Every finding on record at Heritage Care Center

Based on observations and staff interview, it was determined that the facility failed to provide a safe environment for residents on two of two nursing units (Second Floor and Third Floor).Findings include: Review of the facility policy Hazardous Areas, Devices and Equipment dated 10/7/25, indicated. All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. During an observation on 8/13/26, at 12:18 p.m. an unsecured oxygen tank was resting on the seat of a wheeled chair in the Three South hallway. During an observation on 8/13/26, at 3:13 p.m. of the Second Floor shower room, a medicine cup with a sticky orange liquid in it was present on top of a soiled linen hamper. An open bottle of hydrogen peroxide with the cap only resting on it was on top of the paper towel dispenser. During an observation on 8/13/26, at 3:17 p.m. the janitor's closet across from the nurse's station had an unsecured door. Present in the janitor's closet During an interview on 8/13/26, at approximately 5:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents on two of two nursing units. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.20(a)(b) Staff development.28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on a review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to serve food that was palatable for eight of 23 residents (R2, R8, R17, R18, R19, R20, R21, and R23).Findings include: During resident interviews conducted on 8/13/26, the following was stated: -11:36 a.m. Resident R17 stated, The food is terrible. Same all the time, not good variety. A lot of hot dogs.-11:45 a.m. Resident R18 stated the food is not good stating that it tastes bad and has no variety. A lot of spaghetti and a lot of chicken.-11:52 a.m. Resident R2 stated that there is often not coffee or tea on the weekends, always the worst food.-12:06 p.m. Resident R19 stated the food is the same all the time.-3:23 p.m. Resident R23 stated, The food comes cold a lot of the time. The food ain't that great. Breakfast was a slice of untoasted bread and oatmeal.-3:45 p.m. Resident R20 stated shat she was unhappy with the food. She stated she gets cold cereal every day, and does not like cold cereal. I keep having to ask, 'you got another oatmeal, you got another oatmeal. One morning I had two cartons of sour milk.-3:48 p.m. Resident R21 stated, breakfast isn't that great, often the pancakes are hard.-5:15 p.m. Resident R8 stated, All their meals are terrible and cold. How can you eat cold oatmeal. Sick people need their energy and protein. How do you expect people to get well? During an observation on 8/13/26, at 12:35 p.m. the surveyor asked if all of the trays had been delivered on the Three South unit. Observation at this time revealed that an undelivered meal tray was on top of the meal cart. The surveyor asked the nurse aide at the nurses station if the resident that the tray belonged to was present on the unit. The nurse aide walked with the surveyor to the cart, looked at the tray, and said to the surveyor, Oh, thank you. At that time, the nurse aide delivered the cart to the resident's room. Review of three months of facility provided Culinary Council Meeting Minutes) indicated:-6/4/26: Concerns related to coffee not being hot, lack of condiments, not consistently using warmer bottoms on plates, the use of Styrofoam plates, plastic tableware, cold meals, and incorrect food items.-7/9/26: Concerns related to incorrect food items, lack of condiments, the use of Styrofoam plates, and utensils not being consistently provided.-8/6/26: Concerns related to evening snacks, incorrect food items, running out of coffee during meal service, and utensils not being consistently provided. During an interview on 8/13/26, at 5:15 p.m. the Nursing Home Administrator confirmed that the facility failed to serve food that was palatable for eight of 23 residents 28 Pa Code: 211.6(b)(c) Dietary services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medical supplies were properly secured on one of two nursing units (Second Floor).Findings include: Review of the facility policy Storage of Medications dated 10/7/25, indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. During an observation on 8/13/26, at 3:29 p.m. the Second Floor medication room door was noted to be partially open. Present in the room was the medication dispensing unit and an unlocked treatment cart with needles, syringes, and dressing supplies. Additionally present in the cart were intravenous bags fluids, of Levofloxacin (a strong prescription antibiotic used to treat serious bacterial infections) and Metronidazole (a prescription antibiotic and antiparasitic medication bacterial and protozoal). In a red bin on the floor were single dose packets of gabapentin (a prescription medicine used to treat nerve pain and to help control seizures) and trazodone (antidepressant medication that is also used to treat insomnia) for Resident R24. Noted on the door was a printed sign that stated, THIS ROOM IS TEMPERATURE CONTROL PLEASE KEEP DOOR CLOSED AT ALL TIMES. During an interview on 8/13/26, at approximately 5:15 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medications and medical supplies were properly secured on one of two nursing units. 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 a review of resident choice menu selections, and Resident Group and staff interviews, it was determined that the facility failed to provide resident selected menu items for 16 of 19 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R19). Findings include: Review of the facility policy, Resident Food Preferences dated 10/7/25, indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team.During resident observations conducted during noon meal service on 8/13/26, the following was noted:Resident R1 did not receive the two sugar cookies (received one) as indicated on the meal ticket and did not receive creamer, sugar, or sweetener for their coffee.Resident R2 did not receive two coffees, diet cola (received full-sugar cola), or cottage cheese as indicated on the meal ticket.Resident R3 did not receive the two sugar cookies as indicated on the meal ticket (received one).Resident R4 did not receive the two sugar cookies (received one), tomato soup, or broccoli as indicated on the meal ticket.Resident R5 did not receive creamer, sugar, or sweetener for their coffee.Resident R6 did not receive coffee as indicated on the meal ticket.Resident R7 did not receive the two sugar cookies (did not receive any) as indicated on the meal ticket and did not receive creamer, sugar, or sweetener for their coffee.During resident observations conducted during evening meal service on 8/13/26, the following was noted:Resident R8 did not receive margarine for the cornbread, peaches and cream, or diet iced tea, as indicated on the meal ticket.Resident R9 did not receive margarine for the cornbread, peaches and cream, cola, or not tea, as indicated on the meal ticket. Resident R9 did receive lemonade, which was not indicated on their meal ticket.Resident R10 did not receive margarine for the cornbread, peaches and cream, (received diced peaches only), orange juice, or milk as indicated on the meal ticket.Resident R11 did not receive margarine for the cornbread, peaches and cream, two diet lemonades, two coffees, or milk as indicated on the meal ticket.Resident R12 did not receive peaches and cream or tea as indicated on the meal ticket.Resident R13 did not receive margarine for the cornbread, peaches and cream, milk, or non-dairy creamer as indicated on the meal ticket.Resident R14 did not receive cornbread, margarine, peaches and cream, milk, or cola as indicated on the meal ticket.Resident R15 did not receive margarine for the cornbread, peaches and cream, milk, or creamer, sugar, or sweetener for their coffee, as indicated on the meal ticket. Resident R15 did receive vanilla pudding, which was not indicated on their meal ticket.Resident R19 did not receive soda, broccoli, or bread as indicated on the meal ticket, and did not receive or cream and sugar for their coffee.During an interview on 8/13/26, at approximately 5:20 p.m. the Nursing Home Administrator confirmed that the facility failed to provide ordered and selected food items 16 of 19 residents. 28 Pa Code: 211.6(a) Dietary service.

Based on review of facility documents, resident observations, and resident and staff interviews, 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 12 of 23 residents interviewed and/or observed (R2, R7, R8, R10, R11, R12, R17, R18, R19, R20, R21, and R23).Findings include: Review of the Facility Assessment dated 7/27/26, indicated the facility's goal is to ensure enough staff to properly care for the residents and to meet their individual needs. The goal is to also meet or exceed the minimum standards set by the governing body. Review of the facility policy, Answering the Call Light dated 10/7/25, indicated the facility will ensure timely responses to the resident's requests and needs. Review of the facility policy, Supporting Activities of Daily Living dated 10/7/25, indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During an interview on 8/13/26, at 11:36 a.m. when asked if they felt the facility provided sufficient staff to care for residents, Resident R17 stated, No in a strong tone of voice. Resident R7 stated the nurse aides say, We're short, we're short. You have to wait so long. I've waited hours to get changed. Resident R17 stated the first time you push the call light it takes about an hour, but no one comes back, and she needs to push it again to get care. Additionally, Resident R17 stated she hasn't had her hair washed in weeks. During an interview on 8/13/26, at approximately 11:45 a.m. when asked if the facility maintained sufficient staff to provide resident care, Resident R18 stated, Sometimes yes, sometimes no. More times than not, we don't' have enough aides. Resident R18 stated that often call light response times exceed 30 minutes. During an interview on 8/13/26, at approximately 11:52 a.m. when asked if the facility staff provided prompt call light response times, Resident R2 stated, Some do. Call lights can take long. They don't never have enough aides. During an interview on 8/13/26, at 12:01 p.m. when asked if they felt the facility provided sufficient staff to care for residents, Resident R7 stated, No. Resident R7 stated call lights can Sometimes take a while. When asked if she is ever left in soiled clothing or briefs for an extended period of time, Resident R7 confirmed she had been. During an interview on 8/13/26, at 12:06 p.m. when asked if they felt the facility provided sufficient staff to care for residents, Resident R19 stated, No and stated that call light response times are long. Resident R19 stated that there is not enough nurse aides. Observation at this time revealed facial hair on her chin. During an observation on 8/13/26, the following was observed:-12:13 p.m. it was noted that the meal delivery cart for Three South Hall was on the unit, and not being passed out.-12:22 p.m. three staff members, Nurse Aides (NA) Employee E1, E2, and E3, approached the delivery cart, and began to have a conversation in the hall.-12:26 p.m. the first Three East Hall meal delivery cart arrived. The staff conversation continued on Three South.-12:27 p.m. the second Three East Hall meal delivery cart arrived. The staff conversation continued on Three South.-12:28 p.m. NA Employee E4 began passing dining room trays from the Three East Cart. The staff conversation continued on Three South.-12:31 p.m. the staff conversation ended and the Three South Hall meal trays began to be passed out. During an interview on 8/13/26, at 3:23 p.m., when asked if they felt the facility provided sufficient staff to care for residents, Resident R23 stated, Theres times when they are short on help. When asked if call light response times were long, Resident R23 stated, Sometimes it do. It depends on how many are working. Taks a long time to get somebody to finally come. I learned ho9w to go to the bathroom by myself, but I'm not supposed to go. But when you gotta go, you gotta go. They say they will be right back, but they don't come. Observation at this time revealed facial hair on her chin. During an interview on 8/13/26, at 3:39 p.m. when asked if they felt the facility provided sufficient staff to care for residents, Resident R20 visibly grimaced and stated, Last night I was ringing the call bell. They told me not to get out of bed. I was calling and calling. They don't care. I had to go so bad. I was sliding down the bed, I was still trying to hit the buzzer, I hit the floor. Once I got down on the floor, my feet caught on this bar (Resident R20 gestured to the base of the overbed table). It's sad, they need to hire more people. They hear the bell, see it ringing, and they don't answer. Observation at this time revealed facial hair on her chin. During an interview on 8/13/26, at 3:48 p.m. when asked if the provided prompt call light response, Resident R21 stated, So-so. During an interview on 8/13/26, at 5:14 p.m. when asked if the facility provided sufficient staff to care for residents, Resident R8 stated, There isn't. When asked if the provided prompt call light response, Resident R8 stated, If you have a problem with your bowels and have to wait, you are just going to have to clean my ass up. During an interview on 8/13/26, at 5:18 p.m. when asked if the provided prompt call light response, Resident R10 stated, Sometimes. During an interview on 8/13/26, at 5:19 p.m. when asked if they felt the facility provided sufficient staff to care for residents, Resident R11 stated, There aren't. When asked if the provided prompt call light response, Resident R11 stated, It varies. During an interview on 8/13/26, at 5:25 p.m. Resident R12 stated, You have to wait hours for a bed pan. You have to wait hours in the morning, and people need to go first thing in the morning. Review of grievances filed by residents or upon their behalf revealed:-7/8/26: Resident R23 reported she put her call light on at approximately 4:00 p.m. She hit her call light to ask for help going to the bathroom. No one came so she took herself. She hit her light to help her with her brief once she was finished. A CNA (nurse aide) came and left without helping her. She hit light again, a second CNA came and left without helping her. She got herself off the toilet and was trying to get her brief/pants on when a third CNA was walking by and assisted.-8/4/26: Documentation that Resident R12 brought staffing concerns to the Ombudsman. During an interview on 8/13/26, at approximately 5:15 p.m. the Nursing Home Administrator and the Director of Nursing 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 12 of 23 residents interviewed and/or observed. 28 Pa. Code: 201.20(a)(c)(d) Staff Development

