Every finding on record at Highland Hills Post Acute

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to obtain a physician order for wound care and failed to provide appropriate treatment and care in accordance with professional standards of practice for one of four residents (Resident R1).Findings include: Review of facility policy Negative Pressure Wound Therapy (NPWT) dated 11/1/25, indicated NPWT requires cleansing and debridement of the wound, protection of the surrounding skin, and an airtight seal. Stop the pump and remove the dressing if the device stops working for more than 2 hours. Apply saline-moistened dressing and notify the provider. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of infection and inflammatory reaction due to internal left knee prosthesis, high blood pressure, and presence of left artificial knee joint. Review of Resident R1's hospital discharge orders dated 6/10/26, indicated wound to left knee, clean with Vashe (a wound cleanser used to prevent and treat infections), pat dry, Adaptic film (a clear, non-adherent dressing used to protect the wound bed) applied, 125 mmHg (Millimeters of mercury) wound VAC (vacuum-assisted wound closure, NPWT). Wound VAC change MWF (Monday, Wednesday, Friday) or PRN (as needed). Review of Resident R1's Admission/readmission Evaluation/assessment dated [DATE], indicated the resident had a left knee surgical incision and stated, wet to dry dressing until wound vac arrives. Review of a skin and wound progress note dated 6/11/26, stated, Hospital course notable for recurrent left knee prosthetic joint infection with wound dehiscence (unintended separation or opening of a wound or surgical incision) and wound VAC placement. Patient was transferred to facility on 6/10/26 with plan to continue wound VAC and continue IV (intravenous) cefazolin (an antibiotic) through 6/29/26. Left knee open surgical treatment recommendations: cleanse with wound cleanser, apply wound VAC @ 125 mmHg continuous therapy, per Surgeons request to base of the wound, secure with transparent film, change 3 times per week, every M/W/F. Review of a physician order dated 6/12/26, indicated left knee wound: cleanse with Vashe, pat dry, apply Adaptic film and wound vac @ 125 mmHg every day shift every Monday, Wednesday, Friday and PRN for displacement. Review of nursing documentation dated 6/12/26, indicated the above order was not completed as ordered, stating, wound vac not present yet. Review of a resident representative concern dated 6/14/26, stated, My loved one was admitted on the evening of June 10th 2026 with the expectation of a wound vac being available. Upon my visit on Thursday the 11th there was still no wound vac. I called on Friday the 12th to check the status of the equipment. I was told they were still waiting for the equipment to be delivered but a wet to dry dressing had been applied the day before, which I did see while visiting the night before. The dressing was dated 6/11. While visiting today I saw that she still does not have a wound vac and her dressing still had the same date from 6/11 on it. I notified staff who told me there was never an order placed to change the dressing. Review of a skin and wound progress note dated 6/15/26, stated, Left knee is ordered a wound vac @ 125 mmHg continuous therapy - current treatment is dakins (a wound healing solution) moistened gauze due to wound vac supplies not arriving to facility yet, due to arrive today with plans to apply wound vac as soon as the supplies are available. Review of a physician order dated 6/15/26, indicated to apply a wet to dry dressing to L (left) knee, change daily, may DC (discontinue) when wound vac is placed every day shift for wound care. This order was documented as completed on 6/15/26. Review of Resident R1's physician orders failed to include additional wound dressing orders for 6/10/26, through 6/14/26. Review of Resident R1's clinical record failed to include documentation that the left knee dressing was changed On 6/11/26, 6/12/26, 6/13/26, and 6/14/26. During an interview on 6/16/26, Resident R1 stated, I think they were having problems getting the wound vac. They put it on yesterday but I think I broke the tubing last night when I took myself to the bathroom. They took it off and put a dressing on my knee today. I can't remember if anyone from the facility changed the dressing from when I was admitted to yesterday when I had the wound vac placed. During an interview on 6/16/26, at 12:40 p.m. the Director of Nursing confirmed the facility failed to obtain a physician order for wound care and failed to provide appropriate treatment and care in accordance with professional standards of practice for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R2).Findings include: Review of facility policy Prevention of Pressure Injuries dated 11/1/25, indicated the purpose of this procedure is provide an overview of current standards of practice for pressure injury prevention. Interventions are individualized according to each resident's risk factors for pressure injury, clinical condition, and resident wishes for goals and care. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. For example, reposition every 2-3 hours when an appropriate pressure redistribution support surface is used. Review of facility policy Charting and Documentation dated 11/1/25, indicated all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/10/26, indicated diagnoses of high blood pressure, hemiplegia (paralysis or severe weakness affecting one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain) affecting right dominant side, and need for assistance with personal care. Section GG0170A indicated the resident was coded 2 substantial/maximal assistance for the ability to roll from lying on back to left and right side, returning to lying on back on bed. Review of a resident representative concern dated 6/15/26, stated, There is no regular movement or repositioning. Review of Resident R1's comprehensive care plan dated 5/20/26, indicated the resident is at risk for skin breakdown related to activity intolerance, cognitive impairment, and impaired mobility. Interventions include assist to turn and reposition as indicated/tolerated. Review of Resident R1's June 2026 turn and reposition documentation indicated the task was not completed on the following shifts:6/1/26 11 p.m. - 7 a.m. shift, documentation blank6/2/26: 3 p.m. 11 p.m. shift and 11 p.m. - 7 a.m. shift were documented NA not applicable, with no further documentation available to explain why turn and repositioning was not applicable.6/3/26 3 p.m. 11 p.m. shift and 11 p.m. - 7 a.m. shift were documented NA not applicable, with no further documentation available to explain why turn and repositioning was not applicable.6/7/26 3 p.m. 11 p.m. shift and 11 p.m. - 7 a.m. shift were documented NA not applicable, with no further documentation available to explain why turn and repositioning was not applicable.6/9/26 3 p.m. - 11 p.m. shift, documentation blank6/11/26 7 a.m. - 3 p.m. shift, documentation blank6/13/26 7 a.m. - 3 p.m. shift was documented NA not applicable, with no further documentation available to explain why turn and repositioning was not applicable.6/15/26 3 p.m. - 11 p.m. shift, documentation blank During an interview on 6/16/26, at 9:46 a.m. Resident R2 stated, I don't get turned and repositioned, some staff offer to do it, some don't. It's not consistent. During an interview on 6/16/26, at 1:13 p.m. the Director of Nursing confirmed that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers for Resident R2. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of 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 two of four residents (discharged Resident R1 and Resident R3).Findings include: Review of facility policy Transfer and discharge process last reviewed 11/1/25, indicated residents, or their representatives are provided with written notification of an impending transfer or discharge. Information conveyed to a receiving provider includes but is not inclusive of:Practitioners contact informationResident representative informationAdvanced directivesAll special instructions or precautions for ongoing careComprehensive care plan goalsAll other necessary information, including a copy of the resident's discharge summary The medical record must contain the discharge summary information and recipient of the summary. Review of the clinical record indicated discharged Resident R1 was admitted to the facility on [DATE]. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnosis of high blood pressure, anxiety and chronic respiratory failure. Review of the clinical record indicated discharged Resident R1 was transferred to the hospital on 3/8/26 and did not return to the facility. Review of discharged 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 transfer 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 the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/14/26, indicated the diagnosis of high blood pressure, diabetes (high sugar in the blood) and hyperlipidemia (high fat in the blood). Review of Resident R3's nursing progress notes dated 3/5/26, indicated resident became unresponsive during lunch in wheelchair vital signs blood /pressure (B/P) 88/50, (healthy adult normal between 120/60) heart rate 75 (healthy adult normal 60-100), oxygen saturation 95% (healthy adult normal 95-100%) respirations 26 (health adult normal 18-20), maximum assistance of four staff to return to bed. Resident became more aroused B/P 110/58, heart rate 71, respirations 21, pulse ox 94%. Able to appropriately answer questions. Per nurse practitioner send to hospital for evaluation, niece in agreement to go to hospital. Review of Resident R3's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transfer and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview completed on 3/19/26, at 1:05 p.m. the Assistant Director of Nursing (ADON) Employee E1 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents (discharged Resident R1 and Resident R3). 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights

Based on review of clinical records and staff interviews, it was determined and failed to obtain failed to obtain a physician order for a hospital transfer for one of four residents (Resident R3) and failed to obtain physician orders for management of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for one of two residents (discharged Resident R2).Findings include: Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/14/26, indicated the diagnosis of high blood pressure, diabetes (high sugar in the blood) and hyperlipidemia (high fat in the blood). Review of Resident R3's nursing progress notes dated 3/5/26, indicated resident became unresponsive flaccid during lunch in wheelchair vital signs blood /pressure (B/P) 88/50, (healthy adult normal between 120/60) heart rate 75 (healthy adult normal 60-100), oxygen saturation 95% (healthy adult normal 95-100%) respirations 26 (health adult normal 18-20), maximum assistance of four staff to return to bed. Resident became more aroused B/P 110/58, heart rate 71, respirations 21, pulse ox 94%. Able to appropriately answer questions. Per nurse practitioner send to hospital for evaluation, niece in agreement to go to hospital. Review of Resident R3's physician orders failed to include an order to transfer to the hospital. During an interview completed on 3/19/26, at 1:05 p.m. the Assistant Director of Nursing (ADON) Employee E1 confirmed that the facility failed to obtain a physician order for a hospital transfer for one of four residents (Resident R3) Review of the clinical record indicated discharged Resident R2 was admitted to the facility on [DATE]. Review of discharged Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/14/26, indicated the diagnosis of anemia (low iron in the blood) diabetes (high sugar in the blood) and high blood pressure. Review of discharged Resident R2's physician orders dated 1/28/26, indicated Humalog Solution 100 unit/milliliter (ML) (Insulin Lispro (fast acting insulin) Inject as per sliding scale (matches the current blood sugar reading (measurement of glucose (sugar) in the blood) to a corresponding insulin dose:if 0 - 150 = 0 units151 - 200 = 2 units201 - 250 = 4 units251 - 300 = 6 units301 - 350 = 8 units351 - 400 = 10 unitssubcutaneously before meals and at bedtime for diabetes. The physician order failed to contain parameters for when to contact the physician regarding hypoglycemia or hyperglycemia capillary blood glucose checks. During an interview completed on 3/19/26, at 1:18 p.m. Assistant Director of Nursing (ADON) Employee E1 confirmed that the facility failed to obtain physician orders for management of hypoglycemia and hyperglycemia for one of two residents (discharged Resident R2). