Every finding on record at Green Valley Skilled Nursing and Rehabilitation Ce

Based on observations, review of select facility policies and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food and failed to record and maintain food temperature logs to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).Review of the facility policy titled Labeling/Dating last reviewed by the facility on November 26, 2025, revealed all food and non-food supplies will be clearly labeled and dated to ensure the risk of misuse of a product is reduced and that only fresh items are used. All open items or items not in original containers will be clearly labeled, dated and covered. Leftover food will be stored in appropriate containers or wrapping, and dated. Leftover food is checked daily to determine its usage. All perishable food products will follow the three-day rule, if not used within three days it will be thrown out. Items with a factory stamped expiration date (example: yogurt, milk, etc.) will be kept until the expiration date or until it is opened, at which time, date opened will be clearly marked and the three-day rule will apply. Review of the facility policy titled Food Temperatures Policy last reviewed by the facility on November 26, 2025, revealed the temperatures of the food items will be taken and properly recorded for each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 130 degrees Fahrenheit.The initial tour of the dietary department was conducted with the Food Service Director on December 16, 2025, at 10:15 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:Observation of inside the walk-in refrigerator revealed the following food and beverage items were opened and available for use with no open or discard date: one 32-ounce carton of almond milk with manufacturer's instruction to discard within 7-10 days after opening, two 32-ounce containers of thickened dairy beverage with manufacturer's instruction to discard within 4 days after opening, one 32-ounce bottle of thickened cranberry juice and one 32-ounce bottle of thickened apple juice with manufacturer's instruction to discard within 10 days after opening, and two packages of sweet bologna which the Food Service Director's confirmed should be discarded 3 days after opening. Observation of the resident food pantry on December 16, 2025, at 12:50 PM, revealed that inside the refrigerator the following beverage items were opened and available for use with no open or discard date: two 32-ounce containers of thickened dairy beverage with manufacturer's instruction to discard within 4 days after opening. The refrigerator also contained an opened 32-ounce container of almond milk with an opened date of November 1, 2025, exceeding the manufacturer's discard timeframe of 7-10 days after opening. Further observation revealed 16 thawed 4-ounce nutritional shakes without a thaw or discard date. The manufacturer's safe food handling instructions indicate that once they are thawed, supplements are to be used within 14 days.The absence of open, thaw, and discard dates prevents the ability to determine product viability, representing a failure in proper food labeling and tracking procedures.During an interview conducted on December 16, 2025, at 1:00 PM the Food Service Director confirmed that food and beverages are expected to be labeled, dated, stored, and thawed in accordance with food safety standards.Observation of the kitchen tray line during lunch service on December 17, 2025, at 12:10 PM revealed that kitchen staff failed to obtain and record food temperatures prior to the meal service. Review of records indicated the facility was unable to provide a food temperature log for the December 17, 2025, breakfast meal. Interview with the Registered Dietitian and Food Service Director at the time of the observation confirmed that food temperatures are required to be obtained and documented for each meal, and that all hot food items must be held and served at a minimum of at least 130 degrees Fahrenheit.Following surveyor inquiry, food temperatures were obtained with the following results: Chicken 160 degrees Fahrenheit, vegetable 140 degrees Fahrenheit, and pasta 141 degrees Fahrenheit. The facility failed to ensure that food was properly labeled, stored, and used within safe timeframes, in accordance with facility policy, manufacturer guidelines, and federal food safety requirements. The facility also failed to consistently obtain and maintain required food temperature logs to prevent the potential for contamination and microbial growth in food.28 Pa. Code 201.18 (e)(2.1) Management28 Pa. Code 211.10 (c) Resident Care Policies

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication for two of 15 sampled residents (Resident 12 and 36). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the facility policy titled Administering Medications, last reviewed by the facility on November 26, 2025, revealed that medications are administered as prescribed and in a safe and timely manner. The policy required staff to verify medication allergies and obtain vital signs (basic health measurements such as blood pressure, temperature, heart rate, and breathing rate), as applicable, prior to administering medications. A review of the clinical record revealed Resident 12 was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) and osteomyelitis (an infection of the bone that can be either acute or chronic). A review of the physician's order dated November 28, 2025, directed staff to administer Clonidine HCl (medication used to treat high blood pressure) 0.1 mg by mouth two times a day for hypertension and to hold the medication if the systolic blood pressure is less than 120 millimeters of mercury (mm/Hg). Systolic blood pressure is the top number in a blood pressure reading and reflects the pressure when the heart is actively pumping. A review of the Medication Administration Record (MAR) for December 2025 revealed Clonidine was administered 9 times outside the physician-ordered parameters (outside parameter means the medication was given when the blood pressure reading did not meet the hold instruction). The following blood pressure readings were documented at the time the medication was given:December 2 at 8:00 AM: 110/68 mm/HgDecember 3 at 8:00 AM: 112/68 mm/HgDecember 3 at 8:00 PM: 101/60 mm/HgDecember 6 at 8:00 AM: 113/98 mm/HgDecember 6 at 8:00 PM: 112/96 mm/HgDecember 7 at 8:00 AM: 106/66 mm/HgDecember 7 at 8:00 PM: 110/80 mm/Hg December 13 at 8:00 PM: 110/70 mm/HgDecember 14 at 8:00 PM: 98/58 mm/Hg These readings show the medication was administered repeatedly when systolic blood pressure was below the required 120 mm/Hg. A review of the clinical record revealed Resident 36 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues) and chronic atrial fibrillation (an irregular heartbeat). A review of the physician's order dated May 10, 2025, directed staff to administer Midodrine HCl (medication used to treat low blood pressure) 2.5 mg by mouth three times a day for blood pressure, and to hold the medication if the systolic blood pressure is greater than 120 millimeters of mercury (mm/Hg). A review of the MAR for December 2025, revealed Midodrine was administered 7 times outside the physician-ordered parameters. The following blood pressure readings were documented at the time the medication was given:December 2 at 7:00 AM: 128/68 mm/HgDecember 2 at 11:00 AM: 128/68 mm/HgDecember 3 at 7:00 PM: 123/60 mm/HgDecember 7 at 7:00 PM: 130/68 mm/HgDecember 11 at 7:00 AM: 122/63 mm/HgDecember 13 at 7:00 PM: 145/36 mm/HgDecember 16 at 11:00 AM: 121/62 mm/Hg These readings show the medication was administered repeatedly when systolic blood pressure was above the required 120 mm/Hg.During an interview on December 17, 2025, at 11:20 AM, the above information was reviewed with the Director of Nursing and it was confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration as the medications were administered outside of the physician ordered parameters. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services28 Pa Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of the facility's plan of correction from the survey ending December 18, 2025, the documented outcomes of the facility's Quality Assurance and Performance Improvement (QAPI) committee, clinical record reviews, and staff interviews, it was determined the facility failed to ensure its quality assurance program effectively identified and addressed recurring deficient practices related to nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders (Residents 1, 2, and 3).Findings include: A review of the facility policy titled Quality Assurance Performance Improvement, last reviewed by the facility on November 26, 2025, revealed that the primary goal of the Performance Improvement Plan is to continually and systemically plan, design, measure, assess, and improve the performance of the nursing center's key functions and processes relative to resident care. As a result of the deficiencies cited under the requirements related to nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders during the survey of December 18, 2025, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure that solutions were sustained. This corrective plan was to be completed and functional by January 20, 2025. However, during the survey ending February 11, 2026, continuing deficient facility practice was identified with these same requirements. According to the facility's plan of correction for the deficiency cited on December 18, 2025, relating to nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders, procedures implemented to ensure deficient practice was corrected included (1) Physicians were made aware of medications being administered outside of hold parameters and incident reports were generated for the affected residents, (2) Medications with hold parameters will be audited for proper administration for seven days, and any medications administered outside the hold parameters will be addressed accordingly, (3) Licensed staff will be educated on proper medication administration, following physicians' orders, and medication hold parameters, (4) Audits to be conducted on five medications with hold parameters for correct administration and will be conducted by the DON/designee weekly for two weeks, then monthly for two months. Results of the audits will be reviewed at the QAPI meetings. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including hypertension (blood pressure higher than normal) and osteomyelitis (infection of bone tissue).A review of a physician's order dated January 8, 2026, revealed an order to administer Lisinopril 10 milligrams by mouth daily and to hold the medication if systolic blood pressure (top number of a blood pressure reading measuring pressure during heart contraction) was less than 110 millimeters of mercury (mm/Hg).A review of the January 2026 MAR revealed the medication was administered on January 31, 2026, at 8:00 AM when the documented blood pressure was 109/52 mm/Hg, which was below the physician-ordered hold parameter.A review of a physician's order dated January 8, 2026, revealed an order to administer Metoprolol Tartrate 25 milligrams twice daily and to hold the medication if systolic blood pressure was less than 100 mm/Hg or heart rate was less than 60 beats per minute.A review of the February 2026 MAR revealed the medication was administered on February 7, 2026, at 5:00 PM with no documented blood pressure at the time of administration and a heart rate of 68 beats per minute.A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses including congestive heart failure (condition in which the heart cannot pump effectively, causing fluid buildup) and chronic atrial fibrillation (irregular heart rhythm).A review of a physician's order dated January 7, 2026, revealed an order to administer Midodrine HCl 2.5 milligrams by mouth every eight hours and to hold the medication if systolic blood pressure was greater than 120 mm/Hg.A review of the January and February 2026 MARs revealed the medication was administered outside physician-ordered parameters on the following dates and times:January 22, 2026, at 8:00 AM: blood pressure 129/76 mm/HgJanuary 29, 2026, at 12:00 AM: blood pressure 122/60 mm/HgFebruary 5, 2026, at 8:00 AM: blood pressure 126/64 mm/HgThese readings indicated the medication was administered when systolic blood pressure exceeded the ordered hold parameter.A review of the clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnoses including hypertension and hypovolemic shock (life-threatening condition caused by severe loss of blood or body fluids resulting in inadequate circulation).A review of a physician's order dated January 7, 2026, revealed an order to administer Midodrine HCl 5 milligrams by mouth every eight hours and to hold the medication if systolic blood pressure exceeded 120 mm/Hg.A review of the January 2026 MAR revealed the medication was administered outside physician-ordered parameters on the following dates:January 26, 2026, at 12:00 AM: blood pressure 126/64 mm/HgJanuary 27, 2026, at 12:00 AM: blood pressure 122/80 mm/HgThese readings indicated the medication was administered when systolic blood pressure exceeded the ordered hold parameter.A review of facility QAPI documentation failed to reveal evidence the facility identified these medication administration errors through monitoring activities, trended the errors, performed root cause analysis, or implemented corrective action to ensure sustained compliance after the prior citation. During an interview on February 11, 2026, at 3:30 PM, the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to ensure licensed nurses properly evaluated and provided nursing care according to physician orders for Residents 1, 2, and 3. The DON confirmed the facility failed to prevent the recurrence of similar quality deficiencies in the areas of ensuring licensed nurses properly evaluate and provide nursing care according to physician orders.Cross Refer to F68428 Pa. Code 201.18(e)(4) Management. 28 Pa. Code 211.5 (f)(xi) Medical records. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on observations, a review of select facility policy, and interviews with staff, it was determined that the facility failed to ensure personnel must handle, store, process, and transport linens in order to prevent the spread of infection in one out of one laundry room.Findings include:According to the Centers for Disease Control Healthcare-Associated Infections (HAIs) Appendix D dated March 19, 2024, best practices for linen and laundry management in global healthcare settings include maintaining a separation between the soiled linen and clean linen storage areas.A review of the facility policy titled Linen Handling, Storage, Process, and Transportation, last reviewed by the facility on November 26, 2025, revealed it is the facility policy that linen will be handled, stored, processed, and transported to prevent the spread of infection to other residents and the environment. The policy indicated soiled laundry shall be treated as if it were contaminated and shall be handled as little as possible and with a minimum of agitation. The policy indicated soiled laundry and clean laundry will be stored in separate areas in the laundry room. Soiled linen must be clearly separated from areas where clean linen is handled.An observation on December 18, 2025, at 9:53 AM in the facility's laundry room revealed nine blue plastic bags containing soiled laundry. The soiled laundry bags were stored next to the resident's clean laundry (less than 1 foot). The Infection Preventionist confirmed that the soiled laundry was stored directly adjacent to the clean laundry. The Infection Preventionist confirmed that the clean laundry was not stored in a separate area from the soiled laundry.During an interview on December 18, 2025, at 10:45 AM, the above findings were reviewed with the Director of Nursing (DON). The DON confirmed that resident soiled laundry and clean laundry were not stored separately. The DON indicated that the facility would implement a procedural change to ensure that the resident's clean and soiled laundry would not be stored in the same area of the facility's laundry room. 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12 (d)(3) Nursing services

Based on a review of clinical records, select facility policies, the Center for Disease Control and Prevention (CDC) Adult Vaccine Schedules, and staff interview, it was determined the facility failed to ensure residents were offered and/or provided recommended influenza and pneumococcal immunizations for two of five residents reviewed for immunizations (Residents 6 and 16).Findings include:A review of the facility policy titled Pneumococcal Vaccination Policy, last reviewed by the facility on November 26, 2025, revealed that adults over [AGE] years of age are at increased risk for developing pneumococcal infections and that all residents will be offered the pneumococcal vaccination/revaccination as deemed necessary in accordance with the Center for Disease Control and Prevention (CDC) standards of practice.According to the current CDC Adult Vaccine Schedule for Pneumococcal Vaccinations for adults 50 years or older who previously received PCV13, residents should be offered an additional pneumococcal vaccine (one dose of PCV20 protects against 20 pneumococcal bacteria/viruses) or one dose of PCV21 at least one year after the last PCV13 (Prevnar 13, a pneumococcal vaccine that protects against serious infection caused by 13 different types of bacteria) dose to complete their pneumococcal vaccination series.A review of the facility policy titled Annual Influenza Immunizations Policy, last reviewed by the facility on November 26, 2025, revealed that residents who are residing in the facility during the influenza season (typically October through March) will be included in the facility's influenza immunization program.A review of the clinical records revealed Resident 6, [AGE] years of age, was admitted to the facility on [DATE], with diagnosis that included Type 2 diabetes (body has trouble controlling blood sugar and using it for energy). A review of immunization records revealed the resident received one dose of PVC13 on February 8, 2019.A clinical record revealed no documented evidence to indicate that the facility offered the resident or resident representative an opportunity for Resident 6 to receive the recommended additional pneumococcal vaccinations nor documentation of refusal or contraindication. Further review of Resident 6's immunization record revealed the resident received an influenza vaccine on October 11, 2023. There was no documented evidence that the facility offered or administered an annual influenza vaccination for the 2024 or 2025 influenza season.A clinical record review revealed Resident 16, [AGE] years of age, was admitted to the facility on [DATE], with diagnoses that include schizophrenia (a serious, chronic brain disorder that interferes with a person's ability to think clearly, manage emotions, make decisions, and distinguish between reality and delusions or hallucinations).A clinical record review of immunization records revealed Resident 16 received one dose of PVC13 on October 16, 2019.A clinical record revealed no documented evidence to indicate that the facility offered the resident or resident representative an opportunity for Resident 16 to receive the recommended additional pneumococcal vaccinations nor documentation of refusal or contraindication. Further review of Resident 16's immunization record revealed the resident last received an influenza vaccine on October 17, 2023. There was no documented evidence that the facility offered or administered an annual influenza vaccination for the 2024 or 2025 influenza season.An interview with Employee 1, Infection Preventionist, on December 18, 2025, at 10:45 AM confirmed that the facility was unable to provide documented evidence that Residents 6 or 16 were offered or provided the recommended pneumococcal and annual influenza immunizations, or that refusals were obtained. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management.28 Pa Code: 211.10 (c) (d) Resident care policies.28 Pa Code: 211.12 (d)(1) Nursing services

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff and resident interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 15 sampled (Residents 16 and 34).Findings include:The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, requires the assessment to accurately reflect the resident's status; a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.A clinical record review revealed Resident 16 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a serious, chronic brain disorder that interferes with a person's ability to think clearly, manage emotions, make decisions, and distinguish between reality and delusions or hallucinations) and cataracts (a gradual clouding of the eye's natural lens, which is normally clear).A review of a Quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 16 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 to 15 indicates cognition is intact).A review of Resident 16's Significant Change is Status MDS assessment dated [DATE], Section A 1500 Preadmission Screening and Resident Review (PASRR, a required federal screening to ensure residents receive care in the most appropriate, least restrictive setting and get needed specialized services, rather than being placed inappropriately in a nursing home) revealed the resident was not currently considered by the state level II PASRR (a level II PASRR indicates the resident has been identified through the state mental health authority as having a serious mental health diagnosis and qualifies for additional services to meet the resident's needs) process to have serious mental illness and/or intellectual disability or a related condition.However, further review of Resident 16's clinical record revealed a letter dated February 20, 2018, from the Pennsylvania Department of Human Services Office of Mental Health and Substance Abuse Services (OMHSAS) indicated Resident 16 had evidence of a mental health condition that meets the criteria for review by OMHSAS. The letter indicated that Resident 16 was eligible and appropriate for the nursing facility level of care, and the facility must provide or arrange for the provision of mental health services for the resident.A review of Resident 16's Quarterly MDS assessment Section B 1200 Corrective Lenses dated October 18, 2025, revealed that the resident does not use corrective lenses (contacts, glasses, or magnifying glass).However, further review of Resident 16's clinical record revealed a community provider glasses adjustment note, dated December 11, 2025, stating that an external provider adjusted her glasses' frame.During an interview on December 17, 2025, at 10:25 AM, Resident 16 explained that she has been having problems with her vision and she needed new glasses. She explained that last week a man was in to adjust her frames but did not listen to her when she explained that she was