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (Second Floor and Third Floor).Findings include: Review of the facility policy Homelike Environment dated 10/7/25, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. During an observation on 8/13/26, at 11:35 a.m., upon exiting the elevator on the Third Floor, a strong smell of urine was noted. During an observation on 8/13/26, at 11:37 a.m. of the Third Floor shower room the following was noted:-Multiple open containers of personal use toiletries lined up on grab bars in the shower, with used towels also hanging from the grab bars.-Shower chair had deodorants, shavers, unfolded briefs, and personal clothing on it.-A second shower chair with a wet washcloth on it, with blue soap on the washcloth.-In the shower a pile of soiled, wet washcloths were present.-Pieces of torn briefs on the floor.-Hangers on the floor-A reclining chair (not for bathing) in the shower area with power cords and oxygen tubing in the seat of the chair.-A wheelchair with personal clothing draped on the back.-Multiple urinals hanging off of the commode's free-standing grab bars.-An open bottle of hydrogen peroxide with the cap only resting on it, a hairbrush, and a toothbrush were on top of the paper towel dispenser. During an observation on 8/13/26, at 12:14 p.m. a small cart with dirty breakfast trays was observed in the Three South hallway, and a half full cup of coffee was noted to be balanced on the hallway handrail. During an observation on 8/31/26, at 12:16 p.m. a bag of soiled linen was noted to be on the floor next to the soiled linen cart on the Three South hall, with linen falling out onto the floor. During an observation on 8/13/26, at 12:18 p.m. a large, full cart of dirty breakfast trays was present in the hallway near the service elevator on the third floor. During an observation on 8/13/26, at 12:20 p.m. of the Third Floor dining room two used towels were observed on a table, the floors appeared unclean. Visible streaks from mopping revealed that only the areas between the tables were mopped, the floors under that tables were not swept and not mopped. Used paper towels, used disposable cups, and a soiled mug (upside down) were on the tables. During an observation on 8/13/26, at 3:13 p.m. of the Second Floor shower room the following was noted:-Trash can with multiple dirty briefs in it, with no liner.-Multiple open containers of personal use toiletries lined up on grab bars in the shower, with used towels also hanging from the grab bars.-A medicine cup with a sticky orange liquid in it.-A fork on the floor. During an observation on 8/13/26, at 3:35 p.m. a meal tray was observed in the Second-Floor lounge, on a shelf. The tray had on it spaghetti, lima beans, and a carton of partially consumed milk. Review of the posted menu on the unit indicated this was the evening meal on 8/12/26.During an observation on 8/13/26, at 3:43 p.m. of the Two [NAME] hallway, straw wrappers, graham crackers, used alcohol pledgets, and crumpled up facial tissue were present. During an observation on 8/13/26, at 3:44 p.m. the trash can in Resident R22's room was half-full of waste, with no liner in the can. Next to the can was a bag on the floor with trash spilling out onto the floor, a bag of washcloths on the floor, and soiled washcloths on the floor. Additionally, the bedside commode was left with urine in it. During an observation on 8/13/26, at 3:45 p.m. Resident R20's room had trash on her floor. Resident R20 states she has to ask the housekeepers to come in and empty her trash and sweep the floor. During an observation on 8/13/26, at 5:05 p.m. fruit flies were observed swarming over Resident R16's dinner tray. The surveyor had to swipe at the fruit flies to allow Resident R16 to eat. During an interview on 8/13/26, at approximately 5:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units. 28 PA. Code 201.14(a) Responsibility of Licensee28 PA. Code 201.18(b) Management

Based on review of facility policy, Resident Council meeting minutes, and resident and staff interviews, it was determined the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for three of three months (February 2026, March 2026, and April 2026).Findings include: Review of facility policy Resident Council dated 10/10/25, indicated the purpose of the resident council is to provide a forum for residents, families and resident representatives to have input in the operation of the facility; discussion of concerns and suggestions for improvement; consensus building and communication between residents and facility staff; and disseminating information and gathering feedback from interested residents. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of facility provided Resident Council Meeting Minutes dated 2/24/26, indicated: Last month issues/status, continued from 1/20/26: Continued. Staff use earbuds and cellphone while working with residents. Still notice issue of garbage and dirty linens not being taken from rooms sometimes for a long period of time. Response: Spoke to head of Housekeeping and Social Work Director to clarify - when soiled items are put in the trash, the nurse aide is to bag up and throw away. Housekeeping staff are to empty dry trash from the can when cleaning room. Aides are also to put used linen in bag and down the chute. Wrote grievance. Nursing issues: Some residents reported their beds were not being made. Also report sheets are not changed when needed. They heard this is to be done on shower days. Also reported that showers don't happen consistently on shower days. Response: Request put in to clarify when sheets are to be changed and make sure showers are given on shower days. Review of facility provided Resident Council Meeting Minutes dated 3/26/26, indicated: Last month issues/status, continued from 2/24/26: Continued. Staff use of earbuds and cellphone while working with residents. Still notice issue of garbage and dirty linens not being taken from rooms sometimes for a long period of time. Response: Housekeeping, nursing and all staff present agreed that; Nurse Aides are assigned to put used linen in bag and down the chute and any soiled items go in the trash bag and immediately throw away. Housekeeping staff are assigned to empty regular trash from the can when cleaning rooms - but if trash or linen bags left in room - should remove as well. Any other staff are asked to pitch in and help take care of bagged trash or linen if left in the room. Nursing issues: Shower Day Audit had been recommended to find out if they were being scheduled properly and if they are being done as scheduled. Response: In process - still need to audit showers. Review of facility provided Resident Council Meeting Minutes dated 4/28/26, indicated: Last month issues/status, continued from 3/26/26: Continued. Still notice issue of garbage and dirty linens not being taken from rooms sometimes for a long period of time. Response: Last month we clarified who is responsible for taking out of rooms and putting down chutes. Housekeeping, nursing and all staff present agreed that Nurse Aides are assigned to put used linen in bag and bring to chute. Any soiled items go in the trash bag and Aide is to immediately throw away. Housekeeping staff are assigned to empty regular trash from the can when cleaning rooms - but if trash or linen bags left in room - should remove as well. Any other staff are asked to pitch in and help take care of bagged trash or linen if left in the room. Nursing issues: Some showers continue to be missed and beds reportedly not changed regularly. Shower Day Audit was recommended to find out if they were being scheduled properly and if they are being done as scheduled. Does shower schedule correlate to days the bed linens are to be changed? Response: Continues to be a problem. Proposed plan to Audit Showers in process. Review of a resident concern dated 5/1/26, indicated, I was supposed to get showers twice a week, on Mondays and Thursdays. I was there three weeks and got two showers. The aides would come in to take care of me or my roommate and they would be on their cellphones constantly. During an interview on 5/5/26, at 10:48 a.m. Resident R1 stated, I have seen staff on their phones and with earbuds in while providing care, but that's everywhere. I don't know what my shower schedule is. During an interview on 5/5/26, at 10:57 a.m. Resident R2 stated, I have seen staff on their cellphones and earbuds in while providing care to me. I think it's a distraction. I don't get washed up very often, I haven't had a shower since I got here last July. I've never been taken to the shower room. During an interview on 5/5/26, at 11:15 a.m. Resident R3 stated, It has slowed down a little, but there are still a lot of staff who are on their phones and using earbuds while providing care. It's mostly staff on the day shift. I can take myself to the shower, when I'm done I put my things in a blue linen bag and I have to leave it on the floor, I can't lift it. I ask staff to pick it up and they always squawk at me about having to pick the bag up. During an interview on 5/5/26, at 1:44 p.m. Activities Director Employee E1 stated, The shower audit still has not happened yet. Residents have repeatedly brought up at the Resident Council meetings that there is a problem with trash and linen bags not being picked up, staff are seen on their phones and using earbuds while providing care, and showers are being missed and bed linens are not being changed. During an interview on 5/5/26, at 2:06 p.m. the Nursing Home Administrator confirmed the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for three of three months (February 2026, March 2026, and April 2026). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(4) Management.28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of five residents (Resident R6).Findings included: Review of the facility Care Plans, Person-Centered policy dated 10/10/25, indicated a person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Review of Resident R6 clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R6's clinical record MDS (minimum data set a periodic assessment of resident needs) dated 3/30/26, indicated diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). MDS Section K- Swallowing/Nutritional Status, K0520, mechanically altered diet is marked while a resident. Review of Resident R6's care plan, dated 12/30/25, indicated provide diet per order. Review of Resident R6's Physician Orders dated 4/10/26, indicated pureed texture (solid food that has been blended into a smooth, lump free consistency), with allowance for bananas, cakes, and soft cookies. During an interview on 4/14/26, at 2:37 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 reviewed Resident R6's care plan and stated that the diet should have been updated to reflect current physician orders and confirmed the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of five residents (Resident R6). 28 Pa. Code 201.24(e)(1)(5) Admissions Policy 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Resident R1) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Residents R1).Findings include: Review of facility Transfer or Discharge Documentation policy dated 10/10/25, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Review of facility Bed-Holds and Returns policy dated 10/10/25, indicated all residents/representatives are provided written information regarding the facility bed-hold policy at the time of transfer. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/23/26, indicated diagnoses of high blood pressure, anxiety, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the clinical record indicated Resident R1 was transferred to the hospital on 2/22/26, and did not return to facility. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R1's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 2/22/26. During an interview on 4/14/26, at 2:44 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider and failed to notify the resident or resident's representative of the facility bed-hold policy for Resident R1. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for bathing for six of seven residents sampled (Resident R1, R2, R3, R4, R5, and R6).Findings Include:Review of the facility policy Homelike Environment dated 10/7/25, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike.During a facility tour and observation with Maintenance Director Employee E1 on 2/25/26, between 9:00 a.m. and 9:28 a.m. the following resident rooms were observed to have unacceptable water temperatures for bathing:-The water temperature of the resident room sink registered at 60 degrees Fahrenheit for Resident R1.-The water temperature of the resident room sink registered at 59 degrees Fahrenheit for Resident R2.-The water temperature of the resident room sink registered at 77 degrees Fahrenheit for Resident R3.-The water temperature of the resident room sink registered at 55 degrees Fahrenheit for Resident R4.-The water temperature of the resident room sink registered at 73 degrees Fahrenheit for Resident R5.-The water temperature of the resident room sink registered at 79 degrees Fahrenheit for Resident R6.Interview on 2/25/26, at 9:00 a.m. Resident R1 indicated it's very cold. It's been that way for six months when asked if the water temperature in the room was acceptable for bathing.Interview on 2/25/26, at 9:03 a.m. Resident R2 indicated it is ice-cold, I wouldn't wash a dog in water that cold, when asked if the water temperature in the room was acceptable for bathing.Observation on 2/25/26, at 9:25 a.m. Resident R4 sink had water running from the faucet and no staff in the room.Interview on 2/25/26, at 9:27 a.m. Nurse Aide (NA) Employee E2 indicated staff must let the water run sometimes for up to 30 minutes to get it warm enough for bathing.Interview on 2/25/26, at 9:30 a.m. NA Employee E3 indicated sometimes we use the sinks in the hallways because they're used more often and tend to have warmer water than the resident rooms.Interview on 2/25/26, at 9:30 a.m. Maintenance Director Employee E1 confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for bathing for six of seven residents sampled (Resident R1, R2, R3, R4, R5, and R6).28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for one of 11 months (May 2025). Findings include:Review of facility policy Antibiotic Stewardship Program dated 10/17/25, with a previous review date of 9/25/24, indicated usage and outcome data will be collected and documented using a facility tracking form and will guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship.Review of the facility's Infection Control surveillance for December 2024 through November 2025 failed to include documentation to indicate that antibiotic monitoring was completed for May 2025.Interview on 11/19/25, at 1:30 p.m., the Corporate Infection Control Nurse Employee E16 confirmed that the facility failed implement an antibiotic stewardship program for one of 11 months (May 2025). 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly label and date food products in the walk-in cooler and freezer in the designated main kitchen. Findings include: A review of the facility Food Storage policy dated 10/7/25, indicated food storage areas shall be maintained in clean, safe, and sanitary manner. During an observation of the main designated kitchen on 11/18/25 at 10:30 a.m. the following was observed:-crate of iced tea on the floor of the walk-in coolerWalkin Freezer-2 bags of rolls, out of original package, no label or date-Bacon, not covered, no label or date-egg patties,1 bag, no label or date-french fries, 2 bags, no label or date -Bottle of disinfectant stored on the shelf with noodles and open container of bread crumbs During an interview on 11/18/25 at 11:15 a.m., Dietary Manager Employee E8 confirmed that the facility failed to properly label and date food products which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow enhanced barrier precautions (EBP) for two of four residents (Resident R60 and R99) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize proper handwashing and gloving during medication administration for one of five residents observed (Resident R19), and failed to complete Infection Control surveillance from November 2024 through November 2025, failed to monitor Antibiotic Stewardship for May 2025 and failed to provide vaccines for flu, pneumonia and COVID-19 to 105 of 105 residents for the 2025 season, resulting in substandard quality of care.Findings include: Review of the facility policy Enhanced Barrier Precautions dated 10/7/25, indicated enhanced barrier precautions (EBP) are used and expand the use of Personal Protective Equipment (PPE) to donning (putting on) of the gown and gloves during high-contact resident care activities that provide opportunities for transfers of multidrug-resistant organisms to staff hands and clothing. Examples of high-contact resident care activities requiring EBP includes device care or use (central lines, urinary catheter, supra-pubic catheter, feeding tube or tracheostomy. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Review of the facility policy Administering Medications dated 10/7/25, indicated staff follow established facility infection control procedures (handwashing, antiseptic technique, gloves, etc.) for the administration of medications as applicable. Review of the admission record indicated Resident R60 admitted to the facility on [DATE]. Review of Resident R60's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/30/25, indicated diagnoses of malnutrition (body doesn't receive enough calories or the right balance of nutrients to stay healthy), schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, and anemia (the blood doesn't have enough healthy red blood cells). Review of Resident R60's physician order 9/25/25, indicated EBP for G-tube. Observation on 11/17/25, at 9:30 a.m. Resident R60's door had no signage for EBP or PPE outside the room. Staff were observed going in and out of the room without donning gowns. Interview on 11/18/25, at 1:26 p.m. Registered Nurse (RN) Employee E4 confirmed Resident R60's door had no signage for EBP or PPE outside the room as required. Review of Resident R99's admission record indicated she was admitted on [DATE], with the diagnoses of respiratory failure (a serious condition that makes it difficult to breathe on your own), larynx cancer (hollow organ forming an air passage to the lungs and holds the vocal cords), and tracheostomy (a surgical procedure to create an opening in the neck into the windpipe to establish a direct airway for breathing). Review of Resident R99's physician order 11/18/25, indicated EBP for wounds and feeding tube and failed to include the status of a tracheostomy requiring EBP as required. Observation on 11/17/25, at 9:35 a.m. Resident R99's door had no signage for EBP or PPE outside the room. Staff were observed going in and out of the room without donning gowns. Interview with Resident R99 on 11/17/25, at 9:35 a.m. when asked if staff wear gowns while they care for the resident, the resident nodded the head no. Interview on 11/18/25, at 1:26 p.m. Registered Nurse (RN) Employee E4 confirmed Resident R99's door had no signage for EBP or PPE outside the room as required. Observation on 11/18/25, at 9:15 a.m. of a medication pass Licensed Practical Nurse (LPN) Employee E6 failed to utilize proper handwashing and gloving techniques and popped several medications into the bare hand and then placed into a medication cup. Interview with the Director of Nursing on 11/18/25, at 3:00 p.m. confirmed the facility failed to follow enhanced barrier precautions (EBP) for two of four residents (Resident R60 and R99) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize proper handwashing and gloving during medication administration for one of five residents observed (Resident R19). Resident R116 was admitted to the facility on [DATE]. Review of Resident R116's admission record indicated a diagnosis of fracture of right lower leg and COVID (infectious disease caused by the SARS CoV-2 virus). During an interview on 11/17/25, at 9:56 a.m. Resident R116 shared that she didn't realize she had COVID and she thought that was part of the reason she feels (due to feeling weak). During an observation on 11/17/25, at 10:00 a.m. no signage was noted on Resident R116 to identify what PPE equipment should be used, the door was open, and the PPE on the door failed to include all required items. During an interview on 11/17/25, at 10:11 a.m. with Unit Manager RN Employee E9 stated that the facility did not have any active cases of COVID. Unit Manager RN Employee E9 confirmed that the PPE on the door did not contain all required equipment. Review of Resident R116 admission paperwork indicated that Resident R116 was diagnosed with COVID in the hospital and it was indicated on the hospital paperwork. During an interview on 11/20/25, at 9:45 a.m. Director of Nursing was informed that the facility failed to identify and implement infection control practices for Resident R116. During review of the Infection Control Practices surveillance information, Antibiotic Stewardship documentation and 2025 vaccine documentation did not include monitoring of and surveillance that identified trending of infections from November 2024, through November 2025, monitoring of antibiotics for May 2025, or the offering. provision of vaccines for the 2025 flu, pneumonia or COVID-19, season. During an interview on 11/19/25, at 1:30 p.m., Corporate Infection Control Employee E16 stated that due to the frequent changes in the facility management team and change in ownership, the Infection Control practices, antibiotic stewardship monitoring and the offering/provision of vaccines had not been completed and the facility failed to failed to complete Infection Control surveillance from November 2024 through November 2025, failed to monitor Antibiotic Stewardship for May 2025 and failed to provide vaccines for flu, pneumonia and COVID-19 to 105 of 105 residents for the 2025 season, resulting in substandard quality of care. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of clinical records and interview with staff, it was determined that facility failed to ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for 105 of 105 residents. Findings include:During review of the Infection Control Practices for the 2025 vaccine documentation did not include pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for 105 of 105 residents. During an interview on 11/19/25, at 1:30 p.m., Corporate Infection Control Employee E16 stated that due to the frequent changes in the facility management team and change in ownership, the facility failed to ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for 105 of 105 residents. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(1) Management28 Pa Code 211.15(f) Clinical records

