Every finding on record at Highlands Rehabilitation and Healthcare

Based on clinical record review and staff interview it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 109 and 114).Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Closed clinical record review of census information for Resident 114 revealed that the facility provided services primarily paid for by Medicare starting November 19, 2025. Resident 114's Medicare payment for services ended December 31, 2025, when she discharged to the community. Review of a CMS-10123 notice provided by the facility for Resident 114 revealed that Medicare coverage for skilled nursing services would end on December 30, 2025. Additional information on the form indicated that staff delivered the notice verbally via a telephone conversation with Resident 114's son on December 29, 2025. The notation indicated that Resident 114's last covered day would be December 31, 2025 (not December 30, 2025, as indicated on the first page of the form). Neither Resident 114 nor a responsible party signed the notice. Nursing documentation dated December 31, 2025, at 1:01 PM revealed that staff reviewed discharge paperwork with Resident 114's son (who staff documented the telephone conversation with on December 29, 2025) and Resident 114 left the facility. The documentation did not indicate that the facility staff attempted to obtain Resident 114's son's dated signature on the CMS-10123 notice when he was in the facility to transport Resident 114 home. Resident 114's clinical record did not contain evidence that facility staff attempted to contact Resident 114 or her responsible party/son to obtain a dated signature on the form after her discharge from the facility. Interview with the Nursing Home Administrator on February 4, 2026, at 2:00 PM confirmed that the facility did not have a signed CMS-10123 form for Resident 114. Clinical record review of census information for Resident 109 revealed that the facility provided services primarily paid for by Medicare starting July 1, 2025. Resident 109's Medicare payment for services ended July 31, 2025. Resident 109 remained in the facility. The facility did not provide a CMS-10055 notice for Resident 109. The facility provided a CMS-R-131 form that the facility used in place of the CMS-10055 form. Resident 109 signed the CMS-R-131 form on July 29, 2025. The form did not include the date on which Resident 109 would be responsible for paying for care that Medicare was not expected to cover. The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form. The surveyor reviewed the above concerns regarding Resident 109's Medicare notice during an interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 2:00 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for three of six residents reviewed for nutritional concerns (Residents 1, 2, and 44). Findings include: The facility policy entitled, Weight Assessment and Intervention, last reviewed August 27, 2025, revealed that resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Unless notified of significant weight changes, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month: five percent weight loss is significant, greater than five percent is severe Three months: 7.5 percent weight loss is significant, greater than 7.5 percent is severe Six months: 10 percent weight loss is significant, greater than 10 percent is severe Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address to the extent possible: the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Interventions for undesirable weight loss are based on careful considerations of resident choice and preferences, nutrition and hydration needs of the resident, functional factors that inhibit independent eating, medications, environmental factors, and end-of-life decisions and advance directives. Clinical record review for Resident 2 revealed the following weight assessments: August 26, 2025, 206.2 poundsAugust 27, 2025, 204.2 poundsSeptember 2, 2025, 202.2 poundsSeptember 16, 2025, 194.4 pounds (an 11.8-pound, 5.7 percent, severe weight loss in less than one month)September 30, 2025, 194.6 poundsOctober 6, 2025, 190.2 pounds (a 16-pound, 7.75 percent, severe weight loss in less than three months; and 12-pound, 5.93 percent severe weight loss in one month)October 7, 2025, 190.2 pounds Nutritional documentation by Employee 1 on October 17, 2025, (a month after the severe weight loss assessed for Resident 2), at 1:40 PM noted Resident 2's weights on October 6 and 7, 2025, which substantiated a 5.9 percent weight loss. Employee 1 documented that Resident 2 was at risk for malnutrition with variable oral intakes of meals. Employee 1 noted that she updated Resident 2's food preferences, encouraged Resident 2 to consume her meals, and