Every finding on record at Hempfield Manor

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of 29 cognitively impaired residents (Resident R1).Findings Include: Review of the facility, Missing Resident Policy dated 12/2/25, indicated the facility will take all necessary steps to locate a resident that is missing. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. Review of Section C: Cognitive Patterns indicated that Resident R1 has severe cognitive impairment. Review of the facility diagnosis list included acquired absence of the right upper limb. Review of an Elopement Evaluation assessment completed on 1/31/26, indicated Resident R1 was not at risk for elopement. Review of a progress note dated 4/10/26, at 2:09 p.m. indicated Resident R1 attempted to exit the front door of the facility. Review of Resident R1's plan of care developed on 4/10/26, indicated that he was an elopement risk as evidenced by exit-seeking behaviors. Attempting to exit the front door, stating going to the courthouse, watching for flying ships from the window. Included in the interventions was the use of an electronic monitoring device (SCD). Further review of the care plan failed to include a plan of care developed for wandering/elopement prior to 4/10/26. Review of a progress note dated 4/10/26, at 6:39 p.m. indicated a change in condition, Confused, applied for a marriage license at front desk of [facility]. States he is waiting on his ship to pick him up and stated the Germans are coming. The progress note further stated that Resident R1 complained of abdominal pain, and the physician ordered that he be sent to the hospital for evaluation. Review of an Elopement Evaluation assessment completed on 4/10/26, indicated Resident R1 was at risk for elopement. Review of a physician's order dated 4/10/26, indicated Resident R1 was ordered an SCD (secure care device - electronic monitoring device). Review of a progress note dated 4/11/26, at 2:12 a.m. indicated Resident R1 was admitted to the hospital. Review of the physician's order for the SCD indicated that it was discontinued on 4/11/26, due to the resident being admitted to the hospital. Review of a progress note dated 4/14/26, at 10:13 p.m. indicated that Resident R1 was readmitted to the facility. Review of an Elopement Evaluation assessment completed on 4/14/26, indicated Resident R1 was not at risk for elopement. Review of Resident R1's physician's orders for April 2026, indicated that Resident R1's SCD was not reordered upon his readmission to the facility. Review of information submitted by the facility dated 6/13/26, indicated that on 6/12/26, At 7:02 p.m. RN was notified by staff leaving facility after shift that [Resident R1] was on the lower walking track on the far end approximately 0.3 miles from the facility in his power wheelchair. RN Charge called Code Brown, and available staff reported to location [Resident R1] had been witnessed at on the walking track. At 19:16 (7:16 p.m.) staff located [Resident R1] on the walking track near [intersection by the facility]. The weather was sunny and warm at this time. Staff escorted [Resident R1] back to the facility. On shift staff report seeing [Resident R1] near the front entrance inside the building at 18:16 (6:16 p.m.). Staff on the unit report seeing [Resident R1] heading off the unit towards vending machine after 18:00 (6:00 p.m.). [Resident R1] pushed the handicap paddle to open the front door and exited the facility through the front door. Review of a progress note dated 6/12/26, at 7:02 p.m. indicated, Notified by staff that the resident was seen on the lower (furthest) walking track in front of the facility in his power wheelchair at 1902 (7:02 p.m.), heading toward [Street]. The weather was sunny and warm at around 79 degrees. When asked why he went down to the track and down the road, he stated to this RN, Well, I was trying to go to Youngwood. If I'd made it over the hill past the tracks, I would have gone to [local pizza restaurant], if it is even still open. I would have gone past there. When asked again why he was out on the track, he stated If I'd gone the other way, I would have been caught. He was asked again why he left the facility and he stated, It was a spur of the moment to get moving. He kept laughing when he was told that it was dangerous to go out across the roads. CODE BROWN was called. Staff searched the building while other staff searched outside of the facility and along the walking track. Staff located the resident at 1916 (7:16 p.m.) at the corner of [intersection], near a UPS Drop Box. Code [NAME] cleared. He was sitting in his power chair with his flashlight attempting to wave down cars passing by him. Staff turned off the power to his chair and pushed him back into the facility. Review of an employee statement (undated) written by Nurse Aide Employee E1 indicated, At 7pm the ADON (Assistant Director of Nursing) came to A Hall and told me [Resident R1] was outside, that [Dietary Employee E2] from the Kitchen was leaving and seen him across the trail. I then ran outside and ran down the hill I then ran back and got my car and drove to find him, I went around the circle twice; up the street and back, I then went to the end of the circle, out of our building, to the stop sign and seen [Resident R1] across the street to my left, on the side of the road (half way out), waving his hand with his flash light. I then pulled in the gravel beside him as I was calling [Nurse Aide Employee E3] because she was the most recent person on my call list, she notified everyone and multiple people came to help. When I got out of the car I said [Resident R1] where are you going. He told me he was glad to see a familiar face but he was trying to scare us all and that he wanted to go to Youngwood. I backed him up and waited for them to come. I then drove back while [Licensed Practical Nurse (LPN) Employee E4] and [LPN Employee E5] pushed him back to the building. Review of an employee statement (undated) written by LPN Employee E5 indicated, After being relieved of my post I crossed the building to assume another position at which point a nurse approached me asking where a resident is. After searching the entire building in each accessible room, I headed outside and searched the parking lot. After not finding the resident, I began following other cohorts on their search at which point the party located the resident across the road in his motorized wheelchair. Resident was unable to return due to the chair battery losing its charge. The resident was visually observed to be calm and without complaints of pain / injury. Resident was then manually posted in his wheelchair by me and another nurse back to the facility. Resident arrived at facility at 1943 (7:43 p.m.). Resident was put in bed by staff and assessed by charge nurse. Review of an employee statement (undated) written by Dietary Employee E2 indicated, On Friday night, (June 12th), after left work I noticed [Resident R1] on the lower-track in front of our facility but not on the premises. Obviously. I called [Dietary Employee E6] to ask if our residents were even allowed to be there, I wasn't 100% sure. She called the facility right away Review of an employee statement dated 6/12/26, written by Dietary Employee E6 indicated, [Dietary Employee E2] called me Friday night after her shift. She was leaving and saw [Resident R1] on the track. She asked me if he was allowed to be there - I asked who was in charge, [Dietary Employee E2] was not sure. I told her I was going to call the facility. I called after we got off the phone and [Registered Nurse (RN) Employee E7] answered and I told her [Dietary Employee E2] saw [Resident R1] at the tracks. [RN Employee E7] called back and asked where she saw him exactly. I wasn't completely sure - I guess I was just concerned on calling the [facility] asap. I talked to [RN Employee E7], and she said they found him. Review of an employee statement dated 6/12/26, written by NA Employee E8 indicated, Was notified that [Resident R1] was missing at 1915 (7:15 p.m.). NA Employee E9, LPN Employee E5, and I went looking was on C and D side also in also in back parking. [NA Employee E3] got a call he was down the street by [business], by pull off area. He was found safe at 1930 (7:30 p.m.). He was waving at cars asking for a ride to Youngwood. Review of an employee statement dated 6/12/26, written by LPN Employee E4 indicated, 'I arrived at work and clocked in at 6:45pm. I got report at 6:55pm on B hall from LPN Employee E5. At about 7:03 ADON reported to me that a resident [Resident R1] was seen on the walking track in his motorized wheelchair. I immediately alerted staff as I ran out the building to begin searching for him outside in the parking lot and the front road. I returned into the building to continue to check the smoke area and empty rooms. After not finding him returned outside with 2 CNAS (nurse aides) to continue to search. Another CNA called from a block away stating she found him, he was safe and she was waiting with him. Upon reaching the resident he said he was trying to see how long it took someone to stop and help him. Review of an employee statement dated 6/12/26, written by NA Employee E3 indicated, '[NA Employee E1] called me at 7:15pm she had found [Resident R1] at the end of the road. I was on D hall & went to grab other aides and nurses to help. When I got to him [NA Employee E1] had him safe with her. When asked what he was doing he said Trying to get a ride to Youngwood to scare you guys. During an interview on 6/30/26, at 10:13 a.m. NA Employee E9 stated that recently Resident R1 has been more confused. We would put Wanderguards (SCD) on and he would try to cut them off. During an interview on 6/30/26, at 10:15 a.m. LPN Employee E10 stated, One time they came and got the extra one (SCD) I keep in my cart for new admits because the nurse said he cut it off. During an interview on 6/30/26, at 10:33 a.m. RN Employee E11 confirmed that Resident R1 has been confused and had been sent out in April for attempting to leave the facility. During an interview on 6/30/26, at 2:40 p.m. LPN Employee E12 stated that recently Resident R1 has been more confused since his roommate passed approximately one year ago. I think his dementia is definitely getting worse. During an interview on 6/30/26, at 2:46 p.m. NA Employee E13 stated, Some days he's really out of it. The other day he was talking about a motorcycle that was in his room. During an interview on 6/30/26, at 3:05 p.m. NA Employee E1 stated that she has heard staff speaking of Resident R1 cutting his SCD off, and they have tried to put it on his chair. During an interview on 6/30/26, at 3:08 p.m. NA Employee E14 stated that Resident R1 gets confused at random times, that he had days when he makes sense, and others when he does not. During an interview on 6/30/26, at 3:27 p.m. LPN Employee E15 stated that Resident R1 doesn't want anyone to tell him what to do. He is ex-military, rough and tumble. When asked if Resident R1 had been more confused recently, LPN Employee E15 stated, I think so, for the past few weeks. On 6/30/26, at 9:28 a.