Based on a review of facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for 105 of 105 residents reviewed for influenza and pneumococcal immunizations resulting in substandard quality of care. Findings include:A review of facility policies, Pneumococcal Vaccine and Influenza Vaccine, dated 10/17/25, with a previous review date of 9/25/24, indicated vaccines are administered in accordance with Centers for Disease Control and Prevention (CDC) recommendations. All residents are offered pneumococcal and influenza vaccines to aid in preventing infections. The resident or resident's legal representative will be provided information and education regarding the benefits and potential side effects of the vaccines and will be documented in the medical record. During an interview on 11/19/25, at 1:30 p.m., Corporate Infection Control Employee E16 stated that due to the frequent changes in the facility management team and change in ownership, the offering/provision of the flu and pneumonia vaccines had not been completed and the facility failed to document each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for 105 of 105 residents reviewed for influenza and pneumococcal immunizations resulting in substandard quality of care. 28 Pa. Code 211.5(f)(i)-(xi) Medical records.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, resident and staff interviews it was determined that the facility failed to provide residents with food products based on their preferences for 18 of 27 residents (Resident R10, R4, R43, R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710).Based on observations, resident and staff interviews it was determined that the facility failed to provide residents with food products based on their preferences for eighteen of twenty-seven residents (Resident R10, R4, R43, R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710). Review of the facility policy Resident Food Preferences dated 10/7/25, with a previous review date of 9/25/24, indicated all residents' food preferences will be obtained within 72 hours of admission and will be reviewed as necessary to ensure resident acceptance and satisfaction. The Dining Services Manager, or designee, will interview residents and/or family members within 72 hours of admission to the facility to obtain a list of food preferences' including likes and dislikes, choice of beverages, and choice of breakfast cereals. Food preferences will be entered into the electronic meal tracking system. During an interview on 11/17/25 at 9:29 a.m. with Resident R10's family, shared a concern related to ongoing meal inaccuracy. Observation of Resident R10's breakfast tray and tray ticket on 11/17/25, at 9:29 a.m. revealed resident is on a nectar thick puree diet. The meal ticket indicated the resident is to receive two yogurts, nectar thick orange juice, nectar thick milk, puree hot cereal, and puree French toast, no yogurt was provided on the tray. During an interview on11/17/25 at 9:39 a.m., with Registered Nurse (RN) Employee E9 confirmed the tray had no yogurt and that it should have been provided. Review of the admission record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/25/25, indicated the diagnoses of parkinsonism (slowed movements, stiffness, and tremors), cerebrovascular accident (stroke sudden loss of blood flow to part of the brain), and takotsubo syndrome (weakening of the heart's main pumping chamber). During an interview on 11/17/25 at 9:40 a.m. with Resident R43 shared a concern related to ongoing meal inaccuracy. Resident stated he did not eat any of his breakfast this morning as he didn't really want French toast and they didn't send the eggs with the tray. The resident stated this happens all the time. Observation of Resident R43's breakfast tray and tray ticket on 11/17/25, at 9:40 a.m. revealed resident is on a regular diet. The meal ticket indicated the resident is to receive milk, orange juice, hot cereal, scrambled eggs, French toast and a hot beverage, no eggs were provided on the tray. During an interview on 11/17/25 at 9:45 a.m., with Registered Nurse (RN) Employee E4 confirmed that no food on the tray had been touched or eaten by the resident, the tray had no eggs, and eggs should have been provided. Review of the admission record indicated Resident R43 was admitted to the facility on [DATE]. Review of Resident R43's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/24/25, indicated the diagnoses of cerebral ischemia (insufficient blood flow to the brain), high blood pressure, and cerebrovascular accident (stroke sudden loss of blood flow to part of the brain). During an interview on 11/17/25 at 12:24 p.m. with Resident R70 shared a concern related to ongoing meal inaccuracy. Resident stated he did not get his ginger ale on his lunch tray, and they don't have any soda on the nursing unit, it's like they forget something on my tray every day. Observation of Resident R70's lunch tray and tray ticket on 11/17/25, at 12:24 p.m. revealed resident is on a regular diet. The meal ticket indicated that the resident is to receive a dinner roll, tropical fruit, milk, ginger ale, beefaroni, carrots, and a hot beverage, no ginger ale was provided on the tray. During an interview on 11/17/25 at 12:34 p.m., with certified nursing assistant (CNA) Employee E12 confirmed there was no ginger ale on the tray, and it should have been provided. Review of the admission record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/30/25, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), high blood pressure, and depression. During an interview on 11/17/25, at 12:36 p.m., Resident R108 asked the Survey Agency (SA) to take the lunch tray away. When asked what the concern was, Resident R108 indicated they cannot have tomato sauce. Observation of Resident R108's lunch tray on 11/17/25, at 12:36 p.m. revealed macaroni noodles, beef, and tomato sauce (beefaroni). The tray ticket clearly indicated pasta with NO Tomato Sauce. During an interview with Registered Nurse (RN) Employee E1 confirmed the tray had tomato sauce and should not have. Review of the admission record indicated Resident R108 was admitted to the facility on [DATE]. Review of Resident R108's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/25, indicated the diagnoses of atrial fibrillation (irregular heart rhythm), high blood pressure, and gastroesophageal reflux disease (chronic disorder where stomach acid flows back into the esophagus). During an interview of 11/17/25, at 12:36 p.m. Dietary Employee E2 confirmed Resident R108's tray was not correct and that the facility failed to provide residents with food products based on their preferences. During a resident group interview on 11/17/25, at approximately 1:30 p.m., when asked if they felt the facility honored their food preference, consensus from the group was no. Residents verbalized frustration with ongoing inaccuracy with their meal selections. Residents stated it doesn't matter if it's breakfast lunch or dinner, sometimes it's not what you selected, it's missing one item maybe more. Resident R701 stated they called the ombudsman due to the issues she is having with the meals, and nothing has been resolved. Resident R703 stated the meals are an everyday problem for us. Resident R708 broke out into laughter and said, I don't think they get one meal right in a day. During a resident interview on 11/18/25, at 8:47 a.m., Resident R4 stated that food is always cold, and we do not get everything on our trays we request. The kitchen uses foam every other day as the dish machine is always broken. They have sent a breakfast sausage as a hamburger do they think we can't tell? During an interview on 11/18/25, at 8:56 a.m., Resident R46 was lying in bed. The resident's spouse stated that the facility fails to have enough foods that are Kosher for his needed diet as he requires a soft diet. The meals are always cold, and the kitchen uses foam a lot. The kitchen never sends yogurt as requested. During an interview on 11/18/25, at 8:25 a.m., Resident R111 stated that the food was always cold, and the facility sends foam plates up every other day. During an interview on 11/19/25, at 1:35 p.m., Regional Nursing Home Administrator Employee E10 confirmed that the facility failed to provide residents food products based on their preferences. During an interview on 11/18/25 at 10:00 a.m. the Director of Nursing confirmed that the facility failed to provide residents with food products based on their preferences, for eighteen of twenty-seven residents (Resident R10, R4, R43, R46, R70, R108, R111, R700, R701, R702, R703, R704, R705, R706, R707, R708, R709, and R710). Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, resident and staff interview it was determined that the facility failed to follow up on resident grievances for eleven residents. Finding s include: Review of the facility policy dated 2/1/25, Skilled Nursing Facility Grievance Policy indicated: Purpose - To ensure all residents resident representatives and responsible parties in the skilled nursing facility have the right to voice concerns, file grievances, and receive a prompt, though, an impartial response without fear of retaliation. Acknowledgement the grievance official will acknowledge receipt of the grievance in 3 business days. A written decision will be issued within one week unless extenuating circumstances. Review of resident council minutes from July 2025 to October 2025 indicated residents had on-going concerns with using land line telephones in resident rooms and phone extensions for departments in the facility, as they were unable to get through. During a resident group interview on 11/17/25, at 2:00 approximately Residents indicated that they are unable to get in touch with the departments in the facility. Residents were given a list of extensions but are unable to use the extension with the current phone system. During an interview on 11/18/25, at 1:30 p.m. Director of Activities Employee E? indicated that residents who have land lines are not able to use the extensions, and they have been given the extensions to get in touch with the departments. During an interview on 11/19/25, at 12:40 p.m. with Maintenance Director Employee E? indicated that residents with land lines can use their phones to contact the departments, they would need to call the facility number and be connected. During an interview on 11/21/25, at 9:41 a.m. Director of Nursing was informed that the facility failed to follow up on resident grievances for on-going resident concerns. 28 Pa. Code 201.29(a) Resident rights.