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy, observations and resident and staff interviews it was determined that the facility failed to make certain that nail care was provided for four of ten residents (Resident R3, R4, R5, and R6). Findings include: Review of the facility policy Fingernails/Toenails, Care of last reviewed on 11/1/ 25, indicated that nail care includes daily cleaning and regular trimming. Review of a Resident Representative concern dated 12/22/25, stated the following: They don't clean or cut his nails. I'm the one that cuts his nails. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/23/25, indicated diagnoses of stroke (when blood stops flowing to a part of the brain), high blood pressure, and hemiplegia (paralysis on one side of the body). During an observation and interview on 12/20/25, at 11:16 a.m. Resident R3 was noted to have long fingernails, with brown debris underneath. State Agency (SA) asked Resident R3 if he needed his nails cut to which he replied Yeah. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and malnutrition (lack of nutrients in the body). During an observation on 12/30/25, at 11:12 a.m. Resident R4 was noted to have long fingernails. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of muscle weakness, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and low back pain. During an observation and interview on 12/30/25, at 11:30 a.m. Resident R5 was noted to have long and jagged fingernails. SA asked Resident R5 if she needed her nails cut, to which she replied, I need them cut but I don't know who cuts them. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE], indicated diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), high blood pressure, and hip fracture. During an observation and interview on 12/30/25, at 11:31 a.m. Resident R6 was noted to have long fingernails with brown debris underneath. SA asked Resident R6 if he needed his nails cut and resident replied Yes, I do. During walking rounds with the Assistant Director of Nursing (ADON) Employee E1 on 12/30/25, from 12:29 p.m. to 12:36 p.m., the above observations were confirmed by ADON. During an interview on 12/30/25, at 12:36 p.m. the ADON confirmed that the facility failed to make certain that nail care was provided for four of ten residents. 28 Pa. Code:201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, resident interview, and staff interview, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for three of three residents (Residents R1, R2, and R3).Findings include: Review of facility policy Prosthetic/Orthotic Management dated 11/1/25, indicated that splints are used to: Prevent and/or reduce contractures and deformity by applying prolonged, steady stretch of tight muscles/joint structures.Maintain proper joint positioning and alignment.Reduce pain and/or increase functional use of extremity by applying support for involved joint(s). 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 11/21/25, indicated diagnoses of stroke (when blood stops flowing to a part of the brain), high blood pressure, and hemiplegia (paralysis on one side of the body). Review of Resident R1's clinical record revealed the following physician orders:Ankle brace with shoe during waking hours every day and evening shift. May remove when sleeping dated 4/12/25.Left palm guard on at bedtime remove in the morning dated 10/7/25Left elbow splint on during the day and off at bedtime, dated 10/15/25Left hand brace on in morning off at bedtime dated 10/15/25 Review of Resident R1's clinical record conducted on 12/30/25, revealed a Documentation Survey Report that revealed the following: Ankle Brace documentation was marked 'N for No, implying that brace was not applied on 12/2/25, 12/4/25, 12/22/25, /12/23/25, and 12/29/25Ankle Brace documentation was marked NA for Not applicable on 12/3/25, /12/12/25, /12/13/25, 12/17/25, and 12/21/25.Ankle Brace documentation was left blank, with no supporting documentation that brace was applied on 12/7/25, 12/11/25, 12/14/25, and 12/16/25. Review of the above documentation indicated that Resident R1 did not have his ankle brace applied on 14 of 29 days. Left palm guard documentation was marked 'N for No, implying that guard was not applied on 12/4/25.Left palm guard documentation was marked NA for Not applicable on 12/14/25, 12/16/25, 12/18/25, and 12/24/25.Left palm guard documentation was left blank, with no supporting documentation that guard was applied on 12/1//25.Review of the above documentation indicated that Resident R1 did not have his palm guard applied on 6 of 29 days. Elbow splint documentation as marked NA for Not applicable on 12/3/25, 12/5/25, 12/6/25, 12/13/25, 12/15/25, 12/17/25, 12/21/25, and 12/29/25. Elbow splint documentation was left blank, with no supporting documentation that splint was applied on 12/7/25, 12/11/25, 12/14/25, 12/16/25, 12/24/25, and 12/25/25.Review of the above documentation indicated that Resident R1 did not have his elbow splint applied on 14 of 29 days. Hand brace documentation was marked 'N for No, implying that brace was not applied on 12/5/25, 12/18/25, 12/22/25, and 12/23/25.Hand brace documentation as marked NA for Not applicable on 12/6/25, 12/13/25, 12/1/5/25, 12/17/25, 12/21/25, and 12/29/25.Hand brace documentation was left blank, with no supporting documentation that brace was applied on 12/7/25, 12/11/25, 12/14/25, 12/16/25, and 12/24/25.Review of the above documentation indicated that Resident R1 did not have his hand brace applied on 15 of 29 days. Review of clinical record indicated Resident R2 was admitted to the facility 4/30/21. Review of Resident 2's MDS dated [DATE], indicated diagnoses of stroke, high blood pressure, and hemiplegia. Review of Resident R2's clinical record revealed a physician's order dated 11/20/25, for a Left-hand splint on at bedtime and off in the morning. During an interview on 12/30/25, at 11:10 a.m. Resident R2 confirmed that he was to wear a hand splint and stated, I don't even know where it's at anymore. Review of Resident R2's clinical record conducted on 12/30/25, revealed a Documentation Survey Report that revealed the following: Hand splint documentation was marked 'N for No, implying that brace was not applied on 12/3/25, 12/8/25, 12/22/25, and 12/23/25.Hand splint documentation as marked NA for Not applicable on 12/6/25, 12/27/25, and 12/28/25.Hand splint documentation was left blank, with no supporting documentation that brace was applied on 12/4/25, 12/12/25, 12/13/25, 12/15/25, 12/17/25, 12/18/25, 12/20/25, 12/21/25, 12/24/25, 12/25/25, and 12/29/25. Review of the above documentation indicated that Resident R2 did not have his hand splint applied on 18 of 29 days. Review of clinical record indicated Resident R3 was admitted to the facility 2/13/25. Review of Resident 3's MDS dated [DATE], indicated diagnoses of stroke, high blood pressure, and hemiplegia. Review of Resident R3's clinical record revealed a physician's order dated 10/15/25, for a splint to right hand, apply at bedtime and remove in the morning. Review of Resident 32's clinical record conducted on 12/30/25, revealed a Documentation Survey Report that revealed the following: Hand splint documentation as marked NA for Not applicable on 12/2/25, 12/4/25, 12/6/25, 12/7/25, 12/8/25, 12/10/25, 12/13/25, 12/14/25, 12/18/25, 12/20/25, 12/22/25, 12/24/25, and 12/27/25.Hand splint documentation was left blank, with no supporting documentation that brace was applied on 12/25/25.Review of the above documentation indicated that Resident R3 did not have his hand splint applied on 14 of 29 days. During an interview on 12/30/25, at 1:38 p.m. the Assistant Director of Nursing Employee E1 confirmed that the facility failed to ensure that residents with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for three of three residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10(a)(c)(d) Resident care policies.28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain resident's confidential personal and medical records for one of three residents (Resident R1). Findings include: A review of the facility policy titled, Confidentiality of Information and Personal Privacy dated 1/18/25, indicated that the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 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 11/21/25, indicated diagnoses of stroke (when blood stops flowing to a part of the brain), high blood pressure, and difficulty swallowing. During an observation on 12/30/25, at 12:07 p.m. a sign was observed posted above Resident R1's bed that included the following information: Blue [NAME] cup (a cup designed to limit the flow of liquids for residents who have difficulty swallowing) used for thin water. Only 5-10 ccs (milliliters) of liquid for each sip to reduce risk of aspiration (accidently inhaling liquid into the lungs). Encourage resident to sit up when drinking. Review of Resident R1's clinical record failed to include any documentation that the above resident or his representative approved the posting of private health information. During an interview on 12/30/25, at 2:13 p.m. the Assistant Director of Nursing Employee E1 confirmed that the facility failed to maintain resident's confidential personal and medical records for one of three residents (Resident R1). 28 Pa. Code: 201.18(e)(1) Management

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of three residents (Resident R1).Findings include: Review of facility policy Care Plans, Comprhensive Person-Centered dated 11/1/25, indicated that a comprehensive, 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. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Review of a Resident Representative concern dated 12/22/25, stated They are still giving him thin water through a straw. 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 11/21/25, indicated diagnoses of stroke (when blood stops flowing to a part of the brain), high blood pressure, and difficulty swallowing. Review of Resident R1's clinical record revealed a physician's order dated 11/12/25, that stated No straws. A Review of Resident R1's care plan conducted on 12/30/25, did not include an intervention of No straws. During an interview on 12/30/25, at 1:43 p.m. the Assistant Director of Nursing confirmed the facility failed to revise care plan for Resident R1 as required. 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for the facility's Automated External Defibrillators (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias) (Second floor and first floor) and crash cart (a supply cart used in an emergency - second floor). Findings include:Review of the facility provided Heart Start FRx 86/304 AED's Owner Manual' dated Edition 8, indicated the AED's extensive automatic self-test features eliminates the need for any manual calibrations. Other than checks recommended after each use, replace any used, damaged or expired supplies and accessories.Observation of the facility's AED box on the second floor, [DATE], at 9:41 a.m. revealed an AED with AED Smart Pads II attached to the machine with an expiration date of [DATE].Observation of the second-floor crash cart on [DATE], at 9:41 a.m. revealed the crash cart checklist log failed to be completed from [DATE], -[DATE].Interview on [DATE], at 9:45 a.m. Registered Nurse (RN) Manager Employee E8 confirmed the crash cart checklist log was not completed on [DATE] -[DATE], and that AED Smart Pads II were expired.Observation of the facility's AED box on the first floor on [DATE], at 10:16 a.m. revealed an AED with AED Smart Pads II attached to the machine with an expiration date of [DATE].Interview on [DATE], at 10:17 a.m. RN Employee E12 confirmed that AED Smart Pads II were expired.Interview on [DATE], at 3:00 p.m. the Director of Nursing confirmed the facility failed to make certain that equipment was in safe operating condition for the facility's Automated External Defibrillators (Second floor and first floor) and crash cart (second floor).28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to follow established procedures of water storage to ensure that water is available to essential areas when there is a loss of normal water supply. Findings include: Review of the facility policy Emergency Preparedness and Planning dated 11/1/25, indicated the emergency water supply overall total water amount recommended by the Red Cross and FEMA is one gallon per person per day. Further review of the Emergency Water Supply plan indicated total bed capacity is 200 residents, with a total staff of 105 to equal 305 total people. The total people 305 times one gallon, times three days equals 915 gallons.Tour of the facility, with Maintenance Director Employee E25 on 12/17/25, at 11:08 a.m. revealed the Long-Term Care Supply Room that stored one-gallon containers of water in the form of six gallons/box with 16 boxes to equal a total of 96 gallons. The estimated volume for this storage area is 100 gallons.Interview with Maintenance Director Employee E25 on 12/17/25, at 11:10 a.m. confirmed the facility did not meet the adequate volume for that storage area as per their plan.Tour of the facility, with Maintenance Director Employee E25 on 12/17/25, at 11:20 a.m. revealed the Arcadia storage area stored 36 one-gallon jugs on top shelves, with five gallon jugs on the lower shelves. Total volume available equaled 161 gallons. The estimated volume for this storage area is 200 gallons.Interview with Maintenance Director Employee E25 on 12/17/25, at 11:23 a.m. confirmed the facility did not meet the adequate volume for that storage area as per their plan and indicated that the facility has emergency water available in the boiler room's water heaters of 100 gallons, 214 gallons in toilet tanks (134 toilets times 1.6 gallons equals 214.4 gallons), and storage tanks in the boiler room equal to 390 gallons.During further, questioning of Maintenance Director Employee E25 on 12/17/25, at 11:25 a.m. it was pointed out that the total amount of drinking water was inadequate with only 257 gallons stored in gallon jugs, when at total of 915 gallons was required for the facility data, and that the water in the water heaters, storage tanks in boiler room and water in toilet tanks was not acceptable for drinking water. During an interview on 12/17/25, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to have required amounts of drinkable emergency water supply on hand at this time for residents and staff in case of an emergency. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for four of seven residents (Resident R31, R40, R70 and R102). Findings include: Review of the facility policy Self-Administration of Medications dated 11/1/25, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Review of Resident R31's clinical record indicated an admission date of 2/11/21. Review of R31 's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/15/25, indicated diagnosis of anemia (low iron in the blood), heart failure (heart doesn't pump the way it should), and chronic obstructive pulmonary disease (COPD- causes breathing problems). Observation 12/16/25 at 9:15 a.m. indicated a bottle of nasal spray sitting on Resident R31's bedside stand. Review of Resident R31's physician orders failed to include an order for self-administration of medications. Review of Resident R31's care plan failed to include interventions for medication self-administration. Interview 12/16/25, at 9:18 a.m. Registered Nurse Employee E10 removed the nasal spray from the room and confirmed the absence of a physician order or care plan to self-administer medications. Review of Resident R102's clinical record indicated an admission date of 11/22/23. Review of R102's MDS dated [DATE], indicated diagnosis of chronic obstructive pulmonary disease (COPD- causes breathing problems), anemia (low iron in the blood) and depression. Observation 12/15/25, at 11:00 a.m. of Resident R102's bedside table revealed a medicine cup with red liquid. Upon asking Resident R102 what is in the cup replied, it's my cough medicine it's in here from last night so I can take it when I want. Review of Resident R102's physician orders failed to include an order for self-administration of medications. Review of Resident 102's care plan failed to include interventions for medication self-administration. Interview 12/15/25, at 11:08 a.m. RN Employee E10 removed the medicine cup from the room and confirmed the absence of a physician order or care plan to self-administer medications. 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 11/30/25, indicated the diagnoses of chronic kidney disease, adult failure to thrive and anemia. Observation on 12/15/25, at 10:30 a.m. of Resident R70's room indicated a one medicine cup with 4 pills. Review of Resident R70's physician orders dated 12/11/25 indicated Calcium Carbonate-Vit D-Min Oral Tablet 600-400 MG-UNIT give 1 tablet by mouth one time a day for hypocalcemia, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG give one tablet by mouth one time a day for HTN, Nifedical XL Oral Tablet Extended Release 24 Hour 60 MG give one tablet by mouth one time a day for HTN, Apixaban Oral Tablet 5 MG give five mg by mouth two times a day for DVT treatment/prevention. Interview with Registered Nurse (RN) Employee E12 confirmed the cup with four tablets were at the bedside unattended. Review of Resident R70's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications. Review of the admission record indicated Resident R40 was admitted to the facility on [DATE]. Review of Resident R40's MDS dated [DATE], indicated the diagnoses of chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), morbid obesity, and muscle wasting and atrophy. Observation on 12/15/25, at 11:30 a.m. of Resident R40's room indicated one medicine cup and an inhaler at the bedside table. The medicine cup had four Tums. Review of Resident R40's physician orders dated 12/14/25 indicated Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT one puff inhale orally four times a day for COPD and Tums Oral Tablet Chewable 500MG (Calcium Carbonate (Antacid) give one tablet by mouth every eight hours as needed for dyspepsia. Interview with Registered Nurse (RN) Employee E12 confirmed the cup with four tablets were tums and the inhaler at the bedside unattended. Review of Resident R40's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications. Interview on 12/15/25, at 12:00 p.m. RN Employee E12 confirmed the medications were stored in the resident room inappropriately and that Resident R40, R70 failed to have an assessment, physician order, or plan of care for self-administration of medications. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, resident clinical records, and staff interviews it was determined that the facility failed to include hypoglycemia protocols for one of three sampled residents (Resident R19) and failed to obtain a physician order for three of four residents (Resident R10, R102 and R149). Findings include: Review of the facility policy Medication and Treatment Orders last reviewed 11/1/25, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications. Review of Resident R10's clinical record indicated an admission date of 7/8/23. Review of R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated11/27/25, indicated the diagnosis of hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Observation on 12/15/25, at 9:37 a.m. of Resident R10's room indicated a handheld nebulizer (used to deliver respiratory medicine) on the nightstand. Review of Resident R10's physician orders on 12/19/25, failed to include medication for use in the handheld nebulizer. Interview completed on 12/19/25, at 8:54 a.m. Registered Nurse (RN) Employee E10 confirmed that there were not any current orders for the medication for the handheld nebulizer and stated, I found one that was discontinued on 12/2/25. Review of Resident R102's clinical record indicated an admission date of 11/22/23. Review of R102's MDS dated [DATE], indicated diagnosis of chronic obstructive pulmonary disease (COPD- causes breathing problems), anemia (low iron in the blood) and depression. Observation 12/15/25, at 11:00 a.m. of Resident R102's bedside table revealed a medicine cup with red liquid. Upon asking Resident R102 what is in the cup replied, it's my cough medicine it's in here from last night so I can take it when I want. Review of Resident R102's physician orders on 12/19/25, failed to include orders for cough medicine. Review of clinical record indicated Resident R149 was admitted to the facility on [DATE], with diagnoses of diabetes mellitus, morbid obesity and hepatic encephalopathy (brain dysfunction caused by liver dysfunction). Review of Resident R149's MDS dated [DATE], revealed the diagnoses were current. During an observation on 12/16/25 at 10:30 a.m. Resident R149 asked surveyor to check her offloading boot for her right heel in her bed. Review of Resident R149's physician orders dated 12/5/25 indicated no active physician order for an offloading boot. During an interview on 12/18/25, at 2:00 p.m. Assistant Director of Nursing Employee E4 confirmed Resident R149 did not have an active order for an offloading boot as required. During an interview completed on 12/19/25, at 11:08 a.m. RN Employee E10 confirmed there were not any orders for the cough medicine and stated, It was discontinued on 11/24/25, I updated this order on Monday, I don't know why it's not in there. The facility Management of hypoglycemia policy reviewed March 2025, and last reviewed 11/1/25, indicated that hypoglycemia signs and symptoms may include dizziness, restlessness, excessive perspiration, headache, or numbness. For instances of blood glucose below 70, give resident oral form of rapid absorbed glucose, notify the provider and remain with the resident. Documentation instructions included to document provider instructions. The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's (capillary blood glucose). Review of Resident R19's admission record indicated he was admitted on [DATE] and re-admitted on [DATE]. Review of Resident R19's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/21/25, indicated he had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and repeated falls. Review of Resident R19's care plans dated 7/16/25, indicated that Resident R19 has diabetes, he is at risk of hyperglycemia and hypoglycemia, and initiate appropriate protocols. Review of Resident R19's physician orders dated 7/15/25, indicated to provided three times per day with meals Insulin Lispro (a short acting, manmade version of human insulin) Pen-injector 100 UNIT/ML (milliliter) inject as per sliding scale: 70 - 140 = 0 units;141 - 180 = 1 units; 181 - 220 = 2 units; 221 - 260 = 3 units;261 - 300 = 4 units; 301 - 340 = 5 units; Greater than 340= give 6 units and call doctor. Review of Resident R19's physician orders and physician notations did not include a hypoglycemia protocol for Resident R19 in the event his blood glucose level is below 70. During an interview on 12/17/25, at 10:07 a.m. Agency Licensed Practical Nurse (LPN) Employee E2 was asked what actions to take if resident is hypoglycemic: give the resident something that has sugar or the gel that goes on their tongue. When asked about the Hypoglycemia instructions missing from the physician order, she stated: I believe the sliding scale should be in the order. During an interview on 12/17/25, at 10:20 a.m. Agency Licensed Practical Nurse (LPN) Employee E3 was asked if sliding scale should include Hypoglycemia protocol: The sliding scale should be in the physician order. It may be put in separately. During an interview on 12/17/25, at 12:53 p.m. the Director of Nursing (DON) confirmed that the facility failed to include hypoglycemia protocols in the physician orders for Resident R19 as required. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for four of six residents (Residents R10, R127, R158 and R172).Findings include: Review of the facility policy Respiratory Equipment Change and Cleaning Guidelines last reviewed 11/1/25, indicated handheld nebulizers (used to deliver respiratory medicine) are to be labeled and dated with the room number/bed, they are stored in plastic bag when not in use. Nasal cannulas (thin tubing placed in nostrils to deliver supplemental oxygen) are to be labeled and dated when changed and stored in plastic bag when not in use. Continuous Positive Airway Pressure (CPAP-keeps airways open when you sleep) or Bilevel Positive Airway Pressure (BIPAP-normalizes breathing by delivering pressurized air) are to be labeled with room number/bed and to be stored in a plastic bag when not in use. Review of Resident R10's clinical record indicated an admission date of 7/8/23. Review of R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated11/27/25, indicated the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Observation on 12/15/25, at 9:37 a.m. of Resident R10's room indicated a handheld nebulizer on the nightstand, not dated or stored in a bag as required. Interview on 12/15/25, at 11:12 a.m. Registered Nurse (RN) Employee E10 confirmed the nebulizer on the stand was not dated or stored in as bag as required. Review of the clinical record indicated Resident R127 was admitted to the facility on [DATE]. Review of Resident R127's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked). Review of Resident R127's physician order dated 12/7/25, indicated CPAP setting 5 FiO2 (fraction of inspired oxygen) 30, and SpO2 (peripheral capillary oxygen saturation) of 97 percent every night shift for breathing. Review of Resident R127's current care plan failed to include management and use of the CPAP machine as ordered. Review of Resident R127's medication administration record dated December 2025 indicated the CPAP was administered from 12/7/25, through 12/10/25. Observation completed on 12/16/25, at 10:23 a.m. Resident R127 was in bed, with the CPAP machine at bedside. The mask was not stored in a bag as required. Interview on 12/16/25, at 10:23 a.m. Resident R127 indicated using the CPAP machine every night. Interview completed on 12/16/25, at 10:23 a.m. Assistant Director of Nursing (ADON) Employee E4 confirmed Resident R127's CPAP mask was not in a bag as required and failed to be included in the care plan. Review of the clinical record indicated Resident R158 was admitted to the facility on [DATE]. Review of Resident R158's MDS dated [DATE], indicated diagnoses of aphasia (language disorder that affects speech and understanding of language), hemiplegia (paralysis on one side of the body) and cerebrovascular accident (CVA-stroke blood flow to brain becomes damaged due to lack of blood flow). Review Resident R158's physician order dated 3/5/25, indicated Auto CPAP at bedtime. Maximum inspiration positive airway pressure (IPAP) 15 centimeters of water column (cmH20-measure of pressure) minimum expiratory positive airway pressure (EPAP) 5cmH20 pressure at bedtime for obstructive sleep apnea. Observation on 12/15/25, at 11:24 a.m. indicated a CPAP sitting on top of fall mat placed on the floor on the left side of the bed. Interview 12/15/25, at 11:28 a.m. RN Employee E10 confirmed the CPAP machine was sitting on top of the fall mat and was not dated or stored in as bag as required. Review of the clinical record indicated Resident R172 was admitted to the facility on [DATE]. Review of Resident R172's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure), hemiplegia (paralysis on one side of body) and anxiety. Review of Resident R172's physician order dated 12/11/25, indicated oxygen at 3 liters per minute (LPM) via nasal canula continuous. Observation on 12/15/25, at 10:53 a.m. Resident R172 was in her room, her oxygen was on via nasal canula, the tubing failed to be labeled with a date/time as required. Interview on 12/15/25, at 11:11 a.m. RN Employee E10 confirmed the oxygen tubing failed to be labeled with a date/time as required. During an interview completed on 12/15/25, at 3:00 p.m. the director of nursing confirmed that the facility failed to provide appropriate respiratory care for four of six residents (Residents R10, R127, R158 and R172). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R7) and failed to ensure that Enhanced Barrier Precautions were managed properly for three of three residents (Resident R16, Resident R89, and Resident R159).Findings include: Review of the facility policy Dressings, Dry/Clean last reviewed 11/1/25, indicated wash and dry hands thoroughly. Put on clean gloves, remove soiled dressing discard into plastic or biohazard bag. Wash and dry your hands thoroughly. Review of the facility policy Enhanced Barrier Precautions dated 11/1/25, indicated Enhanced Barrier Precautions (EBP's) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. EBPs employ targeted gown and glove use during high contact resident care activities (for example dressing, bathing/showering, providing hygiene, changing briefs or assisting with toileting, etc.). Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.Review of Resident R7's clinical record indicated admission to facility on 8/20/24. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/8/25, indicated diagnosis of hypertension (high blood pressure), diabetes (high sugar in the blood) and depression. Review of R7's physician orders dated 11/20/25, indicated Left Heel: cleanse with wound cleanser, apply Santyl ointment and calcium alginate to wound bed, cover with foam dressing. Observation of dressing change on 12/16/25, at 12:58 p.m. Registered Nurse (RN) Employee E12 removed Resident R7's soiled dressing, cleansed the wound and continued to apply the Santyl ointment, and calcium alginate. Licensed Practical Nurse (LPN) Employee E11 was assisting with dressing change by holding Resident R7's left heel off of bed. LPN Employee E11 placed Resident R7's heel down on a washcloth that was being used as a barrier, removed gloves completed hand hygiene and returned to treatment cart to retrieve a foam cover dressing. Upon returning to room LPN Employee E11 completed hand hygiene and donned new gloves, lifted Resident R7's leg up and RN Employee E12 placed the foam cover dressing. During an interview completed on 12/16/25 at 1:31 p.m. RN Employee E12 confirmed hand hygiene was not completed after removal of soiled dressing and cleansing wound. LPN Employee E11 confirmed placing Resident R7's heel down on the washcloth after the Santyl and calcium alginate were applied and lifting it back up to allow for placement of the cover dressing increasing the risk of cross contamination to wound. Review of the admission record indicated Resident R16 admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated the diagnoses of high blood pressure, atrial fibrillation (irregular heart rhythm), and BPH (enlarged prostate gland that squeezes the urethra). Section H0100 indicated a foley catheter is in use. Review of Resident R16's care plan dated 11/3/25, indicated EBP, resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of an indwelling device. Observation on 12/16/25, at 1:08 p.m. Nurse Aide (NA) Employee E24 and two other unidentified NAs were assisting Resident R16 in the Grand Heritage resident bathroom across from the nurses' desk. Resident R16 had a foley catheter under the wheelchair as staff escorted resident out of the bathroom. No gowns were observed in the bathroom or on the staff. Interview on 12/16/25, at 1:10 p.m. NA Employee E24 indicated not being aware that an indwelling catheter needed EBP and to wear a gown during care and confirmed gowns were not utilized as required. Review of the admission record indicated Resident R89 admitted to the facility on [DATE], with the diagnoses of lung cancer, encephalopathy (broad term for diffuse brain disease that alters the function or structure), and cardiomegaly (enlarged heart). Observation on 12/15/25, at 9:20 a.m. Resident R89 was observed in bed with a foley catheter. The room failed to have a sign posted on the door or wall outside the resident's rooms which communicates the type of precautions and PPE (personal protective equipment) required. Review of the admission record indicated Resident R159 admitted to the facility on [DATE]. Review of Resident R159's MDS dated [DATE], indicated high blood pressure, heart failure (heart doesn't pump blood as well as it should), and BPH. Section H0100 indicated a foley catheter is in use. Observation on 12/15/25, at 9:40 a.m. Resident R159 was noted in the hallway in the wheelchair with a foley catheter under the chair. Observation of Resident R159's room failed to have a sign posted on the door or wall outside the resident's rooms which communicates the type of precautions and PPE required. Interview and tour with Registered Nurse (RN) Employee E9 confirmed Resident R159's doorway failed to include signage to communicate with staff the need for EBP. Interview on 12/19/25, at 12:45 p.m. the Director of Nursing confirmed the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R7) and failed to ensure that Enhanced Barrier Precautions were managed properly for three of three residents (Resident R16, Resident R89, and Resident R159). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.28 (b)(1)(e )(1) Management.28 Pa Code: 211.10 (d ) Resident care policies.

Based on resident group meeting, clinical record review, observation and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R149).Findings include: Review of the clinical record indicated that Resident R149 was admitted to the facility on [DATE], with diagnoses which included hepatic encephalopathy (brain dysfunction caused by liver dysfunction), diabetes mellitus and morbid obesity. During an observation on 12/16/25, at 9:29 a.m. Resident R149's call light above her door illuminated, the call light was not responded to until 9:45 a.m., 16 mintute later, when Nurse Aide Employee E18 and Nurse Aide Employee E19. Review of facility provided documents Call Bell Audit's dated 12/11/15, 12/12/25, 12/16/25, revealed 12/11/25 room [ROOM NUMBER]: 21-minute response time, 12/12/25 room [ROOM NUMBER]: 20-minute response time, 12/16/25 room [ROOM NUMBER]: 16-minute response time. During an interview on 12/16/25, at 1:00 p.m. Registered Nurse Employee R12 confirmed that the facility failed to accommodate Resident R149's call bell needs. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code: 211.10(d) Resident care policies28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) for one of three sampled resident records (Resident R134).Findings include:The facility Medicare Advanced Beneficiary Non-coverage notices policy reviewed 11/1/2024, indicated a resident is informed in advance and in writing when Medicare payment denial or change in coverage is likely. Written notices are provided to the resident as soon as the facility makes the assessment that Medicare payment certainly or probably will not be made.Review of Resident R134's admission record indicated he was originally admitted on [DATE] and readmitted on [DATE].Review of Resident R134's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 10/7/25, indicated he had medical diagnoses included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), aphasia (difficulty swallowing), hyperlipidemia (elevated lipid levels within the blood), and hypertension (a condition impacting blood circulation through the heart related to poor pressure).Facility documents indicated that Resident R134 had exhausted 100 days of Medicare and he was no longer Medicare eligible as of 10/28/25. Review of Resident R134's census documentation indicated he was a Medicaid Pending resident as of 10/29/25.Review of Resident R134's resident records, nurse notes, and social services notes did not show evidence of an Skilled Nursing Facility- Advanced Beneficiary Notice (SNF-ABN) being provided to Resident R134.During an interview on 12/16/25, at 9:57 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to provide a SNF-ABN to Resident R134 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2)(3) Management

Based on review of facility policy, resident council group interview, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three common areas (Vending machine area).Findings include:The facility Homelike environment policy last reviewed on 11/1/25, indicated to provide a safe, clean and comfortable environment. Comfortable and safe temperatures include between 71 and 81 . During a Resident council group interview on 12/16/25, at 1:46 p.m. three out of eight residents voiced concerns that the Grand Heritage room with the vending machines was cold.During an interview on 12/17/25, at 9:35 a.m. Maintenance Supervisor Employee E25 stated: some of the heating units need replaced. It's been like this for a couple of months.During a tour of facility rooms and common areas on 12/17/25, at 9:36 a.m. observations of the vending machine rooms on Grand heritage found the room temperature to be 55 . During an interview on 12/17/25, at 2:45 p.m. information disseminated to the Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to maintain temperatures and a comfortable environment in one resident common area. 