having difficulty seeing despite her glasses.During an interview on December 17, 2025, at 1:30 PM, the Registered Nurse Assessment Coordinator (RNAC) confirmed Resident 16 utilized glasses, and Resident 16's MDS assessment dated [DATE], Section B 1200 Corrective Lenses dated October 18, 2025, was not accurate. Also, the RNAC confirmed that Resident 16 had a serious mental health diagnosis and was considered by the state mental health authority as a level II PASRR. The RNAC indicated the Significant Change in Status MDS assessment dated [DATE], Section A 1500 Preadmission Screening and Resident Review, was not accurate.A clinical record review revealed that Resident 34 was admitted to the facility on [DATE], with diagnoses that include schizophrenia.A review of Resident 34's Annual MDS assessment dated [DATE], Section A 1500 Preadmission Screening and Resident Review, revealed the resident was not currently considered by the state-level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.However, further review of Resident 34's clinical record revealed a letter dated February 23, 2018, from the Pennsylvania Department of Human Services OMHSAS indicating Resident 34 had evidence of a mental health condition that met the criteria for review by OMHSAS. The letter indicated that Resident 34 was eligible and appropriate for the nursing facility level of care, and the facility must provide or arrange for the provision of mental health services for the resident.A review of Resident 34's Quarterly MDS assessment dated [DATE], Section N0415 High-Risk Drug Classes: Use and Indication Subsection E Anticoagulant revealed the resident took an anticoagulant medication (a type of drug that slows down the body's clotting process by targeting specific proteins or clotting factors in the blood) during the last seven days. Further review of Section N0415 Subsection I Antiplatelet revealed Resident 34 had not been taking an antiplatelet medication (a type of drug that interferes with chemical signals, preventing platelets from clumping together to form blood clots) during the last seven days.However, further review of the clinical record revealed the seven-day lookback period from Resident 34's Quarterly MDS assessment dated [DATE], revealed Resident 34 received Aspirin 81 Oral Tablet (an antiplatelet medication) on November 5, 6, 7, 8, 9, 10, and 11, 2025. A review of the Medication Administration Record dated November 2025 revealed no documented evidence Resident 34 received any anticoagulant medication during the same seven-day lookback period.During an interview on December 17, 2025, at 1:30 PM, the RNAC confirmed Resident 34 has a serious mental health diagnosis and has been considered by the state mental health authority as a level II PASRR. The RNAC indicated the Annual MDS assessment dated [DATE], Section A 1500, was not accurate. The RNAC also confirmed that Resident 34 received an antiplatelet medication, not an anticoagulant medication, during the seven-day lookback period for the Quarterly MDS assessment dated [DATE]. The RNAC confirmed the Quarterly MDS assessment dated [DATE], Section N0415, Subsections E and I, was not accurate.During an interview on December 18, 2025, at 10:30 AM, the findings were reviewed with the Director of Nursing (DON). The facility failed to ensure the MDS assessments accurately reflected the status of Residents 16 and 34. 28 Pa. Code 211.5(f)(iv)(xi) Medical records.28 Pa. Code 211.12 (d)(3) (5) Nursing services

Based on a review of clinical records and staff and resident interviews, it was determined the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and arrange for treatment by a professional specializing in the provision of vision assistive devices as needed for one out of 15 residents sampled (Resident 16).Findings include:A clinical record review revealed Resident 16 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a serious, chronic brain disorder that interferes with a person's ability to think clearly, manage emotions, make decisions, and distinguish between reality and delusions or hallucinations) and cataracts (a gradual clouding of the eye's natural lens, which is normally clear).A review of a Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 18, 2025, revealed that Resident 16 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 to 15 indicates cognition is intact).A clinical record review revealed that Resident 16's last evaluation for visual acuity (a test to determine how clearly a person can see, the ability to see details and objects at near or far distances, with or without glasses) was on November 21, 2024.A progress note dated November 28, 2025, at 1:38 PM revealed Resident 16 indicated her vision was blurry as usual.A progress note dated December 2, 2025, at 3:44 AM revealed that Resident 16 had complaints of slight blurry vision. A community provider eye glass adjustment note dated December 11, 2025, revealed that Resident 16's eye glasses were adjusted for comfort.During an interview on December 16, 2025, at 10:45 AM, Resident 16 explained that she had been having problems with her vision and she needs new glasses. She explained that she was upset because last week a man adjusted her frames but did not listen to her when she explained that she was having difficulty seeing even while wearing her glasses. She indicated that she had been reporting problems with her vision to staff, but nothing has been done. Resident 16 indicated that she could not remember when her last vision examination occurred.A progress note dated December 16, 2025, at 4:47 PM indicated Resident 16 reported complaints with vision and needed new eye glasses. A referral was sent to the community provider to be seen on the next visit.During an interview on December 18, 2025, at 10:45 AM, the above findings were reviewed with Director of Nursing (DON). The DON was unable to provide documented evidence that Resident 16 received a comprehensive eye examination in the last year. The DON was unable to provide evidence Resident 16 was scheduled to receive an evaluation with complaints of blurry vision until inquiries were made during the week of the survey ending on December 18, 2025. The facility failed to ensure Resident 16 received proper treatment and assistive devices to maintain vision and arrange for treatment by a professional specializing in the provision of vision assistive devices. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of select facility policies, clinical records, and staff interviews, it was determined the facility failed to assess, evaluate, and monitor the nutritional parameters of a resident with significant weight loss for one of 15 residents reviewed (Resident 2).Findings include: A review of a facility policy titled Weight Policy, last reviewed by the facility on November 26, 2025, revealed that to ensure prompt identification of residents who are at nutritional risk, each resident will be monitored consistently and closely by the interdisciplinary team, and all residents will be monitored to prevent undesirable significant weight gain or loss. Further review of the policy revealed that if a weight loss or gain of five (5) pounds is noticed, the resident is to be re-weighed using a consistent scale within 24 hours, and after an accurate weight has been established, weight and re-weight checks are to be documented by the charge nurse in the weight record. In the event of a pattern of weight loss or significant loss/gain of 5% or more in 30 days or 10% in 180 days, the following interventions will be carried out: the resident will be assessed for signs and symptoms of dehydration or fluid overload; the attending physician and family member/responsible party will be notified by the nursing department; a dietary referral will be sent to the dietitian to review the resident and make appropriate recommendations as indicated; and the documentation will be entered into the resident's medical record. A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) 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 review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 12, 2025, revealed that Resident 2 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 13-15 indicates cognition is intact). A review of Resident 2's care plan dated October 1, 2025, revealed the resident had a nutritional problem related to protein-calorie malnutrition (a condition caused by inadequate intake of protein and calories, which may result in weight loss, weakness, decreased muscle mass, and delayed healing). The care plan included tasks to monitor, record, and report signs and symptoms of malnutrition, including weight loss, to the physician.A review of Resident 2's documented weights revealed the following:September 9, 2025- 111.8 lbs.September 10, 2025 - 113.2 lbs.September 16, 2025 - 109.3 lbs.September 22, 2025- 117 lbs.September 23, 2025- 121 lbs.October 1, 2025- 121 lbs.October 8, 2025-115.8 lbs.October 10, 2025- 114.8 lbs.October 15, 2025- 114.6 lbs.October 22, 2025- 112 lbs.October 23, 2025 - 113.2 lbs.October 29, 2025- 113 lbs.November 5, 2025- 113.6 lbs.December 2, 2025- 108.6 lbs.December 3, 2025- 107.6 lbs. A review of a Registered Dietitian (RD) progress note dated October 16, 2025, documented Resident 2 triggered for significant weight gain and weight loss. The note indicated the resident's weights had fluctuated, food and fluid intake was variable, and the resident had a history of weight fluctuations. No dietary changes were recommended at that time.A review of an RD progress note dated October 31, 2025, documented Resident 2 continued to trigger for significant weight loss and that weights continued to fluctuate. No dietary changes were recommended at that time.A review of an RD progress note dated November 27, 2025, documented Resident 2 triggered for significant weight loss and that weights were stabilizing in the 113-pound range. Intake remained variable, and no dietary changes were recommended.A review of an RD progress note dated December 8, 2025, documented Resident 2 triggered for significant weight loss and was noted to have consistent good intake of meal trays. The note indicated the resident had C. difficile (Clostridioides difficile, a bacterial infection that can cause diarrhea and inflammation of the colon) and anticipated weight improvement as the infection resolved. The note further indicated the resident's prior weights had been variable and previously stabilized between 113 and 115 pounds. No dietary changes were recommended. A clinical record review at the time of the survey revealed no active physician orders for routine or increased weight monitoring for Resident 2. Following surveyor inquiry, a new physician order dated December 18, 2025, was placed for weekly weights. On December 18, 2025, Resident 2 was weighed at 105.6 pounds, reflecting a 15.4-pound weight loss, representing a 12.7 percent loss of body weight since September 23, 2025. An interview with the Registered Dietitian on December 18, 2025, at 10:40 AM, revealed he did not recommend nutritional supplements due to concern they could worsen gastrointestinal symptoms, such as loose stools, related to the resident's ongoing C. difficile infection, which he indicated had been present since September 2025.A review of the clinical record revealed no documented evidence that the attending physician or the resident was notified of the resident's significant weight loss. Additionally, there was no documentation to why interventions were not recommended by the RD and that the lack of nutritional interventions was reviewed with or agreed upon by the attending physician.During an interview on December 18, 2025, at 12:45 PM, the above information was reviewed with the Director of Nursing. 