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that an Immediate Jeopardy situation existed and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 6/30/26, at 12:30 p.m. an acceptable Corrective Action Plan was reviewed which included the following interventions: Investigation initiated following elopement revealed resident was observed by staff at 6: 16pm near front entrance.At 7:02pm off shift staff observed this resident on walking path below facility. Off shift staff contacted her supervisor to inform her a resident was on the walking path. Supervisor contacted facility to inform them this resident was seen on the walking path. Supervisor on shift called Code [NAME] (elopement) and staff began searching for this resident.Resident was found in power wheelchair on far end of walking trail at 7: 16pm. He was escorted back into the facility. Resident appeared to be laughing with staff and stated he was trying to go to Youngwood.The resident was assessed by RN for injury and change in condition by Assist Director of Nursing on 6/12/26. The resident was not harmed and alert and oriented. MD and family made aware of elopement.MD ordered therapy evaluation Psych evaluation and Med review which have been completed.Resident was ordered Secure Care Device and removed resident from power wheelchair until therapy could evaluate, Standard wheelchair put in place. All recommendations are put into place.Assessments completed for skin, BIMs, Elopement, and Nursing Physical Device by RN on 6/12/26.Therapy evaluation completed for motorized wheelchair on 6/16/26, by Therapy Manger. Resident's plan of care updated with all findings and appropriate interventions.Care plan meeting was held and reviewed with family and IDT team on 6/17/26. Immediately following elopement-all residents were accounted for by the competition of a head count and elopement drill on 6/12/26, by Assistant Director of Nursing at 7:45pm.Elopement binder and photos of residents at risk for elopement updated immediately following elopement by ADON on 6/12/26.Elopement evaluation assessment and Care plans were completed on all residents on or before 6/30/26 at 9:00am by the Interdisciplinary Team to ensure all residents were evaluated for elopement risk and appropriate interventions were in place.re-admission elopement assessments reviewed by IDT team during Clinical report meeting following elopement on 6/12/26 and ongoing to ensure accuracy with orders and assessments.IDT team will review Behaviors during clinical report on-going, and Activities Director will update Elopement Binders as needed.Education to registered nurses for accuracy in elopement assessment completion completed by Nursing Home Administrator or designee by 6/30/26 at 11 :25am.Elopement drills were conducted weekly x 1 week all 3 shifts by Environmental Service Supervisor by 6/25/26 at 7:00am. Elopement drills will be completed monthly thereafter by ESS.All staff Educated on elopement policy by Director of Nursing or Designee on 6/30/26 by 4pm.Audits completed to ensure Elopement Drills were completed weekly x 1 weeks by NHA or designee before 6/30/26 at 9:00am, monthly audits thereafter x 6 months. Audit results of audits will be presented and reviewed during QAPI meetings. Review of resident clinical records on 6/30/26, confirmed that all residents were reevaluated for elopement risk on 6/16/26. Review of facility-provided sign-in sheets, dated 6/29/26, and 6/30/26, confirmed reeducation was provided to all facility staff on elopement prevention and actions to take in the event of an elopement. Review of facility-provided sign-in sheets, dated 6/29/26, and 6/30/26, confirmed reeducation was provided to all registered nurses on completing elopement evaluations accurately, reviewing prior evaluations, behavior notes, and checking cognitive scores and diagnoses. Review of facility documents confirmed elopement drills were completed on 6/17/26, at 8:40 p.m.; 6/18/26, at 1:00 p.m.;6/19/26, at 6:00 p.m.; 6/22/26, at 5:00 a.m.; 6/24/26, at 10:22 a.m.; and 6/25/26, at 5:30 a.m. During interviews conducted on 6/30/26, confirmed 15 of 15 facility staff received reeducation on the elopement prevention and actions to take. During interviews conducted on 6/30/26, confirmed two of two registered nurses received reeducation on the accurately completing elopement evaluations. The Immediate Jeopardy was lifted on 6/30/26, at 3:20 p.m. when the action plan implementation was verified. During an interview on 6/30/26, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent a resident exiting the building unsupervised. This failure created an Immediate Jeopardy situation for one of 29 cognitively impaired residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of select facility documents, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident needs for seven of nine residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).Findings include: Review of the facility, Nursing Services Policy dated 12/2/25, indicated the facility will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. During an interview on 5/27/26, at 2:36 p.m. when asked if the facility maintained sufficient staff to care for residents, Resident R1 stated, No. We wait a long time for care. I push the button but no one is coming. Observation at this time revealed Resident R1 to have greasy appearing hair. During an interview with Resident R2 and R3 on 5/27/26, at 2:40 p.m. when asked if the facility maintained sufficient staff to care for residents, Resident R2 stated, No and began to laugh. Resident R2 stated that she has waited up to 90 minutes for call light response. Resident R3 stated No, they don't have enough staff. Sometimes they have one person for two halls. Resident R3 agreed with Resident R2 that she also has waited 90 minutes for care. During an interview with Resident R4 and R5 on 5/27/26, at 2:45 p.m. when asked if the facility maintained sufficient staff to care for residents, Resident R2 stated, No stated that she has waited up to 30 minutes for call light response. Resident R3 stated No stated that call light response time is long. During an interview on 5/27/26, at 2:50 p.m. when asked if the facility maintained sufficient staff to care for residents, Resident R6 stated, No, I don't. This is my only home. I can't walk. They are so frazzled because they only have twenty minutes to take care of each person. That makes me nervous because they're nervous. I hope I'm not endangering myself saying this. You can see they're upset, they're not happy. Sometimes they are helping me get dressed, but they only get halfway done and never finish getting me dressed. Resident R6 stated call lights response can be up to 90 minutes. During an interview on 5/27/26, at 3:20 p.m. when asked if the facility maintained sufficient staff to care for residents, Resident R7 stated, No and shook her head definitively. During a review of Resident Council minutes for the previous three months revealed the following:3/5/26: Residents stated they feel like we need more help.4/2/26: Resident stated she did not get her shower timely and more aides are needed. Resident stated a concern with dining room being closed, with the response that a licensed staff member needs to be available.5/7/26: Residents discussed staffing concerns and the need to guide new staff members. During an interview on 5/27/26, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure sufficient staffing to meet resident need for seven of nine residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for 18 of 28 residents (Resident R4, R12, R20, R29, R48, R53, R56, R63, R74, R85, R90, R95, R100, R101, R102, R103, R114, R119).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated the following instructions: -Section C: Cognitive Patterns - Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available.-Section D: Mood - Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available.-Section O: Special Treatments, Procedures, and Programs - Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, None of the above. -Resident R4 had an MDS completed on 2/7/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R8 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R4 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R4 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R12 had an MDS completed on 3/5/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R12 is sometimes understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R20 had an MDS completed on 1/16/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R8 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R29 had an MDS completed on 1/19/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R8 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R48 had an MDS completed on 1/16/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R48 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R53 had an MDS completed on 2/3/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R53 is usually understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R56 had an MDS completed on 1/19/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R56 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R63 had an MDS completed on 1/9/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R63 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R74 had an MDS completed on 2/4/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R74 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R85 had an MDS completed on 12/30/25. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R85 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R90 had an MDS completed on 12/9/25. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R90 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R90 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R90 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R95 had an MDS completed on 2/8/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R95 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R100 had an MDS completed on 1/19/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R100 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R101 had an MDS completed on 2/6/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R101 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R101 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R101 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R102 had an MDS completed on 2/2/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R102 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. -Resident R103 had an MDS completed on 1/15/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R103 is understood. Review of Sections C: Cognitive Patterns, the BIMS indicated all questions were documented as Not Assessed. -Resident R114 had an MDS completed on 3/3/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R114 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R101 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R114 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R119 had an MDS completed on 1/12/26. Review of Section B: Hearing, Speech, andVision, Question B0700 indicated that Resident R119 is understood. Review of Sections C: Cognitive Patterns and Section D: Mood, the BIMS and Resident Mood Interview indicated all questions were documented as Not Assessed. During an interview on 3/19/26, at 2:27 p.m. the Resident Nurse Assessment Coordinator Employee E8 confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for 18 of 28 residents. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on the review of facility policy and facility documents, observations and resident and staff interviews, it was determined that the facility failed to make certain grievance forms can be filed anonymously in four of four locations where grievance information is available. (front lobby, resident lounges between unit's A/B and C/D - grievance boxes with grievance forms are in front of the activity department and in resident lounges between unit's A/B and C/D). Findings include: A review of the facility policy Grievances last reviewed 12/2/25, indicated A formal grievance must be submitted in writing to the Grievance Officer and signed by the resident or the person filing the grievance on behalf of the resident. During an observation on 3/19/26 between 8:30 a.m. and 9:00 a.m. revealed the grievance policy/procedure posted in the facility did not contain wording that a grievance form can be filed anonymously. Grievance forms available at grievance box location did not contain wording that a grievance form can be filed anonymously. During an interview on 3/19/26, at 9:00 a.m. the Nursing Home Administrator confirmed that the facility grievance policy and procedure failed to provide information on the residents' right to file a grievance anonymously. 28 Pa. Code 201.29(a)Resident rights