Based on observation, resident and staff interview identified that the facility failed to protect Resident R111 from potential burn accident/incident when providing a hot pack without a Physician order and monitoring the use /time placed and failed to provide adequate supervision for Resident R20 during med pass for one of two nursing units. During an observation on 11/18/25, at 8:25 a.m., Resident R111 asked the SA to go into her bedside stand drawer and get out the hot pack and place it on her left shoulder. The SA observed the disposable hot pack and told the resident that the nurse would be told. Resident R111 stated that the nurses always give me them. During a clinical record review Resident R111 was admitted to the facility on [DATE], with diagnoses which included a stoke causing left side hemiparesis. An MDS (Minimum Data Set- a periodic assessment of resident care needs) dated 9/8/25, indicated the diagnoses remained current. Review of Resident R111's current physician's orders did not include use of a hot pack to Resident R111's left shoulder. During a clinical record review on 11/18/25, at 8:28 a.m., Licensed Practical Nurse (LPN) Employee E6 stated the resident does not have a order for a hot pack. During an interview on 11/18/25, at 8:35 a.m., Physical Therapist Employee E14 stated that the therapy department does not have hot packs that nursing keeps them on unit and they are disposable. During an interview on 11/18/25, at 8:30 a.m., LPN Employee E6 confirmed that the facility did not protect Resident R111 from the potential for accident with a burn when providing a hot pack with no physician order or monitoring of the use/time placed on Resident R11's shoulder. Review of the admission record indicated Resident R 20 was admitted to the facility 8/5/25. Review of Resident R20's Minimum Data Set (MDS-periodic assessment of resident care needs) include diagnosis of Alzheimer's (progressive mental deterioration), adult failure to thrive and dementia (loss of cognitive functioning). Review of Resident R20's nurse's progress notes on 11/3/25 (late entry note for 10/31) by Physician indicated that resident ingested another resident meds that were left unattended on the med cart. Review of R20's progress notes, indicated no nurse progress note until 11/1/25. Review of Resident Incident Summary dated 10/31/25, indicated NA (Nurse Aide) requested nurse assist to transfer resident to bed because she was feeling lethargic. Noted that resident could have took a sip of medication that were mixed with water on top of medication cart. Review of facility provided documentation indicated no statement from the nurse on R20's assignment or any witness statements. During an interview on 11/20/25 at 2:30 p.m. Regional Representative E13 confirmed the facility failed to provide adequate supervision for Resident R20 as required.

Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of three residents (Resident R6, and R24) and failed to have a physician order or care plan for location of dialysis treatment center for one of three residents (Resident R120).Findings include: Review of the facility policy End-Stage Renal Disease, Care of a Resident with dated 10/7/25, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The agreements between the facility and the ESRD facility will include how information will be exchanged between the facilities; and the resident's care plan will reflect the resident's needs related to ESRD and dialysis (a treatment that removes excess water, waste, and toxins from the blood when the kidneys are no longer functioning properly) care. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the admission record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/17/25, indicated diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (high blood pressure), and anxiety disorder. Review of Resident R6's physician orders dated 9/10/25, indicated dialysis: at Fresenius Kidney Care on Tuesday, Thursday, and Saturday. Chair time 11:45 a.m. Review of Resident R6's current care plan indicated dialysis: at Fresenius Kidney Care on Tuesday, Thursday, and Saturday. Chair time 11:45 a.m. Review of Resident R6's dialysis communication forms 10/1/25 through 11/18/25 indicated the following:10/4, 10/11, 10/21, 10/23, 10/25, and 11/18 dialysis communication forms had incomplete clinical documentation. 10/14, 10/18, 10/28, 11/1, 11/4, 11/8, 11/11, 11/13, and 11/15 dialysis communications forms were not found on the nursing unit in the Resident R6's dialysis binder.Three dialysis forms are undated and have incomplete clinical data. Review of the admission record indicated Resident R24 was admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/3/25, indicated diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) , hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat). Review of Resident R24's physician orders dated 9/23/25, indicated dialysis: at Davita Northside on Monday, Wednesday, and Friday. Chair time 6:00 a.m. Review of Resident R24's current care plan indicated dialysis: at Davita Northside on Monday, Wednesday, and Friday. Chair time 6:00 a.m. Review of Resident R24's dialysis communication forms 10/1/25 through 11/18/25 indicated the following:10/3, 10/6, 10/10, 10/15, 10/17, 10/20, 10/22, 10/27, 10/29, 11/3, and 11/5 dialysis communication forms had incomplete clinical documentation. 10/1, 10/8, 10/13, 10/31, 11/7, 11/10, 11/12, 11/14, and 11/17 dialysis communications forms were not found on the nursing unit in the Resident R24's dialysis binder. Interview on 11/19/25, at 10:25 a.m. Registered Nurse (RN) Employee E13 confirmed the facility failed to provide consistent and complete communication with the dialysis center for Residents R6 and R24's dialysis center as required. Review of Resident R120's admission record indicated she was admitted on [DATE], with the diagnoses of COPD, heart failure, and end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident R120's MDS dated [DATE], indicated the diagnoses of hypertension, COPD, and obsessive compulsive disorder (OCD- mental health condition with unwanted, recurring thoughts and repetitive behaviors). Review of Resident R120's current physician orders failed to indicate a location name and time of resident's dialysis center as required. Review of Resident R120's baseline care plan failed to indicate a location name and time of resident's dialysis center as required. Interview on 11/19/25, at 11:30 a.m. Registered Nurse (RN) Employee E7 confirmed the facility failed to identify the location name and time of Resident R120's dialysis center as required. Interview on 11/20/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide consistent and complete communication with the dialysis center for two of three residents (Resident R6, and R24) and failed to have a physician order or care plan for location of dialysis treatment center for one of three residents (Resident R120). 28 Pa. Code 201. 18(b)(1) Management 28 Pa code:211.10(c)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code:211.12(a)(c)(d)(1)(2)(5) Nursing services

Based on review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 105 of 105 residents.Finding include:Review of the facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 10/7/25, indicated objectives of the QAPI program include providing a means to measure current and potential indicators for outcomes of care and quality of life; establish and implement performance improvement projects to correct identified negative or problematic indicators; reinforce and build upon effective systems and processes related to the delivery of quality care and services; and establish systems through which to monitor and evaluate corrective actions.Review of the facility's deficiencies and plan of corrections for the State Survey and Certification (Department of Health) survey ending 12/6/24, revealed the facility developed a plan of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations.Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON, or designee, will in-service R.N.'s and L.P.N.'s on the facility policy and procedure for Self-Administration of Medications to ensure that all nurses understand the requirements for resident's to be able to administer their own medications, as well as be educated on the Self-Administration Evaluation Form. - NHA, or designee, will in-service all facility physicians on the facility policy and procedure for Self-Administration of Medications to ensure they have a thorough understanding of the requirements for the facility to self-administer medications.- DON, or designee, will audit all resident orders to ensure any resident that has an order to self-administer medications meets the facility policy and procedure requirements for self-administering medications, any residents identified as self-administering will have a self-administration evaluation completed to determine eligibility.- DON, or designee, will monitor five resident(s) 2 x a week for 2 weeks, 1x a week for 2 weeks and monthly thereafter to ensure that residents with self-administration orders are meeting the facilities policy and procedure requirements. - Education provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to Self-Administration of medications for one resident (Resident R42).Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON, or designee, will in-service all facility R.N.'s and L.P.N.'s on the facility policy and procedure for Enteral Tube Feeding via Continuous Pump and Medication and Treatment Orders to ensure compliance with orders for all residents with tube feeds. - DON audited all residents with tube feeds during survey to ensure that their tube feed was administered per physician order and policy. - DON, or designee, will monitor all residents with a tube feed via continuous pump 2 x per week for 2 weeks, then once per week for 2 weeks and monthly thereafter to ensure all tube feeds are hung per physician order and policy. - Education provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to enteral tube feeding via continuous pump not being labeled properly for three residents (Resident R60, R99, and R117).Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON, or designee, will in-service all direct care staff on the facility policy and procedure for Administering Nebulizer through a Small Volume (Handheld) Nebulizer, Oxygen Administration and Respiratory Therapy-Prevention of Infections to ensure compliance with all policies and procedures surrounding oxygen/nebulizer administration. - All residents with oxygen and nebulizers were audited during survey and identified issues were corrected immediately.- DON, or designee, will monitor residents three (at random) residents with oxygen/nebulizer 2 x per week for 2 weeks, once per week for 2 weeks and monthly thereafter to ensure compliance with nebulizer and oxygen administration policies. - Education provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to nebulizers and respiratory equipment not being labeled with date changed for five residents (Resident R35, R74, R99, R105, and R120).Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON, or designee, will in-service all facility R.N.'s and L.P.N's on the facility policy and procedure for End Stage Renal Disease, Care of a Resident With to ensure compliance with dialysis communication and care-planning.- DON, or designee, will audit all residents currently receiving Dialysis services to ensure that the required information has been care planned for each resident. - DON, or designee, will in-service facility dialysis partners on the requirements of Dialysis Communication per our facility policy and procedure. - DON, or designee, will monitor dialysis residents 2 x per week for 2 weeks, once per week for 2 weeks then monthly thereafter to ensure compliance with dialysis communication and care planning. - Education provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to dialysis care physician orders and care plan along with management and communication to dialysis center for three residents (Residents R6, and R24, R120).Review of the plan of correction for survey ending 12/6/24, revealed the following:- NHA, or designee, will in-service facility DON, ADON and physicians on the facility policy and procedure for Medication Regimen Review to ensure compliance from physicians with the monthly recommendations. - DON, or designee, will audit pharmacy recommendations for the 30 days to ensure compliance with the completion. - DON, or designee, will audit 3 residents (at random) with pharmacy recommendations twice per week for 2 weeks, then once weekly for 2 weeks and monthly thereafter to ensure completion with the pharmacist recommendations.- Education provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to Medication Regimen Review to ensure compliance from physicians with the monthly recommendations for one resident (Resident R1).Review of the plan of correction for survey ending 12/6/24, revealed the following:- DON, or designee, will in-service all facility R.N.'s and L.P.N's on the facility policy and procedure for Administering Medications to ensure compliance and accuracy with the medication pass. - DON audited resident who did not receive their over the counter medications timely during the med pass of survey to ensure that they did not have any adverse reactions and they did not. - DON, or designee, will monitor six med passes per week on varying shifts for 2 weeks, then 4 med passes per week on varying shifts for 2 weeks and monthly after that to ensure compliance and accuracy with med passes. - Education provided, audits and monitoring will be reported to and reviewed by the QAPI team at the next schedule meeting. The results of the current survey, ending 11/21/25, identified a repeated deficiency related to Medication Error Rate greater than 5%. Error rate for current survey was 8% affecting one resident (Resident R19).Review of the plan of correction for survey ending 12/6/24, revealed the following:-DON, or designee, will in-service all facility RN's and LPN's on the facility policy and procedure for Medication Storage and Insulin Storage to ensure compliance with the storage and distribution of all medications. -DON addressed self-administration with resident identified as having senna in his top drawer, resident will no longer self-administer until MD evaluates for the possibility of self-administration. -DON, or designee, will monitor facility med carts 2 x per week for 2 weeks, then weekly x 2 weeks and monthly thereafter to ensure compliance with the storage of all medications.The results of the current survey, ending 11/21/25, identified a repeated deficiency related medication storage and insulin storage for three of three medication carts (Second Floor East and South Medication carts and Third Floor South Medication cart) and two of two medication rooms (Second and Third Floor).Review of the plan of correction for survey ending 12/6/24, revealed the following:-NHA, or designee, will in-service all dietary and direct care staff on the facility policy and procedure for assistance with meals. -NHA, or designee, will audit all existing residents tray tickets versus Point Click Care order to ensure accuracy. -NHA, or designee, will monitor 3 residents (at random) twice weekly for 2 weeks then once weekly for 2 weeks and monthly thereafter to ensure compliance with assistance with meals and the proper tools. -all results of educations, audit and monitoring will be reported to QAPI at the next scheduled meeting.The results of the current survey, ending 11/21/25, identified a repeated deficiency related to assistance with meals and special equipment for one resident (Resident R111).Review of the plan of correction for survey ending 12/6/24, revealed the following:NHA, or designee, will in-service dietary staff on the facility policy and procedure for Preventative Maintenance and Weekly Cleaning and Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices to ensure that all dietary staff are in compliance with regulatory practices. The areas identified during survey have been addressed, cleaned and sanitized. NHA, or designee, will audit the kitchen to ensure all areas of concern with cleanliness are addressed immediately. NHA, or designee, will monitor the kitchen 2x per week for 2 weeks, then once per week for 2 weeks and monthly thereafter to ensure the kitchen maintains proper sanitary conditions. All results of education, audit and monitor will be presented to the QAPI committee at the next scheduled meeting.The results of the current survey, ending 11/21/25, identified a repeated deficiency related to dietary sanitation and food storage, as well as refrigerator temperature logs.Review of the plan of correction for survey ending 12/6/24, revealed the following:-NHA, or designee, will in-service all staff on the facility policy and procedure for Enhanced Barrier Precautions and Handwashing to ensure proper infection control practices are being followed. -DON, or designee, will in-service all facility RN's and LPN's on the policy and procedure for Insulin administration to ensure proper infection control processes are followed during the administration of insulin. -DON, or designee, will perform handwashing competency on all facility staff. -DON, or designee, will monitor 3 residents (at random) who are in ebp 2 x a week for 2 weeks, then 1 time a week for 2 weeks then monthly thereafter to ensure staff compliance with the enhanced barrier precaution regulatory processes. -DON, or designee, will monitor 2 residents (at random) insulin administration twice per week for two weeks, then once per week for two weeks and monthly thereafter to ensure compliance with the infection control practices during insulin administration. -all results of education, competencies, audits and monitoring will be reported to the QAPI committee at the next scheduled meeting.The results of the current survey, ending 11/21/25, identified a repeated deficiency related to Enhanced Barrier Precautions and hand washing for (Resident R60 and R99) with enteral feeding tubes (G- Tube, a tube inserted in the stomach through the abdomen), failed to utilize proper handwashing and gloving during medication administration for one of five residents observed (Resident R19).Interview on 11/21/25, at 12:00 p.m. the Director of Nursing and Nursing Home Administrator were informed that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 105 of 105 residents.42 CFR 483.75 (a)(2)(h)(i) QAPI Program/Plan, Disclosure/Good Faith Attempt.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.18(e)(2)(3)(4) Management.

Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1. Findings include: Review of facility policy Abuse and Neglect- Clinical Protocol, review date undetermined, indicated that neglect is defined 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 the facility job description for Certified Nursing Assistant, indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Job duties include assisting with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 6/17/24, indicated diagnoses Vitamin C deficiency, and generalized edema (fluid accumulation that affects the whole body). Review of Resident R1's admission record indicated additional diagnoses of muscle wasting and atrophy (decrease in size). Review of Resident R1's Physical Therapy evaluation dated 7/22/24, indicated that resident requires maximum assistance of two people with a mechanical lift (Hoyer- a device used to safely lift a person with minimal physical effort) for transfers form one surface to another. Review of Resident R1's progress note dated 7/30/24, at 10:42 p.m. revealed; Resident left facility via stretcher by 911 (non-emergent) to hospital for trauma to left bicep. Safety maintained. Review of a written witness statement dated 7/31/24, from NA Employee E1 stated: Resident R1 was in the shower room on shower chair. NA Employee E2 asked me if I can assist her with putting resident in wheelchair. We stood resident up in shower at bar. Once she (Resident R1) stood she said her legs was 'giving out'. We tried to reach for wheelchair but it was too far so we lower her to the floor. Review of documentation provided by the facility dated 8/1/24, stated the following: Resident R1 was admitted to the facility on [DATE]. On 7/29/24 the resident was given a shower and as two nurse aides stood her to dress her in the shower room by standing her up at grab bar. Resident R1's legs gave out and she was assisted to the ground resulting in a fall. Description of Follow-up Action: The resident was immediately assessed by the registered nurse, and she was lifted off the floor. Vital signs were at baseline. No bruising or injuries noted. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) notified. Fall protocol initiated. Increased pain was found in the left arm over the next day. CRNP (Certified Registered Nurse Practitioner) notified of increased pain and came to assess the resident. CRNP gave orders for the resident to be sent out to the ER (emergency room ) for possible trauma to the left bicep. On 7/31/24 it was founded that Resident R1's left shoulder was dislocated. They attempted to place shoulder back into place but were unsuccessful. Resident was sent back to the facility with orders for Resident R1 to follow up with ortho (orthopedic- a doctor who treats injuries involving muscles, bones, joints, ligaments, and tendons). Upon investigation it was found that the resident should have been lifted by a mechanical lift for transfers. All of the nursing staff will be re-educated on checking the Task list for transfer requirements prior to moving the resident. Resident R1 had a follow-up appointment with her previous surgeon, and she is scheduled to undergo surgery to replace shoulder. Review of Resident R1's nursing progress note dated 8/2/24, at 10:49 a.m. revealed that Resident R1 left for her surgical procedure appointment for her right arm slightly after 10am. Medicated for pain prior to leaving. Review of documentation provided by the facility dated 8/4/24, indicated that Resident R1's fall that occurred on 7/29/24, had been investigated and the facility determined that due to NA Employee E2 Not adhering to the task list of using the mechanical lift causing the resident to fall, this incident is neglect. Review of a written witness statement dated 8/4/24, from Nurse Aide (NA) Employee E2 stated: I called NA Employee E1 to assist me with Resident R1 as she was standing by the rail. She (Resident R1) stated 'my legs are giving out'. NA Employee E1 and myself lowered her. Review of a written witness statement dated 8/5/24, from NA Employee E3 stated: NA Employee E2 ask me for help and I said Resident R1 was a lift (mechanical lift) and she left and ask help to another NA. Review of Resident R1's Kardex (a snapshot of a resident's care needs) indicated that resident was to be transferred via a full body mechanical lift as per Physical Therapy instruction. During an interview on 8/15/24, at 11:14 a.m. Physical Therapist (PT) Employee E4 indicated that Resident R1 required a Hoyer for transfers per the evaluation completed on 7/22/24 and that this information was placed into the Kardex at the time of the evaluation so that it could be communicated to the nurse aides. During an interview on 8/15/24, at 11:20 a.m. Occupational Therapist (OT) Employee E5 stated that if a resident requires a Hoyer for transfers that staff should use the Hoyer to transfer the resident to a shower bed when the resident requires a shower. After the shower, the resident should be dried off while on the shower bed, covered up, and then be transferred back to their room where staff would use the Hoyer to place them back in bed and dress them while they are in bed. During an interview on 8/15/24, at 11:38 a.m. NA Employee E1 confirmed that she was present when Resident R1 was lowered to the ground on 7/29/24, in the shower room. NA Employee E1 stated that she was not familiar with Resident R1 as she had not taken care of her lately, but that NA Employee E2 asked her for help and I was trusting my coworker in regards to how Resident R1 transferred. She added that transfer status if located in the Kardex and is easily located. NA Employee E1 also confirmed that NA Employee E2 had Resident R1 in a shower chair, and not a shower bed, which is typically used for residents requiring a Hoyer. During an interview on 8/15/24, at 11:48 a.m. NA Employee E3 stated that transfer information is located in the Kardex and that is how she knew Resident R1's transfer status and that she required a Hoyer. During an interview on 8/15/24, at 11:58 a.m. Resident R1 confirmed that she had her surgery to repair her shoulder. State Agency informed Resident R1 of awareness of fall in the shower room. Resident R1 replied that she first fell a few days prior when An aide was changing my diaper and rolled me onto my side and pushed me too hard and I went over the side of the bed. I tried to brace myself with my arm and hurt my arm. I kept complaining of pain and they sent me to the ER a couple of days later (7/30/24). The CT scan (computed tomography- a medical imaging technique used to obtain detailed internal images of the body) showed my arm was out of socket and they tried twice to put it back in with no success so I needed surgery on Friday (8/2/24). I'm just pissed that this all had to happen. It's been inconvenient going back and forth (for treatment). Review of Resident R1's medical record did not reveal any documentation regarding Resident R1's account of the fall that occurred when she was rolled out of the bed prior to her fall in the shower room. During an interview on 8/15/24, at 12:52 p.m. Nursing Home Administrator (NHA) stated that Resident R1 did fall out of bed on 7/22/24. During an additional interview on 8/15/24, at 12:55 p.m. NHA confirmed that this fall was not documented in Resident R1's medical record and that the fall was not investigated. During an interview on 8/15/24, at 1:30 p.m. Director of Nursing stated that NA Employee E2 was relieved of her duties on 8/8/24, related to the improper transfer of Resident R1 during the fall that occurred on 7/29/24 During an interview on 8/15/24, at 1:40 p.m. NA Employee E6 stated that resident transfer orders are located in the Kardex, and if a resident were ordered a Hoyer for transfer and needed a shower she would Grab another aide and a Hoyer and transfer them onto a shower bed and dress them in their bed. During an interview on 8/15/24, at 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate assistance with an appropriate device to prevent falls for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1. Findings include: Review of the facility job description for Certified Nursing Assistant, indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Job duties include assisting with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 6/17/24, indicated diagnoses Vitamin C deficiency, and generalized edema (fluid accumulation that affects the whole body. Review of Resident R1's admission record indicated additional diagnoses of muscle wasting and atrophy (decrease in size). Review of Resident R1's Physical Therapy evaluation dated 7/22/24, indicated that resident requires maximum assistance of two people with a mechanical lift (Hoyer- a device used to safely lift a person with minimal physical effort) for transfers form one surface to another. Review of Resident R1's medical record revealed a nursing progress note dated 7/30/24, at 10:42 p.m. that stated; Resident left facility via stretcher by 911 (non-emergent) to hospital for trauma to left bicep. Safety maintained. Review of a written witness statement dated 7/31/24, from NA Employee E1 stated: Resident R1 was in the shower room on shower chair. NA Employee E2 asked me if I can assist her with putting resident in wheelchair. We stood resident up in shower at bar. Once she (Resident R1) stood she said her legs was 'giving out'. We tried to reach for wheelchair but it was too far so we lower her to the floor. Review of documentation provided by the facility dated 8/1/24, stated the following: Resident R1 was admitted to the facility on [DATE]. On 7/29/24 the resident was given a shower and as two nurse aides stood her to dress her in the shower room by standing her up at grab bar. Resident R1's legs gave out and she was assisted to the ground resulting in a fall. Description of Follow-up Action: The resident was immediately assessed by the registered nurse, and she was lifted off the floor. Vital signs were at baseline. No bruising or injuries noted. Doctor and POA (power of attorney- a person who is legally named to act on someone else's behalf) notified. Fall protocol initiated. Increased pain was found in the left arm over the next day. CRNP (Certified Registered Nurse Practitioner) notified of increased pain and came to assess the resident. CRNP gave orders for the resident to be sent out to the ER (emergency room ) for possible trauma to the left bicep. On 7/31/24 it was founded that Resident R1's left shoulder was dislocated. They attempted to place shoulder back into place but were unsuccessful. Resident was sent back to the facility with orders for Resident R1 to follow up with ortho (orthopedic- a doctor who treats injuries involving muscles, bones, joints, ligaments, and tendons). Upon investigation it was found that the resident should have been lifted by a mechanical lift for transfers. All of the nursing staff will be re-educated on checking the Task list for transfer requirements prior to moving the resident. Resident R1 had a follow-up appointment with her previous surgeon, and she is scheduled to undergo surgery to replace shoulder. Review of Resident R1's nursing progress note dated 8/2/24, at 10:49 a.m. stated that Resident R1 left for her surgical procedure appointment for her right arm slightly after 10am. Medicated for pain prior to prior to leaving. Review of a written witness statement dated 8/4/24, from Nurse Aide (NA) Employee E2 stated: I called NA Employee E1 to assist me with Resident R1 as she was standing by the rail. She (Resident R1) stated 'my legs are giving out'. NA Employee E1 and myself lowered her. Review of a written witness statement dated 8/5/24, from NA Employee E3 stated: NA Employee E2 ask me for help and I said Resident R1 was a lift (mechanical lift) and she left and ask help to another NA. Review of Resident R1's Kardex (a snapshot of a resident's care needs) indicated that resident was to be transferred via a full body mechanical lift as per Physical Therapy instruction. During an interview on 8/15/24, at 11:14 a.m. Physical Therapist (PT) Employee E4 indicated that Resident R1 required a Hoyer for transfers per the evaluation completed on 7/22/24 and that this information was placed into the Kardex at the time of the evaluation so that it could be communicated to the nurse aides. During an interview on 8/15/24, at 11:20 a.m. Occupational Therapist (OT) Employee E5 stated that if a resident requires a Hoyer for transfers that staff should use the Hoyer to transfer the resident to a shower bed when the resident requires a shower. After the shower, the resident should be dried off while on the shower bed, covered up, and then be transferred back to their room where staff would use the Hoyer to place them back in bed and dress them while they are in bed. During an interview on 8/15/24, at 11:38 a.m. NA Employee E1 confirmed that she was present when Resident R1 was lowered to the ground on 7/29/24, in the shower room. NA Employee E1 stated that she was not familiar with Resident R1 as she had not taken care of her lately, but that NA Employee E2 asked her for help and I was trusting my coworker in regards to how Resident R1 transferred. She added that transfer status if located in the Kardex and is easily located. NA Employee E1 also confirmed that NA Employee E2 had Resident R1 in a shower chair, and not a shower bed, which is typically used for residents requiring a Hoyer. During an interview on 8/15/24, at 11:48 a.m. NA Employee E3 stated that transfer information is located in the Kardex and that is how she knew Resident R1's transfer status and that she required a Hoyer. During an interview on 8/15/24, at 11:58 a.m. Resident R1 confirmed that she had her surgery to repair her shoulder. State Agency informed Resident R1 of awareness of fall in the shower room. Resident R1 replied that she first fell a few days prior when An aide was changing my diaper and rolled me onto my side and pushed me too hard and I went over the side of the bed. I tried to brace myself with my arm and hurt my arm. I kept complaining of pain and they sent me to the ER a couple of days later (7/30/24). The CT scan (computed tomography- a medical imaging technique used to obtain detailed internal images of the body) showed my arm was out of socket and they tried twice to put it back in with no success so I needed surgery on Friday (8/2/24). I'm just pissed that this all had to happen. It's been inconvenient going back and forth (for treatment). Review of Resident R1's medical record did not reveal any documentation regarding Resident R1's account of the fall that occurred when she was rolled out of the bed prior to her fall in the shower room. During an interview on 8/15/24, at 12:52 p.m. Nursing Home Administrator (NHA) stated that Resident R1 did fall out of bed on 7/22/24. During an additional interview on 8/15/24, at 12:55 p.m. NHA confirmed that this fall was not documented in Resident R1's medical record and that the fall was not investigated. During an interview on 8/15/24, at 1:30 p.m. Director of Nursing stated that NA Employee E2 was relieved of her duties on 8/8/24, related to the improper transfer of Resident R1 during the fall that occurred on 7/29/24. During an interview on 8/15/24, at 1:40 p.m. NA Employee E6 stated that resident transfer orders are located in the Kardex, and if a resident were ordered a Hoyer for transfer and needed a shower she would Grab another aide and a Hoyer and transfer them onto a shower bed and dress them in their bed. During an interview on 8/15/24, at 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide appropriate assistance with an appropriate device to prevent falls for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1. 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)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to make certain a resident received adequate supervision and assistance to prevent accident which resulted in actual physical harm (multiple hematomas, redness to multiple areas, and a fractured left arm that was later diagnosed as no definitive fracture and a radial head contusion of left elbow) for one of five residents (Resident R72). Findings include: Review of the facility policy Falls Care During and After, dated March 2022, indicated all residents experiencing a fall will receive appropriate care and investigation of the cause. Review of Admission record indicated that Resident R72 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/1/22, indicated the diagnoses of Dementia, high blood pressure and stroke. Review of Section G indicated Resident R72 required extensive assistance of two person physical assistance for bed mobility. Review of Resident R72's care plan dated 10/11/22, indicated bed mobility assist of two. Review of Resident R72's incident report dated 12/30/22, indicated Resident R72 was lying face down on the left side of the bed with her head between the night stand and the top leg of the bed where she sustained the following injuries: a hematoma (a pool of clotted blood under the skin) to left forehead measured 4.7 cm x 3.5 cm (centimeter), hematoma to the left forearm 4.2 cm x 3.5 cm, redness to the left thigh, redness to the right side of face, redness to the left face around the eye. Review of incident/accident follow up dated 1/3/22, indicated that Resident R72 had a fracture of the left lower forearm diagnosed as a non-displaced intra-articular fracture (a fracture that crosses a joint surface). Review of office visit dated 1/6/23, at 9:45 a.m. indicated x-rays were completed again and revealed no definitive fracture and a radial head contusion of left elbow. Pain was evaluated at office to the radial head area through facial expression during exam. Review of Employee Statement Form dated 12/30/22, indicated Nursing Assistant (NA) Employee E10 was changing Resident R72 and rolled her onto her side, she was holding on to a chair to steady herself, the chair shifted and Resident R72 rolled onto the floor. She landed face down. Phone interview with NA Employee E10 on 1/10/23, at 12:31 p.m. indicated Resident R72 was incontinent and NA Employee E10 rolled her onto her side toward window, she was holding a wheelchair close to the bed to steady herself, the chair shifted and she rolled out of bed she was wedged between the nightstand and the leg of the bed, Resident R72 doesn't communicate well but she appeared to be in pain with facial grimace. I asked the night nurse heading out for the day and she said I could do her myself. I later found out she was wrong, it should have been two people and I should have looked at the Kardex in the computer at the desk or the kiosk's in the hallways. She had a big bump on her head and left side. Interview with Registered Nurse (RN) Employee E9 on 1/20/23, at 1:53 p.m. indicated I had a new aide of the floor, NA Employee E10 who did not check the Kardex for assistance needs resulting in Resident R72 rolling onto the floor face down and moaning. Interview on 1/10/23 at 3:00 p.m. the Director of Nursing confirmed the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual physical harm (multiple hematomas, redness to multiple areas, and a fractured left arm that was later diagnosed as no definitive fracture and a radial head contusion of left elbow) for one of five residents (Resident R72). 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (d) Resident care policies 28 Pa Code 211.12 (d)(3) Nursing services

