Every finding on record at Harmony Hills Healthcare and Rehabilitation Center

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (a cart that contains supplies in the event of an emergency), (First and Ground Floor).Findings include: Review of the facility policy Crash Cart Monitoring and Rehabilitation dated [DATE], indicated the facility will maintain crash carts and emergency equipment in a clean, secure, accessible, and ready-to-use condition. Crash carts will be monitored by licensed nursing staff. Missing, expired, damaged, opened, or malfunctioning medications, supplies, and equipment will be removed and replaced promptly. During an observation of the facilities crash cart, located on the First Floor, on [DATE], at 1:17 p.m. revealed the following supplies to be expired: (1) Ambu bag (a handheld manual resuscitator used to provide positive pressure ventilation) expired on [DATE]. During an observation of the facilities crash cart, located on the Ground Floor, on [DATE], at 1:30 p.m. revealed the following supplies to be expired: (1) Ambu bag expired on [DATE]. During an interview on [DATE], at 1:41 p.m. Registered Nurse (RN) Employee E1 confirmed the expiration dates of the Ambu bags on the First Floor and Ground Floor crash carts and confirmed that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (First and Ground Floor). 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R46).Findings include: Review of the facility policy Wound Care dated 5/1/26, indicated the policy is to promote wound healing and prevent infection. A licensed nurse will provide wound care using aseptic techniques as prescribed by the physician. Review of the facility policy Handwashing/Hand Hygiene dated 5/1/26, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene is indicated after contact with blood, body fluids, or contaminated surfaces, before moving from work on a soiled body site to a clean body site on the same resident. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/7/26, indicated diagnoses of depression, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and paraplegia (loss of movement and feeling in the lower half of the body). Section M1200 Skin and Ulcer/Injury Treatments indicated pressure ulcer/injury care. Review of Residents R46's physician orders dated 8/29/26, indicated Vashe (wound cleanser), apply to sacral (base of the spine) wound topically every day shift for sacral wound. Cleanse wound with Vashe, apply Veris (a wound dressing made with collagen and honey) to wound base. Pack with Vashe-soaked gauze. Cover with dry dressing. Then place woven gauze pad at the bottom of dressing to prevent bowel from entering the wound. Review of the facility provided pressure ulcer list indicated Resident R46 was admitted with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to her sacrum on 10/20/25. During a wound dressing change observation on 9/9/26, at 9:05 a.m. Licensed Practical Nurse (LPN) Employee E3 failed to perform hand hygiene and cleaning supplies during the following times while performing a dressing change for Resident R46: Failed to perform hand hygiene after removing the old dressingFailed to clean the scissors prior to useFailed to perform hand hygiene after cleaning the wound During an interview on 9/9/26, at 9:35 a.m. LPN Employee E3 confirmed that she failed to perform hand hygiene and clean the scissors prior to use for the dressing change and the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R46). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart for one of three medication carts (First Floor B Medication Cart), and failed to properly store medical supplies in one of two medication storage rooms (First Floor Medication Room).Findings: Review of facility Medication Storage policy dated [DATE], indicated medications and biologicals are stored safely, securely, and properly. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During an observation on [DATE], at 12:10 p.m. the First-Floor B cart was sitting in the hallway unlocked, with no nurse around. During an observation on [DATE], at 12:14 p.m. Registered Nurse (RN) Employee E2 walked by the unlocked cart and locked it. RN Employee E2 stated, She was standing there but I don't know where she is now. During an interview on [DATE], at 12:16 p.m. Licensed Practical Nurse (LPN) Employee E6 walked back to the unlocked cart and stated, It should have been locked, and confirmed that the First-Floor B Medication Cart was left unattended while unlocked. During a medication storage room review on the First Floor on [DATE], at 1:01 p.m. the following were observed: (1) vial of Turberculin (TB-used to detect a respiratory disease) with no open or expiration date.(87) red blood tubes (used to draw blood) expired [DATE]. During an interview on [DATE], at 1:12 p.m. RN Employee E1 stated, The TB should have had dates on it. They expire 30 days after we open them. and confirmed that the facility failed to properly store medical supplies in one of two medication storage rooms (First Floor Medication Room). 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for two of five residents (Resident R4, and R41). Findings include: Review of the facility policy Pharmacy Services dated 5/1/26, indicated the facility will provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in Administrative Regulations. A drug, whether prescribed on a routine, emergency, or as needed basis, will be provided in a timely manner. Review of the admission record indicated Resident R4 was admitted to the facility 7/28/25. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/21/26, indicated the following diagnosis: heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R4's MRR's on the following dates were signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required: 1/12/26- MRR signed by CRNP Review of the admission record indicated Resident R41 was admitted to the facility 4/17/26. Review of Resident R41's MDS dated [DATE], indicated the following diagnosis: Parkinson's (progressive disease of the nervous system), femur fracture, and anemia. Review of Resident R41's MRR's on the following dates were signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required: 3/6/26- MRR signed by CRNP During an interview on 9/10/26, at 10:00 a.m. Director of Nursing stated, I wasn't aware the physician had to sign the MRR's, and confirmed that a CRNP signed Resident R4 and R41's MRR's on the dates noted instead of the physician, as required. 28 Pa Code: 201.14(a) Responsibility of licensee 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weekly weights for one of three residents (Resident R6).Findings include: Review of the facility policy Resident Weight Monitoring dated 5/1/26, indicated resident weights will be obtained and monitored to establish a baseline, identify significant changes, and support the residents' national and medical plan of care. All weights will be documented in the resident's medical record. A suspected significant or unexpected weight change will be promptly verified by obtaining a reweight. Following a confirmed significant weight change, weekly weights for four weeks may be implemented. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/22/26, indicated diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), high blood pressure, and traumatic brain injury (a disruption in the normal function of the brain). During a review of R6's weights on 9/10/26, at 9:30 a.m. revealed the following: admission weight on 7/15/26, was 164.6Weight on 7/22/26, was 155.4Weight on 7/29/26, was marked as NAWeight on 8/5/26, was 154.1Weight on 8/12/26, was 153.8 During a review of Resident R6's admission Nutritional Assessment on 9/10/26, at 9:45 a.m. was completed on 7/22/26. Section 9I indicated loss of 5% or more in the last month marked yes, not on a physician-prescribed weight-loss regimen. Section 16Q- Assessment/Goals/Approaches indicated recommendations of house shake three times a day for additional nutrition, and weekly weights times four. During a review of Resident R6's physician orders dated 7/22/26, indicated weekly weights times four. No re-weights were obtained to determine if the initial admission weight could have been wrong after obtaining the weight on 7/22/26. During a review of Resident R6's care plan dated 7/22/26, indicated the resident has a nutritional problem or potential nutrition problem. Interventions included monitor weights. During an interview on 8/10/26, at 11:57 a.m. the Director of Nursing stated the facility should have gotten a re-weight to determine if the admission weight was accurate, confirmed that there was a missing weight on 7/29/26, and that the facility failed to properly monitor weight and nutrition status by failing to obtain weekly weights for one of three residents (Resident R6). 28 Pa. Code 201.18(b)(1)( Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, resident clinical records, observations and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of four sampled resident records using catheters (Resident R15). Findings include: The facility Care plans policy dated 4/1/25, and last reviewed on 5/1/26, indicated that it is the facility policy to develop a comprehensive individualized care plan for each resident. Review of Resident R15's admission record indicated she was admitted on [DATE]. Review of Resident R15's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/26/26, indicated that she had diagnoses that included major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and Dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning). The MDS assessment, Section H0100-bladder and bowel, indicated an X for the use of an indwelling catheter. Review of Resident R15's physician orders dated 8/21/26, indicated that she had an 18- French Suprapubic catheter in use, order included to change the catheter every four weeks and irrigate the catheter as needed. Review of Resident R15's base line care plan dated 8/21/26, indicated she had a catheter. Review of Resident R15's comprehensive care plans dated 8/26/26 to 9/10/26, did not include a catheter that was in use for Resident R15. During observations on 9/8/26, at 11:22 a.m. Resident R15 was observed with her catheter in use. During an interview on 9/10/26, at 10:14 a.m. Licensed Practical Nurse (LPN) Employee E4 was asked if Resident R15 had a catheter, stated: yes. she does. During observations on 9/10/26, at 10:16 a.m. interview with Resident R15 catheter bag was observed covered and catheter was observed in use. During an interview on 9/10/26, at 10:19 a.m. Assistant Director of Nursing (ADON) Employee E5 and the Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to develop a comprehensive care plan for one of four sampled resident records using catheters as required. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of Resident Assessments Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessments for one of three samples residents (Resident R41).Findings include: Review of Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated [DATE], indicated the significant change assessments (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes in hospice providers and remains a resident at the nursing home. The assessment reference date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). Review of Resident R41's MDS assessment dated [DATE], indicated the following diagnosis: Parkinson's (progressive disease of the nervous system), femur fracture and anemia. Review of Resident R41's physician orders dated 8/19/26 indicated that she was ordered hospice care services. Review of Resident R41's MDS assessments did not include a significant change MDS assessments that included hospice services for Resident R41. During an interview on 9/10/26, at 1:30 p.m. RNAC (Registered Nurse Assessment Coordinator) Employee E1 confirmed that the facility failed to conduct a Significant Change Minimum Data Set assessment for Resident R41 as required. 