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for four of 25 residents (Resident R5, R14. R43, and R60).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). Resident R5 had an ARD of 2/13/26, with an MDS completion date of 3/2/26.Resident R14 had an ARD of 2/11/26, with an MDS completion date of 2/26/26.Resident R43 had an ARD of 10/30/25, with an MDS completion date of 11/13/26.Resident R60 had an ARD of 9/26/25, with an MDS completion date of 10/1425. During an interview on 3/20/26, at 2:27 p.m. the Resident Nurse Assessment Coordinator Employee E8 confirmed that the facility failed to make certain that quarterly MDS assessments were completed in the required time frame for four of 25 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of eight sampled residents (Residents R2, R46, R61, and R138).Findings include: Review of the facility policy Oxygen by Nasal Cannula last reviewed on 12/2/25, indicated Cannula and tubing to be replaced weekly. Label with resident's name and date. Review of Resident R2's admission record indicated she was originally admitted on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/2/26, indicated the diagnoses of respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), hypertension (high blood pressure), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear and uneasiness). Review of Resident R2's current physician orders, indicated resident is on 3 liters per minute of oxygen. During an interview and observation on 3/20/26, at 12:30 p.m. with Registered Nurse (RN) Employee E1, Resident R2 was observed in their room using oxygen. The oxygen tubing had a label dated 2/14/26. Review of Resident R46's admission record indicated he was originally admitted on [DATE]. Review of Resident R46's MDS dated [DATE], indicated the diagnoses of cerebrovascular accident (stroke, blood flow to the brain in interrupted leading to brain cell death), diabetes mellitus (high blood sugar), and bipolar disorder (extreme mood swings). Review of Resident R46's current physician orders, indicated resident is on 0-4 liters per minute of oxygen to maintain oxygen level greater than 90 percent and change oxygen tubing weekly. During an interview and observation on 3/20/26, at 12:40 p.m. with Registered Nurse (RN) Employee E1, Resident R46 was observed in their room using oxygen. The oxygen tubing failed to be labeled. Review of Resident R61's admission record indicated she was originally admitted on [DATE]. Review of Resident R61's MDS dated [DATE], indicated the diagnoses cerebrovascular accident (stroke, blood flow to the brain in interrupted leading to brain cell death), heart failure (heart doesn't pump blood as well as it should), and diabetes mellitus (high blood sugar). Review of Resident R61's current physician orders, did not reveal an order for oxygen use. During an interview and observation on 3/20/26, at 12:50 p.m. with Registered Nurse (RN) Employee E1, Resident R61 was observed in their room using oxygen. The oxygen tubing had a label dated 2/21/26. Review of Resident R138's admission record indicated she was originally admitted on [DATE]. Review of Resident R138's MDS dated [DATE], indicated the diagnoses of chronic obstructive pulmonary disease (COPD irreversible lung and airway damage), pneumonia (lung infection), and diabetes mellitus (high blood sugar). Review of Resident R138's current physician orders, current physician orders, did not reveal an order for oxygen use, though an order was present to change oxygen tubing weekly. During an interview and observation on 3/20/26, at 12:55 p.m. with Registered Nurse (RN) Employee E1, Resident R138 was in their room using oxygen. The oxygen tubing failed to be labeled. During an interview on 3/20/26, at 1:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on resident and staff interviews, and facility documents (grievance and staffing) reviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for fourteen of twenty-three residents (Residents R1, R9, R12, R16, R23, R40, R44, R46, R64, R500, R501, R502, R503, and R505).Findings include: Review of the facility policy Nursing Services Policy last reviewed on 12/2/25, indicated that The Manor will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Conduct of Nursing Personnel answer call lights promptly. During a group interview, on 3/17/26, at approximately 1:30 p.m., when asked if they felt the facility maintained enough staff to care for resident needs and answer call lights, consensus from the group was no. Residents verbalized frustration with the lack of nurse aides in the building. Residents stated it is primarily on the evening shift (11 p.m. to 7 a.m.; the residents stated often the wait time is thirty minutes or longer when you use your call light to get help). Residents stated it's hard to wait that long when you must go to the bathroom, want your pain medication or if someone falls. Review of Resident Council Minutes revealed concerns related to facility staffing, At the 1/8/26, meeting minutes included Staffing is always a concern and the 3/5/26, meeting included Feels like we need more help statements. Review of a grievance filed by Resident R23, dated 2/3/26, revealed concerns documented for care. Resident reported he is not receiving adequate care on all shifts. Resident was told he can't get out of bed, because he won't stay up long enough. The resident would like to be out of bed daily after breakfast. Review of a grievance filed on behalf of Resident R9, dated 2/5/26, revealed concerns documented for care. Resident had a bowel movement and soiled her wound dressing. Resident had reportedly been told the dressing was already changed today, we can't do it again. The resident's sheets had not been changed for a week and had crumbs on them and the resident's hair was not washed. During an interview on 3/18/26, at approximately 10:00 a.m., Resident R1, when asked if he felt the facility maintained sufficient staff to care for resident needs, state no. You wait a long time for help when you use your call light, thirty minutes is common, sometimes more than an hour. During an interview on 3/18/26, at approximately 10:15 a.m., Resident R16, when asked if he felt the facility maintained sufficient staff to care for resident needs, state no. You wait when you call for help, you can wait thirty minutes or more, it happens a lot. During an interview on 3/18/26, at approximately 10:15 a.m., Resident R46, when asked if he felt the facility maintained sufficient staff to care for resident needs, stated, No. Most of the time you wait not always but most. When you must wait, it's usually a long time thirty minutes or more. During a clinical record review Resident R44 post fall progress notes dated 3/16/26, indicated the residents bed side call light was on when resident was found on the floor in the bathroom. During an interview on 3/19/26, at approximately 2:00 p.m., Resident R44 (a poor historian) stated he utilized his call bell to go to the bathroom, but no one comes in for a while, so he gets up by himself. Resident R44's roommate, Resident R109 confirmed that Resident R44 often gets out of bed by himself to go to the bathroom because it takes the staff so long to come and help and this isn't the first time Resident R44 fell while waiting on staff to respond to the call light. During an interview on 3/18/26, at approximately 2:15 p.m. Resident R12 was observed to have unbrushed hair and a brown substance under her fingernails.During confidential staff interviews, when asked if the staff members felt there was sufficient staff to care for resident needs. One staff member stated that we are short staffed on some days just like all other facilities, another staff member stated we have been short staffed here often and it is hard to keep up with everyone's needs as quickly, but we get it done. During an interview on 3/19/26, at approximately 10:19 a.m. when if she felt the facility maintained sufficient staffing, Resident R64 stated, Could use another one Resident R64 further stated he has been incontinent waiting for assistance to urinate.During an interview on 3/19/26, at approximately 10:36 a.m. when asked about call light response time, he stated, Most of the time long. Observation at this time revealed Resident R23 to have long, curled over fingernails with a brown substance underneath the nails.During an interview on 3/19/26, at approximately 2:50 p.m. when if she felt the facility maintained sufficient staffing, Resident R40 stated, Sometimes not and Not a lot of people here. Resident R40 further stated she has often waited 30 minutes for call light response.During an interview on 3/20/26, at 9:00 a.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms (A/B Nursing Unit).Findings include: Review the facility policy Medication Storage in the Facility dated [DATE], indicated that outdated, contaminated, or deteriorated items will be removed from stock. During an observation of the A/B nursing unit medication room on [DATE], at approximately 12:32 p.m. the following was observed: (42) 25-gauge needles with an expiration date of [DATE].(2) 25-gauge needles with an expiration date of [DATE].(1) insulin syringe without sterile wrapping.(41) 22-gauge safety syringes with an expiration date of [DATE].(37) viral transport swabs with an expiration date of [DATE].(15) 5 milliliter syringes with an expiration date of [DATE].(1) saline enema with an expiration date of 02/2026.(2) feeding tube connector sets with an expiration date of [DATE].(1) specimen collection set with an expiration date of [DATE].(5) vacutainer collection winged needles with an expiration date of [DATE].(42) 25-gauge needles with an expiration date of [DATE]. Observation of the cabinet below the medication room sink revealed a bag of Resident R31's medications in community pharmacy bottles and weekly paper dispense kits. Observation of a shelf in the medication room revealed personal daily pill planner sets with multiple medications in the compartments, without a resident name or description of the medications. Observation of the medication refrigerator temperature log from [DATE], through [DATE], revealed temperatures measurements not documented on:[DATE]: 2, 7, 10, 11, 12, 16, 21, 24, 25, 26, 27, 28, 29, 30, 31.February 2026: 1, 2, 3, 4, 8, 12, 13, 17, 22, 23, 27.[DATE]: 4, 9. During an interview on [DATE], at approximately 1:00 p.m. the Licensed Practical Nurse Employee E9 confirmed the above medical supplies were expired. During an interview on [DATE], at approximately 1:05 p.m. the Director of Nursing confirmed it was unknown who the medications in the personal pill dividers belonged to and confirmed the missing dates on the refrigerator temperature log. During an interview on [DATE], at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility documents and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E6 and E7).Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, Nursing Assistants are required to have 12 hours of training per year calculated from their date of hire. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. with approximately 2.00 hours in-service education between 1/9/25, through 1/9/26. Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23 with 6.50 hours in-service education between1/10/25, through 1/10/26. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for five of sixteen residents (Resident R9, R30, R74, R502, and R504).Findings include: Review of the Resident Rights policy last reviewed 12/2/25, indicated that the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Manor. The Manor will protect and promote the rights of each resident, including: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident 's individuality. The facility must protect and promote the rights of the resident. