Every finding on record at Highland Manor Rehabilitation and Nursing Center

Based on a review of facility policy, resident council meeting minutes, grievance documentation, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the resident council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility failed to ensure ongoing communication and timely follow-up regarding issues presented by four of four residents attending a resident council group meeting (Residents 112, 35, 26, and 58).Findings include: A review of the facility's Grievance Policy last reviewed on February 19, 2026, indicated all concerns and questions may be presented to the facility orally or in writing. the policy stated the administrator will follow up on all concerns and grievances registered by any resident or resident representative. A review of the Minutes from a Resident Council meeting dated June 8, 2026, revealed concerns from residents that personal laundry was not being picked up and returned timely and a grievance was filed on June 8, 2026, regarding this concern. A Review of the grievance filed June 8, 2026, revealed concerns with the laundry would be followed up on to ensure resolution. The grievance was signed as resolved as of June 9, 2026. A group meeting conducted on August 18, 2026, at 10:00 AM with four residents (Residents 112, 35, 26, and 58) revealed unanimous reports that the facility failed to address their complaints regarding the timeliness of laundry service in the facility. All residents in attendance stated they felt the timeliness especially of the return of personal laundry is still on ongoing, unresolved concern. The facility was unable to provide documented evidence that residents were satisfied with the outcome of the grievance regarding personal laundry service despite indicating the grievance was resolved on June 9, 2026. During an interview on August 19, 2026, at 10:10 AM, the Nursing Home Administrator (NHA) could not provide documented evidence of resident satisfaction in addressing grievances raised during Resident Council meetings and written grievances. 28 Pa. Code 201.18 (e)(1)(4) Management.28 Pa. Code 201.29(a) Resident Rights.28 Pa. Code 211.10 (d) Resident care policies.

Based on select facility policy, observations, clinical record review, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for one resident out of 24 residents reviewed (Resident 65). Findings include: Review of the facility policy Care of Oxygen Supplies last reviewed August 2026, indicated when a resident is not using tubing/set up (nasal cannula, flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) it should be carefully removed and placed in the bag supplied with set up. If not properly stored in bag the tubing should be replaced, assure it is dated for date it was changed. Review of Resident 65's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include acute and chronic respiratory failure (condition when the lungs cannot get enough oxygen into your blood or remove enough carbon dioxide from the body). A physician order initially dated August 11, 2026, noted an order for oxygen 2 liters/minute via nasal cannula as needed for shortness of breath. An observation on August 20, 2026, at 11:35 AM revealed Resident 65's oxygen tubing with nasal cannula was placed directly on the mattress. Observation on August 20, 2026, at 12:10 PM revealed Resident 65's oxygen tubing with nasal cannula was rolled up and placed on top of the oxygen concentrator and not in a plastic bag as per facility policy. Interview with Employee 2 NA (nurse aide) on August 20, 2026, at 12:15 PM noted that the resident's oxygen tubing and cannula was removed prior to the resident's shower, placed on the mattress, and then placed on top of the oxygen concentrator so that the bed could be made. Interview with the Director of Nursing on August 21, 2026, at approximately 10:20 AM confirmed that Resident 65's respiratory equipment was to be maintained in a sanitary manner and bagged when not in use. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.28 Pa. Code 211.10 (a)(c)(d) Resident Care Policies.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure that necessary behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents reviewed. (Resident 2).Findings include: A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included PTSD (Post Tramautic Stress Disorder a serious mental health condition that can develop after an individual experiences or witnesses a traumatic event), and Bipolar Disorder (a mental disorder characterized by periods of depression and abnormally elevated mood, lasting days to weeks, and in some cases months). A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated June 12, 2026, indicated that Resident 2 had a BIMS (brief screener that aids in detecting cognitive impairment) score of 8 indicating moderate cognitive impairment. Review of Resident 2's care plan revealed a focus area regarding her mental health diagnoses, including bipolar disorder, initiated by the facility on November 12, 2025. This care plan included consulting with psychiatric services as needed. A review of the resident's physician's orders revealed an order dating from admission on [DATE], for psych services with an outside psychiatric provider. A review of Resident 2's clinical record from April 4, 2025, through end of survey August 24, 2026, revealed the resident was never seen by the facility's contracted psychiatric provider. A review of the clinical record revealed the resident had intermittent behaviors including refusal of care and being physically abusive with staff. A review of a progress note dated July 26, 2026, indicated the resident had punched a staff member in the face. The resident stated at that time I don't care, I don't like her. There was no evidence that the facility developed or implemented additional services to address the resident's ongoing behavioral health needs, and psychosocial stressors. During an interview with the Nursing Home Administrator (NHA) on August 20, 2025, at 10:00 AM, the NHA was unable to provide evidence that the resident had been seen by psychiatric services to address the need for behavioral health interventions to maintain the resident's highest practicable level of mental and psychosocial well-being. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on select facility policy, a review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for 1 out of the 24 residents sampled (Resident 9).Findings include: A review of facility policy entitled Controlled Substances last reviewed by the facility on February 19, 2026, revealed that the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications. A review of clinical records revealed the facility utilizes an Individual Patient Controlled Substance Record to track, monitor, and reconcile each controlled medication (a drug that the government tightly regulates because it carries a risk of abuse, misuse, physical dependence, or addiction). Additionally the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a long-term brain disorder that causes problems with movement, balance, and coordination) and Rheumatoid Arthritis (a long term disease where the body fights its own joints causing pain, swelling and warmth). A review of physician orders revealed Resident 9 was admitted to hospice services on February 16, 2026. An order dated March 4, 2026, indicated the resident was to receive Morphine Sulfate Oral Solution (narcotic medication) 20 mg (milligram)/ml (milliliter) administer 0.25 ml. every three hours as needed for pain A comparison of Resident 9's Individual Patient Controlled Substance Record with the MAR from February 21, 2026, through August 21, 2026, revealed an entry indicating Morphine Sulfate was utilized according to Resident 9's Individual Patient Controlled Substance Record. However, there was no documented evidence in Resident 9's MAR indicating the medication was administered on the following dates:May 1, 2026, at 10:00 PM A comparison of Resident 9's Individual Patient Controlled Substance Record with the MAR for February 21, 2026, through August 21, 2026, revealed four entries indicating Morphine Sulfate was documented as administered on the MAR. However, there was no corresponding documentation in the Individual Patient Controlled Substance Record indicating the medication was removed from inventory on the following dates:July 14, 2026, at 12:34 AMJuly 25, 2026, at 7:52 PMJuly 28, 2026, at 4:40 PMAugust 8, 2026, 9:17 PM During an interview on August 21, 2026, at 10:15AM, the Director of Nursing (DON) acknowledged the above findings related to the facility's failure to implement effective procedures to reconcile Resident 9's-controlled substance medications. 28 Pa Code 211.5(f)(x) Medical records.28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.28 Pa Code 211.10 Resident care policies.

Based on select facility policy, observations, and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. (100-unit Medication Storage Room)Findings include: A review of facility policy entitled Disposal of Medications and Medication Related Supplies, last reviewed on February 19, 2026, revealed medications will be disposed of in accordance with federal, state and local regulations governing management of non- hazardous pharmaceuticals, hazardous waste and controlled substances. Observations of the 100 nursing unit medication storage room on August 18, 2026, at 10:15 AM revealed the following:Two boxes of Heparin (a blood thinner used to prevent and treat blood clots) Two single use vials of Iron sucrose(an injection form of iron replacement)One single use vial of Cyanocobalamin( injectable form of Vitamin B12)One single use vial of Meropenem (a broad spectrum antibiotic)One vial of Cefepime (a broad spectrum antibiotic)Twenty five vials of Piperacillin and Tazobactam (a combination of antibiotics used to treat a wide range of bacterial infections) Interview with Employee 1, a licensed practical nurse (LPN), during the time of the observation, revealed the the medications belonged to residents who have been discharged from the facility and should have been destroyed. Interview with the Director of Nursing and the Nursing Home Administrator on August 19, 2026 at 11:30 AM confirmed that the facility's expectation is for discontinued resident medications to be removed from the medication room by a licensed nurse and destroyed in accordance with facility policy. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services.28 Pa. Code 211.12 (d)(3)(5) Nursing services.28 Pa Code 211.10 Resident care policies.

Based on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to ensure licensed nursing staff possessed and demonstrated the appropriate competencies and skill sets to safely assess, manage, and provide care for residents requiring a coude catheter (a specialized urinary catheter with a curved tip used for residents with urinary obstruction and enlarged prostate) for 5 of 5 licensed nurses reviewed (Employees 1, 2, 3, 4, and 5).Findings include: Review of the clinical record revealed Resident 9 was admitted to the facility on [DATE], with diagnosis to include retention of urine (the inability to completely empty the bladder or the complete inability to pass urine) and benign prostatic hyperplasia with lower urinary tract symptoms (noncancerous enlargement of the prostate gland causing urinary obstruction and impaired bladder emptying). Review of a care plan dated March 30, 2026, revealed Resident 9 required the use of a coude catheter. Review of nurse documentation dated May 7, 2026, and interview with the Director of Nursing (DON) on May 27, 2026, revealed Resident 9's coude catheter became obstructed during the night shift. The night shift Licensed Practical Nurse, Employee 2 (LPN) informed the resident that he would need to wait until the day shift staff arrived for the catheter to be changed. During the interview, the DON stated Employee 2 reported she was not comfortable changing the resident's coude catheter due to lack of familiarity and experience with that type of catheter. Employee 2 did not notify the RN supervisor or seek assistance to ensure timely catheter intervention for the resident. Review of the facility documentation titled Skilled Nursing Competency Training revealed a list of competencies for licensed practical nurses. The list included nephrostomy tube (a thin, flexible catheter inserted through the skin of the lower back directly into the kidney to drain urine) and suprapubic catheters (a flexible medical tube surgically inserted directly into the bladder through a small incision in the lower abdomen that continuously drains urine); however, the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management or the more specialized, coude catheter care and replacement. During interviews on May 27, 2026, between 2:10- 2:30 PM, four licensed nurses employed by the facility (Employees 1, 3, 4, and 5) stated they had received general catheter education during nursing school and had prior experience with coude catheters at previous employers. However, all four nurses reported the facility had not provided facility-specific education, training, competency evaluation or skills validation related to the care, evaluation, insertion, replacement or management of coude catheters. During an interview on May 27, 2026, at 2:45 PM, the DON was unable to provide documented evidence that the facility ensured licensed nursing staff completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management. Refer F65828 Pa Code 201.20(a)(6)(d) Staff development.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure a Licensed Practical Nurse (LPN) timely monitored, recognized, communicated, intervened, and obtained appropriate supervisory assistance when a resident experienced a blocked indwelling urinary catheter (a flexible sterile tube inserted into the urinary bladder to drain urine) for one of 10 residents reviewed (Resident 9).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when: (ii) The patient's care needs surpass the LPN's knowledge, skill or ability. (iii) The patient's condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance. (2) An LPN shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures. (3) An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act. Review of the facility policy titled Catheter Care, Urinary last reviewed by the facility on February 19, 2026, indicated staff were to change urinary catheters and drainage bags based on clinical indications such as obstruction (blockage). The policy directed staff to observe the resident for complications associated with urinary catheters and immediately report unusual findings to the physician or supervisor, including when the resident complained of bladder fullness, inability to void (urinate), abdominal discomfort, urinary retention, pain, or signs of catheter obstruction. Review of the clinical record revealed Resident 9 was admitted to the facility on [DATE], with diagnosis to include retention of urine (the inability to completely empty the bladder or the complete inability to pass urine) and benign prostatic hyperplasia with lower urinary tract symptoms (noncancerous enlargement of the prostate gland causing obstruction of urinary flow and urinary systems such as issues with urination, bladder emptying and storage). Review of Resident 9's quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 8, 2026, indicated Resident 9 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). Review of a care plan dated March 30, 2026, revealed Resident 9 utilized a coude catheter (a specialized urinary catheter featuring a slightly curved or bent tip, designed to bypass urethral obstruction. A standard catheter has a straight tip, a coude catheter's curved tip allows it to bypass anatomical blockages rather than poking directly into them and are commonly used for residents with enlarged prostate glands). Review of physician orders dated March 27, 2026, directed staff to flush the indwelling catheter (inject sterile saline solution through the catheter tube into the bladder to clear blockages and maintain unobstructed urine flow) with 60 cc (measurement of liquid volume) normal saline as needed for blockage and/or leakage and to change the indwelling catheter and drainage bag as needed. Review of nurse documentation dated May 7, 2026, at 7:10 AM revealed Resident 9 complained of penile pressure and abdominal discomfort. Documentation indicated the indwelling catheter had zero urine output (no urine noted in the drainage bag), the resident's abdomen was distended and firm, and the resident grimaced during abdominal assessment. Documentation further revealed the resident stated, I told night shift about it and was told, nothing could be done until day shift comes in. Nursing documentation indicated attempts to flush the indwelling catheter were unsuccessful due to blockage.Review of nurse documentation dated May 7, 2026, at 9:30 AM revealed the resident's newly inserted indwelling catheter drained 900 cc of yellow urine (normal bladder capacity is between 400-600 cc). The resident stated, Thank you kindly for helping me. Review of nurse documentation dated May 7, 2026, at 1:34 PM revealed a #14/10 cc (size of catheter) coude catheter was inserted at 8:45 AM without difficulty and draining clear yellow urine. The resident verbalized total relief after the procedure. During an interview on May 27, 2026, at 11:35 AM, Resident 9 stated that sometime after midnight on May 7, 2026, he informed nursing staff that he was experiencing abdominal pain and penile pressure like I've never experienced before. The resident stated staff told him, We don't do that on this shift and informed him he would need to wait until day shift arrived. During an interview on May 27, 2026, at 12:10 PM, Employee 1 (Licensed Practical Nurse) stated she received report (detailed briefing) from the night shift nurse, Employee 2 (Licensed Practical Nurse) on May 7, 2026, at the beginning of the 7:00 AM -3:00 PM shift. Employee 1 stated the only information communicated regarding Resident 9 was that the resident's bed was wet. Employee 1 stated she questioned whether any evaluation or intervention had been attempted and Employee 2 did not provide additional information. Employee 1 stated shortly after beginning her shift, a nurse aide informed her Resident 9 was in pain. Upon assessment, Employee 1 observed that the resident's bed was wet, the resident appeared to be in obvious pain, and he grimaced during abdominal palpation (pressing on the stomach area). Employee 1 stated she attempted to flush the catheter but met resistance and was unable to clear the obstruction. Employee 1 removed the catheter and attempted reinsertion of the coude catheter but was unsuccessful. Employee 1 then contacted the unit manager for assistance, who successfully inserted a new coude catheter, resulting in drainage of 900 cc of urine from the resident's bladder. During an interview on May 27, 2026, at 12:29 PM, the Director of Nursing stated nursing staff were expected to monitor and document catheter output each shift. The Director of Nursing stated that when a catheter obstruction is suspected, staff should evaluate catheter function, attempt catheter flushing per physician orders, and if unsuccessful, replace the catheter or perform a bladder scan (a non-invasive ultrasound procedure used to measure the amount of urine retained in the bladder). The Director of Nursing further stated the expectation was for the night shift LPN to notify and obtain assistance from the RN supervisor if the nurse was not comfortable managing the resident's coude catheter. The Director of Nursing confirmed Employee 2, the night shift LPN reported she was not comfortable changing the resident's coude catheter due to lack of familiarity and experience with that type of catheter and waited until day shift arrived rather than notifying the RN supervisor or obtaining assistance. The Director of Nursing further confirmed the Employee 2 LPN received re-education regarding the expected process; however, no formal competency validation or education related to catheter management or coude catheter care was completed. The facility failed to ensure Employee 2, the night shift LPN followed professional standards of nursing practice and facility policy by failing to recognize and respond to Resident 9's complaints of abdominal pain, penile pressure, abdominal distention (swelling caused by pressure within the abdomen), and absence of urinary output; failing to communicate the resident's change in condition and obtain assistance from the RN supervisor when the resident's care needs exceeded the LPN's knowledge, skill, and experience with coude catheter management; and failing to implement timely interventions for a blocked catheter, resulting in delayed treatment and prolonged resident discomfort. Refer to F726 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in the facility laundry department and the second hallway ice machine. Findings include: An observation of the second hallway, resident unit ice machine, located in the hallway was noted with no airgap. An air gap is defined as the unobstructed vertical space between the end of a water supply or drainage pipe and the flood level of a fixture or drain. In an ice machine, the air gap prevents contaminated water from backing up into the potable (drinkable) water supply or the ice that residents consume. The importance of the air gap is to prevent cross-contamination, which occurs when dirty water or substances can enter and contaminate clean water or ice. Without an air gap, residents are at risk of exposure to harmful bacteria or other contaminants.Water was observed draining directly into the floor drainpipe. The floor underneath the drainage pipe, extending from the front of the ice machine to the drainpipe, contained a thick layer of sticky black material. An observation on September 12, 2025, at 11:30 A.M. in the facility laundry department dirty room (the area used for handling soiled laundry) revealed two slop sinks with clumps of lint and debris inside them, both filled with plastic hangers and a plastic bag containing soiled wheelchair/lift belts. The faucet was leaking water. A dirty mop bucket containing plastic garbage, mop covers, broken mops, and a plastic container were on the floor. An open, overflowing garbage can was present. Behind the washing machines, the floor contained plastic, paper, dirty used gloves, and clumps of lint. The floor had a buildup of a sticky black substance around the perimeter. The exhaust fan had a heavy buildup of lint and dirt. Additional items noted included open plastic bags of floor mats on the floor between the washing machines, two bags of dirty clothing on the floor, a floor cleaning machine placed in front of the washing machines, and a ripped, dirty fall mat propped against the wall. In the clean area (the side with dryers, folding tables, carts, and clothing racks), the garbage can was overflowing. The floor had visible dirt, dried liquid stains, and used plastic gloves scattered throughout. A large pile of lint was on the floor in front of a dryer. The windowsill, dryer exhaust tubing, wall exhaust fan, and door hinges all had a heavy buildup of lint. Clean linen and clothing racks contained mechanical lift pads that were in direct contact with the floor. A dirty washcloth was also observed on the floor. These observations were confirmed with the Nursing Home Administrator at the time of the survey. The facility failed to ensure that both the ice machine and laundry areas were maintained in a sanitary and orderly condition, placing residents at risk for cross-contamination, exposure to environmental contaminants, and a diminished homelike environment.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa Code 201.18 (b)(1)(3) Management