recommended weekly weights for four weeks. Employee 1 indicated that she would continue to monitor Resident 2 and follow-up as needed. Staff documented a weight assessment of 172.4 pounds for Resident 2 on November 3, 2025 (which would have reflected an additional 17.8-pound, 9.35 percent severe weight loss in one month, however, a notation by Employee 7 (nurse aide) on November 21, 2025, at 11:50 PM crossed out the entry as incorrect documentation. There were no additional weights documented for Resident 2 until November 18, 2025 (six weeks since her previous weight assessment). The weight assessment documented on November 18, 2025, at 12:18 PM was 168 pounds (a 22.2-pound, 11.67 percent severe weight loss in six weeks). The surveyor reviewed the above concerns regarding Resident 2's weight loss and lack of interdisciplinary response during an interview with the Nursing Home Administrator and the Director of Nursing on February 3, 2026, at 2:00 PM. The surveyor again reviewed the above weight loss concerns for Resident 2 during an interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 2:00 PM. Interview with the Director of Nursing on February 5, 2026, at 9:56 AM indicated that the nurse aide obtains weight assessments and provides the licensed practical nurse the results who is responsible for entering the information in the resident's electronic medical record; however, this did not occur for Resident 2. There was no evidence that the registered dietitian or physician had the information in the resident's medical record to review. There is no evidence that the registered dietitian assessed Resident 2 during the two months between October 17, 2025, and December 18, 2025. The facility provided no additional information regarding the implementation of new interventions to address Resident 2's severe weight loss. Interview with Employee 1 on February 5, 2026, at 10:39 AM confirmed the following: Staff assessed a 5.72 percent severe weight loss for Resident 2 on September 16, 2025; however, there is no evidence of an interdisciplinary response (to include the registered dietitian or the physician) until October 17, 2025. The plan of care on October 17, 2025, was to include weekly weight assessments; however, Resident 2's electronic medical record had no evidence that these were implemented; or that Employee 1 assessed Resident 2 timely (e.g., within a month) to review the findings of the planned weight assessments. There were no weight assessments for six weeks (when Resident 2 was to have weekly weight assessments) during which a weight assessment that indicated another severe weight loss was inexplicably crossed out as incorrect documentation without a replacement weight assessment. The next documented assessment by Employee 1 for Resident 2 was not until December 18, 2025 (two months following the acknowledgement of a severe weight loss). On August 26, 2025, Resident 2 weighed 206.2 pounds. On December 4, 2025, Resident 2 weighed 177.6 pounds (a 13.87 percent weight loss in less than six months). A quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 10, 2025, assessed Resident 2 as not having a 10 percent or more weight loss in the last six months. Review of a plan of care initiated by Employee 1 on September 3, 2025, to address Resident 2's risk for altered nutritional status revealed no evidence of any revisions to her plan of care despite her severe weight loss since admitted to the facility. Clinical record review for Resident 44 revealed the following weight assessments: June 17, 2025, 166.7 poundsJuly 1, 2025, 169.9 poundsJuly 8, 2025, 170.3 poundsJuly 15, 2025, 162. 0 poundsJuly 22,2025, 171.8 poundsJuly 29, 2025, 175.8 pounds (a 9.1-pound, 5.17 percent significant weight gain)August 5, 2025, 174.0 poundsSeptember 3, 2025, 179.4 poundsSeptember 8, 2025, 183.7 poundsSeptember 23, 2025, 187.2 pounds (a 20.5-pound, 10.95 percent significant weight gain) A full nutritional assessment was completed by Employee 1 on June 19, 2025, noted Resident 44 BMI (body mass index, a tool that estimates the amount of body fat by using height and weight measurements), was 28.5 in the overweight category. The next assessment of Resident 44 weights was not until September 19, 2025, noting a 9.7-pound, 5.6 percent significant weight gain in one month, and a 17-pound, 10.2 percent weight gain in three months. Employee 1 recommended weekly weights times four to better track Resident 44's weight gain. Further review of Resident 44's clinical record revealed the facility initiated a care plan on June 19, 2025, indicating Resident 44 is at risk for altered nutritional status related to her diagnosis of dementia. Resident 44's care plan was not updated to reflect any interventions addressing her significant weight