28 Pa Code: 211.12(d)(1)(2)(3)(5) Nursing Services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of four residents sampled with facility-initiated transfers (Resident R46).Findings include: Review of facility policy Documentation of Resident Discharge and Death dated 5/1/26, indicated documentation in medical record will be completed when a resident is discharged from this facility. Complete the resident transfer form. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/7/26, indicated diagnoses of depression, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and paraplegia (loss of movement and feeling in the lower half of the body). Review of the clinical record indicated Resident R46 was transferred to the hospital on 2/7/26, and returned to facility on 2/11/26, and was also transferred to the hospital on 6/1/26, and returned to the facility on 6/2/26. Review of Resident R46's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 9/9/26, at 10:39 a.m. Registered Nurse (RN) Employee E2 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of four residents sampled with facility-initiated transfers (Resident R46). 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of two residents (Residents R46). Findings include: Review of facility policy Resident Rights dated 5/1/26, indicated the residents have a right to a dignified existence and self-determination. The facility will promote the exercise of rights for each resident. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/7/26, indicated diagnoses of depression, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and paraplegia (loss of movement and feeling in the lower half of the body). Section M1200 Skin and Ulcer/Injury Treatments indicated pressure ulcer/injury care. Review of Residents R46's physician orders dated 8/29/26, indicated Vashe (wound cleanser), apply to sacral (base of the spine) wound topically everyday shift for sacral wound. Cleanse wound with Vashe, apply Veris (a wound dressing made with collagen and honey) to wound base. Pack with Vashe-soaked gauze. Cover with dry dressing. Then place woven gauze pad at the bottom of dressing to prevent bowel from entering the wound. Review of the facility provided pressure ulcer list indicated Resident R46 was admitted with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to her sacrum on 10/20/25. During an observation of wound care on 9/9/26, at 9:03 a.m. Licensed Practical Nurse (LPN) Employee E3 wrote on the dressing after it was placed on Resident R46's sacrum. During an interview on 9/9/26, at 9:35 a.m. LPN Employee E3 confirmed the facility failed to maintain Resident R46's dignity by writing on the dressing while it was on resident's body. 28 Pa. Code: 201.29(a) Resident rights.

Based on review of clinical records and staff interview, it was determined that the facility failed to obtain a complete physician order for a Lumbar Sacral orthosis brace (LSO-brace supports the spine) for one of two residents (discharged Resident R1).Findings include: Review of facility policy Splint and Brace last reviewed 5/1/26, indicated to ensure the safe, appropriate, and consistent application, monitoring, and care of splints and braces to promote resident comfort, prevent injury, and maintain function. Splints and braces shall be applied, monitored, and maintained according to the physician's or licensed practitioner's orders, the resident's individualized care plan, and manufacturer recommendations. Nursing staff are responsible for ensuring proper fit, skin integrity, resident comfort and documentation. Verify the physicians order, including the type of splint or brace, affected extremity, wearing schedule, and any special instructions. Review of discharged Resident R1's clinical record indicated an admission date of 6/2/26. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/8/26, indicated diagnosis of osteoporosis (bone disease characterized by weak and fragile bones, increasing the risk of fractures), anemia (low iron in the blood) and Peripheral Vascular Disease (PVD-reduces blood flow to the arms and legs). Review of Nursing progress notes dated 6/12/26, indicated resident voicing new onset of mid-lower back pain radiating to right ribs. Severe pain with movement & exertion. New orders for thoracic & lumbosacral x-rays to rule out trauma. Order placed with x ray company. Review of Physician orders dated 6/13/26, indicated Lidocaine External Patch 4 % (used for pain) apply to right ribs topically one time a day for pain. Review of X-ray of spine and thoracic area report dated 6/13/26, indicated severe compression deformity mid thoracic vertebral body of uncertain acuity. Mild to moderate degenerative change. Diffuse demineralization of bone/osteopenia/osteoporosis. No evidence of active osteomyelitis. Conclusions: Severe compression fracture mid thoracic vertebral body. Review of physician provider note dated 6/15/26, revealed seen for routine skilled evaluation and back pain follow up. Discussed x-ray findings, recommend an orthopedic follow-up. Education given that these types of fractures typically can be treated with brace, pain management and therapy. Discussed seeing, if possible, to obtain a thoracic-sacral-lumbar-orthosis (TSLO- used to keep the back extended for structural support) or equivalent with therapy while waiting for orthopedic evaluation. Review of physician order dated 6/15/26, indicated TSLP brace for acute thoracic compression fracture. No directions specified for order. Review of nursing progress note dated 6/16/26, revealed Resident was fitted this afternoon for a lumbosacral orthosis brace (LSO-supports the spine) for her compression fracture. Review of physician order dated 6/17/26, indicated Lumbosacral Orthosis (LSO) brace for compression fracture. No directions specified for order. During an interview completed on 7/8/26, at 11:51 a.m. upon asking Rehabilitation Director Employee E1 concerning discharged