28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents as expressed by three out of four residents interviewed during a resident group interview. (Residents 4, 6, and 8). Findings include: A review of Resident Council meeting minutes dated January 16, 2025, revealed residents in attendance expressed concerns about decreased activity staff. The minutes indicated this concern was previously addressed by the Nursing Home Administrator (NHA). A review of Resident Council meeting minutes dated February 21, 2025, revealed residents in attendance expressed a desire to lead Bingo activities one day each week. A clinical record review revealed Resident 4 was admitted to the facility on [DATE]. A review of a change in status Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 17, 2025, revealed that Resident 4 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed Resident 6 was admitted to the facility on [DATE]. A review of a quarterly MDS assessment dated [DATE], Section C1000. Cognitive Skills for Daily Decision Making revealed that Resident 6 has moderate impairment in her ability to make decisions regarding tasks of daily life. The assessment indicated the resident was not able to complete the Brief Interview for Mental Status (BIMS). A clinical record review revealed Resident 8 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 8 is cognitively intact with a BIMS score of 15 indicating intact cognition. During a resident group interview on February 26, 2025, at 10:00 AM, three out of four residents in attendance raised concerns indicating there were no staff available to facilitate programs or activities on Sundays or Mondays. Resident 4 stated that she would prefer at least one program on Sundays and Mondays and expressed an interest in hymn singing on Sundays. Residents 6 and 8 also indicated there is very little to do on Sundays and Mondays. Both residents indicated an interest in an additional bingo activity. Resident 8 stated she would be interested in leading an activity for other residents on days when no activity staff were available. Resident 6 stated that she does not socialize or spend time in the activity room when no staff are present to facilitate activities. Residents 4, 6, and 8 confirmed they had brought up the concern about the lack of activities on Sundays and Mondays during Resident Council meetings, but no action had been taken to resolve the issue. A review of the resident activity calendar for February 2025 confirmed that no staff-facilitated activities were scheduled on Sundays or Mondays from February 1, 2025, through February 28, 2025. A review of facility staffing documentation confirmed that no activity staff were assigned to work on Sundays or Mondays from February 1, 2025, through February 28, 2025. During an interview with the Nursing Home Administrator (NHA) on February 27, 2025, at approximately 1:00 PM, the NHA confirmed that no activity staff were assigned to work on Sundays or Mondays. The NHA also confirmed that residents had raised concerns during Resident Council meetings and that the facility was in the process of assigning activity staff to address residents' interests, needs, and preferences. The NHA acknowledged that it is the facility's responsibility to ensure that residents are provided with an ongoing program of activities designed to meet their needs, interests, and preferences. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to monitor the nutritional parameters of two residents (Resident 36 and Resident 20) with an identified significant weight loss and failed to implement a planned nutrition intervention in response to weight loss for one resident (Resident 20) out of 13 residents sampled. Findings include: A review of a facility policy titled Monitoring Resident's Weight last reviewed by the facility on December 14, 2024, revealed if a resident experiences a weight loss or gain, the resident will be reweighed at the time of the noted change in weight. If there is a weight change a physician will be notified. Further the policy indicated if there is a five-pound weight gain or loss, the resident will be reweighed at the time of the noted change in weight. If there is a gain/loss it will be documented, and the physician and the Food Service Supervisor will be notified. A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction due to unspecified occlusion or stenosis of the right MCA (a type of stroke in the middle cerebral artery that occurs when blood flow to the brain is blocked), dysarthria (a speech disorder that makes it hard to speak clearly), and hemiplegia affecting the left dominant side (the left side of the body including the arm, leg, and face are paralyzed). A review of Resident 36's clinical record noted the following weights: December 8, 2024 - 174.0 lbs. December 17, 2024 - 161.6 lbs. indicating a 12.4 lb. weight loss which was a 7.12% weight loss in 9 days. Further review of the resident's clinical record revealed the following weights: February 9, 2025- 157.2 lbs. February 24, 2025 - 150.2 lbs. indicating a 7 lb. weight loss. There was no documented evidence the facility conducted a required reweight at the time of the weight loss, as outlined in the facility's policy. Additionally, there was no documentation the physician and resident representative were notified of the weight loss. Interview with the Director of Nursing on February 27, 2025, at approximately 10:00 AM confirmed that the resident's reweights were not conducted as per facility's policy when a change in weight was documented, and the weight loss was not communicated to the physician each time a significant weight loss was noticed. Review of the clinical record revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses which include dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and diabetes. A review of the resident's weight record revealed the following recorded weights: September 20, 2024- 255.6 lbs. October 3, 2024- 245.6 lbs. November 1, 2024- 235.2 lbs. November 2, 2024- 234 lbs. December 11, 2024- 232 lbs. January 8, 2025- 226 lbs. February 5, 2025- 217.6 lbs. (reflective of a 38 lb.,14.8% significant weight loss since September 20, 2024) February 19, 2025- 221 lbs. The facility failed to reweigh the resident following the significant weight loss documented on February 5, 2025, and there was no documented evidence that the physician and resident representative were notified. A review of a dietary weight change note written by the registered dietitian on February 14, 2025, indicated that a dietary referral had been made in response to a 37.9-pound weight loss over five months. The resident's current weight was 217.6 pounds, with a body mass index (BMI screening tool calculation that estimates body fat based on weight and height) of 31.2, which falls within the overweight category, despite the significant weight loss. The dietitian recommended daily weights to monitor further changes. The resident's appetite was noted to vary, and the resident was receiving a no concentrated sweets (NCS), no added salt (NAS) regular diet with fortified foods at all meals to support nutritional intake. Additionally, the resident's protein powder supplement was increased from one scoop to three times daily to provide additional protein. The note also referenced a fluid restriction of 1800 cc due to congestive heart failure (a chronic condition in which the heart cannot pump enough blood to meet the body's needs) and edema (swelling caused by excess fluid buildup in the body's tissues). To further support caloric intake, the dietitian recommended adding a daily health shake, a nutritional beverage supplement that provides additional calories, protein, and essential nutrients. However, a review of the clinical record revealed discrepancies as the resident's fluid restriction had been discontinued on October 1, 2024, yet it was still referenced in the dietary note. There was no documented evidence that daily weights were being completed as recommended and there was no documented evidence the recommended health shake was implemented as part of the resident's nutritional intervention. Interview with the director of nursing (DON) on February 28, 2025, at approximately 11:00 AM confirmed that the resident's reweight was not conducted as per facility's policy when a change in weight was documented, and the weight loss was not communicated to the physician and resident representative at the time the significant weight loss was noticed. The DON confirmed that Resident 20's fluid restriction was discontinued, daily weights were not being completed, and that the health shake which was recommended as a nutritional intervention was not implemented. 28 Pa Code 211.5(f)(ii)(ix) Medical records 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records and staff interview, it was determined the physician failed to act upon pharmacist identified irregularities in the medication regimen of three of 13 residents sampled (Resident 11, 24, and 4). Findings include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], and had diagnoses that included anxiety disorder, major depressive disorder (condition characterized by persistent low mood, loss of interest, and other symptoms that significantly interfere with daily life), and dementia (disorder characterized by a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving) Medication regimen reviews were conducted on October 10, 2024, November 11, 2024, December 10, 2024, and February 2, 2025, indicating the pharmacist made recommendations. However, the facility was unable to provide documentation of the recommendations or the physician's response to the recommendations. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia and major depressive disorder. Medication regimen reviews conducted on July 23, 2024, and September 20, 2024, indicated that the pharmacist made recommendations. The facility could not provide documentation of the recommendations or the physician's response to the recommendations. A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and major depressive disorder. Medication regimen reviews conducted on September 20, 2024, and October 10, 2024, indicated that the pharmacist made recommendations. However, the facility was unable to provide documentation of the recommendations or the physician's response to the recommendations. In an interview with the Nursing Home Administrator on February 28, 2025, at approximately 1:00 PM, the administrator confirmed that the facility could not locate documentation of the pharmacist's recommendations and confirmed there was no documentation the physician had acted upon the pharmacist recommendations. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director