gains. Interview with Employee 1 on February 4, 2026, at 11:12 AM revealed that she could provide no further documentation indicating she addressed Resident 44's weight gain until September 19, 2025 (nearly two months after significant weight gain). Employee 1 confirmed Resident 44's care plan was not updated to reflect any interventions addressing her weight gains. The findings for Resident 44 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 4, 2026, at 2:38 PM Clinical record review for Resident 1 revealed the following weight assessments: July 21, 2025, 224 poundsJuly 29, 2025, 216.4 poundsAugust 5, 2025, 216.3 poundsAugust 19, 2025, 217.8 poundsAugust 26, 2025, 223.0 poundsSeptember 9, 2025, 222.0 poundsSeptember 16, 2025, 222.5 poundsSeptember 28, 2025, 218.8 poundsNovember 3, 2025, 208.8 poundsDecember 3, 2025, 201.1 pounds December 11, 2025, 200.5 poundsDecember 11, 2025, 203.4 pounds A full nutritional assessment was completed by Employee 1 on October 2, 2025, and noted Resident 1's BMI was 34.3, in the obese category. A nutrition note dated December 18, 2025, at 8:53 AM revealed that Resident 1 was noted to be down 21.6 pounds, (9.7% significant weight loss in 3 months). The note indicated that weekly weights for four weeks would be put in place, and she added a fortified food. A nutrition note dated January 8, 2026, at 6:43 PM revealed that Resident 1 refused to be weighed monthly for January weight. Interview with the Employee 1 on February 5, 2026, at 1:15 PM revealed that she did not do her risk assessment in January 2026, because Resident 1 refused to be weighed. When surveyor ask about the weekly weights, Employee 1 indicated that Resident 1 refused them too but there was no evidence in the clinical record related to this. Surveyor asked Employee 1 if she followed up with Resident 1 related to her significant weight loss and she said she did not because there was no new weight for Resident 1. The Director of Nursing was made aware of the concerns with Resident 1's weight loss on February 5, 2026, at 1:30 PM. The facility failed to provide the highest practicable care related to Resident 1's weight loss. 28 Pa. Code 211.10(a)(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 store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the facility's main kitchen.Findings include: Observation of the facility's main kitchen on February 2, 2026, at 9:18 AM revealed the following: There were four boxes of thickened coffee packets, three boxes of thickened tea packets, and a sleeve of lids stored in the cabinet under the sink. Two bins with carafes (beverage holder) and lids were stored beside the sink and all the carafes and lids had a white residue on them. There was a silver four tier open shelf. On the bottom shelf there was a large open basin of water/juice pitchers and a large open basin of lids. Observation of the oven revealed the knobs were dirty and there was burnt residue all over the stovetop. Observation of the dry storage room revealed there was a loaf of bread with no use by date, a half loaf of bread not secured, a bag of egg noodles, powdered sugar, vanilla tapioca quick pudding, and pie filling mix opened, with no use by dates. Further observation of the kitchen on February 2, 2026. at 11:28 AM, revealed there were three areas on the floor in front of the dishwasher with tiles missing. There was a piece of board and rubber mat on top of these areas. Interviews with Employee 8 (dietary aide) and Employee 9 (cook), revealed the boards and plastic mats are a tripping hazard when they are utilizing the dishwasher. Interview with Employee 4 (maintenance director) on February 5, 2026, at 8:52 AM revealed that the repairs were completed on the kitchen floor on December 23, 2025. He stated he ordered the floor tiles on December 29, 2025, and picked them up from the supplier on January 21, 2026. He confirmed the three areas had approximately 19 tiles missing and were not placed until after the surveyor's questioning. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of one resident reviewed for pain (Resident 1). Findings include: Interview with Resident 1 on February 2, 2026, at 10:51 AM revealed that she has constant pain. She said sometimes it is from her stomach, and sometimes it is her legs or back. Clinical record review for Resident 1 revealed that she has a diagnosis of chronic pain (pain that last for longer than three months or occurring with an ongoing condition, that affects daily life and well-being). Review of Resident 1's current physician's order revealed that she had the following medications ordered for pain: Gabapentin 100 milligrams (mg) one every morning and at bedtimeTramadol 50 mg one every four hours as needed for pain. Tylenol 325 mg two tablets every six