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of Resident R74's clinical record indicated admission to the facility on 6/5/20. Review of Resident R74's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/13/25, indicated diagnoses of heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), anxiety disorder (intense, excessive, and persistent feelings of worry, fear, and uneasiness), and anemia (lack of healthy red blood cells, leading to insufficient oxygen delivery to the body's tissues) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R74 requires partial/moderate assistance, (helper does less than half the effort) and GG0170 toilet transfers, independent (no assistance). Review of a grievance filed on behalf of Resident R74, dated 10/30/25, revealed concerns documented for care. Resident requested to go to bed after bingo, staff were sitting at the nurse's station and would not place resident into bed. Review of Resident R30's clinical record indicated admission to the facility on 7/1/24. Review of Resident R30's MDS dated [DATE], indicated diagnoses of cerebrovascular accident (stroke, when blood flow to part of the brain is interrupted leading to brain cell death), anxiety disorder (intense, excessive, and persistent feelings of worry, fear, and uneasiness), and depression (feelings of sadness and loss of interest in activities) a BIMS of 3. Review of Section GG: Functional Abilities GG0130, indicated that Resident R30 is dependent on toilet hygiene (helper does all the effort) and GG0170 toilet transfers, not attempted, resident was unable to perform this activity prior to admission. Review of a grievance filed on behalf of Resident R30, dated 11/10/25, revealed concerns documented for care. Resident R30 sister complained of resident having dried feces on her feet and around her colostomy bag. Review of Resident R9's clinical record indicated admission to the facility on 1/30/26 and discharged [DATE]. Review of Resident R9's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD progressive lung disease makes it difficult to breathe), diabetes mellitus (body cannot properly use or make insulin), and hypertension (high blood pressure) a BIMS of 9. Review of Section GG: Functional Abilities GG0130, indicated that Resident R9 is dependent on toilet hygiene (helper does all the effort) and GG0170 toilet transfers not attempted due to medical condition or safety concerns. Review of a grievance filed on behalf of Resident R9, dated 2/5/26, revealed concerns documented for care. Resident had a bowel movement and soiled her wound dressing. Resident had reportedly been told the dressing was already changed today, we can't do it again. The resident's sheets had not been changed for a week and had crumbs on them and the resident's hair was not washed. Review of Resident R502's clinical record indicated admission to the facility on 9/17/24. Resident R502 requested confidentiality. Review of Resident R502's MDS dated [DATE], indicated diagnoses of heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), diabetes mellitus (body cannot properly use or make insulin), and hypertension (high blood pressure) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R502 requires setup or clean-up assistance with toilet hygiene (helper prior to or following the activity) and GG0170 toilet transfers, not attempted, resident was unable to perform this activity prior to admission. During an interview with Resident R502 on 3/17/25 at approximately 10:30 a.m., the resident expressed concerns over call light wait times and that he had to wait extended periods when he needed to go to the bathroom and had soiled himself and had to wait thirty to sixty minutes for help to get cleaned up. Review of Resident R504's clinical record indicated admission to the facility on 2/5/26. Resident R504 requested confidentiality. Review of Resident R504's MDS dated [DATE], indicated diagnoses of heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), diabetes mellitus (body cannot properly use or make insulin), and anxiety disorder (intense, excessive, and persistent feelings of worry, fear, and uneasiness) a BIMS of 12. Review of Section GG: Functional Abilities GG0130, indicated that Resident R502 requires partial/moderate assistance, (helper does less than half the effort) and GG0170 toilet transfers, requires partial/moderate assistance, (helper does less than half the effort). During an interview with Resident R504 on 3/17/25 at approximately 11:30 a.m., the resident expressed concerns over staffing and call light wait times. Resident R504 reported on more than one occasion he had soiled himself and had to wait more than an hour to get cleaned up. During an interview on 3/20/26, at 9:00 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that care was provided in a manner which maintained resident dignity. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility documents, resident and staff interviews, observation, and clinical record review, it was determined that the facility failed to obtain routine services from an eye care professional and failed to accurately document the need for vision care for one of five residents (Resident R12).Findings include: Review of the Facility Assessment dated 10/22/25, indicated the facility will provide vision care for vision loss, cataracts, glaucoma, and macular degeneration. Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/5/26, included diagnoses of Parkinsonism (group of neurological disorders characterized by tremors, stiffness, slowness of movement, and difficulty maintaining balance), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and a seizure disorder. Section B: Hearing, Speech, and Vision indicated that Resident R12 does not use corrective lenses. Review of the plan of care most recently reviewed 12/30/25, did not include goals and/or interventions related to the use of corrective lenses. Review of a physician's order dated 4/24/25, discontinued 2/1/26, indicated, May be seen by the Audiologist, Dentist, Podiatrist, Optometrist, and Ophthalmologist. Review of facility census information revealed Resident R12 was hospitalized on [DATE], and the order for vision services was not renewed upon return to the facility on 2/4/26. During an interview on 3/18/26, at approximately 2:15 p.m. Resident R12 stated she needed to have new eyeglasses. Review of Resident R12's clinical record failed to reveal documentation that Resident R12 has been assessed by a vision provider since admission. During a second interview on 3/20/26, at approximately 10:00 a.m. Resident R12 confirmed that she needed new eyeglasses and directed the surveyor to look at her current glasses. Observation at this time revealed Resident R12 had prescription bifocals, with only one lens in the eyeglass frame. During an interview on 3/20/26, at approximately 1:30 p.m. facility administration stated that the eyeglasses in Resident R12's room were her old pair, and she had a new pair that were currently being repaired. At this time, the surveyor asked for documentation of the repair and any vision care provided. No additional information was provided by the facility. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to obtain routine services from an eye care professional and failed to accurately document the need for vision care for one of five residents. 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 documents and staff interview, it was determined that the facility failed to provide training on the prevention of abuse, neglect, and exploitation for five of ten staff members (Employees E2, E3, E5, E6, and E7).Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Abuse, Neglect, and Misappropriation and Reporting Crimes Pursuant to the Elder Justice Act.Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on the prevention of abuse, neglect, and exploitation.Review of Licensed Practical Nurse Employee E3's facility provided staff list indicated she was hired on 2/12/19. Review of RN Employee E3's training record for 2/12/25, through 2/12/26, did not include training on the prevention of abuse, neglect, and exploitation.Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on the prevention of abuse, neglect, and exploitation.Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on the prevention of abuse, neglect, and exploitation.Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23. Review of NA Employee E7's training record for 1/10/25, through 1/10/26, did not include training on the prevention of abuse, neglect, and exploitation.During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on the prevention of abuse, neglect, and exploitation for five of ten staff members.28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on infection control for four of ten staff members (Employees E2, E5, E6, and E7).Findings include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Prevention and Control of Infections / Standard Precautions. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on infection control. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on infection control. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on infection control. Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23. Review of NA Employee E7's training record for 1/10/25, through 1/10/26, did not include training on infection control. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on infection control for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were completed in the required time frame for four of 22 residents (Resident R14, R25, R27, and R31).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date plus 13 calendar days), and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R14 had an ARD of 8/11/25, with an MDS completion date of 8/26/25 (15 days later). Resident R25 had an ARD of 8/5/25, with an MDS completion due date of 8/20/25 (15 days later). Resident R27 had an admission date of 9/22/25, with an MDS completion due date of 10/8/25 (16 days later). Resident R31had an ARD of 8/5/25, with an MDS completion date of 8/20/25 (15 days later). During an interview on 3/19/26, at 2:27 p.m. the Resident Nurse Assessment Coordinator Employee E8 confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for four of 22 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication for four of ten direct care staff members (Employees E2, E5, E6, and E7).Findings include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Review of Registered Nurse (RN) Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on effective communication. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on effective communication. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on effective communication. Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23. Review of NA Employee E7's training record for 1/10/25, through 1/10/26, did not include training on effective communication. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for five of ten staff members (Employees E2, E3, E4, E5, and E6).Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on the QAPI Program. Review of Licensed Practical Nurse Employee E3's facility provided staff list indicated she was hired on 2/12/19. Review of RN Employee E3's training record for 2/12/25, through 2/12/26, did not include training on the QAPI Program. Review of the Activity Employee E4's facility provided staff list indicated she was hired on 2/16/10. Review of Activity Employee E4's training record for 2/16/25, through 2/16/26, did not include training on the QAPI Program. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on the QAPI Program. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on the QAPI Program. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on the QAPI Program for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on compliance and ethics for three of ten staff members (Employees E2, E5, and E6).Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on on compliance and ethics. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on compliance and ethics. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on compliance and ethics. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on compliance and ethics for three of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on behavioral health for four of ten staff members (Employees E2, E5, E6, and E7).Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Care of Cognitively Impaired Residents and Dementia Training. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on behavioral health. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on behavioral health. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on behavioral health. Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23. Review of NA Employee E7's training record for 1/10/25, through 1/10/26, did not include training on behavioral health. During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on behavioral health for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on resident rights for five of ten staff members (Employees E2, E3, E5, E6, and E7).Findings include:Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Resident Rights and Confidentiality.Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on resident rights.Review of Licensed Practical Nurse Employee E3's facility provided staff list indicated she was hired on 2/12/19. Review of RN Employee E3's training record for 2/12/25, through 2/12/26, did not include training on resident rights.Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on resident rights.Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. Review of NA Employee E6's training record for 1/9/25, through 1/9/26, did not include training on resident rights.Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23. Review of NA Employee E7's training record for 1/10/25, through 1/10/26, did not include training on resident rights.During an interview on 3/20/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on resident rights for five of ten staff members.28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(c) Staff development.