Based on review of facility policy, reports submitted to the State, clinical records, and staff interviews it was determined that the facility failed to make certain that a resident was free from neglect by not providing proper bed mobility which resulted in a small abrasion to the left upper buttocks and transfer assistance with a hoyer lift which resulted in a resident's right toenail being removed, causing actual harm to two out of eight sampled residents (Resident R11 and R33). Findings include: The facility Abuse policy, dated 10/31/19 and last reviewed on 2/14/21, indicated that the nursing facility prohibit all forms of abuse and strive to provide an environment and culture that treats every resident with dignity and respect. Staff are educated to prevent, identify, assess and report suspected abuse to the appropriate authority in accordance with legal and regulatory requirements. Neglect is defined 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. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Incidents are investigated as required and the administrator is responsible for reporting allegations of abuse to the proper authorities. The facility Resident care policy: Resident falls evaluation policy reviewed on 4/1/19, last reviewed on 2/14/21, indicated that it is the policy of the facility to make reasonable efforts to identify residents who are at risk to fall so that appropriate preventative measure can be implemented to minimize the risk of harm. Staff members are required to evaluate residents upon admission and implement appropriate preventive measures. The facility Mechanical lift policy reviewed on 7/20/16, last reviewed on 2/14/21, indicated that mechanical lifts will be used for residents who cannot be transferred comfortably by normal transfer technique. Two staff members must always be present to preform lifts with mechanical devices. Physical therapy may recommend appropriate lifting techniques for specific residents. Review of Resident R11's admission record indicated she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R11's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/5/19, indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R11's care plan indicated to assist with transfers as needed. Review of Resident R11's functional status assessment dated [DATE], indicated that she was to be provided two staff-person assist with rolling and bed transfers. Review of facility provided documentation dated 1/26/20, indicated that Resident R11 had a fall after sliding out of the bed. The fall investigation found that Nurse Aide Employee E6 did not follow the care plan and rolled Resident R11 in the bed on her side by herself. Review of Resident R11's fall incident report dated 1/26/20, indicated that Nurse Aide Employee E6 rolled Resident R11 on her side and she continued to roll out of the bed. Resident R11 placed back in bed with Hoyer lift. Review of the incident statement dated 1/26/20, Nurse Aide Employee E6 stated that she was rolling Resident R11 by herself to change her on last rounds during the 11 p.m. to 7 a.m. shift. As she rolled the resident on her side, she began to slide over and off the bed. She then went to get the RN Supervisor to help Resident R11. Review of Resident R11's skin assessment dated [DATE], indicated Resident R11 had a small abrasion to the left upper buttocks (0.1cm x 2.0 cm). Review of Resident R11's Kardex dated 1/31/20, indicated that the resident was a two staff-person assist with bed mobility prior to the incident. Review of Resident R11's Occupational Therapy assessment dated [DATE], indicated that Resident R11 had a fall and she still needed two staff-person assist with bed mobility. Review of Nurse Aide Employee E6's personnel record indicated she was hired on 6/22/19. Her personnel file indicated she was fully trained on abuse, use of mechanical lifts, transferring residents, and the resident plan of care. Review of Resident R33's admission record indicated he was originally admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R33's hospital record dated 10/11/17, indicated that his transfer status was transfer dependent with two staff-persons. Review of Resident R33's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 2/24/20, indicated these diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R33's Occupational Therapy evaluation dated 3/23/20, indicated that he was non-ambulatory, required a Hoyer lift, and had some inability to follow commands due to impaired cognition. Review of Resident R33's physician assessment dated [DATE], indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R33's care plan dated 4/28/20, indicated to keep free of obstructions and to shower resident on a gurney. Review of Resident R33's Kardex (document explaining resident care needs) indicated that he was a transfer with the use of a Hoyer lift. Review of facility provided documents dated 4/27/20, indicated that Resident R33 was being transferred from bed to shower gurney by Nurse Aide (NA) Employee E1 when his right foot got tangled and caused the right foot's fifth toenail to be removed. Review of Resident R33's clinical nurse progress notes dated 4/27/20, indicated that RN Unit manager/DON was called to his room by Nurse Aide (NA) Employee E1 to assesses right distal phalange (pinky) toenail. Toenail was bleeding. Toe nail subsequently came off. Physician and responsible party notified. Facility incident report completed by Nurse Aide (NA) Employee E1, dated 4/27/20, indicated that she had Resident R33 in the Hoyer lift, and he was already in the sling. Somehow his foot got caught and caused his toenail to get torn off by mistake. Facility incident report completed by Nurse Aide (NA) Employee E2, dated 4/27/20, indicated that she left the room prior to transferring Resident R33. She left the room to answer another resident call light and she heard Nurse Aide (NA) Employee E1 screaming for help. She states Nurse Aide (NA) Employee E1 started to move Resident R33 by herself. Review of Resident R33's Podiatry consultation on 5/4/20, indicated no recommendations, hospitalization , or surgeries are needed. Review of Nurse Aide (NA) Employee E1's personnel file indicated she was originally hired on 5/16/18. Her personnel file indicated she was fully trained on abuse, use of mechanical lifts, and transferring residents. Review of Nurse Aide (NA) Employee E2's personnel file indicated she was originally hired on 3/5/18, and terminated from her position on 5/8/20, no reason doumneted for termination. Her personnel file indicated she was fully trained on abuse, use of mechanical lifts and transferring residents. During an interview on 1/25/22 10:38 a.m. Director of Physical Therapy Employee E3 stated her department assess residents for need of a Hoyer lift, and the reason to use a two staff-person assist is because of resident deficits during transfers (balance, weight issues, leg strength). During an interview on 1/25/22 2:12 p.m., Nurse Aide (NA) Employee E1 stated that she and Nurse Aide (NA) Employee E2 should have completed the lift together, but Nurse Aide (NA) Employee E2 left while Resident R33 was in the sling hanging in the air. He then slid forward while he was in the air, the Hoyer lift caught his toenail as he slid, and that caused his toenail to be injured. She stated that the transfer information for all residents is located in the Kardex. During observations on 1/27/22, at 8:57 a.m. Resident R33 was observed with Registered Nurse (RN) supervisor Employee E7. His right toe was observed and his nail and nail bed have healed. During an interview related to this incident on 1/27/22, at 9:22 a.m., Registered Nurse (RN) Wound nurse Employee E9 stated that she assessed Resident R33 and the toe area of his right toenail was dry and left open to air. Resident R33 showed minimal response to pain related to his injury. During an interview on 1/27/22, at 2:09 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that a Resident R11 and Resident R33 were free of neglect which resulted in harm. 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (d) Resident care policies 28 Pa Code 211.12 (d)(3) Nursing services