hours for mild pain 1-3, (on a 1-10 pain scale). Review of Resident 1's medication administration record for the month of December 2025, revealed that she utilized the as needed Tramadol 50 milligrams 45 times. Review of Resident 1's medication administration record for the month of January 2026, revealed that she utilized the as needed Tramadol 50 milligrams 26 times and she utilized the as needed Tylenol 325 mg two tablets three times. Review of Resident 1's medication administration record for the dates of February 1-3, 2026, revealed that she utilized the as needed Tramadol 50 milligrams five times. There was no evidence in the clinical record indicating Resident 1's physician was made aware of the amount of as needed pain medications she used, or that the physician addressed Resident 1's uncontrolled chronic pain. The Director of Nursing was made aware of the concerns noted above related to Resident 1's pain on February 6, 2026, at 10:45 AM. The facility failed to ensure Resident 1's pain was managed consistent with professional standards of practice. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, observation, clinical record review, and family and staff interview, it was determined that the facility failed to provide routine dental care for one of one resident reviewed for dental concerns (Resident 58).Findings include: The facility policy entitled, Dental Consultant, last reviewed August 27, 2025, revealed that dental care shall be provided through the services of a consultant dentist. A consultant dentist is retained by the facility and is responsible for providing a dental assessment of each resident within ninety (90) days of admission and, .performing or supervising an annual dental revaluation for each resident. The policy did not confirm that the facility would provide dental services provided by the State Medicaid plan (e.g., prophylactic dental cleanings every six months). Interview with Resident 58's daughter on February 2, 2026, at 10:12 AM revealed that she believed Resident 58 needed to have her teeth fixed, and that Resident 58 had natural teeth that likely needed to be extracted. Resident 58's daughter stated that she was aware a mobile dentist provided services at the facility and claimed that she received a bill for an initial exam for $90.00 (ninety dollars). Observation of Resident 58 on February 2, 2026, at 12:29 PM revealed her to have missing teeth. Clinical record review of Resident 58's census information revealed that the facility admitted her on November 7, 2025, and that the State Medicaid plan was her primary payer source. Review of a Consent for Dental Services dated November 9, 2025, indicated that Resident 58's responsible party agreed to the facility's contracted dental provider to perform, an annual dental exam, necessary x-rays, and cleanings. The authorization signed by Resident 58's responsible party noted that, Medicaid recipients are covered for these routine services. The surveyor requested evidence of professional dental services for Resident 58 during an interview with the Nursing Home Administrator and Director of Nursing on February 3, 2026, at 2:00 PM. A letter provided by the facility from the contracted dental provider dated February 4, 2026, indicated that, (Resident 58) is in compliance with annual routine exams. The letter indicated Resident 58's responsible party wanted dental services when her Medicaid plan was active. The letter further noted, Per the facility, her Medicaid became active on January 15, 2026, and (the contracted dental provider) was notified of this change on February 3, 2026. Interview with the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 2:00 PM confirmed that the contracted dental provider was at the facility on February 4, 2026, however, did not provide services to Resident 58. The interview confirmed that Resident 58 had not received any professional dental services in the 90 days since her admission to the facility. The interview indicated that the contracted dental provider sent Resident 58's responsible party notice that an initial exam would be $90.00 if not paid by Medicaid, however, Resident 58 was a Medicaid recipient and would not be liable for the $90.00. Interview with Employee 5 (business office manager) on February 5, 2026, at 1:00 PM revealed that the facility had knowledge that Resident 58's Medicaid application was approved on December 5, 2025 (less than one month after her admission to the facility). Interview with the Director of Nursing on February 5, 2026, at 9:56 AM provided no answer as to how often the contracted dental provider provides services in the facility. Interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2026, at 12:25 PM revealed that the contracted dental provider has no