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 facility policies, facility documents, resident clinical records, and staff interviews it was determined that the facility failed to maintain an environment free of abuse for one of five sampled residents (Resident R167).Findings include:The facility Abuse, neglect, exploitation prevention program policy dated 11/1/25, indicated residents have the right to be free from abuse, neglect, exploitation.Review of Resident R167's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R167's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/26/25, indicated she had diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and hyperlipidemia (elevated lipid levels within the blood).Review of Resident R167's care plan dated 11/19/25, indicated if conflict arises to place Resident R167 in a calm and safe environment and allow her to vent.Review of Resident R167's clinical nurse note dated 11/19/25, indicated that at around 12:30 p.m. the Assistant Director of Nursing (ADON) Employee E4 entered resident's room and found Certified Nurse aide (CNA) Employee E6 and Licensed Practical Nurse (LPN) Employee E5 assisting resident into her wheelchair with a sit-to-stand lift. Assistant Director of Nursing (ADON) Employee E4 heard Licensed Practical Nurse (LPN) Employee E5 yelling at Resident R167 to stop it, you aren't a child. Stop acting like it. It appeared as if the Licensed Practical Nurse (LPN) Employee E5 pushed Resident R167 into the chair with the sling still around her waist.Facility investigation documents dated 11/19/25, Certified Nurse aide (CNA) Employee E6 witness statement was provided and indicated that Licensed Practical Nurse (LPN) Employee E5 yelled at Resident R167.Review of Licensed Practical Nurse (LPN) Employee E5 personnel record indicated she was hired 4/5/94. Her personnel record also indicated she received annual re-education for psychosocial needs dated 11/13/24 and annual re-education on abuse dated 4/27/25.During an interview on 12/16/25, at 8:54 a.m. Assistant Director of Nursing (ADON) Employee E4 was asked about incident with Licensed Practical Nurse (LPN) Employee E5: while Resident R167 was still hooked up to Hoyer lift pad, Licensed Practical Nurse (LPN) Employee E5 appeared to have pushed her down into a chair while she was hooked to a sit-to-stand machine and the sling was still around the resident. Licensed Practical Nurse (LPN) Employee E5 yelled in Resident R167's face to 'stop acting like a child'.During an interview on 12/17/25, at 3:00 p.m. information disseminated to the Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to maintain an environment free of abuse for Resident R167 as required. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of five residents (Resident R11). Findings include: Review of facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program last reviewed 11/1/25, indicated the program consists of a facility wide commitment and resource allocation to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident's property. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review Resident R11's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/20/25, indicated diagnoses of anemia (low iron in the blood), heart failure (heart doesn't pump the way it should) and seizure disorder (surge of abnormal electrical activity in the brain causing loss of consciousness and uncontrollable movements). Observation 12/15/25, at 9:30 a.m. Resident R11 was sitting in her chair, a thin scab was noted to her left side of forehead above eyebrow. Review of Resident R11's plan of care for Falls indicated resident is at risk for falls with or without injury related to altered balance while standing and/or walking. Review of Resident R11's progress note dated 12/13/25, at 10:04 p.m. indicated Late Entry: Per Nurse Aid (NA) statement, she was cleaning her up on her bed and went to the restroom, as NA came back after a few seconds the resident was laying on the floor on the right side of her bed. Registered Nurse (RN) was called, as I went to the room, the resident was lying on her left side beside her bed. The resident was assessed, a small, tiny skin tear noted on her left eyebrow with light signs of blood which is stopped already. Vitals were taken helped the resident to get in bed. The supervisor was notified; a phone call was placed to the family and voice message left for the resident's PCP office. Review of nursing progress note dated 12/15/25, at 2:15 p.m. IDT (interdisciplinary team) reviewed fall from 12/13/25, intervention: staff to provide all care prior to leaving room. Review of an employee statement dated 12/13/25, written at 10:10 p.m. by NA Employee E20 indicated went to bathroom to get water to wash resident came back and she was on the floor. Review of an employee statement dated 12/13/25, written at 10:10 p.m. by NA Employee E21 stated, I was in the resident's room across the hall when I heard her say the resident fell. When I went over, she was on the floor. I went to get the nurse while aid stayed with resident. Further review of facility provided investigation on 12/18/25, failed to include signed and dated witness statements from all staff members who had contact with the resident during the shift incident occurred. During an interview on 12/19/25, at 9:00 a.m. the Director of Nursing confirmed that the facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for one of five residents (Resident R11). 28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of four residents (Resident R127 and R161).Findings include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of care needs), dated October 2025, indicated the following instructions:Intent: The intent of the items in this section (Section O) is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. O0110: Special Treatments, Procedures, and Programs. Facilities may code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff. Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre- and post-operative procedures.Review of the clinical record indicated Resident R127 was admitted to the facility on [DATE].Review of Resident R127's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked). Section O0110 G3 CPAP (non-invasive treatment for sleep apnea that uses a machine to deliver pressurized air through a mask, keeping the airway open during sleep to prevent breathing pauses) was not indicated as in use.Review of Resident R127's physician order dated 12/7/25, indicated CPAP setting 5 FiO2 (fraction of inspired oxygen) 30, and SpO2 (peripheral capillary oxygen saturation) of 97 percent every night shift for breathing.Review of Resident R127's current care plan failed to include management and use of the CPAP machine as ordered.Review of Resident R127's medication administration record dated December 2025 indicated the CPAP was administered from 12/7/25, through 12/10/25.Observation completed on 12/16/25, at 10:23 a.m. Resident R127 was in bed, with the CPAP machine at bedside.Interview on 12/16/25, at 10:23 a.m. Resident R127 indicated using the CPAP machine every night.Interview completed on 12/19/25, at 10:23 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed Resident R127's MDS did not indicate use of the CPAP as required.Review of the RAI User's Manual dated October 2025, indicated the following instructions:-B0700 indicated the definition of making self-understood as able to express or communicate requests, needs, opinions, and to conduct social conversation in their primary language.-B0800 indicated the definition of the ability to understand others as comprehension of direct person-to-person communication whether spoken, written, or in sign language or Braille. Includesthe resident's ability to process and understand language.Review of the admission record indicated Resident R161 admitted to the facility on [DATE].Review of Resident R161's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section B0700 indicated understood. Section B0800 indicated understands - clear comprehension. Section C0500 Brief Interview for Mental Status (BIMS- a screening test that aids in detecting cognitive impairment) score of two severe impairment.Observation on 12/15/25, at 10:18 a.m. Resident R161 was sitting up sideways in a low bed facing the window attempting to get out of bed.Tour and interview on 12/15/25, at 10:19 a.m. with Registered Nurse (RN) Employee E9 indicated Resident R161 as being difficult to redirect and communicate with.Interview on 12/15/25, 10:25 a.m. Nurse Aide (NA) Employee E16 indicated Resident R161 speaks a different language, has dementia, and is very difficult to redirect as resident does not understand or follow instructions well.Interview on 12/19/25, at 12:30 p.m. the Director of Nursing confirmed that Resident R161 was confused and could not make self-understood or understand others and that the MDS coding was not reflective of the resident's current needs.Interview on 12/19/25, at 12:45 p.m. the Director of Nursing confirmed the facility failed to ensure MDS assessments accurately reflected the resident's status for two of four residents (Resident R127 and R161).28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of twelve residents (Resident R1) identified as having a high risk for wandering. Findings include: Review of the facility policy Wandering and Elopements dated 11/1/24, indicated if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. -If a resident is missing, initiate the elopement/ missing resident procedure;-If the resident was not authorized to leave, initiate a search of the building and premises;-When the resident returns to the facility, the Director of Nursing or Charge nurse shall:a. Examine the resident for injuries;b. Contact the attending physician and report findings and conditions of the resident;c. Notify the resident's legal representative;d. Notify search teams that the resident has been located;e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Review of the facility policy Accidents and Incidents - Investigating and Reporting dated 11/1/24, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. -The nurse supervisor/charge nurse and/or department director of supervisor shall promptly initiate and document investigation of the accident or incident.-The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of the Incident/Accident form and submit the original to the Director of Nursing services within 24 hours of the incident or accident. - The Director of Nursing services shall ensure that the administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of the facility policy Care Plans, Comprehensive Person-Centered dated 11/1/24, indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of the admission 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 8/18/25, indicated the diagnoses of high blood pressure, dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and insomnia (persistent problems falling and staying asleep) Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of eight - moderately impaired cognition. Section GG0170 Mobility indicated Section K. Walk 150 feet in a corridor or similar place was independent. Review of Resident R1's Elopement evaluation, upon admission, dated 8/4/24, indicated the following:-History of elopement while at home: No.-Does the resident have a history of elopement or attempted leaving the facility without informing staff: No.-Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: No.-Does the resident wander: Yes-Is the wandering behavior a pattern, goal directed: Yes.-Does the resident wander aimlessly or non-goal directed: No.-Is the resident's wandering behavior likely to affect the safety or well-being of self/others: Yes.-Is the resident's wandering behavior likely to affect the privacy of others: Yes.-Has the resident been recently admitted or re-admitted (within the past 30 days) and is not accepting the situation: No.-Score of one or higher indicates risk of elopement-Risk for wandering/elopement identified: blank. Review of Resident R1's only other Elopement evaluation since admission, entitled Elopement and wandering risk observation/assessment dated [DATE], indicated the following instructions:-Evaluate/Assess the resident status in the seven clinical area listed below. If the total score is ten or greater, the resident would be considered at risk for wandering or elopement. Interventions implemented as determined by the facility Interdisciplinary team (IDT).-A. Mobility Status 4. Does the resident ambulate independently with or without the use of an assistive device? Yes.-B. Cognitive Status 2. Is the resident disoriented or has periods of confusion and/or impaired attention span but does not wander? Yes.-C. Disease Diagnosis: does the resident have a diagnosis that my impact cognition? 4. Two or more are present? Yes-D. Mood/Behavior Status: None-E. Medication: Does the resident take any medications that could increase restlessness or agitation? 4. Takes two or more medications? Yes.-F. History of Elopement Attempts: None-G. Behavior Modification 4. Exhibits unsafe wandering or elopement attempts and is difficult to redirect? Yes.-H Other relevant information-Communication - does the resident have any communication, hearing or vision deficits? Yes. Glasses.-Mood/Behavior known substance abuse - Does the resident exhibit any of the following? Yes. Combative behavior.-Other conditions/concerns? No-I Interventions-Has the care plan been initiated/updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement? Yes.-Based on Elopement and Wandering Risk Observation/Assessment findings: Yes, a wander alarm is added. Review of Resident R1's census documentation record, Resident R1 Resided on the secured dementia unit from admission on [DATE], until being transferred to a non-secured long-term care unit on 5/15/25. Review of Resident R1's progress notes indicated the following:-5/15/25, at 3:24 p.m. eINTERACT form for providers indicated a change in condition related to behavioral status evaluation of physical aggression. Nursing observations, evaluation, and recommendations are to transfer Resident R1 to a room on the non-secured long-term care unit.