Based on facility policy, document review, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for ten of twenty residents who require care (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Based on facility policy, document review, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for ten of twenty residents who require care (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings included: Review of facility policy Resident Rights last reviewed 12/4/24, indicated in part The resident has a right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the Manor. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairmentReview of the clinical record revealed Resident R1 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of cerebral infarction (stroke) and post-traumatic stress disorder (PTSD mental health condition caused by extremely stressful or terrifying event). Review of Section C: Cognitive Patterns, indicated, severe impairment with a BIMS Score of 3. Review of Section GG: 0130 Functional Abilities, indicated Resident R1 required substantial/maximal assistance with toileting hygiene (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Review of facility records revealed Resident R1 on 5/2/25, filed a grievance related to the wait time for the call light response. Resident R1's grievance reads in part he waited a very long time; no one would come to help me to the bathroom. Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], dementia (loss of thinking, remembering and reasoning skills) and pressure ulcer (damage to the skin and/or underlying tissue due to pressure on the skin). Review of Section C: Cognitive Patterns, indicated, severe impairment BIMS Score could not be assessed, resident is rarely/never understood. Review of Section GG: 0130 Functional Abilities, indicated Resident R2 is dependent with toileting hygiene (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R2 on 5/2/25, sister filed a grievance related to care. Resident R2's grievance reads in part, family came in to visit, was in bed with clothing on upper body, no brief or clothes on. The bed was completely soiled, resident laying in feces apparently no one attended to him in a while. Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing) and chronic pain syndrome. Review of Section C: Cognitive Patterns, indicated severe impairment with a BIMS Score could not be assessed, resident is rarely/never understood. Review of Section GG: 0130 Functional Abilities, indicated Resident R3 is dependent with hygiene including dressing (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R3 on 5/6/25, daughter filed a grievance related to care. Resident R3's grievance reads in part, mom is still in her bed clothes, why is she not dressed. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing) and chronic pain syndrome. Review of Section C: Cognitive Patterns, indicated severe impairment with a BIMS Score of 6. Review of Section GG: 0130 Functional Abilities, indicated Resident R4 is dependent with hygiene including dressing. Review of Section GG: 0170 Mobility, indicated Resident is dependent with chair and bed transfers (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R4 on 5/6/25, Power of Attorney (POA) filed a grievance related to care. Resident R4's grievance reads in part, POA was upset because she had requested that Resident R4 be up and out of bed right after breakfast and Resident R4 was still in bed at 12:30 p.m . Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cellulitis of lower limb (bacterial infection of the skin), diabetes with a foot wound, and atherosclerosis of coronary artery bypass graph (hardening of arteries). Review of Section C: Cognitive Patterns, indicated, cognitively intact with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R5 required partial/moderate assistance with toileting hygiene (helper does less than half the effort. Helper lifts or holds or supports trunk or limbs but provides less than half the effort). Review of facility records revealed Resident R5 on 6/24/25, has a grievance that reads in part, resident is constantly wet and her behind in very red and hurts. She is worried about infection. Review of the clinical record revealed Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of parkinson's disease (brain disorder that affects movement), anorexia (eating disorder), and muscle weakness. Review of Section C: Cognitive Patterns, indicated, cognitively intact with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R6 is dependent with toileting hygiene (helper does all the effort). Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R6 on 7/23/25, and spouse had a grievance that reads in part, the call light not answered for long periods, resident is having accidents because she can't wait. She should not go by herself, but the light is frequently not answered in a timely manner. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cellulitis of lower limb (bacterial infection of the skin), uterine cancer (cancer of the female reproductive system), and muscle weakness. Review of Section C: Cognitive Patterns, this portion not completed at this time. Review of Section GG: 0130 Functional Abilities, this portion not completed at this time. Review of facility records revealed Resident R7 on 7/27/25, daughter had a grievance that reads in part, mother called me last night crying was put on a bed pan for more than an hour without being shown where her call bell was placed, she was yelling for someone to come in and help her. Review of the clinical record revealed Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of acute respiratory failure with hypoxia (not enough oxygen in your blood) amaurosis fugax (temporary loss of vision due to disruption of blood flow to the eye) and obesity. Review of Section C: Cognitive Patterns, indicated moderate impairment with a BIMS Score of 9. Review of Section GG: 0130 Functional Abilities, indicated Resident R8 is dependent with toileting hygiene (helper does all the effort). Review of Section GG: 0170 Mobility, indicated Resident R8 required substantial/maximal assistance with toilet transfers (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). During an interview with Resident R8 on 7/30/25, at 10:00 a.m. the following was stated: Often you wait a while for someone when you call for help to go to the bathroom. I have waited an hour on a few occasions recently. Review of the clinical record revealed Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of parkinson's disease (brain disorder that affects movement), muscle weakness and pressure ulcer (damage to the skin and/or underlying tissue due to pressure on the skin). Review of Section C: Cognitive Patterns, cognitively intact with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R9 is dependent with toileting hygiene (helper does all the effort). Review of Section GG: 0170 Mobility, indicated Resident R9 required partial/moderate assistance with toileting hygiene (helper does less than half the effort. Helper lifts or holds or supports trunk or limbs but provides less than half the effort). During an interview with Resident R9 on 7/30/25, at 10:15 a.m. the following was stated: there is about a half an hour wait when you push the call button, sometimes it hard to wait that long. Review of the clinical record revealed Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cardiomyopathy (difficulty for the heart to pump blood), sleep apnea and left bundle branch block (disruption to normal electrical impulses that control the heart). Review of Section C: Cognitive Patterns, moderately impaired with a BIMS Score of 10. Review of Section GG: 0130 Functional Abilities, indicated Resident R10 is dependent with toileting hygiene (helper does all the effort). Review of Section GG: 0170 Mobility, indicated Resident R10 required partial/moderate assistance with toileting hygiene (helper does less than half the effort. Helper lifts or holds or supports trunk or limbs but provides less than half the effort). During an interview with Resident R10 on 7/30/25, at 10:30 a.m. the following was stated: you have to wait anywhere between a half hour to an hour when you ask for help, I can't do things for myself, like go to the bathroom on my own, you have to rely on others. During an interview with Employee E2 RN on 7/30/25 at 9:00 a.m. the following was stated: Residents aren't getting the care they should be due to the staffing. Resident care and outcomes are impacted. During an interview with Employee E4 LPN on 7/30/25 at 9:30 a.m. the following was stated: Residents' care is impacted due to the amount of staffing. During an interview on 7/30/25, at approximately 3:40 p.m. the Nursing Home Administrator confirmed the facility failed to provide an environment and care to promote dignity for each resident's quality of life for ten of twenty residents. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services 28 Pa. Code 201.29 (j) Resident Rights

Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly by failing to utilize a mechanical lift as per order, resulting in actual harm when the resident suffered a fall which caused a left knee fracture that required surgery for one of five residents (Resident R1). A review of the facility policy Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy reviewed 12/6/23, defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and obesity. A review of the Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 2/13/23, Indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section G: Functional Status; G0110: Activities of Daily Living (ADL) Assistance, B Transfer, indicated Resident R1 required extensive assistance; G0300: Balance During Transitions and Walking, E: Surface-to-surface transfer indicated she was not steady, only able to stabilize with staff assistance; Section GG: Functional Abilities and Goals D, E, and F, indicated Resident R1 required substantial/maximum assistance for sit to stand, chair/bed-to-chair transfer, and toilet transfers. A review of a physician order dated 3/16/23, indicated transfer training as per care plan. A review of the care plan dated 3/14/23, indicated Resident R1 required a sit-to-stand lift with assist of two for transfers. Further review of the care plan indicated Resident R1 was at risk for comfort due to right hip pain, and a moderate risk for falls due to bilateral lower leg weakness. A review of the Kardex dated 5/10/23, indicated Resident R1 required sit-to-stand lift with assistance of 2 staff for transfers. A review of facility documents dated 5/10/23, at 8:35 a.m. indicated Resident R1 was being transferred to the bedside commode using the sit-to-stand lift with assistance of one employee, Nurse Aide (NA) Employee E1. Resident R1's left knee gave out and she was lowered to the floor. On assessment, Resident R1's left leg was noted to be laterally rotated (movement of a joint away from the body) from the proximal (near to the center of the body) knee to distal (away from the center of the body) foot. A review of a witness statement dated 5/10/23, NA Employee E1 stated I don't know why I did it by myself. A review of a progress note dated 5/10/23, at 12:13 p.m. indicated Resident R1 had a fractured kneecap requiring surgery. A review of the care plan dated 10/4/22, indicated Resident R1 was at risk for falls due to unsteady gait/slid from wheelchair and to encourage to transfer and change positions slowly, had generalized pain due to arthritis, and was at risk for loss of range of motion related to physical limitation and left sided weakness. Further review of the care plan dated 11/2/22, indicated the resident had a self-care deficit and to encourage wheelchair mobility, was at risk for falls. A review of the hospital discharge summary dated 5/12/23, confirmed Resident R1 underwent surgery to the left leg. A review of facility documents indicated NA Employee E1 completed abuse/neglect training on 3/18/23, and 5/9/23, and completed mechanical lift training on 3/23/23. During an interview on 5/18/23, at 11:00 a.m. NA Employee E2 stated she always has help when using a mechanical lift and would never use one by herself and would look up the resident's transfer status in the Kardex. She denied being asked for help from NA Employee E1. During an interview on 5/18/23, at 11:05 a.m. NA Employee E3 stated she inspects the lift pads and finds another employee to help when using a lift and would never use a mechanical lift by herself and would look up the resident's transfer status in the Kardex. She denied being asked for help from NA Employee E1. During an interview on 5/18/23, at 11:07 a.m. NA Employee E4 stated she always has two people when using the mechanical lifts. She would look in the computer or ask the nurse about the resident's transfer status. During an interview on 5/18/23, at 11:09 a.m. NA Employee E5 stated she uses two staff to use the mechanical lift and would never use it on her own, she would wait until another staff member was available before using the lift. She would look in the Kardex or ask a nurse what is the resident's transfer status. During an interview on 5/18/23, at 11:12 a.m. NA Employee E6 stated she always checks the equipment and pads, always has another staff member, and would never use the mechanical lift by herself, and would look up the resident's transfer status in the Kardex. During an interview on 5/18/23, at 11:15 a.m. NA Employee E7 stated she would never use the mechanical lift by herself, she always gets another staff member to help her, and would look up the resident's transfer status in the Kardex. During an interview on 5/18/23, at 11:17 a.m. NA Employee E8 stated she always gets two people to use the mechanical lifts, and she would run to get someone if it was urgent. She denied being asked to assist Student NA Employee E1 with the mechanical lift. She would ask the nurse, therapy department, or look in the Kardex to find the resident transfer status. During an interview on 5/18/23, at 11:20 a.m. NA Employee E9 stated it always requires an assist of two staff to use the mechanical lifts, and she would never use it by herself no, never, that's a big no-no. She denied being asked to assist Student NA Employee E1 with the mechanical lift on 5/10/23. She stated she would look in the Kardex or ask the nurse for the resident's transfer status. Interviews on 5/18/23, with NA Employee E2, NA Employee E3, NA Employee E4, NA Employee E5, NA Employee E6, NA Employee E7, and NA Employee E8 all indicate that all mechanical lifts and/or transfers in the facility always require an assist of two staff. The interview also indicated that they all know where to find the transfer status if they are unaware. During a telephone interview on 5/19/23, at 11:08 a.m. NA Employee E1 stated Resident R1 was on the bed, she set her up for the sit-to-stand to put her on the bedside commode, then stepped out of the room and went to get someone to help. NA Employee E9 stated she would come to the resident's room for assistance. NA Employee E1 went back to the resident's room and Resident R1 was sliding off the bed and her left knee made a cracking sound. Resident R1 told her that she would not be able to stand and NA Employee E1 lowered her to the floor with the lift. She stated, It happened so fast, I think she's (Resident R1) a two assist. NA Employee E1 stated she would look at the Kardex on the computer to find the resident's transfer status, and stated she was trained on abuse/neglect, and using the mechanical lifts requiring assistance of two staff. This interview on 5/19/23, with NA Employee E1 confirmed that Resident R1 did not receive the services as ordered and this neglect of an improper transfer resulted in a fall and Resident R1 sustained a fracture to the left knee. During an interview on 5/18/23, at 2:00 p.m. the Director of Nursing confirmed the facility failed to prevent injury while transporting a resident using a mechanical lift resulting in actual harm for Resident R1. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 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. 28 Pa Code: 211.11 Resident care plan.

Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide adequate supervision, implement effective fall interventions, and utilize a mechanical lift as per order to promote resident safety resulting in actual harm of a resident (Resident R1) which resulted in a left knee fracture that required surgery for one of five residents. Findings include: The facility does not have policies for use of mechanical lifts, transfers, or Activities of Daily Living. They use staff competency checklists to ensure employee knowledge. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and obesity. A review of the Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 2/13/23, Indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section G: Functional Status; G0110: Activities of Daily Living (ADL) Assistance, B Transfer, indicated Resident R1 required extensive assistance; G0300: Balance During Transitions and Walking, E: Surface-to-surface transfer indicated she was not steady, only able to stabilize with staff assistance; Section GG: Functional Abilities and Goals D, E, and F, indicated Resident R1 required substantial/maximum assistance for sit to stand, chair/bed-to-chair transfer, and toilet transfers. A review of a physician order dated 3/16/23, indicated transfer training as per care plan. A review of the care plan dated 3/14/23, indicated Resident R1 required a sit-to-stand lift with assist of two for transfers. Further review of the care plan indicated Resident R1 was at risk for comfort due to right hip pain, and a moderate risk for falls due to bilateral lower leg weakness. A review of the Kardex dated 5/10/23, indicated Resident R1 required sit-to-stand lift with assistance of 2 staff for transfers. A review of facility documents dated 5/10/23, at 8:35 a.m. indicated Resident R1 was being transferred to the bedside commode using the sit-to-stand lift with assistance of one employee, Nurse Aide (NA) Employee E1. Resident R1's left knee gave out and she was lowered to the floor. On assessment, Resident R1's left leg was noted to be laterally rotated (movement of a joint away from the body) from the proximal (near to the center of the body) knee to distal (away from the center of the body) foot. A review of a witness statement dated 5/10/23, NA Employee E1 stated I don't know why I did it by myself. A review of a progress note dated 5/10/23, at 12:13 p.m. indicated Resident R1 had a fractured kneecap requiring surgery. A review of the care plan dated 10/4/22, indicated Resident R1 was at risk for falls due to unsteady gait/slid from wheelchair and to encourage to transfer and change positions slowly, had generalized pain due to arthritis, and was at risk for loss of range of motion related to physical limitation and left sided weakness. Further review of the care plan dated 11/2/22, indicated the resident had a self-care deficit and to encourage wheelchair mobility, was at risk for falls A review of the hospital discharge summary dated 5/12/23, confirmed Resident R1 underwent surgery to the left leg. A review of facility documents indicated NA Employee E1 completed abuse/neglect training on 3/18/23, and 5/9/23, and completed mechanical lift training on 3/23/23. During an interview on 5/18/23, at 11:00 a.m. NA Employee E2 stated she always has help when using a mechanical lift and would never use one by herself, and would look up the resident's transfer status in the Kardex. She denied being asked for help from NA Employee E1. During an interview on 5/18/23, at 11:05 a.m. NA Employee E3 stated she inspects the lift pads and finds another employee to help when using a lift and would never use a mechanical lift by herself, and would look up the resident's transfer status in the Kardex. She denied being asked for help from NA Employee E1. During an interview on 5/18/23, at 11:07 a.m. NA Employee E4 stated she always has two people when using the mechanical lifts. She would look in the computer or ask the nurse about the resident's transfer status. During an interview on 5/18/23, at 11:09 a.m. NA Employee E5 stated she uses two staff to use the mechanical lift and would never use it on her own, she would wait until another staff member was available before using the lift. She would look in the Kardex or ask a nurse what is the resident's transfer status. During an interview on 5/18/23, at 11:12 a.m. NA Employee E6 stated she always checks the equipment and pads, always has another staff member, and would never use the mechanical lift by herself, and would look up the resident's transfer status in the Kardex. During an interview on 5/18/23, at 11:15 a.m. NA Employee E7 stated she would never use the mechanical lift