expected frequency of services (e.g., monthly, quarter, etc.); however, Resident 58 would be on the list for services during the next onsite visit. Interview with the Nursing Home Administrator on February 5, 2026, at 1:10 PM confirmed that the facility policy and the consultant dental provider letter did not stipulate that residents would receive routine dental services as provided by the State Medicaid plan. The Nursing Home Administrator indicated that she was not certain of the frequency of routine dental services provided by the State Medicaid plan. Interview with the Director of Nursing on February 5, 2026, at 1:35 PM confirmed that the facility was now aware of the frequency of routine dental services covered under the State plan (e.g., every six months) and would begin educating staff regarding the expectation. 483.55(b)(1)-(5) Dental ServicesPreviously cited deficiency 1/16/25 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care for one of one resident reviewed for behavioral health related to suicidal ideation. (Resident 82). Findings include: The facility policy entitled, Suicide Prevention and Intervention Guideline, last reviewed without changes on August 27, 2025, revealed it is the policy of the facility that individuals voicing and/or displaying feelings and/or actions which indicated suicidal ideation (thoughts, or preoccupations with ending one's own life, ranging from fleeting, passing thoughts to detailed, active planning), receive services and interventions to help them manage these feeling and maintain their psychosocial well-being. Employees are responsible for monitoring acute mood and behavior changes which may indicate potential suicidal ideation and for reporting these changes to their supervisor for appropriate assessment and interventions. With any verbalization of suicide/self-harm ideation, or suicide attempt, the resident should immediately be placed on one-to-one observation until they are transferred to the hospital or are evaluated by a physician/clinician. An immediate written care plan should be developed and implemented specific to the resident's situation and needs. The plan should outline the interventions and monitoring for the resident to remain safe. The plan should also include visual checks, which should be completed and documented at an interval that is determined by the individualized assessment. A nursing progress note dated January 7, 2026, at 2:21 PM revealed that Resident 82 was making statements that she wanted to be discharged so she could go home and commit suicide. The note indicated that Resident 82 was put on frequent checks and that she was immediately seen by the provider in the facility who felt there was no immediate danger and that there was no medical cause of her comments but the provider felt the resident was more depressed related to her current situation and he wanted her seen by psychiatry. The note also indicated that Resident 82's family was present in the facility and stated that she made comments like this in the hospital and was seen and cleared by psychiatry. Resident 82 was to be seen by psychiatry on Friday (January 9, 2026). A late entry physician progress noted created January 11, 2026, but noted to be effective January 7, 2026, indicated that the physician was seeing Resident 82 for an initial evaluation because she was a new admission on [DATE]. The physician made no mention of Resident 82 having suicidal ideations in his note but did indicate that Resident 82 was seen and evaluated at bedside and there were no additional concerns. The note also indicated that she had a diagnosis of depression. A psychiatry progress noted dated January 9, 2026, revealed that Resident 82 reported that her mood had been good, and she denied depression, anxiety or mood issues, but that staff reported she had made comments about wanting to go home to commit suicide. The note indicated Resident 82 stated she made comments a while ago about that, but she had no recollection of that and denies suicidal ideation at that time. The note also indicated she has very poor insight into her psych issues as she had some delusions such as reporting that she was married three times which the family indicated was not the case. The psychiatrist also indicated that the family does feel Resident 82 is depressed. He also notes that resident did have a daughter that committed suicide. Clinical record review for Resident 82 revealed a nursing progress note dated January 27, 2026, at 8:26 PM that indicated Resident 82 stated to a nurse aide that she was tired, and she was thinking of committing suicide. The note indicated that the writer then approached resident who was in bed and the resident stated she was tired and they would talk in the morning. The nurse then made