Based on review of facility policy, resident clinical records, facility documentation, hospital documentation, and staff interviews it was determined the facility failed to provide adequate supervision, interventions, and assistive devices to prevent accidents and falls that resulted in abrasions, loss of toe nail, fractured bones, and knee cap displacement for four of four residents (Residents R9, R11, R33 and R38). Findings include: Review of facility policy titled Resident Falls - Evaluation, Re-Evaluation and Documentation revised in April, 2019, and last reviewed 2/14/21, indicated it is the policy of UPMC Senior Communities to make reasonable efforts to identify residents who are at risk to fall so that appropriate preventative measures can be implemented to minimize the risk of harm from a resident fall. The facility Mechanical lift policy reviewed on 7/2016, last reviewed on 2/14/21, indicated that mechanical lifts will be used for residents who cannot be transferred comfortably by normal transfer technique. Two staff members must always be present to perform lifts with mechanical devices. Physical therapy may recommend appropriate lifting techniques for specific residents. Review of facility policy titled Fall Risk Reduction revised in September 2016, and last reviewed 2/14/21, indicated all residents are assessed for falls risk upon admission, readmission, quarterly, and with a significant change in medical condition. Those determined to be a risk receive appropriate interventions to reduce risk and minimize the potential to fall. In the event of an actual fall, an attempt is made to eliminate causal factors and prevent further falls. Review of Resident R9's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included dementia (a group of conditions characterized by impairment such as memory loss and judgement), severe protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), underweight, dysphagia (swallowing difficulty), wasting and atrophy (wasting of muscle tissue), disorders of muscle, palliative care (specialized medical care for serious illnesses), generalized anxiety, and major depressive disorder. Review of Resident R9's MDS (Minimum Data Set, a federal mandatory assessment to determine a resident's care needs) dated 11/2/21, documented a BIMS (Brief Interview for Mental Status - a screening tool to determine cognitive function) score of 09 out of 15, indicating moderate cognitive impairment. Review of Resident R9's care plan initiated 3/30/21, documented a problem as 'at risk for falls' with interventions of non-skid footwear, keep areas free from obstructions, call bell placement and use reminders, reminders to use ambulation and transfer devices, staff to respond promptly to call bell, a low bed, toileting as scheduled, and appropriate restorative nursing programs (nursing care designed to improve or maintain the functional ability of the resident). Review of Resident R9's admission Nursing Evaluation dated 3/30/21, documented the resident has confusion with anxiety, impaired vision and did not have glasses, episodes of bowel and bladder incontinence, needs assistance of 1 for toileting, has decreased muscle tone and reduced strength of lower extremities, and uses a walker. The associated fall risk evaluation documented the resident is chair bound and requires assistance with elimination, has impaired vision, has a balance problem, requires assistive devices for mobility, and is prescribed medications that may increase fall risk. The resident scored a 10 on the fall risk evaluation, indicating a high risk for falls (score of 10 or above). Review of Resident R9's occupational therapy evaluation dated 3/31/21, documented the resident requiring occupational therapy to address a decline in prior level of function in strength, transfers, grooming, endurance, and cognitive functional tasks. Precautions and considerations included fall risk and cognitive impairments. The occupational therapy discharge summary dated 11/21/21, documented the resident was discharge from therapy as reaching maximum rehabilitation potential and due to poor to fair carryover (transferring lesson/skill from one environment to another) due to extreme anxiety and pain. Review of Resident R9's Physician Progress Notes dated 10/25/21, documented the resident had a small fall this AM, lowered [self] to the ground without injury. Review of Resident R9's Nursing Evaluation dated 11/11/21, documented the resident scored a 16 on the falls risk evaluation, indicating a high risk for falls. Review of Resident R9's progress note dated 11/11/21, documented the resident was sitting on the edge of the bed and slid to the floor. The resident stated they may have bumped their head during the fall and bumped both knees on the way down. Resident R9 stated they were on the floor for about 10 minutes before she was able to get help. The resident stated she used her call bell to get someone in to see her. The resident was assessed for injuries with no injuries documented in the record. Review of Resident R9's Physician Progress Notes dated 12/3/21, documented a concern of decrease in overall function and activity, I have noticed the resident has not been out in the hallway or ambulating around her room as she typically does. Review of resident R9's Physician Progress Notes dated 12/6/21, documented the 'palliative CRNP (Certified Registered Nurse Practitioner) saw patient last week due to concern for generalized decline, and no longer walking the halls, now mostly in bed.' Review of Physician Progress Notes dated 12/30/21, documented the resident 'continues to experience significant anxiety, having trouble leaving [resident] bed. Review of Resident R9's progress note dated 1/4/22, documented the resident had a witnessed fall, observed falling at side of the bed, landed on [resident] buttocks and complained of severe right hip pain. An x-ray order was obtained, and pain medication was provided. The facility did not obtain witness statements. Review of Resident R9's progress note dated 1/5/22, documented the resident was transported to a local trauma hospital for evaluation and management of a right hip fracture secondary to a fall. Review of Resident R9's hospital documentation dated 1/5/22, recorded the resident sustained a comminuted intertrochanteric fracture (type of broken bone) of the right hip requiring surgery. Review of Resident R9's progress note dated 1/12/22, documented the resident was found on the floor by a nursing assistant, 1 day after hospital return for hip fracture. X-rays were ordered. The facility did not obtain witness statements. Resident R9's care plan initiated 3/30/21, did not include revised interventions, supervision, and assistive devices to address recent falls. During an interview on 1/28/22, at 11:50 a.m. the Nursing Home Administrator reported fall interventions are reviewed at quality assurance meetings and care plans are revised accordingly. During an interview on 1/28/22, at 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide adequate supervision, interventions, and assistance devices to prevent accidents that resulted in a fall with injuries. Review of Resident R11's admission record indicated she was admitted on [DATE], with diagnoses that included [CONDITION(S)], dementia, major depressive disorder, pressure ulcer to her right heel, and difficulty walking. Review of Resident R11's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/5/19, indicated that the diagnoses remained current. Section G0110A Bed Mobility was coded Self Performance and Support for Bed mobility as 3-Extensive assistance and 3-Two-person physical assistance. Review of Resident R11's care plan indicated to assist with transfers as needed. Review of Resident R11's functional status assessment dated [DATE], indicated that she was to be provided two staff-person assist with rolling and bed transfers. Review of facility provided documents dated 1/26/20, indicated that Resident R11 had a fall after sliding out of the bed. The fall investigation found that Nurse Aide Employee E6 did not follow the care plan and rolled Resident R11 in the bed on her side by herself. Review of Resident R11's fall incident report dated 1/26/20, indicated that Nurse Aide Employee E6 rolled Resident R11 on her side and she continued to roll out of the bed. Resident R11 placed back in bed with Hoyer lift. Review of the incident statement dated 1/26/20, Nurse Aide Employee E6 stated that she was rolling Resident R11 by herself to change her on last rounds during the 11 p.m. to 7 a.m. shift. As she rolled the resident on her side, she began to slide over and off the bed. She then went to get the RN Supervisor to help Resident R11. Review of Resident R11's skin assessment dated [DATE], indicated Resident R11 had a small abrasion to the left upper buttocks (0. 1 cm x 2.0 cm). Review of Resident R11's Kardex dated 1/31/20, indicated that the resident was a two staff-person assist with bed mobility prior to the incident. Review of Resident R11's Occupational Therapy assessment dated [DATE], indicated that Resident R11 had a fall and she still needed two staff-person assist with bed mobility. Review of Nurse Aide Employee E6's personnel record indicated she was hired on 6/22/19. Her personnel file indicated she was fully trained on abuse, use of mechanical lifts, transferring residents, and the resident plan of care. Review of Resident R33's admission record indicated he was originally admitted on [DATE], with diagnoses that included [CONDITION(S)], diabetes, mood disorder, and [CONDITION(S)] (brain disorder). Review of Resident R33's hospital record dated 10/11/17, indicated that his transfer status was transfer dependent with two staff-persons. Review of Resident R33's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 2/24/20, indicated these diagnoses remain current. The MDS assessment Section G0110B Transfers found a 4-total dependence and a 3-Two person assistance. Review of Resident R33's Occupational Therapy evaluation dated 3/23/20, indicated that he was non-ambulatory, required a Hoyer lift, and had some inability to follow commands due to impaired cognition. Review of Resident R33's physician assessment dated [DATE], indicated the resident had a history of [CONDITION(S)] related to multiple strokes. Review of Resident R33's care plan dated 4/28/20, indicated to keep free of obstructions and to shower resident on a gurney. Review of Resident R33's Kardex (document explaining resident care needs) indicated that he was a transfer with the use of a Hoyer lift. Review of reports submitted to the State field office dated 4/27/20, indicated that Resident R33 was being transferred from bed to shower gurney by Nurse Aide (NA) Employee E1 when his right foot got tangled and caused the right foot's fifth toenail to be removed. Review of Resident R33's clinical nurse progress notes dated 4/27/20, indicated that RN Unit manager/DON was called to his room by Nurse Aide (NA) Employee E1 to assesses right distal phalange (pinky) toenail. Toenail was bleeding. Toe nail subsequently came off. Physician and responsible party notified. Facility incident report completed by Nurse Aide (NA) Employee E1, dated 4/27/20, indicated that she had Resident R33 in the Hoyer lift, and he was already in the sling. Somehow his foot got caught and caused his toenail to get torn off by mistake. Facility incident report completed by Nurse Aide (NA) Employee E2, dated 4/27/20, indicated that she left the room prior to transferring Resident R33. She left the room to answer another resident call light and she heard Nurse Aide (NA) Employee E1 screaming for help. She states Nurse Aide (NA) Employee E1 started to move Resident R33 by herself. Review of Resident R33's Podiatry consultation on 5/4/20, indicated no recommendations, hospitalization , or surgeries are needed. Review of Nurse Aide (NA) Employee E1's personnel file indicated she was originally hired on 5/16/18. Her personnel file indicated she was fully trained on abuse, use of mechanical lifts, and transferring residents. Review of Nurse Aide (NA) Employee E2's personnel file indicated she was originally hired on 3/5/18, and terminated from her position on 5/8/20. Her personnel file indicated she was fully trained on abuse, use of mechanical lifts and transferring residents. During an interview on 1/25/22 10:38 a.m. Director of Physical Therapy Employee E3 stated her department assess residents for need of a Hoyer lift, and the reason to use a two staff-person assist is because of resident deficits during transfers (balance, weight issues, leg strength). During an interview on 1/25/22 2:12 p.m., Nurse Aide (NA) Employee E1 stated that she and Nurse Aide (NA) Employee E2 should have completed the lift together, but Nurse Aide (NA) Employee E2 left while Resident R33 was in the sling hanging in the air. He then slid forward while he was in the air, the Hoyer lift caught his toenail as he slid, and that caused his toenail to be injured. She stated that the transfer information for all residents is located in the Kardex. During observations on 1/27/22, at 8:57 a.m. Resident R33 was observed with Registered Nurse (RN) supervisor Employee E7. His right toe was observed, and his nail and nail bed have healed. During an interview related to this incident on 1/27/22, at 9:22 a.m., Registered Nurse (RN) Wound nurse Employee E9 stated that she assessed Resident R33, and the toe area of his right toenail was dry and left open to air. Resident R33 showed minimal response to pain related to his injury. During an interview on 1/27/22, at 2:09 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide an environment free of accidental hazards as required which resulted in actual harm to Residents R11 and R33. Review of Resident R38's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included developmental disorder, lack of coordination, repeated falls, difficulty in walking, spinal stenosis (narrowing of spaces within the spine), scoliosis (curvature of the spine), displaced intertrochanteric (fracture between the bony protrusions of the hip), fracture of the left femur, and dorsopathy (diseases of the spine resulting from impaired nutrition, blood supply, and falls). Review of Resident R38's MDS (Minimum Data Set, a federal mandatory assessment to determine a resident's care needs) dated 9/16/21, documented a BIMS (Brief Interview for Mental Status - a screening tool to determine cognitive function) score of 08 out of 15, indicating moderate cognitive impairment. Review of Resident R38's care plan initiated 3/5/20, documented a problem as 'at risk for falls' with interventions of non-skid footwear, keep areas free from obstructions, call bell placement and use reminders, reminders to use ambulation and transfer devices, staff to respond promptly to call bell, a low bed, toileting as scheduled, and appropriate restorative nursing programs (nursing care designed to improve or maintain the functional ability of the resident). Review of Resident R38's Fall Risk Evaluation dated 3/07/20, documented the resident had intermittent confusion, 1-2 falls in the past three months, impaired vision, chair bound/requires assistance with elimination, has a gait and balance problem, requires assistive devices for mobility, and is prescribed medications that may increase fall risk. The resident scored a 22 on the fall risk evaluation, indicating a high risk for falls (score of 10 or above). Review of Resident R38's progress note dated 11/4/21, documented the nurse saw the resident sitting on the floor in front of [resident] room. The resident yelled help, help. The resident sustained a 2 cm (approximately ¾) skin tear on the left middle finger. The resident also complained of left hip pain. Tylenol administered and an ice pack applied. A left hip x-ray was ordered with negative results. Witness statements were not obtained by the facility. Review of Physician Progress Notes dated 11/5/21, documented the resident has had some falls due to imbalance, complaining of back and left knee pain. Review of Resident R38's progress note dated 11/5/21, documented the resident was found sitting on the floor and stated [resident] was trying to walk to the bathroom. No injuries were documented. Witness statements were not obtained by the facility. Review of Resident R38's progress note dated 11/5/21, documented the resident sustained a second fall this afternoon. X-rays were obtained and showed no fractures. Review of Resident R38's progress note dated 11/7/21, documented [staff] heard a bang from the resident's room, and staff found the resident sitting on the bathroom floor. The resident reported they were trying to go to the bathroom. The resident complained of left hip and left knee pain. An order for an x-ray of the left femur was obtained with no change from the 11/4/21 x-ray. Review of Resident R38's progress note dated 11/8/21, documented the resident had a witnessed fall in the second floor lounge. Resident was assessed and no injuries were documented. Tylenol and an ice pack was applied to left hip for comfort. Review of Resident R38's progress note dated 1/21/21, documented the resident voicing increased discomfort to left knee. Tylenol and ice pack applied. Review of Resident R38's progress note dated 1/29/21, documented the resident was on a leave of absence to a local hospital for leg swelling and pain. The resident was admitted to a local hospital for left leg [CONDITION(S)] (bacterial skin infection), left leg pain, and left tibial plateau fracture-displaced (break of the larger lower leg bone below the knee). Review of Resident R38's hospital documentation dated 11/29/21, recorded the resident sustained a left tibial plateau fracture requiring a knee immobilizer be worn at all times. Review of Resident R38's care plan initiated 3/5/20, did not include revised interventions, supervision, and assistive devices to prevent falls and injuries. During an interview on 1/28/22, at 11:50 a.m. the Nursing Home Administrator reported fall interventions are discussed at quality assurance meetings and care plans are revised accordingly. During an interview on 1/28/22, at 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide adequate supervision, interventions, and assistance devices to prevent accidents that resulted in a falls with injuries. 28 Pa Code 201.18 (e)(1) Management 28 Pa Code:201.29(a)(d) Resident rights Previously cited 2/6/17 and 12/19/17 28 Pa code:211.10(c)(d) Resident care policies Previously cited 2/6/17 and 12/19/17 28 Pa Code:211.12(a)(c)(d)(1)(2) Nursing services Previously cited 2/6/17 and 12/19/17

Based on review of facility policy, facility and hospital clinical records and staff interview, it was determined that the facility failed to provide adequate assistance for manual transfers resulting in harm in the form of a fibular and tibial spiral fracture and failed to report a serious injury in a timely manner for one of six residents reviewed (Resident R1). Findings include: A review of the facility policy titled, Abuse, updated 10/11/16, defines neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatments, and care. A review of the facility policy titled, Abuse Investigation and Reporting, Protection and Response, updated 10/11/16, indicated that employees of the facility have a responsibility to report any observed or suspected incidents of resident abuse, neglect or misappropriation of resident property. A review of the quarterly Minimum Data Set assessment (MDS- a periodic assessment of resident care needs) dated 12/20/16, indicated that Resident R1 had [DIAGNOSES REDACTED]. The 12/20/16, MDS also indicated that Resident R1 rarely or never understood the staff and was unable to be understood and required the extensive assistance of two persons for transfers. A review of the nursing Kardex (electronic information for nursing staff on resident transfer status) dated 12/2/16, indicated that Resident R1 required the assistance of two staff for manual transfers. A review of Resident R1's Plan of Care updated 1/5/17, indicated that Resident R1 required assistance of two staff for manual transfers. A review of the Clinical Notes Report dated 1/16/17, indicated, Nurse assessed the resident and the resident right leg swelling from above the knee to toe. One bruise 8 by 7.5 centimeters (cm) on her front shin, and another 6 by 11.5 cm around her ankle. Right leg is warm and painful when touched. Spoke to physician on call and order obtained for stat (immediate) X-ray of right foot. A review of the X-ray report dated 1/16/17, indicated a fibular and tibular (two lower leg bones) spiral fracture (a bone fracture occurring when torque (a rotating force) is applied along the axis of a bone that often occurs when the body is in motion and one extremity is planted) of the right leg. A review of the Clinical Notes Report dated 1/16/17, indicated that Resident R1 was transferred to the hospital for evaluation and treatment. A review of the hospital Emergency Department Evaluation Note dated 1/16/17, indicated that Resident R1 had a right tibia and fibula spiral fracture and was subsequently admitted to the hospital for treatment. A review of Employee E3's, Witness Statement, undated, indicated that on 1/15/17, on the day shift Resident's R1 I put my arms around her and grabbed the back of her pants, and transferred her into the wheelchair by myself. Employee E3's, Witness Statement also indicated, Around 1:00 p.m., I took (Resident R1) back to her room. I transferred (the resident) back to her bed. A review of NA Employee E2's Witness Statement dated 1/20/17, indicated that on 1/13/17, on the day shift, I cleaned and transferred (Resident R1) into a wheelchair by myself. A review of NA Employee E1's, Witness Statement dated 1/23/17, indicated that on 1/13/17, on the night shift, around 5:00 a.m. I transferred (Resident R1) into wheelchair myself. An interview with NA Employee E2 on 1/31/17, 3:00 p.m. confirmed that they didn't check the Kardex prior to the manual transfer. An interview with the Director of Nursing on 2/1/17, at 1:15 p.m. confirmed that the facility staff neglected to provide adequate assistance with manual transfers which resulted in a [MEDICAL CONDITION] and fibula of the right leg. Refer to F323 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/16/16, 9/15/16, 1/22/16. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/16/16, 9/15/16, 1/22/16. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 12/16/16.