-5/15/25, at 2:59 p.m. Resident was noted to be in the activity room at 1:45 p.m. and was noted by Nurse Aide (NA) to have a hold of a female residents left wrist and struck female resident on the back times two with a closed fist. Resident R1 was redirected away from the situation. Call placed to Resident R1's family to inform of the above. Also notified the provider who saw the resident.-5/15/25, at 4:13 p.m. Resident R1 was noted to have no further behaviors and 15-minute checks initiated. Resident R1 was transferred to long-term care unit with all meds and belongings. Report given to the nurse on the unit.-5/15/25, at 10:00 p.m. Resident R1 had taken some empty pill packets off of med cart and was attempting to take more. When redirected, resident grabbed bag on cart and ripped it; then hit the other nurse in the hand two times with a closed fist. Resident was then asked to return to their room. This writer had shown resident where the new room was, and then resident went in and went to bed with no further issues.-5/15/25, at 11:57 p.m. Resident R1 is alert with confusion. Resident wandering to unit and to other residents' rooms. Becomes combative when told not to touch a bag. Resident redirected after.-5/17/25, at 11:01 p.m. staff reported that resident was going into other residents' rooms and stealing their things. Redirection was attempted and explained those were not resident's belongings and needed to be returned to the owners. Resident said F*** you b*tch, these shoes are classy for you because you are a f*ng whore. The items were eventually returned to the rightful owners. Resident was aggressively charging staff. Ended up hitting staff on the left side of the face, was asked to stop, and hit staff again. Once staff tried to ask resident to please stop, resident hit staff for a third time. Staff was protecting two residents behind them, was scared for their life and pushed Resident R1 out of the way who ended up staggering back and fell to the floor. Staff ran from the room. Resident was assessed and reported no injury or pain.5/18/25, at 9:31 a.m. social services note indicated SW (social worker) contacted the VA (Veteran Affairs) to inquire for services through the VA. emergency room nurse indicated that Resident is eligible for services through the VA. The VA social worker did indicate that they have many behavioral beds. 911 was called to take resident to the VA to have an x-ray and possible 302.-5/18/25, at 9:39 a.m. Resident R1 shows a pattern of behaviors of swearing and threating residents as well as staff. Resident is also hitting staff and going into residents' room. SW did follow the EMS transportation to VA hospital ER in Oakland. The VA did place resident in a behavior emergency room to ensure staff could watch closely. X-rays were negative for fractures. Facility social worker met with Social Worker at VA to see if resident could be admitted under a 201, a voluntary commitment as the 302 could not happen as we had no witness to petition resident this day. -5/18/25, at 9:56 p.m. Resident R1 was swearing and threatening to harm nurse. Emergency medical services, whom just returned resident from the VA Hospital, were still waiting outside the resident's room. They stated that the VA could not 302 him earlier today because no one showed up to petition the 302. Contacted DON and Administrator and was instructed to call Resolve Crisis Center. Resolve Crisis Center contacted, and they will send a team to the facility as soon as they are able to.-5/18/25, at 11:29 p.m. resident was attempting to enter other residents' rooms when redirected resident responded, Well screw you too, I'll have you thrown out of here.-5/19/25, at 2:11 p.m. eINTERACT form indicated behavioral status evaluation for physical aggression, verbal aggression and danger to self or others.-5/19/25, at 2:28 p.m. resident propelling self about the unit.-6/30/25, at 12:05 a.m. Resident R1 punched another resident in the ear. Residents were separated. Provider contacted along with DON and order to send to the hospital was obtained.-6/30/25, at 11:50 p.m. police and EMS stated they are not able to take Resident R1 at this time. Crisis line contacted.-7/1/25, at 12:29 a.m. Resident was calm at the time of the police interview and were unable to take resident due to dementia diagnosis.-7/1/25, 2:49 a.m. Remote Provider note indicated date of service as 6/30/25, at 9:40 p.m. Chief complaint aggressive behavior. Summary resident was in a different lock down unit previously. Resident has been having increasing aggressive behaviors since moving to this unit. Resident hit another resident.-7/9/25, at 11:07 a.m. another nurse reported to this nurse resident was aggressive with her. Reported to supervisor. DON and social workers are in with resident to talk with resident.7/9/25, at 12:01 p.m. resident was verbally abusive and threatening physical violence by swinging punches at staff. At the nursing cart when resident walked up and quickly grabbed the scissors and attempted to harm me with them. Staff grabbed to end of the scissors to take them away from resident and yelled for help. Staff came and helped prevent the resident from physically attacking and assaulting staff with a deadly weapon. Floor nurse, DON, and Administrator were notified of the incident. Resident eligible for 302. 911 was called and picked up patient to take him to a city hospital for psychiatric evaluation and treatment.-7/9/25, at 1:01 p.m. Resolve in and warranted for 302 committal. Family notified via voice message to return the call.-7/9/25, at 2:03 p.m. Provider note the resident was seen and examined this morning at the request of staff after the patient was reported to have grabbed a pair of scissors and attempted to stab a nurse. Reportedly, the patient had increasing agitation throughout the morning and was difficult to redirect. Discussed with DON as well as unit director. Resolve Crisis has been called with a probable petition to 302.-7/9/25, at 9:34 p.m. Resident returned from hospital with diagnosis of urinary tract infection with antibiotics ordered.-7/17/25, at 7:59 p.m. resident swinging fist at another resident on unit. No contact made. Residents were separated.-8/16/25, at 4:37 p.m. nurse supervisor made writer aware that resident opened the side door of unit. Resident is now sitting in the dining room area. Interview on 9/22/25, at 11:10 a.m. Nurse Aide (NA) Employee E1 indicated I heard Resident R1 got out at the carnival, but I wasn't here that day. Back door was open for the carnival. People were telling me it was a big fuss. Interview on 9/22/25, at 11:15 a.m. Registered Nurse (RN) Employee E2 indicated I don't remember. Interview on 9/22/25, at 11:19 a.m. Nurse Aide (NA) Employee E3 indicated I was here that day, but worked a different unit. I know I did hear that Resident R1 got out that day. Interview on 9/22/25, at 11:25 a.m. Nurse Aide (NA) Employee E4 indicated Resident R1 went out the door down the hall by room [ROOM NUMBER]. It's an emergency door. Staff is not to use that door, only central supply and maintenance get deliveries through there. They were bringing supplies in through that door for the carnival. NA Employee E5 had to go out and get resident in the parking lot. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/29/25, indicated the diagnoses of lung cancer, chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and muscle weakness. Section C0500 indicated the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) score as 15, cognitively intact. Interview on 9/22/24, at 11:35 a.m. Resident R2 indicated I'm the one that saw Resident R1 go out. Resident R1 was always trying to get out that door. A lot of the residents do, that are, you know confused. I try to explain to them the best I can that they can't go out the door. I heard the door open just outside my room, looked out the window and saw Resident R1 in the parking lot walking towards the street by the fire hydrant. When I went in the hallway the door was still partially open but I was afraid to go out to get Resident R1 because Resident R1 can have a temper, so I went to the nurses station, nobody was there, until finally a NA came into the hall and I screamed help, Resident R1 is outside in the parking lot. Per Resident R2, Resident R1 leaned on the door and it just opened, it wasn't locked. Telephonic interview on 9/22/25, at 1:15 p.m. RN Employee E6 indicated being supervisor that day and received a STAT call on the first floor. RN was on the other unit at the time, grabbed another nurse from the floor and went to the unit calling for help. There was Resident R2 who told the RN supervisor Resident R1 got out the door and the door was unlocked. RN indicated the door could not have been locked, when Resident R1 leaned on the door, it opened. NA Employee E5 went and got resident. RN supervisor indicated reporting the incident to Assistant Director of Nursing (ADON) Employee E7 and informed them that Resident R1 got outside. ADON Employee E7 contacted Maintenance Director Employee E8 who arrived fairly quickly and said the door is locked now. Attempted interview on 9/22/25, at 1:20 p.m. with ADON Employee E7 and was informed staff member called off. Interview on 9/22/25, at 2:02 p.m. Maintenance Director Employee E8 indicated There's a bypass code for the door, only nursing can reset the wander alarm themselves. My opinion, I genuinely think Resident R1 guessed the code. I looked at the camera afterward and resident was pacing up and down that hallway. The door would not have been open all day. I saw resident go up to the door on the tv screen, stood at the keypad for a minute and did this a couple times. You can see resident not come back from the door. The code has since been changed. Telephonic interview on 9/22/25, at 2:12 p.m. NA Employee E5 indicated I was in another room taking care of another resident, I stepped outside to find a helper and a resident yelled help, Resident R1 got out. I flew down the hall and resident was probably around 100 yards or so by the fire hydrant. I don't know how resident got through the door, it's for deliveries. Personally, I think if the door wasn't pulled shut it may not latch. We don't know the code. I'm assuming it was left unlatched. Resident R1 has been exit seeking for quite a while. Asks where's the front door and things like that. Review of Resident R1's physician orders dated 4/4/25, indicated alert bracelet to right lower extremity. Check placement every shift for exit seeking. Review of Resident R1' physician orders dated 7/10/25, indicated check function every night shift for monitoring. If alert bracelet test fails, replace transponder. Review of Resident R1's care plan dated 4/4/25, indicated resident is at risk for elopement/exit seeking/wandering related to dementia. Goal - will not wander out of the facility. Interventions allow wandering in safe areas within the facility. Approach in a calm, non-threatening manner. Attempt to refocus when exhibiting behavior. Interview on 9/23/25, at 10:00 a.m. the Director of Nursing indicated Resident R1 was transferred off the secured memory care unit prior to their employment for being flirtatious and aggressive with other residents. Confirmed Resident R1 has not had an elopement evaluation prior to July since admission on [DATE], and no documentation was in the clinical record of interdisciplinary team meeting prior to moving Resident R1 from the secured unit. When asked if the family, or physician were notified, of the elopement, DON indicated I don't know. There is not an incident report for the event, or reportable notification to the Department of Health, and the progress note from 8/16/25, at 4:37 p.m. did not reveal the entire story of Resident R1 getting out of the facility. Interview on 9/23/25, at 10:10 a.m. the Director of Nursing (the Interim Nursing Home Administrator was out of the facility at a conference) confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 8/16/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. On 9/23/25, at 2:15 p.m. an immediate action plan was received and accepted which included the following interventions:Immediate Action:Upon Resident R2 alerting staff that Resident R1 was outside, staff was unaware Resident R1 was outside but were alerted. Retrieved Resident R1 from the rear parking lot. Resident returned to the unit on 8/16/25. No signs or symptoms of any adverse effects from time off the unit. System Correction:Root cause: the door failed to remain secured. Nursing staff will be re-educated on updating the elopement care plan form immediate interventions and elopement assessment. All residents will be reassessed by the unit manager/designee by 9/24/25, for an elopement risk. All staff will be educated on elopement risk and assessments, care plans and supervision of residents by the unit manager/designee by 9/24/25. A care plan with measurable goals and interventions for residents will be implemented to identify residents at risk for eloping by the unit manager/designee by 9/24/25. Review and revise policies if needed to identify residents who are at risk for eloping. Door will be monitored by staff stationed at the door, until door vendor arrives by 9/24/25, to verify functioning of the door and residents are unable to exit. Facility will review the incidents at an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting on 9/24/25. Monitoring:New admissions, change in condition or any new behavior will be monitored by the DON/designee weekly for four weeks, monthly for two months to ensure elopement assessments are completed and care plans updated as required. Maintenance/designee will audit the doors are secure seven days a week for four weeks. Findings of audits will be submitted through facility QAPI program. Verification of the facility's Corrective Action Plan revealed all elements of plan were met as follows:-Vendor into facility and checked that everything was functioning on the door, the magnetic lock and the keypad to the door itself. The door alarm was not alarming. It's going to alarm instantly instead of 25 second delay. Changing deliveries to the front door. Code is changed to an eight-digit number instead of four digits.