Based on a review of clinical records, resident grievances, observations, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance for 5 residents out of 10 sampled. (Residents CR1, 2, 3, 4, and 5). Findings include: A review of a grievance filed with the facility by the daughter of Resident CR1, dated April 9, 2025, revealed that Resident CR1 had a bowel movement in her brief and required staff assistance for hygiene care. She activated her call bell at 9:41 AM requesting assistance. Facility records indicated that by 11:41 AM no staff had responded to the call bell, and as of 12:00 PM she remained unchanged. Resident CR1 was ultimately provided incontinence care at 12:30 PM, approximately three hours after her initial request for assistance. The grievance documentation indicated the daughter informed the nurse on duty, who stated that someone would respond; however, timely care was not provided. Facility records show that the facility acknowledged to the daughter that the excessive delay in responding to the request for assistance was not acceptable and that she should notify the supervisor immediately if delays occur. An interview with Resident CR1 and her daughter could not be completed during the survey During an interview with Resident 2 on June 18, 2025, at 10:45 AM she reported she frequently has waited over an hour for staff to answer her call bell. She stated, I've soiled myself so many times waiting for them to come, I've lost count, and added Supper time is the worst. They don't come, so I had to stop asking. During an observation on June 18, 2025, at 10:55 AM in room [ROOM NUMBER], there was a strong odor of BM (bowel movement) permeating throughout the room. Resident 5 was observed lying in bed uncovered, with a visibly soiled brief. Bowel movement matter was observed to be leaking out of the sides of the brief, soiling the bedsheet underneath. Resident 5's call bell was activated at 10:55 AM. The call bell alert light was visible above the resident's doorway. At 11:10 AM Employee 1 (Occupational Therapist) entered Resident 5's room. The call bell light was turned off and Employee 1 exited the room without providing care. At 11:14 AM the call light was activated again with the resident yelling help me. At 11:25 AM the Activities Director entered the room, turned off the call bell, and told the resident Someone will be right in. Employee 2 exited the room and did not provide the required care. At 11:30 AM, 35 minutes after the resident first activated the call bell, a nurse aide entered the room to provide assistance for incontinence. During an interview with Resident 3 on June 18, 2025, at 11:40 AM, he stated he has often waited over an hour for staff to respond to his call bell. He reported that staff frequently enter his room, turn off the call bell light, and leave without providing assistance, stating they would return but often do not return for another hour or longer. He indicated that such delays occur more frequently during early morning and second shifts. During an interview with Resident 4 on June 18, 2025, at 12:00 PM she stated the first weekend after she was admitted (June 7-8, 2025), for staff to respond to her call bell while needing to use the bathroom She stated she was almost in tears and desperately needed to use the bathroom. She also reported this past weekend (June 14-15, 2025) she waited over one hour for staff assistance after she activated her call bell. She stated a nurse finally came in after an hour but did not assist her to the restroom. Instead, the nurse started yelling for the aides. She expressed frustration the nurse would not provide the assistance but instead had to continue to wait for a nurse aide to become available. During an interview on June 18, 2025, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged that the residents should not have to wait extended periods of time for staff to answer call bells. The DON verified that staff are not to turn off the call bell light until care is provided. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services.

Based on a review of select facility policy, clinical records, information submitted by the facility, select investigative reports, and staff interviews, it was determined the facility failed to conduct a thorough investigation into an injury of unknown origin (a fractured humeral neck) for one resident out of 24 sampled (Resident 23). Findings include: A review of facility policy titled Abuse Prevention Policy and Procedure, last reviewed by the facility on January 2, 2024, revealed it is the facility policy that an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, then the administrator will assign the investigation to an appropriate individual. The policy indicates the information to be collected includes a review of all events leading up to the incident, a review of the resident's medical record to determine events leading up to the incident, and interviews with staff members on all shifts who have had contact with the resident at the time of the incident. The policy defines an injury of unknown source as the injury was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, location of the injury, number of injuries, or the pattern of injuries over time. A clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a circulatory condition that occurs when blood vessels outside the brain and heart narrow, spasm, or become blocked). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 2, 2024, revealed that Resident 23 is severely cognitively impaired with a BIMS score of 00 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). A progress note dated June 13, 2024, at 9:59 AM revealed Resident 23 rolled out of bed during care. During care, Employee 6, Nurse Aide (NA), reported the resident was rolled to her side to complete care and proceeded to fall out of bed. The resident landed on her knees on a fall mat with her torso remaining on the bed. New orders for X-rays to right femur and bilateral knees was obtained. The certified registered nurse practitioner was in to assess the resident and identified bruising to her lateral right femur. Resident 23 grimaced when bilateral knees were palpated. A witness statement dated June 13, 2024, provided by Employee 6, NA, revealed that while doing care, Resident 23's legs started going off the side of the bed. I grabbed her shirt to stop her upper half from going, but she rolled off the bed onto her knees. A fall investigation report dated June 13, 2024, revealed Resident 23 was unable to give a description of the incident. A progress note dated June 13, 2024, revealed Employee 7, Certified Registered Nurse Practitioner (CRNP), assessed Resident 23 following the fall incident. The note indicated Resident 23 had evidence of pain and discomfort on palpitation of both knees and the right femur. Resident 23 stated, I'm fine, during the assessment. Employee 7, CRNP, indicated Resident 23 jerks and moves legs during assessment and yelled out. The CRNP ordered an X-ray of bilateral knees and the right femur and Tylenol and morphine (an opioid analgesic medication) for as-needed pain An X-ray report dated June 13, 2024, at 1:53 PM, indicated multiple views of Resident 23's right femur, and routine views of bilateral knees revealed no fractures or acute findings. Physician's orders for Resident 23 to receive morphine sulfate (concentrate) oral solution 20 mg/ml with direction to give 0.25 ml by mouth every four hours as needed for pain was initiated on January 12, 2024 and was a current order as well as acetaminophen tablets of 325 mg with directions to give two tablets by mouth every four hours as needed for mild pain initiated on March 17, 2020. Physician's orders for Resident 23 to receive a pain screen every shift and medicate as needed with directions to check for pain each shift. A review of Resident 23's Medication Administration Record (MAR) from June 14, 2024, through June 17, 2024, revealed Resident 23 was assessed for pain each shift and had a pain level of 0 out of 10. A review of Resident 23's Medication Administration Record (MAR) from June 14, 2024, through June 17, 2024, revealed Resident 23 did not receive any as-needed pain medication during this date range. A progress note dated June 14, 2024, at 2:09 PM revealed Resident 23 with no injuries or complaints post fall from bed. A review of Resident 23's clinical record from June 14, 2024, through June 17, 2024, revealed no indication Resident 23 was experiencing pain. The first documented evidence indicating Resident 23 experienced shoulder pain was on June 18, 2024, five days after the resident fell . A progress note dated June 18, 2024, at 2:44 PM, revealed an X-ray report of Resident 23's right shoulder positive for right humeral fracture. The impressions indicate old fracture with a refracture. A new order is noted to consult with an orthopedic physician. Orders noted for the resident right upper extremity to be non-weight bearing, sling to right upper extremity, and hydrocodone (an opioid analgesic) straight for pain. A progress note dated June 18, 2024, revealed Employee 7, CRNP, assessed Resident 23 with reported increase in right shoulder pain. The note indicated Tylenol extra strength has been effective until recently and seems to not be working as per nursing staff. The resident is unable to answer questions correctly or verbalize the timeline of events correctly. Patient does wince and yell out with assessment of the right shoulder and humerus. An X-ray report dated June 18, 2024, indicated Resident 23 had a new linear lucency (a thin, dark line or transparent area on an X-ray that can indicate a foreign object or bone fracture) across the right humeral neck that is suspicious for fracture of an indeterminate age but appears non-united and potentially acute. The report indicated Resident 23 has a prior healed fracture of the right humeral neck, with reinjury and likely refracture on multiple views. A physician's order for hydrocodone-acetaminophen 5-325 mg with directions to give one tablet by mouth every eight hours for pain control initiated on June 19, 2024. A Medication Administration Record (MAR) dated June 2024 revealed Resident 23 received hydrocodone-acetaminophen 5-325 mg each shift from June 19, 2024, through June 30, 2024. A review of progress notes revealed Resident 23's representative declined further orthopedic consultation for the resident's humeral injury and agreed to the current plan of treatment. Further review of facility investigation reports and clinical records revealed no documented evidence the facility attempted to investigate the source of Resident 23's humeral fracture identified on June 18, 2024. During an interview on December 19, 2024, at approximately 9:00 AM, the Director of Nursing (DON) indicated the facility attributed Resident 23's humeral neck fracture identified on June 18, 2024, to the resident's fall on June 13, 2024. The DON was unable to provide any documented evidence indicating the facility reviewed and determined Resident 23's humeral neck fracture was a result of the fall on June 13, 2024. The DON confirmed that Resident 23 was not able to indicate how she sustained an injury. The DON confirmed that Resident 23 was assessed following the fall incident on June 13, 2024, by Employee 7, CRNP, and at the time of the assessment, no fractures or indicators of arm or shoulder pain were identified. Also, the DON confirmed the facility had no documented evidence indicating Resident 23 was experiencing pain from June 14, 2024, through June 17, 2024. The DON confirmed the first documented evidence that Resident 23 was experiencing increased shoulder pain was on June 18, 2024. The DON confirmed the facility failed to conduct a thorough investigation to attempt to identify how Resident 23 sustained a humeral neck fracture. 28 Pa. Code 201.14 (c) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on observation, clinical record review, and staff interviews, it was determined the facility failed to implement a person-centered fall and injury prevention plan of care for one resident out of 24 sampled (Resident 104). Findings include: A clinical record review revealed Resident 104 was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure (a condition that occurs when the lungs can't exchange enough oxygen and carbon dioxide with the body, making it difficult to breathe). Further clinical record review revealed Resident 104 was at risk for falls and injury related to decreased mobility, medications, and history of falls with a care plan initiated on November 21, 2023. Interventions in place to protect Resident 104 from injury included bilateral fall mats on the sides of the bed initiated on December 13, 2024. A progress note dated December 13, 2024, at 4:15 AM revealed Resident 104 rolled out of his bed and was found on the floor. He was assessed and did not sustain any injury from the fall. An observation on December 17, 2024, at 9:30 AM in the resident's room revealed Resident 104 was in his bed. No mats were observed on either side of his bed. An observation on December 17, 2024, at 10:15 AM in the resident's room revealed Resident 104 was in his bed. No mats were observed on either side of his bed. At the time of the observation, Employee 5, Registered Nurse (RN), confirmed he has a current care plan intervention for bilateral floor mats. Employee 5, RN, confirmed the mats were not in place. During an interview on December 19, 2024, at approximately 9:30 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure staff implement interventions developed on each resident's comprehensive person-centered care plan. The DON confirmed the facility failed to implement Resident 104's care plan to mitigate his risk of injury from falls, including implementation of bilateral mats in place when the resident is in bed. 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 observation, review of clinical records, and resident and staff interviews it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a medical treatment that manages chronic lung conditions and promotes lung capacity and recovery for one resident (Resident 15) out of 24 sampled residents. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care including Medication Records. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses which included pneumothorax (a collapsed lung that occurs when air enters into the pleural cavity, the space around lungs and can cause pain in the chest and difficulty breathing), and post coronary artery bypass (a surgical procedure wherein a healthy artery or vein is grafted to bypass the blocked artery/vein). Further review of the clinical record revealed Resident 15 had a follow-up consultation with a cardiothoracic surgeon on November 18, 2024, with new physician's orders dated November 18, 2024, at 2:14 PM, for the resident to utilize an incentive spirometer (a medical device that exercises the lungs and is typically used after an illness, surgery or an injury to the chest or abdomen to prevent lung infections by expanding the lungs) every-two hours while awake (resident and/or family may utilize). A review of Resident 15's medication and treatment administration records dated November 18, 2024, through December 17, 2024, failed to reveal documented evidence that the physician's orders for incentive spirometry were implemented. Additionally, Resident 15's clinical record revealed a nurse's note completed by the Director of Nursing (DON) effective December 17, 2024, at 5:25 PM and initiated on December 18, 2024, at 8:27 AM, indicated the facility received a call from physician office (thoracic surgeon) that the resident's chest tube was not draining and the lung was not expanded - and reported this had been ongoing issue for this resident, even when he was in hospital, and was going to admit the resident to the hospital to see if anything else can be completed. During an interview with the DON on December 18, 2024, at 11:15 AM, confirmed the facility could not provide documented evidence that physician's orders for medical treatment, incentive spirometry, was implemented and completed as prescribed. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(i)(ii)(iii) (viii)Medical records

