 28 Pa Code 211.12(d)(1) Nursing services Previously cited 7/13/18, 4/11/18, 1/4/18, 8/4/17 28 Pa Code 211.12(d)(3) Nursing services Previously cited 7/13/18, 4/11/18, 8/4/17

Based on review of clinical records and a facility investigative report and staff interview, it was determined that the facility failed to provide sufficient staff assistance to prevent falls and serious injury for one out of 24 residents reviewed (Resident 99). Findings include: A review of the clinical record of Resident 99 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurses' notes dated March 10, 2016, at 9:35 a.m. revealed that a nurse aide reported that the resident was becoming more difficult to transfer and will not keep their feet on the (foot) rest. On March 11, 2016, physician's orders [REDACTED]. Review of the nurses' notes dated May 12, 2016, at 8:30 a.m. revealed that the Licensed Practical Nurse (LPN) assisted with the resident's transfer from the shower chair to the wheelchair. The entry indicated that the resident does not assist (with the transfer) and does not stand well on their own. A request was sent to physical therapy to screen (to determine if the resident may require physical therpay services) the resident. A new physician's orders [REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 21, 2016, revealed that the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADL- routine activities that people tend to do every day without needing assistance) including the assistance of two staff with transfers. The resident's balance during transitions (between transfers and ambulation) and walking was not steady and the resident was only able to stabilize with staff assistance according to the MDS assessment. Review of the nurses' notes dated June 15, 2016, at 7:30 a.m. revealed that the, resident complained of pain with a.m. care .resident lying in bed, outer rotation noted left lower extremity .pain with palpation (examination with the hands) and facial grimacing .CRNP (Certified Registered Nurse Practitioner) aware .left hip/pelvic x-ray .new onset pain with range of motion (movement) rule/out fracture/dislocation. Review of the nurses' notes dated June 15, 2016, at 9:20 a.m. revealed that the resident was transferred to the hospital emergency room noting, send to hospital ER for evaluation of structural changes left lower extremity rule/out hip fracture .history of osteoporosis (weak bones). Review of the nurses' notes dated June 15, 2016, at 1:45 p.m. revealed that the resident returned from the hospital ER and the X-rays were negative. However, the nurses' notes dated June 15, 2016, at 1:50 p.m. revealed that staff were, still noting outer rotation at left knee .CRNP aware .X-ray, 2-3 views, left knee new onset pain in absence if trauma and external rotation of left lower leg, knee to ankle .keep in bed until results of X-ray known. Review of the nurses' notes dated June 15, 2016, at 5:00 p.m. revealed, X-ray done left distal fracture .new order send to ER for evaluation. Review of a hospital discharge summary dated June 20, 2016, revealed a moderately displaced, angulated (a fracture in which the fragments of bone are at angles to one another) and overriding oblique (bone breaks diagonally) acute fracture of distal shaft of the left femur (broken thigh bone). Review of the facility's, Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property, dated June 15, 2016, revealed, that when interviewed by the facility regarding Resident 99's injury, Employee 4, Nurse Aide (NA), stated she transferred the resident (Resident 99) after supper on June 14, 2016, by herself (physician's orders [REDACTED]. The NA then placed the resident in bed by herself. The investigative report further indicated the nurse aide did not report this fall to her charge nurse or supervisor at the time it occurred. According to the facility's investigation and Employee 4's statement, Employee 4, transferred the resident from her chair to her bed after dinner and when she put her arms around her and stood her up to pivot her, the resident's knees buckled and she lowered her to her knees .she then cradled her and lifted her into bed. When interviewed by the facility at the time of their investigation, Employee 4 acknowledged that the resident was identified as requiring the assistance of two staff for transfers, but that she had transferred the resident before by herself and had no problems. The facility failed to provide the necessary planned amount of staff assistance during transfer, which was also a physician prescribed safety measure, that resulted in the resident's serious injury. An interview with the Nursing Home Administrator and the Director of Nursing on July 27, 2016, at approximately 1:57 p.m. confirmed that the nursing staff failed to follow the physician's orders [REDACTED]. 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services Previously cited 2/17/16, 8/14/15 28 Pa. Code 211.12(e) Nursing services