Based on a review of clinical records, select facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to ensure that residents are free from physical restraints that are not required to treat a resident's medical symptoms for one resident out of three closed records reviewed (Resident 196). Findings include: A review of facility policy titled Abuse Policy and Procedure, last reviewed December 14, 2024, revealed it is facility policy to protect residents from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. The policy indicates physical abuse includes, but is not limited to, hitting, slapping, pinching, or kicking. It also includes controlling behavior through corporal punishment. A review of facility policy titled Restraint Utilization and Reduction Policy, last reviewed December 14, 2024, revealed for each resident to attain and maintain his or her highest practicable well-being in an environment that prohibits the use of restraints, physical or chemical, for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms. The policy indicates that restraints will only be considered 1.) as a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2.) with a physician's order; 3.) with the consent of the resident (or legal representative); 4.) when the benefits of the restraint outweigh the identified risks. A clinical record review revealed Resident 196 was admitted to the facility on [DATE], with diagnoses that include osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down) and acute respiratory failure (a condition where the lungs are unable to exchange oxygen and carbon dioxide between the blood and environment to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 23, 2024, revealed that Resident 196 is 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 0-7 indicates severe cognitive impairment). A review of Resident 196's care plan revealed the resident has an altered sleep and wake cycle, feeling tired, initiated on July 22, 2024. Interventions in place included decreasing environmental stimulation at night and evaluating for reasons sleep is not being obtained, such as grief, noise, pain, disease management, and disease diagnoses. The care plan indicated Resident 196 has a communication problem related to usually understanding and being understood initiated on July 25, 2024. Interventions in place include providing a safe environment with call light in reach, the bed in the lowest position, and avoiding isolation. A care plan indicated Resident 196 has a behavior problem related to suicidal ideation initiated on September 21, 2024. Interventions include calling external behavior health services as needed, 15-minute checks when in bed, and allowing the resident to lie on fall mats for safety when threatening to throw themselves on the ground. A clinical record review revealed a progress note dated October 27, 2024, at 12:28 AM, indicating the resident was found on the floor near her bed. The note indicated the resident was assessed without injury and transferred to the nursing station for observation and safety. The note indicated that Resident 196 requested to return to bed but continued under observation for safety reasons. A progress note dated October 27, 2024, at 3:38 AM, indicated the resident was returned to bed at approximately 1:00 AM but attempted to roll out of bed. The resident was brought out to the nurse's station in her wheelchair, where she ate pudding, and watched videos. Resident 196 requested to be put back in bed, stating, I don't want those pillows suffocating me. Resident 196 was offered a mattress on the floor in the common area, where she appeared comfortable. Resident assessed with vital signs within normal limits. A review of a witness statement dated November 4, 2024, revealed Employee 1, Registered Nurse's (RN), description of events that occurred on October 27, 2024, indicated Resident 196 was unwilling to remain in her bed. Resident 196 continually attempted to stand and slide from her wheelchair despite being offered snacks, toileted, diverted with videos, covered with warm linens, or engaged in conversation. Employee 1, RN, placed Resident 196's mattress and safety mats directly on the floor in the common area. Employee 1, RN, indicated she utilized available furniture to surround Resident 196 while she was positioned on the mats and mattress to create an adult-sized playpen. Employee 1, RN, indicated that after a while, Resident 196 stated, I don't like it in here, and Get me out of the cellar. Employee 1, RN, indicated she directed staff to remove Resident 196 from the playpen and return her to her wheelchair. A review of a witness statement dated November 4, 2024, revealed Employee 2, Licensed Practical Nurse (LPN), indicated that on October 27, 2024, Employee 1, RN, placed furniture around Resident 196 to make a playpen around the resident. Employee 2, LPN, indicated that Employee 1, RN, brought the bed out into the dayroom, placed the resident on the bed, and surrounded the bed with furniture to keep Resident 196 safe. Employee 2, LPN, explained that the resident attempted to get off the mattress, and additional mats were placed near the resident. Employee 2, LPN, confirmed that furniture was placed around Resident 196 to prevent her from moving. Employee 2, LPN, expressed concern regarding this intervention but did not report taking further action. A witness statement from Employee 3, Nurse Aide (NA), described the placement of furniture around Resident 196 as abusive and confirmed the resident remained surrounded by furniture for at least one hour before being removed. A review of Resident 196's clinical record revealed no physician's orders or documented evidence that a licensed provider authorized the use of surrounding furniture as a restraint to ensure her safety. Additionally, there was no documented evidence that other less restrictive measures were attempted and failed prior to the use of this restraint method. Further, there was no evidence that the resident or the resident's representative consented to the intervention or documented evidence that Employee 1, RN, attempted to call the external behavioral health service with concerns regarding the resident's safety. During an interview on February 27, 2025, approximately 12:30 PM, Employee 3, Nurse Aide (NA), indicated that on October 27, 2024, she recalled that Resident 196 was not herself. Employee 3, NA, indicated that Resident 196 was more active than usual, attempting to get out of bed and out of her chair. Employee 3, NA, indicated she remembered the resident's bed and chair alarm went off frequently that night. Employee 3, NA, indicated she observed Resident 196 in the dayroom surrounded by furniture but did not see who placed the furniture around the resident. Employee 3, NA, estimated the resident was surrounded by furniture for about an hour but was uncertain of the exact duration. Employee 3, NA, explained that Resident 196 would not have been able to remove the furniture without staff assistance. Employee 1, RN, and Employee 2, LPN, were not available for interview in person or by telephone interview. During an interview conducted on February 28, 2025, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed there was no documented physician order, care plan intervention, or resident or resident representative consent for the use of surrounding furniture as a safety intervention. The DON and NHA acknowledged the facility failed to ensure that Resident 196 was free from physical restraints not required to treat a medical symptom and that all appropriate interventions should have been exhausted before considering a restraint. 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 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate accounting of controlled drugs when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 43). Findings include: Review of the facility's Disposition of Controlled Medications Policy last reviewed December 14, 2024, indicated all controlled medication will be disposed of in accordance with federal and state laws and regulations. To prevent unauthorized/potential misappropriation of property, all controlled medications will be disposed of in a timely manner. Controlled medications must be accounted for, inventoried, and destroyed in the presence of two licensed clinicians. The disposition is documented on the accountability record to include the prescription number of the drug, name of the drug, and dosage of the drug, the quantity of the drug being disposed, method of disposal, and the signature of the clinicians present. Review of Resident 43's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included diabetes and prostate cancer (cancer that develops in the prostate gland, which is part of the male reproductive system). A physician's order dated November 14, 2024, noted an order for Oxycodone (opioid analgesic pain medication, a controlled medication) 2.5 mg every 2 hours as needed for pain or dyspnea. (difficult breathing). Nursing documentation dated November 27, 2024, revealed Resident 43 was discharged to home with discharge instructions and medications. Review of Resident 43's signed discharge instructions indicated the resident was discharged home with medications which included a total of 10 Oxycodone 2.5 mg tablets. Further review Resident 43's closed record revealed no documented evidence of a controlled medication accountability record for the Oxycodone 2.5 mg tablets. Interview with the director of nursing (DON) on February 28, 2025, at 10:00 AM failed to provide documented evidence that Resident 43's controlled medication accountability record for the Oxycodone 2.5 mg tablets was completed per facility policy. The DON confirmed that a controlled medication accountability record is to be completed for all controlled medications to prevent unauthorized or potential misappropriation of property and ensure accurate accounting and disposition of controlled drugs. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs, and failed to follow physician orders for management of a PICC line for one of 13 residents sampled (Resident 94). Findings include: Review of the facility Flushing Central Vascular Access Devices (CVAD- also known as a central line or central venous catheter is a thin flexible tube that is inserted into a vein to deliver fluids, medication, and other therapies into the bloodstream) and Midline Catheters (thin flexible tube that is inserted into a vein in the upper arm to deliver fluids and medications into the bloodstream)last reviewed December 14, 2024, indicated that Central Venous Access Devices and midline catheters will be flushed and aspirated for a blood return prior to each infusion to assess catheter function and after each infusion to clear the infused medication/solution from the catheter lumen, to decrease the risk of contact between incompatible medication/solutions, and to prevent complications. A physician order is required and should include type, amount, and frequency of flush. Review of the clinical record revealed that Resident 94 was admitted to the facility on [DATE], with a PICC line (a long tubing introduced through a vein in the arm, then through the subclavian vein into the superior vena cava or right atrium of the heart to administer parenteral fluids and medication) in the upper left arm for antibiotic therapy and had diagnoses to include right total knee replacement (TKR) and left knee infection. A physician order dated February 6, 2025, noted an order for Vancomycin HCL (an antibiotic) 1.5 gm intravenous (within a vein) one time daily for left knee infection until March 13, 2025. A physician order dated February 6, 2025, noted an order for Cefazolin Sodium (an antibiotic) 2 gm intravenous three times per day for right TKR until March 13, 2025. A physician order dated February 5, 2025, noted an order for Normal Saline flush 0.9% use 10 ml intravenously every shift for medications before and after IV (intravenous- within a vein) antibiotic administration. Review of Resident 94's February 2025 Medication Administration Record (MAR) failed to indicate the Resident's PICC line was flushed before and after the administration of each IV antibiotic as per