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to prevent the development of a pressure injury for one resident out of 24 sampled residents (Resident 26). Findings included: A clinical record review revealed Resident 26 was admitted to the facility on [DATE], with diagnoses that included dementia (a syndrome characterized by a decline in cognitive function severe enough to interfere with daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and history of a left femoral neck fracture (a break in the upper part of the thigh bone). A review of the resident's person-centered plan of care, initiated on May 2, 2024, identified that Resident 26 was at risk for skin breakdown as evidence by impaired skin sensation, incontinence, and limited mobility with a resident goal to demonstrate no signs or symptoms of skin breakdown. Planned interventions included float heels while in bed, weekly skin assessments by a licensed nurse, and pressure redistribution mattress to the bed. A significant change Minimum Data Set (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment was completed on June 6, 2024, due to the implementation of hospice service for comfort measures due to weakness and deteriorating medical status. Further review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 26 had severe cognitive impairment with a BIMS score of 6 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). Additionally, this quarterly MDS indicated that Resident 26 required extensive assistance of two-plus persons physical assistance with bed mobility, transfers, and toilet use. A review of a facility provided incident investigation completed by Employee 1, RN/Nursing Unit Coordinator, dated September 4, 2024, at 7:50 AM, revealed during am care a hospice aide reported to her that Resident 26 had a DTI (deep tissue injury - The National Pressure Ulcer Advisory Panel defines a deep tissue injury as a pressure-related injury to subcutaneous tissues under intact skin and has the appearance of a deep bruise) on her right heel. The area was cleansed and elevated and the facility contracted wound healing specialists were notified. Physician and RP (responsible party) were notified. Further review of Resident 26's clinical record revealed a progress note completed by the contracted wound healing specialist's CRNP (certified registered nurse practitioner) dated September 4, 2024, at 5:28 PM, revealed that the resident was evaluated due to a newly developed DTI to her right heel and measured 2.2 cm by 2.4 cm by 0 cm with 100% intact maroon/brown epithelial tissue and fragile intact area surrounding the wound without exudate (bloody fluid). New recommendations were to keep heels floated at all times with pillows and cleanse with normal saline and apply skin prep to base of the wound twice per day. Further review of Resident 26's comprehensive person-centered plan of care failed to reveal that the facility revised pressure relieving interventions were developed and implemented to prevent the development of pressure injuries. Additionally, the facility could not provide documented evidence that preventative pressure injury tasks were consistently completed by staff. During an interview with the Director of Nursing (DON) on December 19, 2024, at 2:00 PM, confirmed that the facility failed to develop and implement interventions that prevented Resident 24 from developing a facility acquired pressure area after a significant change in condition and implementation of hospice services. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 33) of 24 residents reviewed. Findings include: A review of the clinical record revealed that Resident 33 was admitted to the facility on [DATE], with diagnoses to include low back pain and muscle weakness. A review of Resident 33's physician orders revealed the following orders: Tramadol 50mg (narcotic pain medication) give one tablet by mouth every six hours as needed (PRN) for pain initially dated November 20, 2024, and discontinued November 22, 2024. Oxycodone 5mg (narcotic pain medication) give one tablet by mouth every six hours as needed (PRN) for moderate to severe pain initially dated November 22, 2024, and discontinued November 29, 2024. Tramadol 50 mg give one tablet by mouth every 6 hours as needed for moderate to severe pain initially dated December 12, 2024, and remains as an active order. A review of the resident's November 2024 Medication Administration Record (MAR) revealed that staff administered the PRN Tramadol three times and the PRN Oxycodone eight times for the month of November. All doses of the pain medications were administered with no non-pharmacological interventions attempted prior to giving the pain medication. A review of the resident's December 2024 MAR revealed that staff administered the PRN Tramadol one time for the month of December. No non-pharmacological interventions were attempted prior to giving the pain medication. Interview with the Nursing Home Administrator and Director of Nursing on December 19, 2024, at approximately 2:00 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of the PRN pain medication. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 24 residents sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], and had diagnoses which included major depressive disorder and schizophrenia (a mental health condition that is marked by symptoms such as hallucinations and delusions). A review of an October 2024 Consultant Pharmacist Medication Regimen Review revealed the consultant pharmacist indicated the resident's order for Abilify 10 MG (antipsychotic medication) was to be reviewed for a gradual dose reduction. Further review revealed the resident's attending physician failed to write an appropriate response to the pharmacy recommendation. Instead, the facility's consultant psychiatric CRNP (certified registered nurse practitioner) had responded to the pharmacy recommendation and signed off as she reviewed it. The resident's attending physician failed to document in the resident's clinical record the rational and justification for the continued use of Abilify and a reason for the rejection of the gradual dose reduction. An interview with the Director of Nursing (DON) on December 19, 2024, at approximately 2:00 PM confirmed that consultant psychiatric CRNP was responding to the pharmacy recommendations. Further the DON confirmed the attending physician failed to provide justification in the clinical record for the continued use of Resident 1's Abilify. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c)(d)(3) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on October 8, 2024, at approximately 9:45 AM, revealed the following: The shower room in the 200 hall was noted to have a black substance built-up on the caulking around the shower. room [ROOM NUMBER] was noted to have water damage to the ceiling. Old brown water stains were seen along with a black mold like substance. A bath blanket was noted on the floor with dried brown water stains on it. Further, there was a dead earwig (bug that is attracted to moisture) on the bath blanket. A bedside table was noted to be cracked and chipped. [NAME] spots and streaks were noted on the wall next to the nightstand. The molding was peeling off the wall. The center hallway had water damage to the ceiling. Brow stains were noted on the ceiling and a piece of plywood was screwed to the ceiling covering a hole. The shower room in the center hall was noted to have cracked tile in the shower, along with a black substance built-up on the caulking around the shower. The soiled utility room in the center hall had a large amount of a black like mold substance on the walls around the hopper (Flushing-Rim Clinical Sink is used for disposal of blood or body fluids). The hopper was noted to be leaking water. There was a strong smell of mildew in the soiled utility room. The hallway in front of the dining room had brown water stains on the ceiling. There was joint tape peeling away from the ceiling and wall with a black substance noted under the tape. Interview with the Nursing Home Administrator on October 8, 2024, at approximately 1:00 PM, confirmed that the facility failed to maintain a clean and sanitary environment for the residents. 28 Pa. Code 201.18 (e)(2.1) Management

Based on review of minutes from the Residents' Council meeting and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life, by failing to respond timely to residents' request for assistance as evidenced by experiences reported by five residents out of five sampled (Residents 14, 11, 9, 13 and 10 ). Findings include: During interviews conducted throughout the day tour of duty on March 6, 2024, the residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their requests via the nurse call bell system. A review of minutes from the Residents' Council meeting on February 1, 2024, revealed that Resident 14 was requesting staff assignments be reassessed as he has been left in the bathroom for long periods of time when his assigned aide is off the floor. He reported that staff tell him they do not have him on their assignment and do not provide the necessary assistance, which has caused him to wait extended periods of time in the bathroom. Interview with Resident 11 on March 6, 2024, at 10:43 AM revealed that she feels that short staffing and agency nursing staff are a problem in the facility. She stated that over that last couple of days I would ring the bell to use the bathroom because I can't do it myself. I had to wait over an hour. I couldn't hold it and, unfortunately, I soiled myself. Interview with Resident 9 on March 6, 2024, at 11:15 AM, revealed that she has waited over 2 hours for staff to answer her call bell. The resident stated that these long waits often occur an hour or so around shift changes. Resident 9 reported that on March 4, 2024, she was put in bed at 7:30 PM. At 1:00 AM an aide came in to check if the resident needed to be changed, and the resident replied that she did not at that time. Resident 9 stated she woke at 5:00 AM and activated the call bell as she needed to use the bathroom at that time. No one answered her call bell until 6:20 AM, when an aide peeked in the resident's room and said she would tell the other girls that she needed to be changed. Resident 9 stated that she soiled herself waiting for staff assistance. It was not until 7:30 AM, 2.5 hours after Resident 9 activated her call bell for assistance, that a nurse aide came in the resident's room to provide assistance. Resident 9 stated that she was so saturated with urine by that time that they had to change all the bed linens. She stated, I was so embarrassed, but I couldn't help it, I had to go. Interview with Resident 13 on March 6, 2024, at 11:30, revealed that the resident stated he has learned to do everything for himself because staff take forever to answer the call bell and provide assistance when needed. Interview with Resident 10 on March 6, 2024, at 12:00 PM, revealed that he has waited over an hour for staff to answer his call bell. The resident stated that these waits occur mostly on 2nd shift (evening shift). He further stated he feels that short staffing is a problem in the facility that creates these long waits for residents to receive personal care and assistance when requested from nursing staff. Interview on March 6, 2024, at approximately 2:15 PM with the Director of Nursing (DON) verified that it is her expectation that all residents be treated with dignity and respect. The DON was unable to explain why multiple residents are reporting untimely staff response times to their call bells and requests for assistance, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (c)(d)(4)(5) Nursing Services