-97% of all staff educated on risk, assessments, care plan, and supervision - 201 of 206 total employees verified with signatures.- 51-in-person interviews conducted of all staff confirmed education and understanding.-32 of 32 residents identified as elopement risks were identified. Twenty new residents were identified as at risk for elopement within the dementia secured unit.-Policy reviewed and revised by the Director of Nursing to identify residents who are at risk for eloping.-Door monitor by staff was in place on 9/24/25. - Ad Hoc QAPI held 9/24/25.-Audit tool for new admissions, change in condition or any new behavior will be monitored moving forward will be conducted weekly for four weeks, monthly four two months to ensure elopement assessments are completed and care plans updated as required and reviewed at the QAPI meeting.-Audit by maintenance will be completed on the doors being secure seven days a week for four weeks and reviewed at the QAPI meetings. Next QAPI meeting is at the end of September 2025. The Director of Nursing was made aware that the Immediate Jeopardy was lifted on 9/24/25, at 1:31 p.m. Interview on 9/24/25/25, at 2:35 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement. This failure created an immediate jeopardy situation for one of twelve residents (Resident R1) identified as having a high risk for wandering. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a) Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on manufacturer's instructions, clinical record reviews, and staff interviews it was determined that the facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed two of two residents in immediate jeopardy in which health and safety were impacted (Resident R1, and R2). Findings include: Review of the [NAME] Life Vest Patient Manual updated 2021, indicated the following: Wear all day and all night Life Vest slides on and off like a backpack. If the garment fits loosely, call [NAME] (manufacturer). The garment should be snug against the skin. Remove Life Vest to bathe, shower, or change the garment, Turn on Life Vest by inserting the battery. Always have the garment on before inserting the battery. Every 24 hours, change and recharge the batteries. There are two batteries. Always charge one while using the other. Place the charger in a safe place where it can be plugged in. Battery should slide in easily. Do not force the battery into the monitor. Practice changing the battery. Act quickly for siren alerts. Press the response buttons. This alert signals that Life Vest has detected a life -threatening rapid heart rhythm. Only the patient should press the response button. If a treatment is received by the Life Vest, leave the Life Vest on and call the doctor. Call [NAME] for a new electrode belt, and check display for any messages and take action. Read the display for [NAME] alerts and follow the instructions on the screen. When connecting and disconnecting the electrode belt be careful not to bend the pins. Remove the battery from the monitor before you remove the garment. Remove the electrode belt from the garment and insert it into a clean garment. Make sure the silver sides of the therapy pads (with the green label) face the mesh of the pocket. Snap the pockets closed. Position and secure the vibration box to the garment. Attach the round electrodes to the garment. Match the colors on the backs of the electrodes to the colors on the garment. Electrodes and therapy pads should press against bare skin. The mesh fabric pockets, and silver side of the therapy pads (with green labels) MUST TOUCH BODY for the device to work properly. Do not put the monitor, electrode belt, battery or charger in water; do not get components wet. Call [NAME] immediately if a Call for Service- Message Code 102 appears on the Life Vest screen. A replacement device will be provided within 24 hours from your notification to [NAME]. Wash the garment every 1-2 days. Do not use bleach or fabric softener. If prompted to download data, follow the instructions to do so. Review of Resident R1's clinical record revealed a Printable Discharge Form dated 2/5/25, that included correspondence between the facility and the discharging hospital, in which the hospital had documented, Will you have a bed for this patient today? Patient will be coming with a Life Vest. On 2/5/25, at 10:15 a.m. the facility responded, I can take. Just let me know what time you get for transport please. Resident was accepted to facility and admitted [DATE]. 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 2/7/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), coronary artery disease (damage or disease in the heart's major blood vessels), and high blood pressure. Review of Resident R1's physician orders 3/5/25, at 10:30 a.m. included physician orders to change the battery for a Life Vest dialy. During Resident R1's interview and observation on 3/5/25, at 10:47 a.m. a charging station for Life Vest batteries was observed on the bedside stand and resident confirmed that he was wearing a Life Vest. During an interview on 3/5/25, at 10:57 a.m. Registered Nurse (RN) Employee E2 stated, This is my first time at this facility. I was not given any training on a Life Vest. I've never had to change the battery. I'm not to sure what the alarms mean. I would presume that they can shower with it on. During an interview on 3/5/25, at 11:03 a.m. Nursing Assistant (NA) Employee E3 stated, I'm not familiar with the Life Vest. I haven't gotten any training with his Life Vest. I'm not sure if they can get a shower but I'm pretty sure we can wrap something around it. When asked what the alarms mean, NA Employee E3 stated, What alarms. During an interview on 3/5/25, at 11:05 a.m. NA Employee E4 stated, I am not familiar with a Life Vest. I have taken care of him, but I don't know anything about a Life Vest. The resident told me that he could get a shower. I have not been trained on a Life Vest. I don't know anything about alarms. During an interview on 3/5/25, at 11:08 a.m. NA Employee E5 stated, I think I took care of him once. I have not been educated on a Life Vest for this resident. It allows the resident to be supported well and allows their spine to be stable. It's for people with back issues. I don't know if he is allowed to get showers. I do not know about alarms. During an interview on 3/5/25, at 11:14 a.m. NA Employee E6 stated, I did not receive any training on taking care of Resident R1's Life Vest. I wanted to know for my protection what it was, so I googled it. During an interview on 3/5/25, at 11:34 a.m. RN Employee E7 stated, I am here maybe once a week to work. I have not received any training on the Life Vest from the facility. Review of Resident R1's care plan on 3/5/25, at 11:55 a.m. failed to reveal instructions for care and operation of Resident R1's Life Vest. Review of Resident R1's current orders on 3/5/25, at 11:58 a.m. failed to reveal a physician order for the care of and monitoring of a Life Vest. During an interview on 3/5/25, at 12:57 p.m. Director of Nursing (DON) confirmed the facility had two residents with a Life Vest. Review of Resident R2's clinical record revealed a Printable Discharge Form dated 1/20/25, that included correspondence between the facility and the discharging hospital, that stated that Resident R2 was ordered a Life Vest during his previous hospitalization . Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. Review of Resident R2's physician orders 3/5/25, at 12:59 p.m. included physician orders for a Life Vest. During an interview and observation on 3/5/25, at 1:20 p.m. in Resident R2's room, a charging station for Life Vest batteries was noted to be on the bedside stand, which Resident R2 confirmed, and that he was indeed wearing a Life Vest which he had upon admission to the facility. During an interview on 3/5/25, at 1:34 p.m. NA Employee E9 stated, I have not been educated on the Life Vest by the facility. Someone told me you can take it off to shower. I have no idea what the alarms are. During an interview on 3/5/25, at 1:37 p.m. NA Employee E10 stated, I am not familiar with a Life Vest. I was not given any education by the facility. I don't know if the resident can get a shower or what alarms mean. During an interview on 3/5/25, at 1:39 p.m. NA Employee E11 stated, I am not familiar with his Life Vest. This is my first day here. The facility has not provided me with any education on a Life Vest. I don't know what the alarms mean. On 3/5/25, at 3:01 p.m. the DON was made aware that Immediate Jeopardy (IJ) existed, DON was provided the IJ Template, that placed two residents (Resident R1, and R2) in immediate jeopardy in which health and safety were impacted, and a corrective action plan was requested. On 3/5/25, at 7:05 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: - Educate all clinical staff on the care and operation of Life Vests, that includes but is not limited to what the different alarms mean, the dangers of electrical shock, the care of the batteries, the care of the garment for laundering, monitoring and placement of the Life Vest, check skin integrity, and special needs for bathing. All prior to the next shift, by 3/6/25, at 12:00 p.m. in person and/or through witnessed phone calls with signatures. - Clinical staff will complete competencies, pre and posttests by 3/6/25 at 12:00 p.m. - Obtain physician orders and ensure implementation for Resident R1, and R2. - The facility must develop a resident center comprehensive care plan outlining the care of Resident R1 related to the Life Vest by 3/5/25, at 6:00 p.m. - The facility will update Resident R2's comprehensive care plan outlining the care related to the Life Vest by 3/5/25, at 6:00 p.m. - The facility obtained additional physician orders for the implementation of the Life Vest and ensured the orders were complete. - Clinical staff will be educated on updates and policies related to specialty equipment by 3/6/25, at 12:00 p.m. - Admission Staff will be educated on updates and policies related to specialty equipment by 3/6/25, at 12:00 p.m. Residents: - Resident R1's physician's orders and care plan were updated. - Resident R2's physician's orders and care plan were updated. System Correction: - The facility must review/develop, and update the policy related to specialty equipment by 3/5/25, at 6:00 p.m. - The facility must review/develop policy and procedure related to the admission of residents with anticipated equipment by 3/5/25, by 6:00 p.m. Monitoring: - The facility will audit 100 percent of residents for Life Vests placement, operation, battery backup, and associated documentation (skin checks, physician orders, and care planning) daily for one week starting 3/6/25, one time a weekly thereafter for three weeks, and monthly thereafter with reporting through Quality Assurance and Process Improvement (QAPI) for review and recommendation. -The facility will conduct random competency audits of two clinical staff per shift starting 3/6/25, that have assignment with Life Vest residents daily for one week, one time weekly thereafter for three weeks, and monthly thereafter with reporting through QAPI for review and recommendations. - The education plan will be reviewed by QAPI and further recommendations in a meeting conducted on 3/6/25. During an interview on 3/6/25, at 10:17 a.m. NA Employee E5 verified that he had received education on the Life Vest and stated, I know now how to care for the Life Vest because of the education. I feel more comfortable taking care of the resident now. During an interview on 3/6/25, at 10:24 a.m. NA Employee E6 verified that she had received education on the Life Vest and stated, The education should have been done prior to them coming to facility but I feel better now. During an interview on 3/6/25, at 10:30 a.m. NA Employee E14 verified that she received education on the Life Vest and added, This is the first time educated. I learned a bunch of stuff. Very educational. During an interview on 3/6/25, at 10:17 a.m. NA Employee E13 verified that she had received education on the Life Vest and stated, I didn't know anything about it (prior to receiving the education). These are things that we should know. During an interview on 3/6/25, at 10:33 a.m. RN Employee E15 verified that she had received education on the Life Vest and stated, I feel comfortable taking care of a Life Vest. During a clinical record review on 3/6/25, at 10:45 a.m. Resident R1, and R2 had new physician orders and care plans for Life Vest. Review of facility documents on 3/6/25, revealed that the facility had 133 clinical employees and that 116 had received Life Vest education. The remaining employees were to receive their education prior to the start of their next shift. 