physician order and facility policy. Interview with the Director of Nursing on February 28, 2025, at approximately 11:30 AM confirmed that there was no documented evidence that Resident 94's PICC line was consistently flushed before and after use for medication administration in accordance with physician orders and facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the increase of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use. (Resident 2). Findings included: Clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that include psychotic disorder (a mental health condition that causes a significant loss of touch with reality) 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 a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 15, 2024, revealed that Resident 2 is severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). Additionally, a care plan for impaired cognitive function related to dementia, initiated on March 30, 2020, included interventions such as encouraging engagement in activities, promoting movement within the facility, and ensuring consistent caregivers whenever possible. A care plan indicating Resident 2 has the potential to be physically aggressive related to anger and dementia was initiated on September 20, 2021, with interventions including medication administration as ordered, behavioral analysis, psychiatric consultation as needed, and redirection from distressing stimuli. Additionally, a care plan for impaired cognitive function related to dementia, initiated on March 30, 2020, included interventions such as encouraging engagement in activities, self-propelling in facility hallways and activity rooms, and providing consistent caregivers as much as possible. A progress note dated January 27, 2025, at 1:25 PM, documented that a psychiatric interdisciplinary team meeting was held, where new recommendations were made, and the physician was noted to be aware and in agreement. Subsequently, a new physician order was written to increase Quetiapine Fumarate Oral Tablet 25 MG, directing 12.5 mg (1/2 tablet) by mouth twice a day, revised from once a day to twice a day. However, further review of the clinical record revealed no documented evidence of the clinical rationale for increasing Resident 2's antipsychotic medication, no discussion of alternative treatment options, and no documentation of resident or resident representative involvement in the decision-making process. A review of medication administration records from January 2025 through February 2025 confirmed that Resident 2 received the additional dose of Quetiapine Fumarate daily from January 28, 2025, through February 28, 2025 (32 doses administered). During an interview on February 27, 2025, at approximately 1:00 PM, the Director of Nursing (DON) stated they were unable to provide documented evidence of a clinical rationale for the medication increase. The DON confirmed the resident's antipsychotic medication was increased and acknowledged the clinical record lacked documentation supporting the rationale for the dosage increase, alternative interventions considered, or evidence of resident or resident representative participation in the decision-making process. The DON also confirmed it is the facility's responsibility to ensure residents are free from unnecessary psychotropic medication. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.2 (d)(3)(7)(9) Medical director. 28 Pa. Code 211.5 (f)(ii)(iii)(x) Medical records. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of select facility policy, observation, and staff interview, it was determined the facility failed to maintain respiratory equipment in a manner to promote optimal functioning for one resident out of 13 sampled residents. (Resident 24). Findings include: A review of facility policy entitled Oxygen Therapy Mask and Nasal Cannula; Nebulizer Treatments last reviewed on December 14, 2024, revealed oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties Additionally, the policy states that oxygen tubing and humidifier bottles are to be changed weekly. A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). A review of the resident's clinical record revealed a physician's order dated January 16, 2025, and discontinued on January 23, 2025, for oxygen at 2 liters per minute via nasal cannula (a device that delivers extra oxygen through a tube into the nose) as needed for shortness of breath. A current physician's order dated January 24, 2025, was noted for oxygen at 1 liter per minute via nasal cannula as needed for shortness of breath. An observation on February 25, 2025, at approximately 11:00 AM revealed an oxygen concentrator in the resident's room. The oxygen tubing attached to the machine was dated January 20, 2025. An observation on February 26, 2025, at 11:45 AM, revealed the oxygen tubing remained attached to the oxygen concentrator and dated January 20,2025. An observation on February 27, 2025, at 9:20 AM revealed the oxygen tubing remained attached to the resident's oxygen concentrator dated January 10, 2025. An interview with the Director of Nursing on February 27, 2025, at 9:28 AM revealed the oxygen tubing should be changed weekly, and the DON acknowledged the oxygen tubing for Resident 24 had not been replaced per facility policy and confirmed the facility's failure to maintain the resident's oxygen equipment. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 13 sampled. (Residents 4). Findings included: A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of the resident's Pennsylvania Preadmission Screening Resident Review Identification (PASRR) Level 1 form dated October 4, 2016, revealed the resident had a positive screen for serious mental illness and requires a further Level II evaluation. A review of a letter from the Pennsylvania Department of Human Services Office of Mental Health and Substance Abuse Services dated October 6, 2025, revealed the resident had been determined eligible for Level II services and the facility must provide or arrange for provision of mental health services. A review of Resident 4's significant change MDS assessment dated [DATE], revealed in Section A 1500 Preadmission Screening and Resident Review (PASRR) the resident was not considered a state Level II PASRR to have a serious mental illness. An interview with the RNAC (registered nurse assessment coordinator) on February 27, 2025, at 12:40 PM, confirmed the aforementioned MDS Assessment was inaccurate. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and interviews with staff and a resident's family, it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain the physical health of one resident out of 14 residents sampled (Resident 33), resulting in an sprained ankle, which caused the resident pain and a decline in abilities to perform activities of daily living. Findings include: A review of the facility policy titled Abuse Policy and Procedure, indicated as last reviewed by the facility on November 1, 2023, revealed that it is the facility's policy to protect residents from neglect and all incidents of suspected neglect will be thoroughly investigated and reported to the Pennsylvania Department of Health and other agencies as directed by law. The policy defines neglect as the failure of the facility, its employees, or service providers to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident 33 was admitted to the facility on [DATE], with diagnoses that included cerebral ischemia (a condition characterized by impaired blood flow to the brain) 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 a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 16, 2024 revealed that Resident 33 has severe cognitive impairment with a BIMS score of 05 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). The resident's care plan identified that Resident 33 had ADL self-care performance deficit related to dementia and impaired balance, initiated August 14, 2023, with planned interventions that the resident requires the assistance of two staff for toileting. A physician's order was noted on January 3, 2024, indicating that Resident 33 requires two staff for all transfers with a gait belt and rollator walker (a mobility assistance device with wheels). A physician's order was initiated on January 19, 2024, for physical therapy, therapeutic exercise, therapeutic activity, wheelchair training, and gait training. An employee witness statement dated February 29, 2024, provided by Employee A1, nurse aide, revealed that on February 29, 2024, at 9:45 AM, he was transferring Resident 33 from the toilet when the resident's left knee gave out. Employee A1's statement indicated that he then lowered Resident 33 to the floor. The employee's statement indicated that Employee A1 transferred the resident by himself without the assistance of another staff member as the resident required. A progress note dated February 29, 2024, at 9:58 AM revealed that Resident 33's left leg gave out while being transferred from toilet to wheelchair. The note indicated that no injuries were identified and that the resident had no complaints of pain. A progress note dated February 29, 2024, at 3:03 PM revealed that Resident 33 was reporting left ankle tenderness, edema, and pain. The resident's left ankle was swollen. The resident's representative was present and indicated that Resident 33 was not able to bear weight on her ankle. The physician ordered that Resident 33 was to receive an X-ray of her left ankle. A progress note dated February 29, 2024, at 5:08 PM revealed that X-ray results were received and no fractures were noted. A review of a facility incident report dated March 1, 2024, revealed that Employee A1, nurse aide, was aware that Resident 33 required the assistance of two staff members for transfers, but Employee A1 felt he was strong enough {to transfer the resident by himself}. The report indicated that Employee A1 received a written disciplinary warning and was educated on following physician orders and care plans. The report also indicated that Resident 33's ankle was sprained with edema and slight redness. A progress note dated March 1, 2024, at 12:30 PM revealed that the resident continued to have left ankle pain. Resident 33's left ankle was wrapped for support, ice was applied, and the leg was elevated. The resident had complaints of pain when bearing weight. A review of the resident's Medication Administration Records for February 2024 and March 2024 revealed that Resident 33 received: Tylenol 325 mg on February 29, 2024, at 2:53 PM with a pain level of 6 out of 10 Tylenol 325 mg on February 29, 2024, at 11:57 PM with a pain level of 4 out of 10 Tylenol 325 mg on March 1, 2024, at 10:30 AM with a pain level of 6 out of 10 Tylenol 325 mg on March 1, 2024, at 3:42 PM with a pain level of 6 out of 10 A physician order was initiated on March 2, 2024, for Resident 33 to be transferred with a Hoyer lift until her ankle swelling decreased. The order was discontinued on March 13, 2024. A review of physical therapy treatment encounters revealed that on February 26, 2024, prior to the injury to the resident's ankle, on February 29, 2024, Resident 33 performed gait training for 10 feet, 40 feet, and 30 feet with a front wheeled walker (mobility device) with the assistance of one staff and performed sit-to-stand transfer training with the assistance of one staff. The summary of service indicated that the resident did not experience pain during the session. On February 26, 2024, the resident's progress was discussed with Resident 33's family member. The resident was able to