Based on observation, review of clinical records and select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure fresh water was consistently readily accessible to residents to promote adequate hydration, resident preference and comfort for five out of 14 residents reviewed (Residents 11, 9, 12, 13, and 2). Findings include: A review of the facility policy titled Water Pass provided by the facility on March 6, 2024, indicated that the facility will provide the residents with fresh water every shift and that straws, cups, and lids are changed at a minimum of every three days. During an interview with Resident 11 on March 6, 2024, at 10:43 AM, the resident expressed frustration that she has to consistently ask staff to provide fresh drinking water, and staff do not routinely provide fresh drinking water daily. She stated you have to ask for it, and even then, they're so busy, they forget. My son got me a cup yesterday, but no staff member has been in to give me any (fresh water) since then. During an interview with Resident 9 on March 6, 2024, at 11:15 AM, she reported that staff do not provide fresh drinking water every shift and that the only drinking water she receives is the one she gets on her breakfast tray. She stated, I have to ask them every day for 1/2 cup of ice. Observation at the time of the interview revealed a Styrofoam cup with lid and straw in it on which on the side of the cup was written the resident's room number and bed location (A or B) dated February 29, 2024. During an observation in Resident 12's room on March 6, 2024, at 11:25 AM, revealed a Styrofoam cup with lid and straw in it on the nightstand, out of reach of the resident on which was written, on the side of the cup, the resident's room number, bed location, and the date of February 29, 2024. During an interview with Resident 13 on March 6, 2024, at 11:30 AM, he reported that I get it (fresh water) myself. No one comes in to give me fresh water, so I go across the hall and get it myself. Observation at the time of the interview revealed a Styrofoam cup wit a lid and straw in it, on which was written, on the side of the cup, the resident's room number, bed location, and date of February 29, 2024. During an interview with Employee 1 (nurse aide) on March 6, 2024, at 11:35, she confirmed that the Styrofoam cups for drinking water, observed in the rooms of Residents 11, 12, and 13 were dated six days ago, February 29, 2024, and that Resident 12's cup was also out of the resident's reach. Observation in Resident 2's room on March 6, 2024, at 11:45 AM, revealed no water cup or other beverage available to the resident. Review of Resident 2's care plan revealed that the resident was on a regular diet with thin liquids and was independent with self-feeding. Interview with Employee 2 (licensed practical nurse) on March 6, 2024, at 11:48 AM, confirmed that Resident 2 was independent with drinking thin liquids and able to manipulate the water cup independently. She also confirmed the absence of fresh water or another beverage available to Resident 2. During an interview on March 6, 2024, at approximately 12:40 PM, the Director of Nursing (DON) stated that it is facility policy that the water pass is to be conducted once per shift and as needed. The DON stated it is facility policy to change straws, cups and lids every three days and as needed. The NHA confirmed that the facility failed to provide clean water drinking cups every three days and failed to demonstrate that fresh ice water was readily accessible as preferred by residents to promote adequate and hydration and comfort for residents. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on an observation, review of clinical records, select facility policy and fall incident reports, and staff interviews, it was determined that the facility failed to consistently implement, and evaluate the effectiveness, of planned individualized fall prevention measures and provide sufficient staff supervision at the level and frequency required, of residents identified as at high risk for falls and known unsafe behaviors to prevent falls resulting in serious injuries, a fractured femur, for one resident (Resident 98) and a fractured neck for one resident (Resident 56), and failed to provide necessary assistance devices and assure that the resident's environment was free of potential accident hazards to prevent a fall and injuries, abrasions and bruises, to one resident (Resident 39) out of nine residents sampled for accidents. Findings include: A review of the facility policy titled Managing Falls and Fall Risk, last reviewed by the facility on January 2, 2024, indicated that it is the facility's policy to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Also, the policy indicates that if interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. A clinical record review revealed that Resident 98 was initially admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and a history of repeated falls with significant injuries including a fracture of the right femur (thigh bone) and a fracture of the left radius (the radial bone is one of the two large bones of the forearm). Resident 98's care plan, initially dated October 25, 2022, revealed that Resident 98 was at-risk for falls with behaviors that do not allow staff to assist, including swinging at staff during redirection. The resident's care plan also noted the use of both chair and alarms, initiated November 12, 2022 and December 5, 2022, respectively. A Physical Therapy Discharge Summary dated July 6, 2023, indicated that Resident 98 required the assistance of one staff member for ambulation. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 27, 2023, revealed that Resident 98 was severely cognitively impaired with a BIMS score of 01 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). This quarterly MDS assessment dated [DATE], Section G0300 Balance during Transition and Walking, indicated that Resident 98 was not steady when moving from a seated to a standing position or when walking and was only able to stabilize with staff assistance. A review of facility fall reports revealed that between July 2023 and September 2023 Resident 98 fell five times before falling on September 29, 2023, and sustaining a serious injury. The facility's fall investigations identified that Resident 98 had four unwitnessed falls during this time period. A facility fall report noted that Resident 98 had an unwitnessed fall on July 13, 2023, at 7:00 PM in her bathroom. Staff found the resident on the bathroom floor, near her wheelchair. No injuries were noted. The facility developed an intervention for staff to toilet Resident 98 each day at 7:00 PM. Facility fall reports revealed that Resident 98 had an unwitnessed fall on July 14, 2023, at 4:15 PM in the hallway. Staff found the resident on the floor lying in front of her wheelchair. No injuries were noted. An intervention was developed to evaluate labs and obtain a urine analysis A physician progress note dated July 31, 2023, indicated that the resident's recent labs, urine, medications, and medication management were reviewed. The entry noted that Resident 98's plan was being formulated. A facility fall report noted that Resident 98 had an unwitnessed fall on July 29, 2023, at 2:15 PM in the hallway. Staff found the resident on the floor in the doorway outside of her room. No injuries were noted. A care plan intervention was developed for staff to conduct 15-minute safety checks of the resident. The 15 minute safety checks of the resident were discontinued on July 31, 2023. A fall risk assessment dated [DATE], indicated that Resident 98 was at high risk for falls. A facility fall report noted that Resident 98 had an unwitnessed fall on August 19, 2023, at 9:05 PM near her room doorway. Staff found the resident lying on the floor in the doorway of her room. The preventative approach was developed for staff to restart every 15 minute safety checks, which was planned after the fall on July 29, 2023. An additional care plan intervention was developed for staff to check the resident's alarm pads to ensure proper placement. A review of the resident's clinical record and task and intervention tracking documentation revealed no evidence that staff were conducting every 15-minute checks of Resident 98 as a safety measure, after the resident's fall on August 19, 2023. Nursing documentation dated August 2023, indicated that the resident continued frequent attempts to ambulate without staff assistance. A nursing progress note dated August 22, 2023, at 2:04 PM indicated that Resident 98 was self-rising and attempting to ambulate at times. Nursing noted that redirection was unsuccessful at times but does well with one-to-one interaction. A nursing note dated August 22, 2023, at 7:06 PM indicated Resident 98 was frequently yelling out and attempting to stand and ambulate from the wheelchair. A nursing progress note dated August 23, 2023, at 3:22 AM indicated that Resident 98 was attempting to self-transfer out of bed. Staff assisted the resident into a wheelchair and to the nurse's station. Nursing progress note dated August 23, 2023, at 2:45 PM indicated that Resident 98 displayed frequent self-rising attempts. A nursing progress note dated August 23, 2023, at 6:11 PM indicated that the resident made multiple attempts at standing and ambulating without assistance this shift. The also entry noted that the resident does well with one-on-one assistance. Nursing noted on August 24, 2023, at 2:32 PM that Resident 98 continued with impulsive self-rising or attempting to ambulate unassisted. A nursing progress note dated August 25, 2023, at 11:19 PM indicated that Resident 98 displayed multiple behaviors, to include standing up frequently, kicking at staff, slapping, and poking staff. The entry noted Resident 98 enjoys one-on-one (interaction) but reverts to the same behavior when left by herself. Nursing noted on September 21, 2023, at 1:34 AM that Resident 98 made multiple attempts to get out of bed without assistance. The entry further noted that that reorientation, redirection, and distraction were attempted and failed. The resident's care plan included interventions to mitigate Resident 98's risk of falls as of September 29, 2023, including a chair alarm, ensuring the resident was wearing appropriate footwear when ambulating or mobilizing in a wheelchair, giving the resident a cat to hold to keep her busy in one spot, keeping frequently used articles within reach of the resident, 15 minute safety checks, and keeping the resident out at the nurse's station when restless to have staff around for close observation. However, review of the resident's clinical record, Resident 98's task and intervention tracking and fall investigation reports for September 29, 2023, revealed no documented evidence that staff had implemented all planned interventions in accordance with her care plan for mitigating her risk of falling. Specifically, the clinical record, task documentation and intervention tracking failed to reveal documented evidence that staff had implemented the follow care planned interventions: (1) provided Resident 98 with her toy cat to hold to keep her busy in one spot: (2) ensured that frequently used articles were within reach of Resident 98: or (3) conducted 15-minute safety checks. A nursing progress note dated September 29, 2023, at 11:16 AM indicated that staff found Resident 98 lying on her back with her left leg flexed near her wheelchair near the nurse's station. The resident was yelling out in pain. The note indicated that neurological checks were initiated and that a cold pack was provided to the resident. A mobile x-ray report dated September 29, 2023, at 11:44 AM indicated that Resident 98 had a mildly displaced, impacted, and angulated acute subcapital fracture of the proximal left femur. The nursing progress note dated September 29, 2023, also noted that the resident's x-ray was positive for a proximal femur fracture and the Certified Registered Nurse Practitioner (CRNP) evaluated the resident. The resident was transferred to the emergency room A facility investigation report dated September 29, 2023, indicated that Resident 98 had an unwitnessed fall near the nurse's station at 11:15 AM. Staff found the resident lying on her back with her wheelchair alarm sounding. A witness statement dated September 29, 2023, provided by Employee 5, a Licensed Practical Nurse (LPN), indicated that she did not witness Resident 98 fall. Employee 5, LPN, indicated that the last time she saw the resident was at 9:30 AM when administering medication. Employee 5, LPN, indicated that she was in the hallway administering medications when she heard a thump and saw the resident on the floor next to her wheelchair. Employee 5, LPN, indicated that Resident 98 was evaluated, and nursing supervisor notified about the incident. A witness statement dated September 29, 2023, provided by Employee 7, Nurse Aide (NA), indicated that she did not witness Resident 98 fall. Employee 7, NA, indicated that she last saw Resident 98 at 9:30 AM. A witness statement dated September 29, 2023, provided by Employee 6, Nurse Aide (NA), indicated that she did not witness Resident 98 fall. Employee 6, NA, indicated that the last time she saw Resident 98 was at 9:30 AM in front of the resident's room. A witness statement dated September 29, 2023, provided by Employee 8, Registered Nurse (RN), indicated that she did not witness Resident 98 fall. Employee 8, RN, indicated that the last time she saw Resident 98 was 11:00 AM in her wheelchair near the nurse's station. A hospital discharge summary indicated that Resident 98 was admitted on [DATE], due to a fall with hip pain and a fracture. The report indicated that Resident 98 underwent open reduction and internal fixation surgery (ORIF- a type of surgery that is used to repair broken bones) to repair a fracture of her left femoral neck. The resident was discharged from the hospital on October 2, 2023. Nursing noted on October 2, 2023, at 9:20 PM that Resident 98 was readmitted to the facility with intact surgical wound dressings. During an observation on January 7, 2024, at 12:51 PM, Resident 98 was observed seated in a wheelchair near the nurse's station. Resident 98 was observed moving from a seated position to a standing position multiple times, which caused her alarm to engage and disengage. There were no employees present at the nursing station, but after 60 seconds, Employee 3, Registered Nurse (RN), responded to Resident 98's alarm. Employee 3, RN, was observed talking to Resident 98. During an interview on January 9, 2024, at approximately 9:30 AM, the Director of Nursing (DON) confirmed that the facility was unable provide documented evidence of consistent implementation of planned safety and fall prevention measures, including sufficient staff supervision, to prevent Resident 98's fall and serious injury on September 29, 2023. A review of the clinical record of Resident 39 revealed admission to the facility on [DATE], with a history of falls with fracture and heart failure. A review of the resident's annual MDS assessment dated [DATE], revealed that the resident was moderately cognitively impaired and required extensive staff assistance with activities of daily living, including bed mobility, transfers, and toileting. Review of Resident 39's care plan, last revised February 25, 2020, indicated that the resident was at risk for falls related to a history of falls, non-compliance with transfer status, impaired balance, impaired coordination, weakness, pain, and medication. Planned interventions for prevention included a high-density contour mattress, bilateral fall-[NAME] mats to the bedside, transfer via mechanical lift, keep pathways clear and free of clutter, maintain call bell within reach, and non-skid footwear at all times. According to the care plan, Resident 39 also utilized bilateral bed enablers (side rails) to assist in bed mobility, which was initiated October 7, 2019. Nursing noted on November 24, 2023, at 1:28 PM that the resident was transferred to another room for isolation precautions after testing positive for COVID. Nursing progress notes dated November 28, 2023, at 7 PM indicated that staff found the resident found face down on the floor next to the bed with arm of bed side table underneath right upper leg. The resident sustained abrasions to right upper thigh, the bridge of her nose was swollen with slight bruising, redness and swelling was observed on the left temporal area, and the resident complained of left shoulder pain. An x-ray was ordered due to complaints of left shoulder pain, which was negative for fracture or dislocation. A review of a facility investigation dated November 28, 2023, at 5:45 PM indicated that the resident had an unwitnessed fall from the bed. At time of event, the resident stated that she forgot I didn't have my handrails (side rails on the bed {enablers}). Facility description of potential contributing factors identified that when the resident was moved to another room for isolation, the temporary room's bed had an air mattress versus a high-density contour mattress, no bilateral bed enablers, and fall mats were not in place on each side of the bed. The facility failed to implement the resident's fall prevention measures when the resident was transferred to the temporary room for isolation precautions for COVID. The bed in which the resident was placed had a different type of mattress, no enabler bars and no fall mats were placed on the floor at the bedside. In response to the resident's fall from bed on November 28, 2023, the facility planned the immediate interventions of removing the air mattress and replace it with the appropriate mattress and apply bilateral enablers (side rails on the bed). Interview with the Director of Nursing on January 9, 2024, at approximately 2:00 PM confirmed that the facility failed to implement Resident 39's planned interventions, and assure that the resident's temporary environment was free of potential accident hazards, to prevent the resident's fall with injuries. Clinical record review revealed that Resident 56 was admitted to the facility on [DATE], for short-term therapy after a fall at home during which the resident sustained a hip fracture. The resident had a history of repeated falls and a diagnosis of rheumatoid arthritis. The resident's care plan, dated November 5, 2023, indicated that the resident was at risk for falls with an intervention for staff to be sure that the resident's call light was within reach, to encourage the resident to use it for assistance, and education to the resident on safety issues. The care plan also included an intervention for the resident's bed to be in lowest position, dated November 8, 2023. A review of a facility fall investigation report dated November 6, 2023 at 2:53 PM revealed that staff observed Resident 56 on the floor, next to the foot of the resident's bed. According to the report, he stood up and stepped out of the wheelchair. The investigation indicated that it appeared that he was attempting to pick up something from the floor. The noted intervention was to refer the resident to therapy for a reacher with associated education. A review of a facility investigation report dated December 10, 2023 at 5:30 AM revealed that staff found Resident 56 laying on the floor, on his right side, between the beds in his room. He told staff he was going to the ball game. He had a small bump on the top of his forehead approximately one inch under his hairline. Neuro checks were initiated. He had non skid socks on and was last given care at 5 AM The physician was contacted and because this resident was taking an anticoagulant medication (Eliquis) he was transferred to the hospital for evaluation. New interventions to prevent falls dated December 10, 2023, was for the resident to wear non-skid socks, although the facility's fall investigation report indicated that the resident was wearing non-skid socks at the time of this fall. Nursing documentation dated December 10, 2023 at 5:48 AM revealed that staff in the hall, heard Resident 56 say I hope that doesn't happen again. Staff went into the resident's room and found the resident lying on the floor, between both beds. The resident was facing his bed. Staff assessed the resident to have two small superficial open areas noted to the top of the forehead, approximately one inch inside the hairline. The area had a small, elevated purplish discolored lump at the site of the open area, no further bleeding or drainage noted. The resident's physician and responsible party notified. The ambulance was called and the resident was transported to the hospital for treatment. The emergency room staff contacted the facility and relayed information that the resident was being admitted to the hospital for a non-displaced fracture of the base of the odontoid in the cervical region (of the neck), and was to be seen by neurology services and also that the resident had a urinary tract infection. A review of hospital documentation dated December 12, 2023 at 7:39 A.M. revealed a CT scan (a computerized x-ray imaging procedure) revealed that Resident 56 had an acute type 2 odontoid fracture, undisplaced fractures of posterior arch C1 (cervical 1 vertibra). The hospital placed an Aspen collar (cervical collar, also known as a neck brace) on the resident and the resident was admitted to the facility on [DATE]. A significant change MDS assessment dated [DATE], revealed that the resident was moderately cognitively impaired with a BIMS score of 8 and was dependent on staff for activities of daily living. A review of a facility investigation dated December 26, 2023 at 4:30 P.M., revealed Resident 56 was found on the floor. His Aspen collar was in place. He had been sitting in the wheelchair at the time of the fall and was incontinent of bowel at that time. The resident stated that he was trying to go to the bathroom for a bowel movement. The noted intervention was to offer toileting at 4 PM daily and the additions of bed and chair alarms. A review of a facility investigation report dated December 30, 2023 at 3:45 P.M. revealed that Resident 56 was found on the floor in his room from bed. Planned interventions added at the time of this fall was to add bilateral fall mats next to his bed. A nurses note dated December 30, 2023 at 6:08 PM revealed that at 3:45 PM that date staff found the resident sitting on the floor next to his bed. He stated he was trying to get to call his wife. The facility failed to demonstrate the implementation of necessary fall prevention approaches, including sufficient staff supervision of resident with a known history of falls and identified at risk for falls to prevent repeated falls and serious injury. The facility failed to re-evaluate the effectiveness of existing planned safety measures as the resident continued to fall and revise the resident's fall prevention plan accordingly to include increased supervision of the resident, which was confirmed during interview conducted on January 10, 2024, at 10 AM with the Director of Nursing. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on observation, and staff interviews it was determined that the facility failed to maintain infection control practices during medication administration on one out of two medication carts (Station A, Back Hall), failed to maintain ice machines and ice distribution areas in a sanitary manner on two of two resident units and failed to maintain the facility's laundry area in a clean and sanitary manner. Findings include: Observation of medication administration pass, on January 7, 2024, at approximately 10:05 AM, revealed Employee 1, Registered Nurse (RN), on the Station A, Back Hall, medication cart. During the medication pass observation, the surveyor observed an open, purple can Monster energy drink, on the top left side of the medication cart. Additionally, a dark colored, winter jacket was draped over the rear, right side of the medication cart. Interview with Employee 1, RN, on January 7, 2024, at approximately 10:18 AM, confirmed the observation, and stated it was her drink, and winter coat. She further acknowledged she had not adhered to infection control procedures during this medication pass by placing personal items on the medication cart. An observation January 8, 2024, and January 9, 2024 at 10 AM and again at 1 PM on the A resident hallway, the ice machine, located outside the medication room, was observed to have large areas of a white, dried liquid on the stainless steel backsplash,, drain area and the front of the machine. There were multiple areas of a black substance at where the stainless steel back splash meets the drain area as well as in the drain area (on the front of the machine). There were dried liquid drips on the entire front of the machine. There was a styrofoam cup, multiple plastic cup lids and a metal basket with handles on the top of the ice machine. Food and liquid stains were observed on sides of the ice machine and food and liquid stains extending from the top to the bottom of the machine. The floor on both sides and underneath the ice machine was dirty and littered with paper and plastic materials as well as sticky food and liquid stains. The floor on the right side of the ice machine was dirty with a large brown stain, paper debris. There was a large build-up of a sticky substance with a large buildup of lint on the electrical lines from the machine to the outlet. There was a buildup of a black substance on the molding at the floor level. On the left side of the floor/machine, a large build-up of black substance was observed on the plastic PVC drain pipe leading from the machine to the floor drain. A large accummulation of the same black substance was observed inside of the plastic drain water collection device. Several areas of the black substance were observed on the bottom of the plastic drain pipe. The ice machine on the B resident hallway, located in the hallway was dirty with liquid stains on the front and sides. The stainless steel backsplash was covered in a dried white substance. The drain tray surrounding the ice machine drain was observed to have a large amount of white substance as well as a sticky red dried liquid substance. The floor on the right side of the machine was dirty with food and liquid debris. There was a black substance on the floor and also on the plastic PVC pipe leading into the machine drain. There was paper and plastic debris under the machine and on the left side floor. An environmental tour of the facility laundry facility, in the soiled/dirty area, January 8, 2024 at approximately 10 A.M., revealed that the floors were dirty in front and behind the washing machines. There was a large buildup of lint, dirt paper and plastic, used disposable gloves and spoons on the floor in the room, including around the 3 washing machines. There were clean, damp mop heads and rags used by cleaning staff in the facility, piled up on top of the washing machines. The window sill in the room had a large build up of cobwebs on the windows and the window sill. There were two pairs of resident shoes covered with cobwebs along with a used glove and 2 spoons on the windowsill. In front of the window there were 16, 5 gallon plastic pails of cleaning chemicals. There were 5 uncovered resident pillows on top of the containers of chemicals. There were multiple, just laundered floor rugs draped over large garbage cans. There was a dirty wheelchair mat on the floor next to the washing machine on the floor. A floor mop/duster and a dirty dust pan wa lying on the floor with paper and plastic debris on the floor next to the third washing machine. In between the first two washing machines there were multiple wheelchair cushions, a resident pillow, a bath blanket directly on the floor. In the clean area of the laundry room the floors were littered with dirt, paper and plastic debris. In the corner of the room there was a slop sink with multiple cleaning items including, a resident plastic basin, used scrub brushes. On the floor in this area were three dirty mop buckets with dirty brown water in them. A floor mop was directly in the dirty water in one of the buckets. There was a floor buffing machine in the area. The floor and wall areas were dirty with dirt and liquid stains as well as paper and plastic debris. The sink was observed with a large amount of a white substance on the front of the the sinks. Observation of the clean resident laundry room ( the area where resident clean clothing was received, folded/hung up prior to delivery to the resident) revealed that the floor was dirty with dirt, food and liquid debris. There was a black substance on the base board and along the floor running the perimeter of the room. There was a floor buffer stored next to the desk with clean resident clothing on and multiple floor buffer pads under the desk. There were multiple floor mops/dusters, dust pans and an overflowing garbage can in the corner of the room. There was a pair of resident shoes in between the mops and dust pans. During an interview at the time of the observation, Employee 4 (laundry) stated that there were 3 staff members in the laundry department. The last shift was completed at 3 PM. She stated that the laundry staff attempted to get residents' personal laundry back to them in 24 hours. She stated that it is the responsibility of the laundry staff to clean the laundry area and confirmed that the laundry area was not presently clean and orderly. Interview with the Director of Nursing (DON) on January 8, 2024, at approximately 1:45 PM confirmed the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection in the facility. 28 Pa. Code 211.12 (c)(d)(1) Nursing services 28 Pa. Code 205.26 (c) Laundry