her aware to use her call light if she needed anything. The note indicated the charge nurse was updated to closely monitor Resident 82, and for social work to follow up tomorrow. There was no social service follow-up noted in the clinical record. A nursing progress note dated January 27, 2026, at 9:11 PM revealed that Resident 82 stated she was fine but really tired and just wanted to sleep. A nursing progress note dated January 28, 2026, at 3:26 am indicated that Resident 82 had no suicidal statements voiced or reported and was resting in bed. Review of Resident 82's care plan revealed that there was no care plan addressing her suicidal ideation until after the surveyor brought it to the facility's attention during a meeting on February 3, 2026, at 2:20 PM, during a meeting with the nursing home administrator and director of nursing. Interview with Employee 3, social service director, on February 4, 2026, at 12:14 PM confirmed the above noted findings that she did not initiate a care plan with individualized interventions related to Resident 82's suicidal ideation until February 3, 2026. There was no evidence in the clinical record to show that the facility initiated one-to-one, more frequent checks, or that individualized interventions were initiated for Resident 82, related to her suicidal ideation on January 7, 2026, or January 27, 2026. The nursing home administrator and director of nursing were made aware of the above noted findings related to Resident 82's suicidal ideation during a meeting on February 4, 2026, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of three residents reviewed for advance directives concerns (Resident 2).Findings include: Clinical record review for Resident 2 revealed an active physician order dated [DATE], that instructed staff to not resuscitate Resident 2 (DNR, do not attempt to resuscitate, do not perform CPR, allow natural death) in the event of no pulse or breathing. Review of a POLST (Pennsylvania Orders for Life Sustaining Treatment, a binding medical order that instructs healthcare providers the specific types of medical treatment a resident wishes to receive at the end of life) form signed by Resident 2's physician on [DATE], and signed by Resident 2 indicated that Resident 2 desired CPR/attempt resuscitation (cardiopulmonary resuscitation, chest compressions and artificial breathing assistance) if there is no pulse or breathing. The surveyor reviewed the above concern that Resident 2's active physician orders did not reflect Resident 2's emergency care wishes during an interview with the Director of Nursing and the Nursing Home Administrator on February 4, 2026, at 2:00 PM. Interview with the Director of Nursing on February 5, 2026, at 10:05 AM confirmed that staff obtained a verbal physician's order following the surveyor's questioning to update Resident 2's active physician orders to reflect Resident 2's wishes for CPR as per the [DATE], POLST.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of two nursing units (Second and Third Floor Nursing Units, Residents 1, 5, 10, and 11), and provide a safe and clean environment in the facility's main laundry area. Findings include: Observation of the facility's main laundry area on February 4, 2026, at 11:53 AM with Employee 6, Director of Environmental Services, revealed a folded blanket on the floor behind the washing machines and under the wall mounted chemical dispensers. There was an extensive build-up of a dried and flaky substance on the blanket and surrounding floor. The Nursing Home Administrator was informed of the main laundry area findings on February 4, 2026, at 12:02 PM. Observation of Resident 5's room on February 3, 2026, at 9:25 AM revealed that door to the room was all marred and the floor was dirty around the bed and under the dresser near the cove base. Observation of Resident 1's room on February 3, 2026, at 10:30 AM revealed the floor to be dirty with crumbs under the over bed table and by her bed. The door to the room was all marred. Observation of Resident 10's room on February 2, 2026, at 12:44 PM revealed that the door to her room and the bathroom door was all marred. The nursing home administrator and the director of nursing were made aware of the concerns with Resident 1, 5, and 10's environment on February 5, 2026, at 11:00 AM. Observation of Resident 11 on February 2, 2026, at 9:34 AM, and February 3, 2026, at 10:12 AM revealed Resident 11 was seated in the recliner chair in his room. The wall behind Resident 11's recliner was marred. Resident 11 stated it has been like that for a long time. Reviewed the above findings for Resident 11 during a meeting with the Nursing Home Administrator and Director of Nursing on February 4, 2026, at 2:25 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review