ambulate 15 to 20 feet. The family member indicated that he is hopeful that with continued treatment he will be able to take Resident 33 home. The note indicated that there would be a greater focus on transfer training. The summary of service indicated that the resident did not experience pain during the session. Therapy documentation indicated that on February 28, 2024, Resident 33 performed sit-to-stand transfer training with minimal staff assistance. The summary of service indicated that the resident did not experience pain during the session. Following the injury to the resident's ankle on February 29, 2024, therapy noted on March 4, 2024, that Resident 33 performed transfer training from sit to stand with moderate assistance from one staff member. During the physical therapy session, the resident complained of a constant stabbing left foot/ankle pain level of 5 out of 10. The summary of service indicated that the resident's left foot pain impacted the therapy session. Therapy noted on March 6, 2024, that Resident 33 performed transfer training from sit to stand with moderate and maximum assistance from one staff member. During the physical therapy session, the resident reported moderate pain in the left ankle/foot. The summary of service indicated that pain limited the resident's ability to transfer and ambulate. Therapy noted on March 8, 2024, that Resident 33 performed transfer training from sit to stand with moderate assistance from one staff member. The resident was able to stand for a maximum of 30 seconds with caregiver assistance. The summary of service indicated that the resident was reporting pain in the left foot that limited transferring and ambulation. A documentation survey report for February 2024 of the activities of daily life tasks walking in the corridor (how the resident walks in the corridor) and walking in the room (how the resident walks in her room) revealed that Resident 33 was able to walk in the facility corridors on 12 occasions with staff assistance and 16 times in her room with staff assistance from February 1, 2024, through February 29, 2024. However, following the resident's ankle injury on February 29, 2024, the documentation survey report for March 2024 for the activities of daily life tasks walking in the corridor and walking in her room revealed that these tasks were not applicable or that the resident was dependent on staff for the activities occurring from March 1, 2024, through March 25, 2024. During an interview on March 26, 2024, at 11:10 AM, Resident 33's family member stated that Resident 33 fell and twisted her ankle a few weeks ago while one staff member was trying to transfer her instead of two people that she requires. He explained that since the resident's fall, Resident 33 has had a setback in her physical rehabilitation. He stated that the resident is now unable to walk as well as she did before the incident. He explained that the goal is for Resident 33 to be discharged home after rehab, but now he's unsure when the resident will have recovered enough to return home. During an interview on March 28, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed that the facility staff failed to ensure that Resident 33 received the services necessary to avoid physical harm. The NHA confirmed that Employee A1, Nurse Aide, was aware that Resident 33's transfer was to be performed with two people but neglected to assure the presence of a second person and performed the transfer by himself, resulting in Resident 33's sprained ankle and subsequent decline in activities of daily life (i.e. walking in her room and corridor. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on staff interview and a review of employee time sheets and qualifications, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian. Findings include: An interview with the food service director (FSD) on March 26, 2024, at 9:30 AM revealed that she was currently enrolled in an online course to become a certified dietary manager and she was presently not qualified for the position according to regulatory criteria. Further interview with the FSD revealed that the facility employed a part-time consultant dietitian who works approximately four hours per week. Review of monthly time sheets for the consultant dietitian dated December 4 through March 22, 2024, confirmed that the consultant dietitian did work four hours per week and was not full-time. Interview with the nursing home administrator (NHA) on March 26, 2024, at approximately 11:30 AM, confirmed that the previous full-time qualified foodservice director's last day of employment was on October 20, 2023. The administrator confirmed that the facility did not currently employ a full-time qualified food service director in the absence of a full-time qualified dietitian. Refer F812 28 Pa Code 201.18 (e)(1)(6) Management.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and resident pantry. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). According to CMS guidance, dated May 20, 2014 (S & C 14-34-NH) Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritis (SE). The use of pasteurized eggs allows for resident preference for soft-cooked, undercooked or sunny-side up eggs while maintaining food safety. In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs. Observation during the initial tour of the food and nutrition services department on March 26, 2024, at 9:15 AM revealed two cases of fresh shell eggs, which were not pasteurized (salmonella infections may be prevented by using pasteurized eggs in place of unpasteurized eggs in the preparation of foods where the egg will not be thoroughly cooked) were present on a shelf in the walk-in refrigerator. Interview with the food service director (FSD) at this time confirmed that the fresh shell eggs were being used to serve dippy eggs. The FSD confirmed that the fresh shell eggs were not pasteurized. The FSD confirmed that the fresh shell eggs were ordered by mistake instead of pasteurized shell eggs from the food supplier. Observation of the resident pantry refrigerator on March 26, 2024, at 11:30 AM revealed the following food storage/sanitation concerns: There was a thawed 4-ounce nutritional shake and a 10-gallon plastic bag which contained 4-ounce nutritional shakes in the refrigerator which were not dated with a thaw or discard date. The manufacturer label noted the shakes should be used within 14 days after thawed. There were two plastic storage containers of applesauce on the shelf, which were not dated. There were two 46-ounce bottles of thickened juice, which were opened but not dated. The manufacturer label noted that the juice should be used within 10 days of opening. There was a 60-ounce bottle of apple juice, which was opened but not dated. There was a spill observed under the plastic pull-out crisper drawer of the refrigerator. Interview with the foods service director (FSD) on March 27, 2024, at 9:30 AM confirmed that food and beverages were to be stored and thawed according to acceptable practices. The FSD confirmed that the food and nutrition services department and resident pantry were to be maintained in a sanitary manner to prevent potential contamination of food and storage items. Refer F801 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary services

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to consistently provide adequate supervision and/staff assistance and implement effective safety interventions based on individual resident needs to promote safety and prevent falls and injury for one of 10 sampled residents (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on March 22, 2010. The resident had [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set Assessment (MDS - a standardized assessment completed at specific times to identify resident care needs) dated January 28, 2014, revealed that the resident was severely cognitively impaired, required extensive staff assistance for activities of daily living, including the assistance of two staff for bed mobility, transfers and ambulation in her room. The MDS assessment also indicated in the area of balance during walking and turning around that the resident was not steady and only able to stabilize with staff assistance. Review of the resident's revised care plan dated June 17, 2013, revealed a problematic area that included the potential for falls due to difficulty walking, decreased coordination and impaired mobility. Care planned interventions at the time and up until March 2014, included call bell light in reach of the resident, bed alarm at night, anti-skid strips on bathroom floor and in front of dresser, rest periods, offer snacks between 10:00 p.m. and 6:00 a.m., assist with transfers, ambulation and bed mobility as allowed by resident and tab alarm. A review of facility completed "Assessment of Risk for Falls" dated November 9, 2013, December 24, 2013, February 26, 2014 and March 1, 2014, revealed that Resident 24 was severely impaired and required assistance with mobility and transfers. A review of two "Therapy Screening Forms" dated November 11, 2013 and February 26, 2014, respectively, revealed that the resident was screened by therapy as a result of falls. The screenings indicated, at the time, that physical therapy was not warranted at the time due to no change in functional mobility. The screenings also identified that the resident continues to require staff assistance for all mobility secondary to poor safety awareness. A review of the nursing documentation from November 17, 2013, at 12:00 a.m. through March 1, at 1:00 p.m., indicated similarly documented behavior that included the following: attempts to get oob (out of bed) several times, assisted to bathroom, unsteady on feet, repeatedly rising from bed - offered food, snacks, activity, brought to nurses station continuously asking "What do I do? Where am I?" - interventions ineffective, sitting at bedside and trying to get up, setting off alarm and trying to get up, frequently rising oob with poor gait and unsteady on feet, continues to climb out, attempting to get out of lounger, difficulty trying to stand with walker, continues to yell and attempt to stand, frequent attempts to rise without assistance, crawling oob, trying to stand up alarm sounding, brought to nurses station for close observation, several attempts to crawl oob, taken to room and one to one provided, laundry offered to fold, threw clothes on floor, swatting at staff - continues with behaviors - Xanax (an anti-anxiety medication) given. Examples of these types of behavior were by noted by nursing staff on 21 occasions and documented in the resident's clinical record. A review of a nurses' note dated November 9, 2013, at 9:45 a.m., and a corresponding "Incident/Accident Report" revealed that the NA (nursing aide) reported finding the resident on the floor, between the bed and the wall. The report indicated that the bed sensor alarm did not sound; the NA failed to turn on the alarm according to the incident/accident report. Intervention planned at the time, included in-service of the nurse aide to ensure safety devices (alarms) are activated. A review of a nurses' note dated December 24, 2013, at 11:00 p.m., and a corresponding "Incident/Accident Report" revealed that staff heard an alarm ring and then a loud bang. The nurses' note and report indicated that the resident was observed on the floor. Interventions planned following this incident included more rest periods in a geri chair (a type of titled chair used for safety and positioning) and a therapy screen, which