Based on a review of clinical records and select facility fall investigation reports and staff interviews, it was determined that the facility failed to provide necessary assistance devices as planned to safely transfer a resident identified at high risk for falls to prevent a fall resulting in a serious injury, a fractured tibia/fibula, sustained by one resident out of five residents reviewed for accidents/falls (Resident 42). Findings included: Review of Resident 42's clinical record revealed admission to the facility on [DATE], with diagnoses that included a history of falling and abnormal gait. Resident 42 was identified at high risk for falls based on the resident's history of falls and abnormal gait. A review of resident's care plan for the problem/need of fall prevention dated August 31, 2022 indicated that the resident was to be transferred with a Vanderlift (a mechanical lift). An incident report completed by the facility on September 19, 2022, at 9:29 p.m. indicated that Resident 42 was in the bathroom with Employee 1 (CNA) and Employee 2 (CNA) for toileting. Employee 1 and 2 were attempting to transfer the resident from the toilet back into the wheelchair when her right leg gave out. The nurse aides indicated that they lowered the resident to the floor and the resident's right leg bent under her. The resident expressed pain in her right lower extremity and x-rays were ordered. X-ray results indicated the resident had a fracture of the right tibia and fibula (lower leg fracture). There was no indication Employees 1 and 2 used a Vanderlift to transfer the resident from the toilet to the wheelchair at the time of the resident's fall resulting in serious injury on September 19, 2022. Interview with the Administrator on November 15, 2022 at 2:05 p.m. confirmed that Resident 42 required the use of the mechanical lift, the Vanderlift, for safe transfers. The Administrator confirmed that Employees 1 and 2 failed to use the necessary assistance device to transfer the resident resulting in the resident's fall with injury on September 19, 2022. This deficiency is cited as past non-compliance. The facility's corrective action plan was to assess Resident 42 for proper transfer status and to update the care plan. All residents were audited for their current transfer status, care plan and cardex information. Corrections were made when found. Staff inserviced on proper transfer techniques. Any new nurse aides working in the facility will be paired up with an experienced nurse aide for transfers. Audits were completed weekly with results reported to the QAPI committee by the Director of Nursing. This plan of correction was completed by October 13, 2022. Refer F726 28 Pa. Code: 211.11(d) Resident Care Plans 28 Pa. Code: 211.12 (a)(c)(d)(3)(5) Nursing Services