and resident and staff interview it was determined that the facility failed to provide written notice of transfer and written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer for two of six residents reviewed for hospitalization concerns (Residents 2 and 6).Findings include: Clinical record review for Resident 2 revealed profile information that indicated that she had resident representatives that included her mother, a male emergency contact, and an adult protective services county representative. Nursing documentation dated October 1, 2025, at 1:45 PM revealed that Resident 2 was admitted to the hospital following an above-the-knee amputation. The facility provided a Notice of Transfer or discharge date d October 1, 2025, addressed to Resident 2, that noted the transfer to the hospital on October 1, 2025, was necessary for the surgical procedure of a right above-the-knee amputation. Staff documented a verbal review of the notice with Resident 2 on October 1, 2025. There was no indication that Resident 2 and one of her resident representatives received a written copy of the notice. The facility did not provide evidence that Resident 2 and one of her representatives received written notice which specified the duration of the facility's bed-hold policy within 24 hours of Resident 2's transfer. Nursing documentation dated November 21, 2025, at 10:34 AM revealed that Resident 2 was lethargic, difficult to arouse, and had a low blood pressure. Staff contacted the physician who instructed staff to send Resident 2 to the emergency room. Nursing documentation dated November 21, 2025, at 11:52 PM revealed that the hospital informed facility staff that Resident 2 was admitted for an infection related to kidney stones and revision of ureteral stents (tubes placed in the vessels from the kidney to the bladder to correct and/or prevent obstruction). The facility provided a Notice of Transfer or discharge date d November 21, 2025, addressed to Resident 2, that noted the transfer to the hospital on November 21, 2025, was necessary due to abnormal laboratory results. Staff documented, resident unable to sign at present, on November 21, 2025. There was no indication that Resident 2 and one of her resident representatives received a written copy of the notice. A Bed Hold Notice form noted, unable to sign at present time, that Resident 2 was contacted by facility staff on November 21, 2025, at 10:00 AM, and that the Bed Hold Election form was mailed to Resident 2 for signature on November 24, 2025 (three days after the transfer to the hospital). The facility did not provide evidence that Resident 2 and one of her representatives received written notice which specified the duration of the facility's bed-hold policy within 24 hours of Resident 2's transfer. The surveyor reviewed the above concerns regarding Resident 2's and her resident representative's receipt of the required notices upon her transfers to the hospital during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2026, at 12:25 PM. Interview with Resident 6 on February 2, 2026, at 2:13 PM revealed that she was recently hospitalized after she fell and broke her femur (long leg bone in the thigh area). Census information for Resident 6 confirmed that she was on hospital leave starting December 26, 2025. Review of Resident 6's profile information revealed that her resident representatives included her son. The facility provided a Notice of Transfer or discharge date d December 26, 2025, addressed to Resident 6, that noted the transfer to the hospital on December 26, 2025, was necessary due to a fall with possible fracture. Resident 6 signed the notice on December 26, 2025. There was no evidence that Resident 6's representative received a written copy of the notice. A Bed Hold Notice form noted, verbal (son's name), on December 26, 2025. The section of the Bed Hold Notice that is used to document the mailing or emailing of the notice was left blank. The surveyor reviewed the above concerns regarding Resident 6's representative's receipt of the required notices upon her transfer to the hospital during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2026, at 12:25 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of 22 residents reviewed (Residents 3, and 4).Findings include: Clinical record review for Resident 4 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated October 2, 2025, in which facility staff assessed Resident 4 as having no impairments to her upper extremities. The next quarterly assessment completed on January 20, 2026, revealed staff now assessed Resident 4 as having bilateral upper extremity impairments. Review of Resident 4's occupational therapy treatment notes from September 30, 2025, to October 27, 2025, noted Resident 