concluded that the facility continue the current interventions. A review of a nurses' note dated February 26, 2014, at 7:30 a.m., and a corresponding "Incident/Accident Report" revealed that the resident was found on the floor (in the hallway) by the nurse aide. The report indicated that the resident was placed in her wheelchair due to frequent crawling out of bed. Further review of the facility's investigative report revealed that the sensor pad alarm did not sound because an incontinence pad had been placed on top of the sensor pad alarm when the resident was placed in the wheelchair. A new intervention implemented at the time included a tab alarm when the resident was out of bed and the notification of the resident's physican of the resident's recurrent behaviors. A review of a nurses' note dated March 1, 2014, at 2:00 a.m., and a corresponding "Incident/Accident Report" revealed that the alarm sounded and that staff found the resident sitting on floor. The report indicated that the resident got out of bed and walked with the walker to the end of the bed and fell . Further review of the report revealed that, prior to the resident's fall, the resident was taken to the bathroom several times then given a snack and placed back in bed. Intervention added by the facility at that time included offering a snack at start of night shift. A review of a nurses' note dated March 1, 2014, at 4:20 a.m., and a corresponding "Incident/Accident (I/A) Report" revealed that staff heard a "loud bang" and heard the resident's roommate call out for help. The report indicated that the resident fell /rolled out of bed and was found on the floor. The resident complained of right hip and leg pain and after conferring with the resident's physican and family, was sent out to the hospital emergency room (ER) for evaluation. Further review of the I/A report revealed that the nurse aide was unsure if the alarm was turned on, because prior to the incident, Resident CR1 tried rising several times (from bed) and was taken to the bathroom. Results from the ER evaluation revealed that the resident suffered a fractured right hip. Additional interventions added following this fall included bilateral bed bolsters. Nursing documentation indicated that the resident displayed frequent unsafe behaviors of attempting to stand up from her bed or wheel chair and ambulate unassisted. There was no evidence that the facility had evaluated the resident for the type and degree of staff supervision required to prevent repeated unsafe behaviors, falls and injury. The facility failed to provide the necessary staff supervision during period of restless and unsafe behaviors to prevent the fall with serious injury. The facility also failed to ensure that the safety alarms used for this resident were consistenly operational to alert staff to the resident's unsafe acts in a timely manner. Interview with the nursing home administrator and director of nursing on April 1, 2014 at 12:05 p.m. and on April 2, 2014, at 9:35 a.m., confirmed that the resident exhibited unsafe behaviors. The facility failed to provide evidence that the resident, identified at risk for falls, which was known to the facility, was provided with adequate staff supervision and timely and effective intervention to prevent this fall with serious injury. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 5/8/13

Based on clinical record and Injury/Incident report review and staff interview, it was determined that the facility failed to provide adequate supervision and/or implement effective safety interventions to prevent falls and injury for two of 10 sampled residents (Residents CR1, and 14). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set Assessment (MDS - a standardized assessment completed at specific times to identify resident care needs) dated February 7, 2012, revealed that the resident was moderately cognitively impaired, required staff assistance for activities of daily living, including the assistance of one staff for transfers and ambulation. Review of the resident's initial care plan dated January 26, 2012, revealed that one of the problematic areas was falls, due to a history of falls or his assessment at high risk for falls. The interventions at the time of admission included a bed alarm and ambulation and transfer with a walker and supervision. A review of a "Assessment of Risk for Falls" dated January 26, 2012, revealed that Resident CR1 received a score of eight, which indicated that the he was at high risk for falls and had mild/moderate impairment. Review of a social worker's note dated February 13, 2012, indicated that the resident ambulated with a roll-walker, needs frequent supervision and re-direction for safety, is strong willed, doesn't respond well to re-direction and will continue to monitor safety needs. A review of a nurses' note dated January 28, 2012, at 4:15 p.m., and a corresponding "Incident/Accident Report" (I/A) revealed that the resident was found on the floor in a kneeling position. Recommendations at the time included adding anti-skid strips and continue with the bed alarm while in bed. Review of nurses' note dated January 31, 2012, at 9 a.m. indicated that the "resident frequently changed from bed and chair....gait slow and unsteady at times with cane." A review of a nurses' note dated February 2, 2012, at 3:30 p.m., and a corresponding I/A Report revealed that the resident's bed alarm was sounding and the resident was found on his back on the floor next to the window. Resident stated he fell out of bed. Recommendations at the time included changing the mattress to a contour mattress. A review of nurses' note dated February 3, 2012, at 2:30 a.m. indicated that the resident continues to ring bell or get out of bed without assistance "....bed alarm on and functioning frequently." At 7:00 a.m., a nurse noted that the resident was out of bed, ambulating in room with steady gait was re-directed to his chair, at times difficult to re-direct and is strong willed with poor safety awareness. Review of nurses' note dated February 4, 2012, at 11:30 a.m. indicated that the resident was to the bathroom three times and not waiting for assist before attempting to rise...."disturbing roommate and brought to nursing station to keep in visual field." A review of a nurses' note dated February 5, 2012, at 9:30 a.m. revealed that the resident was restless and in and out of his bed and chair. On February 7, 2012, at 2:15 a.m., a nursing note indicated that the resident was "restless, agitated while attempting to hit staff and brought to the nursing station to keep in visual field. Explained to him (resident) we were bringing him to the nursing station to keep him safe." At 2:50 p.m., on February 7, 2012, a physician's orders [REDACTED]. Later that same day at 11:00 p.m., a nurse documented that the resident was in and out of bed constantly, hitting staff when trying to assist him and brought to the nurses station to keep in visual field. A review of nurses' note dated February 10, 2012, at 4:00 p.m. indicated that the resident was constantly in and out of bed to bathroom. On February 12, 2012, at 2:30 a.m., a nurse noted that the resident was ringing the call bell continuously and was out of bed continuously bothering his roommate. Review of a nurses' note dated February 18, 2012, at 4:15 p.m., and a corresponding I/A Report revealed that Resident CR1 was observed touching a female resident's shoulder. Orders were obtained to do 15 minute checks. A review of nurses' note dated February 18, 2012, at 2:00 a.m. indicated that the resident was cursing at staff, frequently attempting to rise unassisted and brought to the nurses station to keep in visual field. On February 20, 2012, 2:45 a.m., a nurse wrote that the resident was at the nurses station with no inappropriate behaviors and "keeping the resident in visual site." Review of a nurses' note dated February 23, 2012, at 12:35 p.m., and a corresponding I/A Report revealed that the resident was observed sitting on the floor when told by the nursing aide to wait. A review of nurses' note dated February 24, 2012, at 3:30 a.m. indicated that the resident would not stay in bed or recliner chair, was constantly up and down and brought to the nursing station to keep in visual field. Review of a nurses' note dated February 24, 2012, at 9:15 p.m., and a corresponding I/A Report revealed that the resident was found in his room on the bathroom floor yelling "help me, help me." The I/A report indicated that the resident was sitting at the nurses station prior to the incident, his bedroom slippers were on and his roll walker was found in the bath room. Ten minutes after the fall, the resident complained of right hip pain and the physician ordered the resident be sent to hospital ER for evaluation. Results from the ER evaluation revealed that the resident suffered a fractured right hip. Nursing documentation indicated that the resident was frequently placed at the nurses station when displaying unsafe behaviors to be kept in visual field, but the facility failed to adequately supervise the resident when at the nurses station and/or plan the consistent use of the intervention as effective safety measure to prevent accidents. There was no evidence that the facility staff had intervened when the resident left the nurse's station and was no longer in the staff's visual field during this time period when the resident was displaying restless and/or unsafe behaviors on February 24, 2012. Interview with the nursing home administrator (NHA) and assistant director of nursing (ADON) on June 14, 2012, at approximately 11: 40 a.m., confirmed that staff, at times, placed the resident at the nursing station for observation when the resident exhibited unsafe behaviors and that the resident was uncooperative at times asking and waiting for assistance. The facility failed to provide evidence that this resident, identified at risk for falls and poor safety awareness, which was known to the facility, was provided with adequate staff supervision and intervention to prevent this fall with serious injury. A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired and required staff assistance for activities of daily living including the assistance of one staff for transfers and ambulation. Review of a resident "Incident/Accident Report" (I/A) dated January 27, 2012, at 7:30 p.m., revealed that Resident 14 was seated in her chair, stood up and ambulated to the bathroom and on her way back from the bathroom she was found on the floor on her buttocks. The report also indicated that the alarm was sounding, but the nurse aides were with other residents and unable to leave to answer the alarm. There were no injuries noted at this time. A review of a resident "Incident/Accident Report" (I/A) dated February 19, 2012, at 3:30 p.m., revealed that Resident 14 was found on the bathroom floor, sitting on her buttocks. A skin tear was noted to her left thumb, an abrasion to her right knee and a pink area was noted to Resident 14's forehead. The resident was sent to the hospital emergency department for evaluation, and returned with orders for Tylenol for pain. It was noted in the report that the resident was in bed prior to the fall, and the alarm box was connected to the chair pad and not the bed pad alarm. Interview with the Administrator and Assistant Director of Nursing on June 13, 2012 at 11:45 a.m. failed to explain why the alarm box was not transferred to the bed pad when Resident 14 was placed in bed. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 10/28/11