by herself, she always gets another staff member to help her, and would look up the resident's transfer status in the Kardex. During an interview on 5/18/23, at 11:17 a.m. NA Employee E8 stated she always gets two people to use the mechanical lifts, and she would run to get someone if it was urgent. She denied being asked to assist Student NA Employee E1 with the mechanical lift. She would ask the nurse, therapy department, or look in the Kardex to find the resident transfer status. During an interview on 5/18/23, at 11:20 a.m. NA Employee E9 stated it always requires an assist of two staff to use the mechanical lifts, and she would never use it by herself no, never, that ' s a big no-no. She denied being asked to assist Student NA Employee E1 with the mechanical lift on 5/10/23. She stated she would look in the kardex or ask the nurse for the resident's transfer status. During a telephone interview on 5/19/23, at 11:08 a.m. NA Employee E1 stated Resident R1 was on the bed, she set her up for the sit-to-stand to put her on the bedside commode, then stepped out of the room and went to get someone to help. NA Employee E9 stated she would come to the resident's room for assistance. NA Employee E1 went back to the resident's room and Resident R1 was sliding off the bed and her left knee made a cracking sound. Resident R1 told her that she would not be able to stand and NA Employee E1 lowered her to the floor with the lift. She stated, It happened so fast, I think she's (Resident R1) a two assist. NA Employee E1 stated she would look at the Kardex on the computer to find the resident's transfer status, and stated she was trained on abuse/neglect, and using the mechanical lifts requiring assistance of two staff. During an interview on 5/18/23, at 2:00 p.m. the Director of Nursing confirmed the facility failed to prevent injury while transferring a resident using a mechanical lift resulting in actual harm for Resident R1. 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. 28 Pa Code: 211.11 Resident care plan.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm for one of three residents reviewed (Resident R85), which resulted in actual harm of a knee fracture to Resident R85. This was identified as harm for past non-compliance for one resident (Resident R85). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility document entitled, Abuse, Neglect, Exploitation & Misappropriation of Resident Personal Property dated 12/6/22, stated the facility will not tolerate neglect of its residents. Review of Resident R85's admission record indicated she was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R85's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 1/17/23, indicated diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination) and Guillain-Barre syndrome (disorder where the immune system attacks the nerves, eventually paralyzing the whole body). Review of Section G - Functional Status, Questions G0110B, ADL Assistance for Transfer, indicated that Resident R85 required extensive assistance of two or more staff members. Review of the physician's current orders on 3/3/23, failed to reveal a physician's order specifying Resident R85's required assistance level. Review of Resident R85's plan of care for ADL (activities of daily living) Self-care performance deficit related to limited mobility, weakness initiated 9/30/22, updated 10/3/22, indicated Resident R85 required Mechanical Lift with A (assistance) x 2 participation with transfers. Review of Resident R85's Nurse Aide (NA) Task List (Listing of ADLs, continence levels, and behaviors, which generates directly from the resident care plan) utilized by nurse aide staff dated 10/7/22, indicated that Resident R85 as Transferring via Mechanical Lift with Assist x2. Review of Resident R85's Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 2/1/23, through 3/2/23, Resident R85 had transfer documented on 45 times, with 43 of those times (approximately 95%) documented has having required two persons and a mechanical lift. Review of a progress note written by Registered Nurse (RN) Employee E3 dated 3/3/23, at 9:45 a.m. indicated that Resident R85 reported pain 9/10 to left knee and stated, I heard a pop last night while being put to bed. Resident alert and oriented. able to make needs known. refuses medications. Review of a progress note written by RN Employee E3 dated 3/3/23, at 1:12 p.m. indicated Resident R85 had sustained an acute lateral tibial plateau fracture (a new break of the larger leg bone below the knee, that breaks into the knee joint itself). Review of a progress note written by RN Employee E4 dated 3/3/23, at 7:19 p.m. indicated that Resident R85 returned to the facility with a knee immobilizer on her left leg. Review of an employee statement written by NA Employee E5 dated 3/3/23, revealed Resident when being placed in bed her left leg/knee popped. Then once in bed when roller her opposite knee (right) popped. Resident mentioned slight pain in leg once pillow were placed under her leg. Resident was transferred by myself as an Ax1 (assist of one). Review of a facility report form for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property dated 3/6/23, indicated on On 3/2/23 Nurse Aide Employee E5 transferred Resident R85 into bed with the assist of one, both the resident and the nurse aide heard a popping/cracking noise. The resident is a mechanical lift with assist of two for transfers. Nurse aide bear hugged the resident and assisted into bed. Immediately pain to the left knee as per the resident. Nurse aide did not inform anyone regarding pain or noise heard. The next morning resident complained of pain to the left knee nine of ten. Order obtained to get a stat x-ray of the left knee revealing an acute lateral tibial plateau fracture. Further review of this report indicated the facility found that NA Employee E5 failed to follow the plan of care for this resident and was terminated. The conclusion was indicated to be substantiated abuse. During an interview on 4/12/23, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to protect a resident from neglect that resulted in actual harm for one of three residents which resulted in actual harm of a knee fracture to Resident R85. On 3/3/23, the facility initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure that ordered transfer guidelines were understood and followed appropriately. This plan included the following: -Immediate termination of NA Employee E5. -Facility completed a full house audit to ensure correct transfer statuses were documented for each resident. -Education was provided on 3/28/23, to all nursing staff on abuse and neglect. -Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes. The facility has demonstrated compliance with the regulation since 3/28/23. During an interview on 4/14/23, at 4:00 p.m. with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident neglect. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record reviews, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that pain control interventions were attempted prior to wound care being provided, which resulted in harm to one of two residents reviewed (Resident R1) by causing her severe pain during wound care. The facility also failed to follow the physician's orders [REDACTED]. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated January 26, 2017, revealed that the resident was confused and required extensive assistance from staff for care. A physician's consultation report, dated February 18, 2017, indicated that the resident's right lower extremity was cool and painful to touch, particularly in the calf and the foot. A recap of the physician's orders [REDACTED]. There was also an order [REDACTED]. Super Absorbent (a foam dressing with a silicon adhesive border for easy removal). The resident's right buttock wound was to be cleaned with NSS, patted dry, [MEDICATION NAME] was to be applied, and then the wound was to be covered with [MEDICATION NAME] dressing. physician's orders [REDACTED]. Resident R1's care plan, dated February 27, 2017, indicated that the resident had wounds on her buttocks and right lower leg, and had pain whenever she was touched. The care plan indicated that the resident wished to be as comfortable as possible, and that she was to be offered pain medication before having any wound care treatments done. Observations on February 28, 2017, at 10:10 a.m. revealed that Licensed Practical Nurse 1 performed a wound care treatment to Resident R1's left AKA site. The observations revealed that the previously applied dressing was secured with tape which touched the resident's skin, and there was no [MEDICATION NAME] in place as ordered. As the nurse started to remove the tape from the resident's skin, the resident started yelling out, God help me, that hurts! and, Please don't do any more, I can't stand the pain! The resident continued to yell, and then to cry, as the nurse removed all of the tape. Observations on February 28, 2017, at 10:20 a.m. revealed that Nurse Aides 3 and 4 assisted Licensed Practical Nurse 1 with repositioning Resident R1, while the nurse completed a wound treatment to the resident's buttocks. While the resident was rolled onto her right side, she yelled, God help me, it hurts! and, Where is my husband, he would help me if he was here. The resident also cried during the treatment. Observations on February 28, 2017, at 10:25 a.m. revealed that Licensed Practical Nurse 1 removed the old dressing from Resident R1's lower right leg while the leg was held in an elevated position by Nurse Aide 3. As the Licensed Practical Nurse cleaned the wound and applied [MEDICATION NAME] and the dressing, the resident cried and yelled, God help me that hurts! and, Please stop, it hurts! Review of Resident R1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Interview with Resident R1 on February 28, 2017, at 11:17 a.m. revealed that it hurt when the tape was pulled off her skin. Interview with Licensed Practical Nurse 1 on February 28, 2017, at 11:45 a.m. confirmed that the dressing on Resident R1's left AKA wound was secured with tape, and there was no [MEDICATION NAME] on the wound as ordered, and there should have been. Interview with Licensed Practical Nurse 2 on February 28, 2017, at 11:20 a.m. revealed that the wound nurse who normally did treatments on Resident R1's unit would notify her ahead of time to pre-medicate