Based on a review of clinical records, select facility policy and investigation reports and staff interviews, it was determined that the facility failed to provide adequate supervision of residents with known unsafe/restless behaviors and history of falls, to prevent falls with serious injuries, multiple rib fractures with pneumothorax (collapsed lung) and [CONDITION(S)] for two residents out of six residents reviewed with falls (Resident 79 and Resident 68). Findings include: Review of the facility's policy and procedures titled, Safety Observations, with a facility review date of January 2021, revealed that a process will be implemented to identify high risk behaviors and monitor residents who demonstrate those behaviors in an effort to maintain the resident's safety and the safety of others. The procedure for determining the level of observation is based on the resident's level of risk, which is determined by the following: · 1:1 observation is indicated for any resident posing a direct of potential, and/or aggressive threat to themselves or others by verbal, physical, or sexual statements, restlessness that could cause personal harm will be placed on 1:1 observation when appropriate by staff, to be conducted within visual sight and within arm's length of the resident. · 15 minute observations are indicated for any resident who is confused and exhibits unsafe wandering, intrusive behaviors with no intent to harm others, but may be at increased risk to harm themselves or others due to their cognitive status, will be placed on 15 minute checks for visual observations by staff to identify the residents location in the facility and provide redirection as needed. · 30 minute observations are indicated for any resident who is at minimal risk to harm self or others due to cognitive status, but require additional re-direction to monitor the resident's clinical or behavioral status will be placed on 30 minute visual observations by staff to identify the resident's location in the facility and provide re-direction as needed. The policy noted that the primary nurse will initiate safety observation based on the resident's clinical and behavioral needs at the time. The unit manager/charge nurse are accountable to provide education to the direct care staff regarding the reason for the level of safety observation. The progress notes will be updated to indicate the resident's behaviors and the reason for the level of safety observation. Once a resident is placed on safety observations, the primary nurse or IDT (interdisciplinary team) will discontinue the safety observations for resolved behaviors. A review Resident 79's clinical record revealed that the resident was initially admitted to the facility on [DATE], with diagnoses to include [CONDITION(S)] (inflammation of one or more joints), anxiety and major depressive disorder (is a mental health disorder having episodes of psychological depression). The resident was readmitted to the facility on [DATE], from the hospital with a diagnosis of COVID-19. Resident 79's comprehensive care plan revealed a problem/need of falls implemented on April 9, 2020. The resident's plan of care identified the resident as at risk for falls related to cognitive impairments, dementia with behaviors, anxiety, depression, weakness, arthritis, impaired mobility, fatigue, medications, impaired coordination, impaired balance, and gait dysfunction (is a change in normal walking patterns often related to a disease or abnormality). The goal established was that the resident have a decrease incidence of falls, with planned interventions of a lowered clothing bar in the resident's closet, brightly colored tape on the resident's call bell and was labeled tap bell for help, furniture adjustments were made to accommodate Resident 79's needs, and to keep pathways clear and free of clutter. The resident had a physician order dated December 4, 2020, at 3:30 PM, for the use of sensor alarm to the bed and wheelchair to alert staff of the unsafe/unassisted transfers with staff checking the placement and function of the alarms every shift. Resident 79's, Fall Risk Assessment, dated on December 4, 2020, upon the resident's readmission to the facility from the hospital, revealed that the resident scored a nine (9) indicating that the resident was at moderate risk for falling. A 5-Day MDS Assessment (Minimum Data Set - is a federally mandated standardized assessment process completed periodically to plan resident care) dated December 7, 2020, revealed that the resident was severely cognitively impaired with a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 2. The MDS indicated that Resident 79 required extensive assistance of two plus persons physical assist to perform bed mobility and transfers and one-person physical assist with dressing, extensive assistance of one-person physical assist for toileting, performing bathroom activities and personal hygiene. The MDS indicated that Resident 79 was not steady, only able to stabilize with staff assistance during transfers and mobility. A facility, Investigation of Fall, dated December 6, 2020, at 7:30 PM, revealed that Resident 79 had an unwitnessed fall. Staff found Resident 79 kneeling on the left side of her bed on her knees. A witness statement by Employee 4, (Licensed Practical Nurse) LPN, that indicated Resident 79 was last seen in bed sleeping twenty minutes prior to her fall. The facility's investigation conclusion was that the resident's fall was related to Resident 79 changing rooms due to COVID-19. Additionally, it was noted that the resident had increased confusion and weakness. The facility's planned intervention was a referral to occupational therapy (OT). Review of the Rehabilitation Department's form, Status/Post Fall Assessment, dated December 7, 2020, revealed potential reasons for Resident 79's fall that included impulsivity, poor judgement, and unawareness of physical limitations and recommended OT to re-screen when the resident can tolerate. Review of a therapy progress note dated December 7, 2020, at 1:24 PM, revealed that during the screen the resident had a, fixed stare and was unable to attend (pay attention) to the therapist. The OT screen was not able to be completed due to Resident 79's medical instability and it was noted that OT would re-screen when medically stable. A, Physician's Progress Note, dated December 7, 2020, at 12:00 PM, revealed that there were changes in Resident 79's mental status since hospitalization and that a urine analysis [(UA) is a test that is used to examine the urine contents for any abnormalities that indicate a disease condition or infection], culture and sensitivity [(C&S) is a test that checks for the presence of bacterial infections in a particular body fluid or area of the body], complete blood count [(CBC) is a blood test used to evaluate overall health and detect a wide range of disorders, including [CONDITION(S)], infection and leukemia], complete metabolic panel [(CMP) is a blood test that checks the status of blood sugar, protein levels, electrolytes, and fluid balance in the body], and a [CONDITION(S)] sensitivity hormone test [(TSH) is a is a blood test that measures this hormone] were to be obtained to assess for causes of change in mental status. A facility, Investigation of Fall, dated December 7, 2020, at 6:07 PM, revealed that Resident 79 had another unwitnessed fall. Staff found Resident 79 lying on the floor on the right side of her bed (between the bottom of the bed and dresser). The resident sustained a 3 centimeter (cm) skin tear to her elbow with no bruises or open area noted. The resident was noted to be weak and lethargic. Neuro checks were completed and within normal limits (WNL). Review of an employee witness statement that was completed by Employee 4, LPN, revealed that the resident was last seen at 5:15 PM sleeping in bed. The intervention planned was to implement bilateral fall mats to each side of the resident's bed. A facility, Investigation of Fall, dated December 8, 2020, at 4:00 AM, revealed that Resident 79 had another unwitnessed fall. Staff found Resident 79 kneeling on the right side of the bed with her elbows resting on the bed. An employee witness statement by Resident 79's Employee 5, Nurse Aide (NA), revealed that the resident was observed kneeling by her bed and then getting herself back into bed. The bed alarm was on the resident's bed. The employee's statement that care was last provided to the resident at 12:30 AM, but the resident had been observed in bed five minutes prior to the fall. An employee witness statement that was completed by Employee 6, LPN, revealed that she observed the resident five minutes prior to the fall. The LPN's statement noted that the NA observed the resident getting herself back into bed and the bed alarm was not sounding. The LPN noted that the resident has a history of disconnecting her alarms. Another witness statement that was completed by Employee 7, Registered Nurse (RN), for this investigation report also noted that Resident 79's bed alarm was disconnected and the resident had a history of disconnecting her alarms. Nurse notes dated December 8, 2020, at 6:08 AM, revealed that the resident was awake and alert with confusion, denied hitting head, and that the resident was unsure what happened. Nursing noted that the resident got herself up from the floor and laid on the bed before being assessed by the RN. The RN added that the resident's bed was in a low position and that the alarm did not sound, but had been connected 5 min prior when the NA was in room. The alarm was disconnected at the time of the fall. The RN further noted that Resident 79 has a history of disconnecting alarms. A, Physician's Progress Note, dated December 8, 2020, at 12:00 PM, revealed that the results of the CBC and CMP (lab tests) were largely unremarkable (no significant findings/abnormalities). A, Fall Risk Assessment, dated December 8, 2020, at 3:03 PM, conducted due to recent falls, revealed the resident now scored a 23, which indicated a high risk for falls. A Rehabilitation Department form, Status/Post Fall Assessment, dated December 8, 2020, revealed that the potential reasons for Resident 79's fall included impulsivity, poor judgement, unawareness of physical limitations, and illness and recommended an occupational therapy (OT) evaluation. The OT assessment completed on December 8, 2020, at 2:28 PM, indicated that Resident 79 was not able to follow commands with decreased balance and increased need for assistance from caregivers. Resident 79's status was changed to non-ambulatory status due to loss of balance, required an assist of two persons for transfers, and was total dependence for feeding. OT completed an environmental assessment and moved the nightstand away from Resident 79's bed and added pressure alarms to the bed and wheelchair. Bilateral floor mats to each side of Resident 79's bed were noted to be in place and to continue. A facility, Investigation of Fall, form dated December 8, 2020, at 2:43 PM, revealed that an activity staff member found the resident kneeling on the floor at the left side of the bed. The bed alarm was again not sounding due to the clip being broken. The facility replaced the bed alarm pad and returned the resident back to bed. A witness statement completed by Employee 5, Resident 79's assigned shift NA, revealed that the resident was taken to the bathroom at 11:00 AM and was last observed (no time) lying in bed sleeping. A Rehabilitation Department form, Status/Post Fall Assessment, dated December 9, 2020, revealed potential reasons for Resident 79's fall included impulsivity, poor judgement, unawareness of physical limitations and improper use of assisted devise. Rehab recommended a low bed with bilateral wedges to the resident's bed. An interdisciplinary note dated December 9, 2020, at 8:24 AM, revealed that occupational therapy completed a screen secondary to fall and transfer status was changed to assist of two persons, arm and arm, with the addition of bilateral bed wedges added to the bed. A, Physician's Progress Note, dated December 9, 2020, at 12:00 PM, noted that the resident had a fourth fall and questioning whether the resident was falling or placing herself on the floor, due to the falls being unwitnessed. Three of the past four falls, Resident 79 had been found on her knees with her upper body on the bed in an almost a praying-like position. Nursing reported that prior to COVID-19 infection, the resident would often be found in the same position. The physician further noted that the resident was unable to appropriately answer if she was falling purposefully by moving herself to the floor. The physician continued to note that there was still no sign of injury and ROM (range of motion) was positive for all extremities. It was identified that there was still an outstanding urinalysis and culture pending due to the sample not yet collected since initial order on December 7, 2020, for the resident's previous change in mental status. The physician requested again for the urine be collected and sent to the lab. The physician also noted to continue to monitor due to falls and change in mental status. A facility, Investigation of Fall, dated December 16, 2020, at 1:10 PM, revealed that Resident 79 had another unwitnessed fall. The resident was found sitting on her buttocks at the window side of her bed. The alarms were not sounding. Staff noted that the resident was last observed lying in bed with the bed alarm attached. The resident stated that she was getting up out of bed and fell hitting her head. The nurse assessed and noted that the resident was able to move extremities without gross abnormalities, however a small hematoma to the back of the resident's head was palpated. The resident was then placed on, close observation, due to continued weakness and confusion. Review of an employee witness statement that was completed by Employee 8, NA, revealed that Resident 79 was last seen at 1:00 PM during care (brief change). The nurse aide noted that the resident was left lying in bed with the alarm plugged in. Review of an employee witness statement completed by Employee 9, LPN, revealed that she last saw Resident 79 at 8:00 AM while she was responding to her sounding alarm and found the resident getting out of bed at that time. Another, Fall Risk Assessment, was completed on December 16, 2020, at 1:49 PM, due to recent falls, revealed that the resident scored 25, which indicated the resident was a high risk for falls. However, this score was a decline from the previous assessment that was completed on December 8, 2020. Rehabilitation Department's form, Status/Post Fall Assessment, dated December 18, 2020, revealed that the potential reasons for Resident 79's fall that included impulsivity, poor judgement, unawareness of physical limitations and noted that the resident was currently receiving OT, Physical Therapy (PT), and Speech Language Pathology (SLP) services. A facility, Investigation of Fall, dated December 18, 2020, at 3:40 AM, revealed that Resident 79 had an unwitnessed fall. The alarm sounded and staff found the resident sitting on her right hip with both legs bent on the right floor matt and staff assisted her back to her wheelchair. The resident was then seated at the nurse's station to monitor for safety. According to staff witness statements completed at the time of the incident, the resident was observed five minutes prior to the fall and was seen standing (unassisted) with her alarm sounding. The employees' statements also noted that the resident had been out of bed all shift and was non-compliant with staying in bed. The employee witness statement provided by Employee 10, NA, noted at the time of the incident, revealed that she had assisted the resident back to bed and the resident was last seen at 3:35 AM lying in her bed. Resident 79 reported to the NA that she wanted to go to sleep. The Rehabilitation Department form, Status/Post Fall Assessment, dated December 18, 2020, revealed that the potential reason for Resident 79's falls was that the resident was restless and recommended to continue with therapy. A, Physician's Progress Note, dated December 18, 2020, at 1:00 PM, revealed that Resident 79 was seen due to a fall overnight and noted increased lethargy. The physician was still awaiting the urine culture results needed to assess if the resident had a urinary tract infection. According to the resident's clinical record the resident displayed no other signs or symptoms (i.e. elevated temperatures, complaints of burning upon urination, increased need to urinate, blood tinged urine, etc.) of a urinary tract infection (UTI). The facility report, Investigation of Fall, dated December 20, 2020, at 6:58 PM, revealed that the resident had an unwitnessed fall that occurred at 6:45 PM. The nurse was called to the resident's room, finding Resident 79 sitting on the fall matt at the right side of her bed. The resident was found on her buttocks with her legs extended in front of her. The resident was returned to her wheelchair and was brought out to the nurses' station for closer observation. The employee witness statement Employee 11, NA, indicated that before dinner tray pass, the resident was trying to climb out of bed. At that time, nursing staff had assisted Resident 79 to her wheelchair and placed the resident at the nurses' station. An employee witness statement completed by Employee 9, LPN, revealed that the resident was seen five minutes prior to the incident self-rising from her wheelchair and was attempting to walk. The LPN found the resident sitting on the right side of her bed on her buttocks. Staff brought her back out to the nurses' station for closer observation. A facility, Investigation of Fall, dated December 20, 2020, at 7:10 PM, revealed that Resident 79 had another unwitnessed fall. The RN was called to the room by the LPN and reported that the resident had fallen out of bed and then put herself back into her bed. The resident was back in her bed when the RN entered the room. At this time, Resident 79 reported lower back pain and was assessed to have a bump to her lower back without bruising present. The immediate action taken was to place the resident in her wheelchair with a chair alarm in the hallway for supervision. The physician ordered a STAT (immediate) X-ray of the lower back which was obtained. Review of STAT X-ray results dated December 20, 2020, at 10:26 PM, revealed no acute fracture with modest [CONDITION(S)] of the lumbar spine. A nurses' note dated December 21, 2020, at 3:11 AM, revealed that the resident required 1:1 (supervision) during that shift due to increased behaviors, numerous self-transfers with unsteady gait, and repetitive verbalizations with redirection ineffective. Nurses' note dated December 21, 2020, at 6:14 AM, revealed that the resident continued with unsafe behaviors such as self-transfers, attempting to ambulate with unsteady gait, and re-direction ineffective with need to continue 1:1 during the shift. An interdisciplinary team note dated December 21, 2020, at 11:31 PM, revealed that Resident 79 remained restless through the evening and offered complaints of back pain. Tylenol given and effective. [MEDICATION(S)] (is a prescription medicine used to treat the symptoms of seizures and panic disorder) was administered for anxiety with some positive effect and the resident remained on 1:1 for most of evening shift. A, Physician's Progress Note, dated December 22, 2020, at 12:00 PM, noted that a hematoma continued to the back of the head and the resident had intermittant complaints of pain. The physician noted to continue with safety precautions to prevent further falling. An interdisciplinary team note dated December 22, 2020, at 1:50 PM, by the occupational therapist noted that the resident sits out of bed to high-back wheelchair with anti-rollbacks and a gel foam cushion and demonstrated good upright posture in high-back wheelchair during OT session. A facility, Investigation of Fall, dated December 24, 2020, at 3:05 AM, revealed that the resident had another unwitnessed fall. The resident was yelling out for help and staff observed the resident on the floor on the right side of her bed, on her left side, with her feet pointed towards the bed. No injuries noted at the time of the incident. The immediate action taken was that the resident was assessed, neuro checks initiated and to keep the door open to her room at all times. An employee witness statement from the Employee 13, LPN, revealed that the resident was last seen at 2:45 AM during a brief check that was initiated at 2:30 AM. An employee witness statement by Employee 12, NA, revealed that the resident was last seen at 3:00 AM. The resident was yelling for help and was found lying on the floor mat. The NA statement also noted that the alarm box was disconnected and the door to the resident's room was shut. A, Fall Risk Assessment, completed on December 24, 2020, at 4:05 AM, due to recent falls, revealed that the resident scored 16, which indicated that the resident was a high risk for falls. The Rehabilitation Department form, Status/Post Fall Assessment, dated December 24, 2020, revealed that the resident has impaired balance, impulsivity, poor judgement and was unaware of physical limitations. Rehab recommended to review the bilateral bed wedges and leave resident's door open. A facility, Investigation of Fall, dated December 24, 2020, at 2:00 PM, revealed that when Employee 13, NA, was walking past Resident 79's room, the nurse aide heard the alarm sounding and observed the resident getting up and over her bed wedge. The NA was not able to get to her in time and observed the resident sliding out of bed and landing on her back toward her left side on the fall mat. The aide reported that the resident had bumped her back on the over bed table, pushing it toward the wall. The facility investigation indicated that all fall interventions were in place at the time of the resident's fall. Resident 79 reported to staff, I don't know what happened, I just fell . The facility again placed Resident 79 on 1:1 supervision for resident's safety and placed the mattress on the floor near the bed as a preventative measure. Physician orders dated December 24, 2020, at 2:40 PM, were noted for an X-ray with rib cage series and a chest X-ray secondary to bruises on Resident 79's right mid back. Review of Resident 79's X-ray results dated December 24, 2020, at 5:05 PM, revealed displaced fractures of the right ninth, eighth, seventh, and sixth ribs with a small right pleural effusion and/or infiltrate. The nurse practitioner was notified and ordered for Resident 79 to be transferred to the emergency room (ER) for an evaluation. A, Nurses' Note, dated December 24, 2020, at 8:46 PM, revealed that the resident was admitted to the intensive care unit (ICU) and diagnosed with multiple rib fractures with pneumothorax (a collapsed lung that can occur with a chest injury such as any [MEDICATION(S)] or penetrating injury to the chest). An Interdisciplinary Team Note revealed that the resident was readmitted to the facility on [DATE], at 1:45 PM. The resident was assessed by nursing and noted to continue making multiple attempts to stand on her own with re-direction unsuccessful. The resident was seated at the nurses' station for observation. The most recent, Fall Risk Assessment, dated January 18, 2021, at 6:18 PM, due to recent falls, revealed that the resident scored 14, which indicated that the resident was a moderate risk for falls. This score improved from the previous assessment that were completed in December 2020, decreasing the resident's risk for falls. Subsequent to the fall with rib fracture and pneumothorax requiring intensive care, Resident 79 continued to fall, with falls occurring on January 19, 2021, at 4:45 PM, March 22, 2021, at 12:36 AM, March 25, 2021, at 5:20 AM, March 27, 2021, at 11:10 PM, and April 1, 2021, at 8:15 PM. A facility, Investigation of Fall, for March 27, 2021, at 11:23 PM, revealed that the NA found the resident sitting on the floor in the middle of the room and complained of lower back pain (chronic). The NA and nurse assisted the resident to the bathroom and then to her wheelchair. It was documented that [MEDICATION(S)] (a pain medication) was administered to relieve pain. Review of Employee 15's, NA, witness statement dated March 27, 2021, at 11:10 PM, revealed that when walking up the hall, the nurse aide heard a female voice saying, come in. The aide observed Resident 79, scooting, across the floor on her bottom. The nurse aide noted that the bed alarm was not on the resident's bed as ordered. The nurse aide's statement further noted that the bed alarm had not been applied by the staff on the prior shift when the resident was placed back into bed. There was no documented evidence that the facility consistently provided increased supervision, and the level and frequency required, to maintain Resident 79's safety. The resident had an identified change in mental status with frequently documented unsafe behaviors, including numerous attempts to self-transfer and ambulate resulting in repeated falls. It was also known to the facility that the resident was frequently disarming and disassembling her bed and chair alarms, which proved ineffective in preventing the resident's falls. A review of the clinical record of Resident 68 revealed admission to the facility on [DATE], with diagnoses that included [CONDITION(S)] (a loss of blood flow to part of the brain, which damages brain tissue), [CONDITION(S)] (is an impairment of language, affecting the production or comprehension of speech and the ability to read or write), and [CONDITION(S)] disorder/[CONDITION(S)] (a [CONDITION(S)] is a sudden, uncontrolled electrical disturbance in the brain). A review of an Admission Minimum Data Set assessment dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 5. Resident 68 required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene. On March 26, 2021, Resident 68 returned to the facility following a stay at an acute care hospital since March 24, 2021, for acute changes in her mental status (unresponsive) and new onset of [CONDITION(S)] activity. A nursing note dated March 26, 2021, at 5:28 PM indicated that the resident was readmitted to the facility from the acute care hospital and was alert with confusion, unable to answer questions appropriately and had difficulty following commands. A facility investigation into a fall revealed that on March 26, 2021, at 6:45 PM Resident 68 was in her room and staff heard her chair alarm sound. Staff observed the resident in front of her wheelchair on her knees. An employee witness statement for this unwitnessed fall revealed Employee 1, NA, last observed Resident 68 at 6:00 PM. Employee 1 noted that Resident 68 was leaning over and she repositioned her to sit back in the wheelchair. Employee 1 indicated that the resident kept reaching to the floor. An employee witness statement from Employee 2, LPN, indicate that the resident had been in her line of site, but last observed the resident at 6:42 PM 3 minutes prior to the fall. Employee 2 noted that Resident 68 was, trying to touch the floor for nothing, redirection was ineffective. Employee 2 noted that Resident 68's alarm sounded, which alerted that the resident was not in the chair. The facility investigation indicated Resident 68 was, brought out of room for closer supervision. However, Resident 68 had another unwitnessed fall in her room at 7:50 PM on the same evening. The facility fall investigation documentation revealed that the resident had an unwitnessed fall in the resident's room that occurred on March 26, 2021, at 7:50 PM Employee 3, a RN Supervisor, noted that an LPN found Resident 68 on the floor in front of her wheelchair. Resident 68 was found lying on her left side and had a 2-centimeter skin tear above her left eye. The documentation indicated that the resident's chair alarm did not sound. A nursing note dated March 26, 2021, entered at 9:07 PM indicated that the resident had pain in her left arm and left leg with movement. Orders were obtained to perform X-rays. Resident 68 had X-rays performed on her left shoulder, left humerus, left elbow, left forearm, left wrist, left hand, left hip, left femur, left knee, left tibia/fibula, left ankle, and left foot. Further review of the X-rays performed revealed findings of, AP (anterior/posterior) and lateral views were obtained. An angulated fracture of the intertrochanteric region of the left hip is noted. Impression: Acute Hip Fracture Resident 68 was transferred to an acute care facility. Review of acute care facility documentation revealed in addition to the intertrochanteric fracture of the left femur, the resident had an acute displaced fracture of the left superior and inferior pubic rami. Subsequently, Resident 68 underwent an operation called locked intramedullary nailing femur (a metal rod that is inserted into the medullary cavity of a bone and across the fracture in order to provide solid support for the fractured bone). Interview with the Nursing Home Administrator (NHA) on April 15, 2021, at 1:25PM confirmed that the safety interventions, such as bed and chair alarms, that were implemented for these residents at high risk for falls, displaying decreased cognition, and known unsafe behaviors of self-transferring without assistance were ineffective for preventing repeated falls leading to serious injuries. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices 28 Pa. Code 211.12(a)(c) Nursing Services Previously cited 2/1/9, 3/29/19, 10/29/19, 1/9/20, 8/4/20, 11/15/20 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 2/1/9, 3/29/19, 1/9/20, 11/15/20 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 2/1/9, 3/29/19, 10/29/19, 1/9/20, 11/15/20