116 employees had received education on Life Vest and had been administered a written test to verify their knowledge. The remaining employees will take the test prior to the start of their next shift. During employee interviews on 3/6/25, from 10:05 a.m. through 11:30 a.m. 32 employees confirmed they had received education on the safe care, operation, and policies of the Life Vest as stated above. 32 of these employees had also completed a written test on Life Vest prior to the start of their next shift. 14 employees verified stated that they had received the education at home but were to take the written test when they came into the facility prior to the start of their next shift. Review of facility documents on 3/6/25, verified that a policy was reviewed and revised for Specialty Equipment that included Life Vest and that policy was reviewed for the admission process of residents with anticipated equipment needs including a Life Vest. Review of facility documents on 3/6/25, verified that audits were conducted for two clinical staff members to demonstrate competency of caring for a resident with a Life Vest. Review of facility documents on 3/6/25, verified that the facility conducted a QAPI meeting on 3/6/25, to review the education plan concerning residents with a Life Vest. The Immediate Jeopardy was lifted on 3/6/25, at 12:24 p.m. when the action plan was verified. During an interview on 3/6/25, at 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that nursing staff have the specific competencies, and skill sets necessary to provide care for a resident with a Life Vest, and placed two residents in immediate jeopardy in which health and safety were impacted (Resident R1, and R2). 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)Resident rights. 28 Pa Code 211.5(f) Clinical records. 28 Pa. Code: 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records and facility specific documents, and resident and staff interviews, it was determined that the facility failed to make certain that residents were free from neglect that resulted in actual harm for one of six residents reviewed when the resident fell from bed during care and sustained a fractured humerus (Resident R144). Finding include: The facility's Patient Protection: Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention policy dated 11/5/18, indicated that all residents have the right to be free of abuse and neglect and that the facility develop and implement policies and procedures to prohibit abuse and neglect which included investigating all allegations and providing training to employees. The facility's Interdisciplinary Care Planning policy dated 11/5/18, indicated that the care plan was a communication tool that guided members of the interdisciplinary team on how to meet each individual resident's needs and that once a care plan was developed the staff must implement the interventions identified in the care plan. The facility's current Nurse Aide Job Description indicated that the Nurse Aide (NA) participates in care conferences and follow individual resident care plans. The Admission Record Report indicated that Resident R144 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 11/15/18, indicated that Resident R144 required the assistance of two staff for all activities of daily living (ADL-which included bed mobility, transfer needs, personal hygiene). due to the resident's debility and [MEDICAL CONDITION]. The physical therapy and occupational therapy evaluation and plan of treatment forms dated 11/16/18, identified Resident R144 as a fall risk who required the assistance of two staff for mobility and out of bed activity. The admission Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 11/22/18, indicated that Resident R144 was alert, oriented and able to make decisions, required the extensive assistance of two or more persons with transfers, bed mobility and personal hygiene and that the resident had range of motion impairment of the upper and lower extremities on both sides. A nurse's note dated 12/9/18, at 11:21 a.m. indicated Resident receiving morning care while in bed, was rolled onto (resident) left side. Resident was propping (self) against the bed for stability, then reached (resident) right arm out over the floor, lost balance and rolled onto the floor .Resident c/o (complained of) right shoulder pain. A physician order [REDACTED]. A nurse's note dated 12/9/18, at 5:04 p.m. indicated that Resident R144 continued to complain of right shoulder pain, a decision was made to obtain the x-ray of the resident's shoulders and that results were pending. The results of the x-ray were received at the facility on 12/9/18, at 8:27 p.m. and showed that Resident R144 had an acute minimally displaced [MEDICAL CONDITION] (upper) right humeral neck. The physician was contacted with the results and an order was received to transfer the resident to the hospital for evaluation of the fracture. A review of the facility investigation of Resident R144's 12/9/18 fall from bed, indicated that when NA, Employee E7, rolled the resident to provide care, Resident R144 rolled off the bed, onto the floor, landing on the right side. NA, Employee E7, did not follow the resident's care plan for two staff assistance as required for bed mobility. In a typed statement signed by NA, Employee E7, and dated on 12/10/18, the NA acknowledged being aware that Resident R144 was a two-person assist and that the employee did not ask for assistance because, I thought I could take (resident) from the bedpan myself. During an interview on 1/15/19, at 9:20 a.m. Resident R144 reported that I was mad and still am. (NA, Employee E7) told me to roll onto my left side knowing that I always have two people. I'm holding on with all my might to the mattress but ended up falling full force onto the floor with my body on my right arm full force. During an interview on 1/18/19, at 9:30 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed make certain that Resident R144 was free from neglect during care which resulted in actual harm to the resident. The facility failed to make certain that Resident R144 was protected from neglect while providing personal hygiene resulting in actual harm. 42 CFR 483.12(a)(1) Free From Abuse and Neglect. Previously cited 12/18/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/16/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/18/17, 12/16/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 12/16/16. 28 Pa. Code 201.29(a)(d)(j) Resident rights. Previously cited 12/18/17. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/16/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/18/17, 12/16/16. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of facility policy, clinical records and specific facility documents and staff interview, it was determined that the facility failed to make certain that residents were provided the appropriate assistance for activities of daily living resulting in actual harm for one of six residents reviewed when the resident fell out of bed during care resulting in a fractured humerous (Resident R144). Findings include: The facility's Interdisciplinary Care Planning policy dated 11/5/18, indicated that the care plan was a communication tool that guided members of the interdisciplinary team on how to meet each individual resident's needs and that once a care plan was developed the staff must implement the interventions identified in the care plan. The facility's current Nurse Aide job description indicated that the Nurse Aide (NA) participated in care conference and followed individual resident care plans. The Admission Record Report indicated that Resident R144 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 11/15/18, indicated that Resident R144 required the assistance of two staff for all activities of daily living (ADL-which included bed mobility, transfer needs, personal hygiene) due to the resident's debility and [MEDICAL CONDITION]. The Physical Therapy and Occupational Therapy Evaluation and plan of treatment forms dated 11/16/18, identified Resident R144 as a fall risk who required the assistance of two staff for mobility and out of bed activity. The Admission Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 11/22/18, indicated that Resident R144 was alert, oriented and able to make decisions, required the extensive assistance of two or more persons with transfers, bed mobility and personal hygiene and that the resident had range of motion impairment of the upper and lower extremities on both sides. A nurse's note dated 12/9/18, at 11:21 a.m. indicated Resident receiving morning care while in bed, was rolled onto (resident) left side. Resident was propping (self) against the bed for stability, then reached (resident) right arm out over the floor, lost balance and rolled onto the floor .Resident c/o (complained of) right shoulder pain. A physician order [REDACTED]. A nurse's note dated 12/9/18, at 5:04 p.m. indicated that Resident R144 continued to complain of right shoulder pain, a decision was made to obtain the x-ray of the resident's shoulders and that results were pending. The results of the x-ray were received at the facility on 12/9/18, at 8:27 p.m. and showed that Resident R144 had an acute minimally displaced [MEDICAL CONDITION] (upper) right humeral neck. The physician was contacted with the results and an order was received to transfer the resident to the hospital for evaluation of the fracture. A review of the facility's investigation of Resident R144's 12/9/18 fall from bed, indicated that when NA, Employee E7, rolled the resident to provide care, Resident R144 rolled off the bed, onto the floor, landing on the right side. NA, Employee E7, did not follow the resident's care plan for two staff assistance as required for bed mobility. In a typed statement signed by NA, Employee E7, and dated on 12/10/18, the NA acknowledged being aware that Resident R144 was a two-person assist and that the employee did not ask for assistance because, I thought I could take (resident) from the bedpan myself. During an interview on 1/15/19, at 9:20 a.m. Resident R144 reported that I was mad and still am. (NA, Employee E7) told me to roll onto my left side knowing that I always have two people. I'm holding on with all my might to the mattress but ended up falling full force onto the floor with my body on my right arm full force. During an interview on 1/18/19, at 9:30 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that Resident R144 was provided adequate assistance during care which resulted in actual harm to the resident. The facility failed to make certain that Resident R144 was provided adequate staff assistance during personal hygiene to prevent accidents, thus resulting in actual harm. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 12/16/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/18/17, 12/16/16. 28 Pa. Code 201.18(b)(3)(e)(1) Management. Previously cited 12/16/16. 28 Pa. Code 201.29(a)(d)(j) Resident rights. Previously cited 12/18/17. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/16/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/18/17, 12/16/16. 28 Pa. Code 211.12(d)(3) Nursing services.