Resident R1's back brace replied, I do not even know what the P is for or where the order dated 6/15/26, for a TSLP brace came from. We provided discharged Resident R1 with an LSO brace on 6/19/26. discharged Resident R1 had a consultation with the orthopedist on 6/24/26, and a custom TSLO brace was ordered, the specialty company was here on 6/25/26, completed the measurements. The order for that brace did not go through as she was transferred out on 6/26/26. Upon asking concerning orders for the LSO brace replied, there is an order on 6/17/26, for a LSO brace, however the order did not contain any instructions for specific use such as wear time, or checking skin integrity. During an interview completed on 7/8/26, at 1:50 p.m. the Nursing Home Administrator confirmed that the facility failed to obtain a complete physician order for an LSO brace for one of two residents (discharged Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility provided documents, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of a resident utilizing a Lumbar Sacral orthosis brace (LSO-brace that supports the spine) for one of two residents (discharged Resident R1).Findings include: Review of facility policy Splint and Brace last reviewed 5/1/26, indicated to ensure the safe, appropriate, and consistent application, monitoring, and care of splints and braces to promote resident comfort, prevent injury, and maintain function. Splints and braces shall be applied, monitored, and maintained according to the physician's or licensed practitioner's orders, the resident's individualized care plan, and manufacturer recommendations. Nursing staff are responsible for ensuring proper fit, skin integrity, resident comfort and documentation. Verify the physicians order, including the type of splint or brace, affected extremity, wearing schedule, and any special instructions. Review of discharged Resident R1's clinical record indicated an admission date of 6/2/26. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/8/26, indicated diagnosis of osteoporosis (bone disease characterized by weak and fragile bones, increasing the risk of fractures), anemia (low iron in the blood) and Peripheral Vascular Disease (PVD-reduces blood flow to the arms and legs). Review of physician order dated 6/17/26, indicated Lumbosacral Orthosis (LSO-supports the spine) brace for compression fracture. No directions specified for order. Review of discharged Resident R1's current care plan initiated on 6/13/26, revealed the following:Focus: The resident has compression Fracture related to Osteoporosis/degenerative changes/deformity.Goals: The resident will not develop complications or permanent loss of mobility related to fracture through review date. The resident will be free from sign/symptoms of pain or will express/exhibit relief of pain after administration of ordered meds, alternative comfort measures.Interventions: Instruct resident regarding fracture healing process, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up. PT, OT evaluate and treat as indicated. Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness. On 6/20/26, added intervention: TLSO brace to be worn at all times. During an interview completed on 7/8/26, at 11:51 a.m. upon asking Rehabilitation Director Employee E1 concerning discharged Resident R1's back brace replied, We provided discharged Resident R1 with an LSO brace on 6/19/26. During an interview completed on 7/8/26, at approximately 2:00 p.m. upon asking the Director of Nursing (DON) concerning the care plan for discharged Resident R1's LSO brace confirmed that the current care plan did not include interventions for the LSO brace and that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of a resident utilizing a LSO for one of two residents (discharged Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for nine of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).Findings include: The facility policy Medication Administration - General Guidelines last reviewed 2/1/26, indicated The individual who administers the medication dose records the administration on the resident's MAR (medication administration record) directly after the medication is given. Review of Resident R1's MAR (medication administration record) for February 2026, revealed an order for oxycodone 5mg (a narcotic pain medication used to treat moderate to severe pain) to be given every six hours as needed for pain. Ten administrations were documented on the MAR from 2/5/26, through 2/27/26. Review of Resident R1's Controlled Substance Record indicated that 15 additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/6/26, 2/7/26, 2/12/26, 2/14/26, 2/15/26, 2/16/26 (x2), 2/17/26, 2/18/26, 2/20/26, 2/22/26, 2/24/26, 2/25/26, and 2/26/26. Review of Resident R2's MAR for February 2026, revealed an order for Endocet 5-325 (a oxycodone and acetaminophen) half-tablet to be given every six hours as needed for moderate pain, and one tablet to be given every six hours for severe pain. Nineteen administrations were documented from 2/7/26, through 2/26/26. Review of Resident R2's Controlled Substance Record indicated that six additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/3/26, 2/15/26, 2/17/26 (x2), 2/20/26, and 2/24/26. Review of Resident R3's MAR for February 2026, revealed an order for Endocet 5-325 one tablet to be given every six hours for severe pain. Nineteen administrations were documented from 2/5/26, through 2/26/26. Review of Resident R3's Controlled Substance Record indicated that ten additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/6/26, 2/10/26, 2/14/26, 2/16/26 , 2/17/26, 2/20/26, 2/23/26 (x2), 2/24/26, and 2/25/26. Review of Resident R4's MAR for February 2026, revealed an order for oxycodone 5mg to be given every four hours as needed for pain. Twelve administrations were documented on the MAR from 2/14/26, through 2/27/26. Review of Resident R4's Controlled Substance Record indicated that seven additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/23/26, 2/24/26, and 2/26/26. Review of Resident R5's MAR for February 2026, revealed an order for Endocet 5-325 (a oxycodone and acetaminophen) half-tablet to be given every six hours as needed for moderate pain, and one tablet to be given every six hours for severe pain. Four administrations were documented on the MAR from 2/17/26, through 2/27/26. Review of Resident R5's Controlled Substance Record indicated that six additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/17/26, 2/20/26, 2/23/26, 2/24/26, 2/25/26, and 2/26/26. Review of Resident R6's MAR for February 2026, revealed an order for oxycodone 5mg to be given every four hours as needed for pain. Three administrations were documented on the MAR from 2/25/26, through 2/27/26. Review of Resident R6's Controlled Substance Record indicated that three additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/25/26, and 2/26/26 (x2). Review of Resident R7's MAR for February 2026, revealed an order for Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) to be given every four hours as needed for pain. Four administrations were documented on the MAR from 2/21/26, through 2/27/26. Review of Resident R7's Controlled Substance Record indicated that three additional doses of Tramadol were signed out without corresponding documentation of administration to the resident on 2/22/26, 2/23/26, and 2/24/26. Review of Resident R8's MAR for February 2026, revealed an order for hydrocodone/ acetaminophen 5-325 (hydrocodone, and opiate narcotic pain medication and acetaminophen) to be given every eight hours for severe pain. Two administrations were documented on the MAR from 2/16/26, through 2/24/26. Review of Resident R5's Controlled Substance Record indicated that two additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/16/26, and 2/20/26. Review of Resident R9's MAR for February 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for pain. Eleven administrations were documented on the MAR from 2/15/26, through 2/26/26. Review of Resident R9's Controlled Substance Record indicated that three additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/16/26, 2/2/26, and 2/2/26. During an interview on 2/27/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain controlled substances were accounted for accurately for nine of twelve residents.28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain sanitary conditions and practice proper infection control which created the potential for cross contamination and food borne illness (Main Kitchen) the facility failed to properly monitor refrigerator temperatures on one of two nursing units (C & D Hall unit) and failed to properly monitor residents in room personal refrigerator temperatures for three of three residents (Resident R20, R23, R50) which created the potential for food borne illness. Review of facility policy Environment dated 1/13/25 indicates all food preparation areas, and dining areas will be maintained in a clean and sanitary condition. Review of the facility policy Resident's Private Refrigerators last reviewed 1/13/25, indicated residents’ private refrigerators will be cleaned to maintain proper infection control. Monitor temperature daily and document on log. Findings include: During an observation of the main designated kitchen on 7/15/25, at 9:05 a.m. the following was observed: - fan on side of dishwasher, brown debris During an observation of lunch tray line in the main designated kitchen on 7/15/25, at 12:22 p.m. the following was observed: - Dietary Aide Employee E5 was on tray line handling food trays with no facial hair covering. During an interview on 7/17/25, at 1:00 p.m. District Manager Employee E3 confirmed that the facility failed to maintain sanitary conditions and which created the potential for food borne illness and cross contamination in the Main Kitchen. During an observation on 7/15/25 at 10:59 a.m. the C and D Hall unit refrigerator temperature log revealed missing temperatures for the following dates: 6/17/25, 6/19/25, 6/23/25, 6/26/25 and 6/30/25. During an interview completed on 7/15/25, at 11:03 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the C and D Hall unit refrigerator temperature log was incomplete missing temperatures for the following dates: 6/17/25, /6/19/25, 6/23/25, 6/26/25 and 6/30/25. During an interview and observation completed on 7/15/25, at 9:38 a.m. it was revealed that a personal refrigerator was in Resident R20's room the refrigerator failed to have a temperature log. Upon asking Resident R20 concerning the refrigerator monitoring stated, “there is a thermometer inside, they check it once or twice a month. During an interview and observation completed on 7/15/25, at 9:53 a.m. it was revealed that a personal refrigerator was in Resident R50's room the refrigerator failed to have a temperature log. Upon asking Resident R50 concerning the refrigerator monitoring stated, the maintenance man checks it every couple of months. During an observation completed on 7/15/25, at 12:37 p.m. it was revealed that a personal refrigerator was in Resident R23's room the refrigerator failed to have a temperature log. During an interview completed on 7/15/25, at 10:58 a.m. upon asking LPN Employee E4 about the residents in room personal refrigerator stated, staff do go in and check, the families usually maintain, I don’t know if anyone checks the temperatures. Further interview completed on 7/15/25, at 11:03 a.m. LPN Employee E4 stated the temperature logs are kept in the narcotic count book and are checked on night shift. Observation of the narcotic count book revealed no temperature logs for July of 2025. LPN Employee E4 confirmed that refrigerator logs were not completed for July of 2025, and stated, I didn’t even know we did that.Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of five residents (Resident R2, R31, and R43). Findings include:The facility Participation in Planning Care and Treatment policy dated 1/13/25, indicated that the resident and their family or responsible party have the right to participate in planning care and treatment or changes in care and treatment. The resident care plan shall be reviewed, evaluated, and updated quarterly and as necessary by the interdisciplinary team involved in the care of the resident. The resident and their representative shall be notified of care plan meetings and care conference and offered the opportunity to attend in person or via phone. Review of Resident R2's admission record indicated resident was admitted on [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/26/25, indicated diagnoses of depression, migraines (headache), and paraplegia (paralysis of the legs and lower body). During an interview on 7/15/25, at 9:41 a.m. Resident R2 stated: What is that? I never attended any meetings, when asked if she has participated in care plan meetings. Resident R2 stated she would like to attend if she knew when they were and that she never received an invitation for a care plan meeting. During an interview on 7/16/25, at 1:46 p.m. Assistant Director of Nursing Employee E2 stated that Resident R2 should have had a care conference December 2024, March 2025, and June 2025.The facility failed to provide documented evidence of meetings and failed to send invitations to the meeting to the resident. Review of Resident R31's admission record indicated resident was admitted on [DATE]. Review of Resident R31's MDS dated [DATE], indicated diagnoses of depression, high blood pressure, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). During an interview on 7/17/25, at 9:38 a.m. Resident R31 stated: I haven't been to any care conferences, and I would like to go when asked if she has participated in care plan meetings. Resident R31 stated that she never received an invitation for a care plan meeting. During an interview on 7/17/25, at 11:02 a.m. Assistant Director of Nursing Employee E2 stated that Resident R31 should have had a care conference September 2024, December 2024, February 2025, and May 2025. The facility failed to provide documented evidence of meetings and failed to send invitations to the meeting to the resident. Review of Resident R43's admission record indicated resident was admitted on [DATE]. Review of Resident R43's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). During an interview on 7/15/25, at 9:55 a.m. Resident R43 stated: I haven't been to any care conferences, and I would like to go when asked if she has participated in care plan meetings. Resident R31 stated that she never received an invitation for a care plan meeting. During an interview on 7/16/25, at 1:46 p.m. Assistant Director of Nursing Employee E2 stated that Resident R43 should have invited resident to her initial care plan meetings. The facility failed to send invitations to the meetings to the resident. During an interview on 7/17/25, at 1:30 p.m. Nursing Home Administrator stated that he was aware that residents have not had care conferences for a while and confirmed that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of five residents (Resident R2, R31, and R43). 28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with hospital transfers (Residents R3, R6, and R43) and failed to obtain a physician order for discharge to home for one of six residents (Resident R56). Findings include: Review of facility policy Documentation of Resident Discharge last reviewed 1/13/25, indicated documentation in Point Click Care will be completed when resident is discharged from the facility. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident 3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/25, indicated diagnoses of acute pancreatitis (condition where the pancreas becomes inflamed), diabetes mellitus and hypertension (force of blood pushing against the artery walls is consistently too high). Review of the clinical record indicated Resident R3 was transferred to the hospital on 4/29/25, and returned to the facility on 5/2/25. Review of Resident R3's clinical record failed to include documented evidence that the resident or the resident's representative were provided with Resident R3's care plan at the time of the transfer to the hospital on 4/29/25. Review of the clinical record revealed that Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE], indicated diagnoses of high blood pressure, dysphagia (difficulty swallowing), and cancer (a disease caused by an uncontrolled division of abnormal cells in a part of the body). Review of the clinical record indicated Resident R6 was transferred to the hospital on 6/7/25, and returned to the facility on 6/11/25. Review of Resident R6's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, to meet the resident's specific needs at the receiving facility. Review of the clinical record revealed that Resident R43 was admitted to the facility on [DATE]. Review of Resident R43's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of the clinical record indicated Resident R43 was transferred to the hospital on 6/1/25, and returned to the facility on 6/5/25. Review of Resident R43's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident CR56 was admitted to the facility on [DATE]. Review of Resident CR56's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and depression. Review of the clinical record indicated Resident CR56 was discharged home on 4/19/25. Review of Resident CR56's clinical record failed to include a written physician order for discharge as required. Interview on 7/16/25, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to obtain a physician order for Resident CR56's discharge as required. Interview on 7/16/25, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with hospital transfers (Residents R3, R6, and R43) and failed to obtain a physician order for discharge to home for one of six residents (Resident R56). 28 Pa. Code: 201.29 (a)(c)(3)(2) Resident rights.