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to implement an assessed safety device to meet the safety needs of one resident resulting in a fractured ankle for one of five residents reviewed (Resident 84). Findings include: A review of the clinical record revealed that Resident 84 was admitted to the facility on (MONTH) 16, 2019. The resident had [DIAGNOSES REDACTED]. A review of a nurses note dated (MONTH) 16, 2019, at 5:27 p.m. revealed that the resident was admitted to the facility with a right hip incision dressing. The resident was admitted status [REDACTED]. A review of a 5-day Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated (MONTH) 23, 2019, revealed that the resident was severely cognitively impaired, required extensive staff assistance for activities of daily living (ADL's - routine activities that people tend do every day without needing assistance, such as bathing, dressing, toileting, transferring (walking) and bladder and bowel continence), including the assistance of two staff for bed mobility, transfers, moving in the room and off the unit. The MDS assessment also indicated, that the resident got around either with a wheel chair or a walker. Further review of the MDS assessment also revealed that the resident had sustained a fracture from a recent fall prior to her admission to the facility. Review of the resident's initial ADL care plan dated (MONTH) 29, 2019, revealed that the resident was to sit out of bed in a wheel chair with an Equagel cushion (a cushion which helps disperse pressure equally with comfort), leg rests and bilateral brake extenders. Review of the resident's Visual/Bedside Kardex (quick reference to the particular needs of each resident for certain aspects of nursing care) under the Safety section revealed interventions to include bi-lateral leg rests. A review of a nurses' note dated (MONTH) 9, 2019, at 3:02 p.m. revealed that the Employee 1 (nurses aide) CNA reported this a.m. resident's right foot got twisted under wheelchair during transport yesterday (6/8/19) and that resident did not have foot rests on when returning from dining room No bruising or redness noted Skin intact, resident complaint of pain to right ankle legs elevated with leg rests and PRN medication pain administered with effect. Will continue to monitor. A review of a nurses' note dated (MONTH) 9, 2019, at 6:35 p.m. revealed that resident and daughter requesting an x-ray of right ankle and foot due to injury reported. Covering MD notified and a new order for an x-ray of right ankle and foot. A review of a nurses' note dated (MONTH) 11, 2019, at 4:50 p.m. revealed that resident returned from an ortho appointment without incident. Resident has a right ankle distal fibula fracture. A review of a Witness Statement (a documented account made by an employee in relation to an event\incident involving a resident) dated (MONTH) 8, 2019, made by Employee 1 revealed that the employee was bringing the resident back to her room and her right foot fell and got bent under chair. I reported it to the nurse. Her foot pedals were not on. A review of a Witness Statement dated (MONTH) 9, 2019, made by Employee 2 (registered nurse) revealed that CNA reported on 6/8/19, providing care, right ankle got caught in wheel chair - directed to her to report to Employee 3 (LPN). Another Witness Statement made by Employee 2 dated (MONTH) 8, 2019, indicated that Employee 1 stated she reported incident that happened during transport. This was at change of shifts and I don't remember or didn't hear her. A review of a Job Performance Employee Counseling dated (MONTH) 10, 2019, revealed that Employee 1 received formal counseling for failure to utilize leg rests on wheel chair for resident safety during transport. The facility failed to implement care planned safety measures, which resulted in this resident's serious injury. During an interview with the Director of Nursing on (MONTH) 3, 2019, at approximately 1:05 p.m. the DON confirmed that the foot rests on Resident 88's wheel chair were not in place/applied prior during transport and that they were required for safe transport of the resident. This deficiency is cited as past non-compliance. The facility's corrective action plan was to immediately conduct a facility-wide audit by therapy, to ensure that foot rests were appropriate for all residents who utilized wheel chairs. Any discrepancies were noted and corrected. An immediate in-service for all nursing staff on providing transport services utilizing wheel chairs was conducted. This training continued through all shifts. All staff were trained on any new policy changes. Quality assurance random audits were conducted to ensure compliance. The facility's immediate corrective action plan was completed (MONTH) 1, 2019. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited 2/1/19

Based on a review of clinical records, select facility reports and policies, and resident and staff interviews, it was determined that the facility failed to provide nursing services, which met professional standards of quality according to Title 49. Professional and Vocational Standards Chapter 21 State Board of Nursing during medication administration to one resident out of 14 sampled resulting in a significant medication error requiring medical intervention to treat the affected resident (Resident 3). Findings include: Review of the facility's policy entitled, Medication Administration: General Guidelines, dated as reviewed by the facility February 2017, revealed that the facility staff will provide safe and accurate medication administration to the residents. The nurse reviews each resident's Medication Administration Record [REDACTED]. The nurse observes the five (5) rights of administering medication: the right resident, the right time, the right medication, the right dose and the right method of administration. The nurse identifies the resident by name and by the facility identification system in place (ID bracelet, photo, etc.). According to Title 49. Professional and Vocational Standards of Nursing practice reveals in section 21.145(a)(b). Functions of the Licensed Practical Nurse (LPN), is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. The LPN administers medications and carries out therapeutic treatment order for the patient in accordance with (1) accepts a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility policy to issue orders for medical and therapeutic measures. A review of a incident and accident report revealed that at approximately 10:15 a.m. on February 11, 2017, Resident 3 approached Employee 2 (LPN) and informed the nurse that she was concerned that she received the wrong medications that morning. Employee 2 immediately relayed the resident's concern to the Director of Nursing (DON) at that time. The DON then immediately interviewed Employee 1 on February 11, 2017, and Employee 1 stated that she had not realize that she had made the medication error and had administered medications twice to Resident 3 during the morning medication administration pass Review of nursing documentation dated February 11, 2017, at 10:30 a.m. revealed that Resident 3 received medications from Employee 1 in error that were meant for Resident 5 at approximately 8:00 a.m. The following medications were erroneously given to Resident 3: [MEDICATION NAME] (an antidepressant) 20 mg (milligrams), [MEDICATION NAME] HCL ER/24 hours 240 mg, (treats high blood pressure and chest pain), [MEDICATION NAME] (a diuretic to remove excessive fluids from the body through the urine) 40 mg, [MEDICATION NAME] (used in the treatment of [REDACTED]. 20 meq (used in the treatment of [REDACTED]. Further review of nursing documentation in Resident 3's clinical record dated February 11, 2017, at 10:30 a.m. revealed that an error was noted that morning with the resident's medications. The resident's vital signs (body temperature, pulse rate, respiration rate (rate of breathing) and blood pressure) were obtained. The resident's blood pressure was noted as stable at 90/54 mmHg (millimeters of mercury), (a normal blood pressure for an adult is defined as a systolic (blood pressure when the heart beats while pumping blood) pressure below 120 mmHg and a diastolic (blood pressure when the heart is at rest between beats) pressure below 80 mmHg). The resident's pulse was 76 (normal resting heart rate for adults ranges from 60 to 100 beats a minute) and oxygen saturation was 88% (how much oxygen the blood is carrying compared with its full capacity, greater than 95% is generally considered to be normal). A review of Resident 3's clinical record and Medication Administration Record [REDACTED]. The facility contacted the resident's physician on February 11, 2017, at 10:30 a.m. and the facility was waiting a return call. However, the Medical Director was present in the facility, at that time, and was made aware of the medication error. The Medical Director gave new orders to monitor the resident's blood pressure and pulse every 2 hours for the next 8 hours, then every 4 hours for the next 24 hours. The residents' daughter was made aware of the medication error on February 11, 2017, according to nursing documentation. Further review of nursing documentation on February 11, 2017, at 8:30 p.m. revealed that the physician had been notified of the day's blood pressure monitoring. The resident's blood pressure had decreased to 76/48 mmHg. The physician ordered an IV (intravenous) of Normal Saline Solution 9% (a sterile salt solution) 1 liter at 75 cc (cubic centimeters) per hour for one liter only for [MEDICAL CONDITION] (low blood pressure). The physician ordered that the resident's blood pressure and pulse monitoring was to continue as ordered. An interview with Resident 3 on February 14, 2017, at approximately 9:00 a.m. revealed that during the medication pass on the morning of February 11, 2017, the resident questioned Employee 1 about the medications she had given her because there were so many in the medicine cup and they were a different color than the resident usually received. Resident 3 stated that when she questioned Employee 1 about receiving so many pills and the difference in color, Employee 1 reportedly stated, take them anyway. Resident 3 also stated that Employee 1 did not check her name bracelet to identify the resident and make sure that she was the correct resident to receive the prescribed medications. Further interview with the Director of Nursing (DON) on February 14, 2017, at 1:00 p.m. confirmed the medication error had occurred for Resident 3 on February 11, 2017, and that Employee 1 failed to confirm the resident's identify prior to administering the medications. The DON stated that when she interviewed Employee 1 on February 11, 2017, after the medication error was discovered, Employee 1 had nothing to say. Refer F333 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 1/17/17, 12/8/16