Resident R1 prior to wound care being done. She stated that the usual wound nurse was not present and that Licensed Practical Nurse 1 never informed her of the time that wound care was to be done for Resident R1, so she did not offer Resident R1 pain medication prior to Licensed Practical Nurse 1 completing the wound treatments. Interview with the Director of Nursing on February 28, 2017, at 12:45 p.m. confirmed that the dressing on Resident R1's left AKA wound should have been secured with [MEDICATION NAME] and not with tape. She indicated that Resident R1 had pain in her leg and that she should have been pre-medicated for pain prior to wound treatments being completed by Licensed Practical Nurse 1. An admission [DIAGNOSES REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. The resident's wound was to be cleaned with soap and water and then a calcium alginate with silver dressing (a dressing that provide antimicrobial action to prevent infection, and absorbs drainage and maintains a moist environment to promote rapid healing) was to be applied to the wound bed. The wound was then to be covered with an ABD (large gauze dressing) and then skin prep (creates a protective film, which would make it easier to remove tape) was to be applied to the periwound (the area around the wound), and the dressing was to be secured with [MEDICATION NAME] tape (adhesive tape for securing dressings). There was no documentated evidence that staff changed the resident's wound dressing daily as ordered on February 21, 2017. Interview with the Director of Nursing on February 28, 2017, at 1:10 p.m. confirmed that there was no documented evidence that staff changed Resident R2's wound dressing as ordered on February 21, 2017. physician's orders [REDACTED]. to the wound bed, then for the wound to be covered with an Xtrasorb dressing (absorbent dressing). The wound was then to be covered with an ABD (large gauze dressing) and skin prep was to be applied to the periwound, and the dressing was to be secured with [MEDICATION NAME] tape. Wound documentation for Resident R2, dated February 27, 2017, revealed that the resident's buttock wound measured 30 x 18 centimeters (cm) (approx. 12.0 x 7.2 inches). Observations of wound care for Resident R2, on February 28, 2017, at 9:35 a.m. revealed that Licensed Practical Nurse 1 cleansed the wound then applied a calcium alginate dressing over the wound bed, leaving an approximately four by one inch area of the wound to the right upper aspect uncovered by the dressing. The nurse then applied one (6 x 9 inch) Xtrasorb dressing over the wound area, which did not fully cover the wound (which was approximately 12.0 by 7.2 inches), and then she placed ABD pads over the wound and secured the dressings with [MEDICATION NAME] tape without first applying skin prep to the periwound area as ordered. Interview with Licensed Practical Nurse 1 on February 28, 2017, at 10:00 a.m. confirmed that she did not fully cover Resident R2's buttock wound, and she did not use skin prep to the area around the wound as ordered. 42 CFR 483.24, 483.25(k)(1) Provide Care/Services for Highest Well Being. Previously cited 11/10/16. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/10/16, 6/16/16, 5/9/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 6/16/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/10/16, 8/24/16, 6/16/16, 5/9/16, 4/12/16, 12/13/15.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete an assessment for potential safety hazards with the use of air mattresses on residents' beds for seven of seven residents reviewed (Residents CR1, R2, R3, R4, R5, R6 and R7), resulting in a fall with a fracture for Resident CR1, and failed to provide ongoing monitoring to ensure proper functioning of air mattresses for seven of seven residents reviewed (Residents CR1, R2, R3, R4, R5, R6 and R7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR1, dated May 17, 2016, revealed that the resident was alert and oriented, dependent on staff for bed mobility and transfers in and out of bed, and was at risk for falls. A Hospice care plan for Resident CR1, dated February 16, 2016, indicated that the resident had a low air loss mattress (a specialized mattress to aide in comfort and prevent increased pressure for residents with fragile skin or skin breakdown) and that the resident's bed was to be in a low position. A nursing note and an incident report and investigation, dated June 7, 2016, at 5:08 p.m., revealed that Resident CR1 was found on the floor between her bed and her roommate's bed, propped up against the bedside stand, and she was complaining that her left hip hurt. The resident was transferred to the emergency room and was diagnosed with [REDACTED]. condition. Subsequent nursing notes following the resident's return from the hospital indicated that her condition continued to decline, and a nursing note on June 9, 2016, at 2:23 a.m., indicated that the resident ceased to breathe at 1:23 a.m. The resident's death certificate, dated June 9, 2016, indicated that the cause of death was cardiopulmonary failure due to physiological stress and immobilization secondary to trauma, left hip fracture, and a fall at the nursing home. Review of the post-fall investigation statements, dated June 9, 2016, from Hospice Aide 1, Nurse Aide 2, and Licensed Practical Nurse 3 reflected that the resident was very restless and anxious in the morning on June 7, 2016. Additional statements stated,The resident called out, thrashed her arms about, refused a shower, and refused to get out of bed, and was attempting to climb out of bed, and The resident was observed sitting on the side of the bed in the morning, and again in the afternoon, and was again trying to climb out of bed. Interview with Licensed Practical Nurse 3 on June 16, 2016, at 12:30 p.m., revealed that the resident was acting different for her that day. There was no documented evidence that an assessment was completed for Resident CR1 to determine if there were any potential safety hazards with the use of an air mattress on the resident's bed, either when the device was initially implemented or when the resident exhibited changes from her normal behavior and was restless and attempted to climb out of bed. There was also no documented evidence that ongoing monitoring of the air mattress was completed in order to ensure proper use and functioning, and no documented evidence that the facility's investigation included whether the position of the bed or the low air loss mattress were possible safety issues that could have contributed to the resident's fall and fracture. A comprehensive MDS assessment for Resident R5, dated October 20, 2015, indicated that the resident was dependent for bed mobility and transfers and was at risk for falls. A Hospice care plan, dated October 9, 2015, indicated that the resident had an air mattress on her bed. A nursing note and an incident report and investigation, dated February 21, 2016, at 12:00 p.m., revealed that the resident was observed on the floor on a fall mat next to the bed and was without injury. There was no documented evidence that an assessment was completed for Resident R5 in order to determine any potential safety hazards with the use of the air mattress, either when the device was initially implemented or after the resident fell out of bed. There was also no documented evidence that ongoing monitoring of the air mattress was completed to ensure proper use and functioning. A quarterly MDS assessment for Resident R2, dated May 10, 2016, indicated that the resident was dependent for bed mobility and transfers and was at risk for falls. The resident's care plan, dated May 17, 2016, indicated that the resident had an air mattress on the bed and that the mattress was initially implemented on November 9, 2012. An annual MDS assessment for Resident R3, dated April 21, 2016, indicated that the resident was dependent for bed mobility and transfers and was at risk for falls. The resident's care plan, dated April 28, 2016, indicated that the resident had an air mattress on the bed and that the mattress was initially implemented on September 24, 2015. An admission MDS assessment for Resident R4, dated April 5, 2016, indicated that the resident was dependent for bed mobility and transfers and was at risk for falls. The resident's care plan, dated April 4, 2016, indicated that the resident had an air mattress on the bed and that the mattress was initially implemented on March 29, 2016. A quarterly MDS assessment for Resident R6, dated June 1, 2016, indicated that the resident was dependent for bed mobility and transfers and was at risk for falls. The resident's care plan, dated April 19, 2016, indicated that the resident had an air mattress on the bed and that the mattress was initially implemented on January 7, 2016. A quarterly MDS assessment for Resident R7, dated April 7, 2016, indicated that the resident was dependent for bed mobility and transfers and was at risk for falls. The resident's care plan, dated April 26, 2016, indicated that the resident had an air mattress on the bed and that the mattress was initially implemented on April 3, 2012. There was no documented evidence that assessments were completed to determine any potential safety hazards with the use of air mattresses for Residents R2, R3, R4, R6 and R7, either when the air mattresses were initially implemented or on an ongoing basis, to ensure that the devices remained appropriate. There was also no documented evidence to reflect that ongoing monitoring of the air mattresses was completed to ensure proper use and functioning. An interview with the Director of Nursing on June 16, 2016, at 2:45 p.m., confirmed that there was no documented evidence that safety assessments for potential safety hazards associated with the use of air mattresses were completed for Residents CR1, R2, R3, R4, R5, R6 and R7 until June 13, 2016, after Resident CR1 fell from bed and sustained a left hip fracture. She also confirmed that there was no documented evidence of ongoing monitoring of air mattresses for proper use and function. 42 CFR 483.25(h) Free of Accident Hazards/Supervisor/Devices. Previously cited 4/12/16. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.5(f) Clinical records. Previously cited 12/31/15, 7/24/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/9/16, 4/12/16, 12/31/15, 11/16/15, 10/20/15, 9/2/15, 7/24/15, 12/5/14, 11/24/14.