Based on review of clinical records and staff interviews, it was determined the facility failed to conduct a significant change assessment for one of two residents reviewed (Resident R37).Findings include:According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS - a periodic assessment of care needs) assessments dated October 2024, the facility must conduct a comprehensive assessment of a resident within fourteen days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition. The RAI Manual indicates a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.Review of the admission record indicated Resident R37 was admitted to the facility on [DATE].Review of Resident R37's MDS dated [DATE], indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), anemia (the blood doesn't have enough healthy red blood cells), and depression. Section O0110 K1. Hospice care indicated yes.Review of Resident R37's physician orders dated 4/28/25, indicated Hospice, effective date 3/21/25.Review of Resident R37's MDS assessment schedules indicated a significant change assessment was not completed within 14 days of hospice effective date of 3/21/25, as required.Interview on 7/17/25, at 1:15 p.m. the Director of Nursing confirmed the facility failed to conduct a significant change assessment for one of two residents reviewed (Resident R37).28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on review of facility policy, record review, resident and staff interviews, and observations it was determined that the facility failed to provide a resident environment free of potential accidental hazards for one of three residents (Resident R21).Findings include: Review of the facility policy Incident and Accident dated 1/13/25, indicated the facility shall make every effort to ensure that the resident's environment remains as free of accidental hazards as is possible. Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/7/25, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), renal insufficiency (poor function of the kidneys), and high blood pressure. Review of Resident R21's clinical record on 7/15/25, at 9:00 a.m. failed to include an assessment, identify the risks (burns and fires), ongoing evaluation, and physician's orders for the personal hot plate warmer for coffee cups. Review of Resident R21's current care plan indicated resident presents as needing twenty four hours of care and supervision. Self-care performance deficit related to limited mobility. Observation on 7/15/25, at 10:00 a.m. Resident R21 was sitting up on bed. The bedside stand had a small square hot plate device with a coffee cup on it. Interview with Resident R21 on 7/15/25, at 10:01 a.m. indicated the device was a coffee cup warmer used to keep her coffee hot. Interview on 7/15/25, at 1:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the presence of the hot plate and indicated Resident R21 keeps on ordering things despite the safety rules and confirmed the facility failed to provide a resident environment free of potential accidental hazards for one of three residents (Resident R21). 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.28 Pa. Code: 201.18 (b)(1)(d)(e)(1) Management.

Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R19).Findings include: Review of facility policy Colostomy Care and Management dated 1/13/25, indicated the facility will ensure the safe, effective, and person-centered care and management of residents with colostomies. Use appropriate pouching system based on stoma (opening in the abdomen), output type, and skin sensitivity. Stoma type, pouching and wafer system including size shall be documented in the medical record. Review of the clinical record revealed that Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/10/25, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and colostomy (surgery to divert the colon into an artificial opening in the abdominal wall for waste elimination). Review of Resident R19's physician orders dated 5/20/25, indicated to change colostomy skin barrier appliance (wafer) every three days and as needed. The order failed to include size and type of colostomy appliance to be used. Review of Resident R19's current care plan dated 5/12/25, failed to include size and type of colostomy appliance being used. During an Interview on 7/16/25, at 2:25 p.m. the Director of Nursing confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R19). 28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility for one of three residents (Resident R2).Findings include: The facility policy Pharmacy Services reviewed 1/13/25, indicated the facility will provide routine and emergency drugs and biologicals to the residents, or obtain them under an agreement and will be provided in a timely manner. Drug regimen review to include: - - A licensed pharmacist will review the drug regimen of each resident at least once a month.- - The pharmacist will report any irregularities to the attending physician and the Director of Nursing. Review of Resident R2's admission record indicated resident was admitted on [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/26/25, indicated diagnoses of depression, migraines (headache), and paraplegia (paralysis of the legs and lower body). Review of Resident R2's clinical record on 7/16/25, at 11:04 a.m. indicated the following: December 2024- facility failed to provide the completed MRRApril 2025 - facility failed to provide the completed MRRMay 2025 - facility failed to provide the completed MRRJune 2025 - facility failed to provide the completed MRR During an interview on 7/17/25, at 10:00 a.m. Director of Nursing stated that the facility has received the encrypted emails from pharmacy however has failed to have all the recommendations reviewed and completed by the physician. During an interview on 7/17/25, at 10:10 a.m. the Director of Nursing confirmed that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility for one of three residents (Resident R2). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.9 (k) Pharmacy services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (C and D Hall Medication Cart) and failed to store drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (C and D Hall Medication Room).Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (C and D Hall Medication Cart), failed to store drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (C and D Hall Medication Room) and failed to maintain documentation of medication refrigerator temperatures in one of two medication rooms (C and D Hall medication refrigerator). Findings include: Review of the facility policy Storage of Medications last reviewed 1/13/25, indicated that medications and biologicals are stored safely, securely, and properly. Medication storage areas are kept clean, well lit, and free of clutter. During an observation on 7/15/25, at 10:03 a.m. the C and D Hall medication cart contained the following: Resident R4's Novolog insulin pen (insulin pen- a device used to inject insulin) not labeled with the date opened and not stored in bag. Resident R4's Basaglar insulin pen not labeled with the date opened and not stored in bag. Resident R17's Aspart insulin pen not stored in a bag. Resident R21's Lantus insulin pen opened and not stored in a bag. Resident R47's Lispro insulin pen not labeled with the date opened and not stored in bag. Resident R17's inhaler spacer (a plastic tube that is attached to the end of an inhaler that allows the user to take multiple breaths of the medication dose) not stored in bag. During an interview completed on 07/15/25, at 10:14 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the above observations and that the facility failed to store medications and biologicals properly and securely in one of three medications carts (C and D Hall Medication Cart). During an observation completed on 7/15/25, at 11:09 a.m. the C and D Hall medication storage room it was revealed that two refrigerators were present both failed to have a temperature monitoring log. A shelf contained: Two winter coats A tan tote bag During an interview completed on 7/15/25, at 11:13 a.m. LPN Employee E4 confirmed the refrigerators failed to have temperature monitoring logs and stated, these coats belong to a discharged resident, the family was to come in and pick them up, this is my tote bag.28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide adequate assistance during a transfer, resulting in actual harm (laceration [cut] to lower left leg between the calf and ankle) for one of two residents (Resident R1). Findings include: The facility Fall Risks and Prevention Guideline policy last reviewed 5/4/21, indicated the facility, through resident assessment, fall risk assessment and implementation of appropriate intervention, will provide a medical and environmentally safe home for the resident thus ensuring his/her optimum physical, mental, and psychosocial well-being. Review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included right below the knee amputation, muscle weakness, cutaneous abscess of the left heel, and restless leg syndrome. Review of the Minimum Data Set assessment (MDS- periodic assessment of care needs) dated 9/10/22, Section G, Question G0110: Activities of Daily Living (ADL) Assistance indicated Resident R required two plus persons for physical assistance for transfers. Review of the physician orders dated 9/8/22, indicated Resident R1 was to be a transfer with an assist of two, and was able to use sit to stand lift (a mechanical lift that utilizes the patient's knees in a saddle while an underarm strap is wrapped around the torso to raise the patient to a semi upright position for transfers) when resident was fatigued. Review of the care plan dated 7/7/22, indicated Resident R1's had no documented interventions in place for transfer assistance level until 11/1/22 after the resident had a second laceration incident on the left lower leg occurred. Review of a Sava-Transfer Evaluation (an evaluation based on a points system evaluating the resident's ability to transfer) dated 9/25/22, indicated Resident R1 was a category 3 caregiver performs 50% of the task or greater and Equipment Mechanical lift. Review of the progress note dated 10/20/22, at 7:10 p.m., revealed Resident R1 had acquired a laceration to the left outer calf 7.5 cm (2.95 inches) long. Unsure how acquired but was being transferred back to bed after toileting. Laceration was too deep and active bleeding to approximate and use Steri strip (strips of special tape used in lieu of stitches), so Resident R1 was transferred to hospital for sutures. Review of the progress note dated 10/28/22, at 11:05 p.m., revealed Resident R1 had acquired another laceration 11.5 cm (4.528 inches) long, to the left outer calf during a transfer into bed. Resident R1 had severe bleeding and needed a pressure bandage applied until the ambulance arrived and transported her to the hospital emergency department. Review of an investigative phone interview with Nursing Assistant (NA) Employee E1 on 11/3/22, at 1:37 p.m., revealed NA Employee E1 did not use the sit to stand mechanical lift or ask additional staff for assistance, NA Employee E1 stated that she did not have the assignment sheet with the transfer status, because she did not know the facility had them, and only asked the shift supervisor the resident transfer status. NA Employee E1 also stated that the Resident R1 was transferred the night before the same way. NA Employee E1 also revealed that the afternoon and evening shifts only get transfer status changes by word of mouth. Review of an investigative phone interview with NA Employee E3 on 11/3/22, at 1:45 p.m., revealed NA Employee E1 did check with NA Employee E3 about transfer status and admitted to telling NA employee E1 to transfer Resident R1 not using the sit to stand mechanical lift. NA Employee E3 stated that was she didn't have the assignment sheet with the transfer status, because she didn't know the facility had them, and stated transfer status is communicated through word of mouth. Interview with the Physical Therapist (PT) Employee E4 on 11/4/22 at 2:20 p.m., indicated that the therapy department only communicates changes in status to the nursing staff by word of mouth. PT Employee E4 also stated that she was unsure of any communication between shifts. PT Employee E4 confirmed there was no changes in the transfer order for Resident R1 until after the second laceration incident on 10/28/22. During an interview on 11/4/22, at 2:30 p.m. with the Nursing Home Administrator, Director of Nursing, and Clinical Consultant Employee E2 confirmed the facility the facility failed to provide adequate assistance during a transfer, resulting in actual harm (laceration [cut] to lower left leg between the calf and ankle) for one of two residents (Resident R1) and had failed to update the transfer status on the sheets and in the Kardex (an electronic charting system that nurse aides use to get updated information on the residents such as bathing and transfer status). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 28 Pa Code: 211.10 (c)(d) Resident care policies.