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to promptly implement necessary interventions including sufficient staff supervision to meet the safety needs of a newly admitted resident at risk for falls to prevent a fall with serious injury for one of 23 residents reviewed (Resident 32). Findings include: A review of the clinical record revealed that Resident 32 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of a Transfer To Another Level Of Care form dated November 19, 2016, which was a transfer form from the rehabilitation facility where Resident 32 had received therapy prior to her admission to this skilled nursing facility, revealed that the resident had a fall at home on November 7, 2016, resulting in a left hip fracture. Further review of the transfer form indicated that while Resident 32 was a patient at the rehabilitation facility, she was alert and anxious at times, disoriented to place, time and situation, required frequent cueing for safety, that chair/bed alarms (safety devices and emit an audible alarm when a resident attempts to rise unassisted) were used and she showed poor awareness to total hip precautions (guidelines for those who have had hip replacement surgery). A review of a facility generated Fall Risk Assessment dated November 19, 2016, revealed that Resident 32 had a history of [REDACTED]. Review of the resident's initial care plan dated November 21, 2016, revealed a problematic area that included the potential for falls due to a history of falls, impaired mobility and dementia. The care planned interventions at the time included bed and chair alarms, to keep the call bell within reach and non-slip footwear. A review of a 5-day Minimum Data Set assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated November 22, 2016, revealed that the resident was moderately cognitively impaired, required extensive staff assistance for activities of daily living (routine activities that people tend do every day without needing assistance, such as eating, bathing, dressing, toileting, transferring (walking) and bladder and bowel continence), including the assistance of two staff for bed mobility, transfers, moving in the room and off the unit. The MDS assessment also indicated, in the area of balance during walking and turning around, that the resident was not steady during transfers (transfers that included from bed to wheelchair and from a seated to a standing position) and that the resident was only able to stabilize with staff assistance. Further review of the MDS assessment also revealed that the resident had sustained a fracture from a recent fall prior to her admission to the facility. A review of a nurses' note dated November 19, 2016, at 11:18 a.m. revealed that Resident 32 was admitted to the facility and was alert and oriented to person only. A review of a nurses' note dated November 19, 2016, at 7:45 p.m. revealed that the resident attempted to self-transfer multiple times throughout the shift. The staff redirected the resident to use call bell and the resident's understanding was noted. A review of a nurses' note dated November 20, 2016, at 1:55 p.m. revealed that the resident was awake and alert with confusion. A review of a nurses' note dated November 20, 2016, at 6:06 p.m. revealed that the resident made frequent attempts to stand from the wheelchair, redirection had little effect and that the resident's chair alarm was intact and functioning. A review of a Physical Therapy Plan of Care - Initial Assessment dated November 21, 2016, revealed that the resident was screened by therapy to assess her ambulation, transfers, balance and strengthening abilities. The screening indicated that the resident was hospitalized after falling at home where she suffered a fracture of her left hip. The assessment also identified that the dependent-helper (physical therapy personnel) did more than half the effort during the sit to stand assessment that involved lifting or holding trunk/limbs. The dependent-helper did all the effort during the chair/bed to chair transfer assessment (the assistance of two or more helpers was required to complete the activity). The dependent-helper also did all the effort during the toilet transfer assessment (the assistance of two or more helpers was required to complete the activity). Therapy noted that the walking of 50 feet exercise with turns was not attempted due to the resident's medical condition or safety concerns. A review of a nurses' note dated November 21, 2016, at 6:34 a.m. revealed that the resident was, Day 2 admit (second day of admission), had slept quietly for a long period and then began climbing out of bed, wanting to get up. A review of a nurses' note dated November 21, 2016, at 12:39 p.m. revealed that the resident was alert with confusion and that she does not remember falling at home and fracturing her left hip. A review of a nurses' note dated November 21, 2016, at 6:34 p.m. revealed that new measures were added to the resident's safety care plan that included a pressure alarm to the resident's wheelchair and bed. A review of a nurses' note dated November 21, 2016, at 7:18 p.m. revealed that the resident was currently seated in the wheelchair in front of the nurses station for safety reasons. Nursing noted that the resident attempted to stand by herself multiple times throughout the shift, multiple redirections and educating the resident of the value of safety precautions were needed continuously, staff also noted that they, will continue to monitor. A review of a nurses' note dated November 21, 2016, at 10:17 p.m. revealed that the resident was alert most of the shift and remained confused. Redirection was required when the resident was sitting in the wheelchair as the resident attempted to ambulate without assistance. Nursing noted that the alarms were in place and that they would continue to monitor the resident. A review of a nurses' note dated November 22, 2016, at 3:45 a.m. and a corresponding facility, Resident Incident/Accident Investigation Review indicated that at 11:45 p.m., on November 22, 2016, the resident's alarm was sounding and the resident was heard yelling. The staff found the resident on the floor on the right side of the bed in a semi-siting position on her right hip. The report indicated that the resident is confused, ambulates without assist, is oriented only to person and that she did not know why she got up out of bed. Interventions at the time of the fall included bed and chair alarms, a non-skid mat, a contour mattress (mattress that contours to the body to secure the position in bed) and non-skid footwear. New interventions planned at the time, included lowering the resident's bed and bilateral (both sides) fall mats. Further review of the nurses' note date November 22, 2016, revealed that the resident yelled in pain with right hip movement and that the physcian and responsible party were notified at that time. Physcian's orders were obtained for mobile X-rays. A review of a nurses' note dated November 22, 2016, at 4:05 a.m. revealed the results from the X-rays indicated that the resident suffered a right hip fracture. The nursing documentation since the resident's admission on November 19, 2016, indicated that the resident repeatedly displayed unsafe behaviors of attempting to stand up from her bed or wheelchair and ambulate unassisted. There was no evidence that the facility had promptly evaluated the resident for the need for increased staff supervision at the type and/or level required to prevent falls, due to the repeated unsafe behaviors displayed by the resident and the resident's history of falls and lack of safety awareness. The facility failed to provide staff supervision during periods of restless and unsafe behaviors to prevent the fall with serious injury. The facility also failed to implement safety measures prior to this fall that would prevent or decrease the potential severity of injury as the result of the fall. The facility relied on the use of safety alarms to maintain this resident's safety, but these devices were ineffective in preventing this fall with serious injury for this at risk resident. During an interview with the Nursing Home Administrator and the Director of Nursing on December 7, 2016, at approximately 2:05 p.m. they were unable to explain why staff supervision/assistance and other types of safety interventions were not evaluated and initiated when the resident exhibited unsafe behaviors. The facility failed to provide evidence that the resident, identified at risk for falls, which was known to the facility, was provided with adequate staff supervision and timely and effective intervention to prevent this fall with serious injury. 483.25 Free of Accident Hazards/Supervision/Devices Previously cited 1/15/16 28 Pa. Code 211.12(a)(c)(d)(1)(3) Nursing services. Previously cited 1/15/16, 12/7/15, 7/14/15, 12/19/14 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/15/16

Based on a review of clinical records, medication error reports, select incident and accident reports, select facility policy and information submitted by the facility and staff and resident interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and required clinical monitoring and corrective treatment (IV fluid administration) following the medication error for one of 14 residents reviewed (Resident 3). Findings include: Review of the facility's policy, Medication Administration: General Guideline, dated as reviewed by the facility February 2017, revealed that the facility staff will provide safe and accurate medication administration to the residents. The nurse reviews each resident's Medication Administration Record [REDACTED]. The nurse observes the five (5) rights in administering each medication: The right resident, the right time, the right medication, the right dose, the right method of administration. The nurse identifies the resident by name and by the facility identification system (ID bracelet, photo, etc.). Review of the clinical record of Resident 3 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The kidneys filter wastes and excess fluids from your blood, which are then excreted in your urine. When [MEDICAL CONDITION] reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can build up in your body; stages 3-4 are advanced chronic kidney insufficiency) and [MEDICAL CONDITION] (a chronic, [MEDICAL CONDITION] neurological disorder of the central nervous system that results from the loss of cells in various parts of the brain). Review of a 30 day Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 19, 2017, revealed that the resident was cognitively intact, understood the spoken word and was able to make her needs known. Review of a resident incident and accident report and documentation submitted by the facility dated February 11, 2017, at 10:30 a.m. revealed that Employee 1, a Licensed Practical Nurse (LPN), who was employed by a nurse staffing agency contracted by the facility, was preparing morning medications for administration to the residents on the morning of February 11, 2017. Employee 1 prepared the medications for administration to Resident 3 on February 11, 2017, at approximately 8:00 a.m. However, the medications poured had been prescribed for Resident 5. In error, Employee 1 adminstered Resident 5's medications to Resident 3. Resident 3 erroneously received the following medications: [REDACTED]. 20 meq (used in the treatment of [REDACTED]. A review of Resident 3's clinical record and Medication Administration Record [REDACTED]\100 mg. At approximately 10:15 a.m. on February 11, 2017, Resident 3 approached Employee 2 (LPN) and informed the nurse that she was concerned that she received the wrong medications that morning. Employee 2 immediately relayed the resident's concern to the Director of Nursing (DON) at that time. The DON then immediately interviewed Employee 1 on February 11, 2017, and Employee 1 stated that she had not realized that she had made the medication error and had administered medications twice to Resident 3 during the morning medication administration pass. Review of nursing documentation in Resident 3's clinical record dated February 11, 2017, at 10:30 a.m. revealed that an error was noted that morning with the resident's medications. The resident's vital signs (body temperature, pulse rate, respiration rate (rate of breathing) and blood pressure) were obtained. The resident's blood pressure was noted as stable at 90/54 mmHg (millimeters of mercury) - (a normal blood pressure for an adult is defined as a systolic (blood pressure when the heart beats while pumping blood) pressure below 120 mmHg and a diastolic (blood pressure when the heart is at rest between beats) pressure below 80 mmHg). The resident's pulse was 76 (normal resting heart rate for adults ranges from 60 to 100 beats a minute) and oxygen saturation was 88% (how much oxygen the blood is carrying compared with its full capacity, greater than 95% is generally considered to be normal). The facility contacted the resident's physician on February 11, 2017, at 10:30 a.m. and the facility was waiting a return call. However, the Medical Director was present in the facility, at that time, and was made aware of the medication error. The Medical Director gave new orders to monitor the resident's blood pressure and pulse every 2 hours for the next 8 hours, then every 4 hours for the next 24 hours. The resident's daughter was made aware of the medication error on February 11, 2017, according to nursing documentation. Further review of the nursing documentation on February 11, 2017, at 8:30 p.m. revealed that the physician had been notified of the day's blood pressure monitoring. The resident's blood pressure had decreased to 76/48 mmHg. The physician ordered an IV (intravenous) of Normal Saline Solution 9% (a sterile salt solution) 1 liter at 75 cc (cubic centimeters) per hour for one liter only for [MEDICAL CONDITION] (low blood pressure). The physician ordered that the resident's blood pressure and pulse monitoring was to continue as ordered. An interview with Resident 3 on February 14, 2017, at approximately 9:00 a.m. revealed that during the medication pass on the morning of February 11, 2017, the resident questioned Employee 1 about the medications she had given her because there were so many in the medicine cup and they were a different color than the resident usually received. Resident 3 stated that when she questioned Employee 1 about receiving so many pills and the difference in color, Employee 1 reportedly stated, take them anyway. Resident 3 also stated that Employee 1 did not check her name bracelet to identify the resident and make sure that she was the correct resident to receive the prescribed medications. Further interview with the Director of Nursing (DON) on February 14, 2017, at 1:00 p.m. confirmed the medication error had occurred for Resident 3 on February 11, 2017. The DON stated that when she interviewed Employee 1 on February 11, 2017, after the medication error was discovered, Employee 1 had, nothing to say. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services. Previously cited 12/8/16 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 1/17/17, 12/8/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 12/8/16