Based on review of facility policies, facility and hospital clinical records and staff interviews, it was determined that the facility failed to provide adequate assistance for safe transfers to prevent accidents resulting in a fibular and tibial spiral fracture to one of six residents reviewed (Resident R1). Findings include: The facility policy entitled, Safe Resident Handling and Mobility, dated 10/11/16, indicated that all residents are assessed upon admission to determine their mobility and transfer ability including care requirements related to handling and moving and how best to accomplish this in the safest way. This information is incorporated into the plan of care/support plan and communicated to other care providers and interdisciplinary team members. A review of the quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated 12/20/16, indicated that Resident R1 had [DIAGNOSES REDACTED]. The 12/20/16, MDS also indicated that Resident R1 rarely or never understood the staff and was unable to be understood and required the extensive assistance of two persons for transfers. A review of the nursing Kardex (electronic information for nursing staff on resident transfer status) dated 12/2/16, indicated that Resident R1 required the assistance of two staff for manual transfers. A review of Resident R1's Plan of Care updated 1/5/17, indicated that Resident R1 required assistance of two staff for manual transfers. A review of the Clinical Notes Report dated 1/16/17, at 6:41 p.m. indicated that the, nurse assessed (Resident R1) and (noted) right leg swelling from above the knee to toe. One bruise 8 centimeters (cm.) by 7.5 cm. on her front shin, and another 6 cm. by 11.5 cm. around her ankle, right leg is warm and painful when touched. The 1/16/17, clinical note also indicated that Resident R1's right leg circumference measurement was greater than the left leg and that the staff called the physician and an X-ray was ordered to be done immediately. A review of the X-ray report dated 1/16/17, indicated a fibular and tibular (two lower leg bones) spiral fracture (a bone fracture occurring when torque (a rotating force) is applied along the axis of a bone that often occurs when the body is in motion and one extremity is planted) of the right leg. A review of the Clinical Notes Report dated 1/16/17, indicated that Resident R1 was transferred to the hospital for evaluation and treatment. A review of the hospital Emergency Department Evaluation Note dated 1/16/17, indicated that Resident R1 had a right tibia and fibula fracture and was subsequently admitted to the hospital for treatment. A review of the hospital clinical records Impression and Plan dated 1/16/17, indicated this could be non-accidental trauma or neglect. A review of Nursing Assistant (NA) Employee E3's, Witness Statement, undated, indicated that on 1/15/17, on the day shift, Resident R1's foot was still swollen, so didn't put shoes on her. I put my arms around her and grabbed the back of her pants, and transferred her into the wheelchair by myself. Employee E3's, Witness Statement also indicated, Around 1:00 p.m., I took (Resident R1) back to his/her room. I transferred (the resident) back to her bed. A review of NA Employee E2's Witness Statement dated 1/20/17, indicated that on 1/13/17, on the day shift, I cleaned and transferred (Resident R1) into a wheelchair by myself. A review of NA Employee E1's, Witness Statement dated 1/23/17, indicated that on 1/13/17, on the night shift, around 5:00 a.m. I transferred (Resident R1) into wheelchair myself. During interviews with the Nursing Home Administrator and the Director of Nursing on 1/30/17, at 12:30 p.m. it was confirmed that Resident R1 required two staff for transfers and that the facility failed to provide adequate supervision for safe transfers to prevent an accident resulting in a fibular and tibial spiral fracture to Resident R1. Refer to F224 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/supervision/devices. Previously cited 12/16/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/16/16, 9/15/16, 1/22/16. 28 Pa. Code 201.29(a)(d) Resident rights. 28 Pa. Code 201.29(c) Resident rights. Previously cited 9/15/16. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/15/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/16/16, 9/15/16, 1/22/16. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 12/16/16. 28 Pa. Code 211/12(d)(5) Nursing services. Previously cited 12/16/16, 9/15/16.

Based on review of facility policies, review of clinical records, and staff interviews, it was determined that the facility failed to implement physician approved safety recommendations for one of five residents reviewed (Resident R1). Findings include: A review of the facility policy "Falls Risk Reduction" dated 9/28/10, indicated that residents determined to be at risk for falls will receive appropriate interventions to reduce the risk and minimize the potential to fall and to review appropriate assessments for any additional information related to falls risk. A review of the clinical record indicated that Resident R1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission nursing review dated 5/23/11, indicated that Resident R1 was assessed as completely immobile and was a high risk for pressure sores, had a fall risk score of 14 indicating the resident was a high risk for falls, was nonambulatory, had fluctuations in the level of consciousness, had a reduction in safety awareness due to cognitive declines and had poor balance. A review of the physical therapy cognitive status evaluation dated 5/24/11, indicated that Resident R1 was lethargic (decreased alertness and awareness with decreased energy), required repeated verbal cues to follow directions, required a mechanical lift (a device used to lift a resident) for transfer, and required two staff to provide bed mobility. The physical therapy evaluation form's, safety recommendation check boxes, indicated wheelchair alarms (a device that alarms when a resident tries to leave their wheelchair), a bed alarm (a device that alarms when a resident attempts to get out of bed), and a low bed/mats (a bed that is lower to the floor and mats placed on the floor beside the bed). The physician had co-signed the evaluation on 5/25/11. A review of Resident R1's admission Minimum Data Set (MDS - a periodic review of care needs) assessment dated [DATE], indicated that Resident R1 had severely impaired cognition, had impaired range of motion to all extremities, did not ambulate, was unable to perform any activities of daily living without staff assistance, and required assistance of two staff for bed mobility and transfer. A review of Resident R1's clinical record indicated on 6/15/11, at 12:00 p.m., Resident R1 was found on the floor, lying face down, and bleeding from the front of her head. Resident R1 was transferred to the hospital on [DATE], and admitted with a [DIAGNOSES REDACTED]. During an interview on 7/7/11, at 12:50 p.m., Registered Nurse (RN) Employee E3 stated that Resident R1 did not have a bed alarm or fall mats in place at the time of the fall on 6/15/11. During an interview on 7/7/11, at 2:15 p.m., Physical Therapist Employee E8 stated that the safety recommendations from the physical therapy evaluation, which was completed on 5/24/11, for Resident R1 should have been implemented, because they were approved by the physician. During an interview on 7/8/11, at 2:30 p.m., the Director of Nursing confirmed that Resident R1 did not have a bed alarm or fall mats in place at the time of the fall on 6/15/11. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 12/03/10, 4/19/11. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 4/19/11, 6/17/11. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 12/3/10, 4/19/11, 6/17/11. 28 Pa. Code: 211.10(a) Resident care policies. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 4/19/11, 6/17/11. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services. Previously cited 1/29/10, 3/2/10, 12/3/10, 4/19/11, 6/17/11. 28 Pa. Code: 211.12(d)(2) Nursing Services. Previously cited 3/2/10. 28 Pa. Code: 211.12(d)(3) Nursing Services. Previously cited 4/19/11, 6/17/11.

Based on review of clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to protect a resident from a burn for one of two residents (Resident R1). Findings include: A review of the facility contracted rehabilitation services' policy, "Physical Agent Modalities - Moist Heat Packs" dated 9/28/10, indicated that, "Caution is required when applying moist heat packs to the very young, the elderly, patients taking medications intended to produce relaxation...The skin under the packs must be inspected frequently to avoid the possibility of a burn." A review of the Physician Admission History and Physical indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- Periodic Assessment of Care Needs) dated 3/17/11, indicated that Resident R1 was alert and oriented. Review of the April 2011, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of an incident report submitted to the State Survey Agency dated 4/11/11, indicated that a moist heat pack was placed on Resident R1's right shoulder by a Restorative Nurse Aid (RNA), Employee E1, on 4/9/11. The incident further indicated that Employee E1 failed to remove the moist heat pack. On 4/11/11, a third degree burn with two fluid filled blisters was noted to Resident R1's right shoulder. A review of the April 2011, physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the Event Reporting System Report (ERS) dated 4/15/11, indicated that a hydroculator pad had been applied to the right shoulder of Resident R1 for approximately 15 minutes prior to its removal. An observation on 4/19/11, at 10:15 a.m., revealed a wound on Resident R1's right shoulder, which was consistent with a burn in the process of healing. During an interview at that time, Resident R1 confirmed the decreased sensation of the shoulder and was unaware of the injury until notified by the staff. Resident R1 stated, "I couldn't feel that the pad was hot enough to burn me." During an interview on 4/19/11, at 11:15 a.m., the Director of Rehabilitation, Employee E2, indicated that moist heat applications required a physician order. During an interview on 4/19/11, at 8:30 a.m., the Director of Nursing confirmed that Employee E1 applied a moist heat pack without a physician order, neglected to check the application and neglected to remove the moist heat pack which resulted in Resident R1 sustaining a third degree burn to the right shoulder. Refer F323. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 12/03/10. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 12/03/10, 3/02/10, 1/29/10. 28 Pa. Code: 211.12(d)(3) Nursing services.

Based on review of clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to provide adequate supervision and failed to implement safety measures to protect a resident from burns, for one of two residents (Resident R1). Findings include: A review of the facility contracted rehabilitation services' policy entitled, "Physical Agent Modalities - Moist Heat Packs" dated 9/28/10, indicated to, "Check the moist heat pack unit...is operating in a safe temperature range for therapeutic use (150-160 degrees Fahrenheit)" and that, "Caution is required when applying moist heat packs to the very young, the elderly, patients taking medications intended to produce relaxation...The skin under the packs must be inspected frequently to avoid the possibility of a burn." A review of the "Daily Hydrocollator Temperature Records" for the Restorative Department provided by Registered Nurse/Restorative Nursing Director, Employee E3, on 4/19/11, at 8:50 a.m., revealed that there were no temperatures recorded in February 2011, March 2011, and April 1-10, and April 16-19, 2011. Employee E3 confirmed that the only temperature monitoring for the hydrocollator (moist heat pack unit) was documented from April 11, 2011 through April 15, 2011. During an interview on 4/19/11, at 1:30 p.m., the Nursing Home Administrator and the Director of Nursing (DON) indicated that a hydrocollator was made available to the Restorative Nursing staff on approximately February 7, 2011. The DON indicated that on 4/11/11, it was noted that no temperature monitoring was completed on the hydrocollator. A review of the Physician Admission History and Physical indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- Periodic Assessment of Care Needs) dated 3/17/11, indicated that Resident R1 was alert and oriented. The April 2011, Medication Administration Record (MAR) indicated that Resident R1 was ordered Oxycodone (a narcotic pain medication) twice a day as needed for pain and had received the medications twice each day from April 1, 2011 to April 19, 2011. A review of an incident report submitted to the State Survey Agency dated 4/11/11, indicated that a moist heat pack was placed on Resident R1's right shoulder by Restorative Nurse Aide, Employee E1, on 4/9/11. The incident report further indicated that Employee E1 failed to remove the moist heat pack. On 4/11/11, a third degree burn with two fluid filled blisters was noted to Resident R1's right shoulder. A review of the April 2011, physician orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the Event Reporting System Report (ERS) dated 4/15/11, indicated that a hydroculator pad had been applied to the right shoulder of Resident R1 for approximately 15 minutes prior to its removal. An observation on 4/19/11, at 10:15 a.m., revealed a wound on Resident R1's right shoulder. During an interview at that time, Resident R1 confirmed the decreased sensation in the shoulder and was unaware of the injury until notified by the staff. Resident R1 stated, "I couldn't feel that the pad was hot enough to burn me." During an interview on 4/19/11, at 11:15 a.m., the Director of Rehabilitation Employee E2 indicated that moist heat applications required a physician order [REDACTED]. Employee E2 confirmed that special care would be needed with residents with decreased sensation and diabetes. During an interview on 4/19/11, at 1:30 p.m., the DON confirmed that the facility failed to monitor the temperature of the hydrocollator, Employee E1 applied a moist heat pack without a physician order, and failed to provide adequate supervision and monitoring of the area, which resulted in Resident R1 sustaining a third degree burn to the right shoulder. Refer F224. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 12/03/10. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 12/03/10. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 12/03/10, 3/02/10, 1/29/10. 28 Pa. Code: 211.12(d)(3) Nursing services.