4's range of motion was impaired to her bilateral upper extremities. Interview with Employee 2 (registered nurse assessment coordinator) on February 5, 2026, at 9:21 AM, confirmed the above findings for Resident 4. Employee 2 verified the therapy documentation from the lookback period for October 2, 2025, MDS noted impairments to Resident 4's left and right shoulders with active range of motion limitations. Observation of Resident 3 on February 2, 2026, at 11:30 AM revealed her in bed with bilateral enabler bars on her bed. She indicated that she used the enabler bars to help her turn and move in bed. She also indicated that she can't get out of bed on her own. Review of Resident 3's MDS quarterly assessment date January 8, 2026, revealed that the facility coded her as using bedrails daily as a restraint. Interview with the nursing home administrator and director of nursing on February 3, 2026, at 2:20 PM revealed that this was an MDS coding error and that Resident 3 has enabler bars on her bed, not bedrails that are used as a restraint. 483.20(g) Accuracy of AssessmentsPreviously cited 1/16/25 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of three residents reviewed (Resident 7). Findings include: Clinical record review revealed the facility admitted Resident 7 on September 26, 2024, with diagnosis including a family history of alcohol abuse and dependence. Review of Resident 7's clinical record revealed a PASARR Level II determination letter dated May 22, 2024, from the Department of Human Services noted based on a review of the information submitted, the Office of Mental Health and Substance Abuse Services had determined that Resident 7 does not meet the mental health criteria for further review by the office. The letter further stated that although Resident 7 did not meet the criteria for serious mental illness, the documentation submitted indicates that Resident 7 could benefit from drug and alcohol services. Further review of Resident 7's clinical record revealed there was no documentation that the facility recommended and/or provided any drug and alcohol services to Resident 7 as the result of the PASARR II recommendation. Interview with Employee 3 (social worker) on February 4, 2026, at 12:08 PM, confirmed the facility had no documentation that they incorporated the recommendations from Resident 7's PASARR Level II into her care at any time while residing at the facility. The above findings for Resident 7 reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 4, 2026, at 2:35 PM There was no evidence at the time of the survey the facility had timely identified and coordinated the provision of specialized services for Resident 7. 28 Pa. Code 211.5(f)(iv)(vi) Medical records.

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to include a resident's representative in participation with care planning for one of 22 residents reviewed (Resident 6), revise a care plan after a resident's change in condition for one of 22 residents reviewed (Resident 2), and revise a care plan related to a pacemaker intervention for one of 22 residents reviewed (Resident 86).Findings include: Clinical record review for Resident 86 revealed the resident had a physician order dated December 26, 2025, that noted a pacemaker (an implanted electronic device to help regulate the beating of the heart). Hospital documentation for Resident 86 dated December 24, 2025, at 1:30 PM revealed that the resident had a permanent pacemaker insertion on February 15, 2023. Observation on February 3, 2026, at 12:14 PM revealed that there was an electronic pacemaker transmittal device on the dresser next to Resident 86's bed. Review of Resident 86's current care plan revealed the resident has an impaired cardiovascular status related to the resident's medical history and presence of a cardiac pacemaker. The care plan did not address the electronic transmittal device (proper placement, troubleshooting any issues, contact information, etc.). The above information for Resident 86's pacemaker was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 3, 2026, at 2:00 PM. Clinical record review for Resident 2 revealed that on August 26, 2025, Resident 2 weighed 206.2 pounds. On December 4, 2025, Resident 2 weighed 177.6 pounds (a 13.87 percent weight loss in less than six months). Review of a plan of care initiated by Employee 1 (registered dietitian) on September 3, 2025, to address Resident 2's risk for altered nutritional status revealed no evidence of any revisions to her plan of care despite her severe weight loss since admitted to the facility. The surveyor reviewed concerns regarding Resident 2's weight loss and interdisciplinary response during interviews with the Nursing Home Administrator and the Director of Nursing on February 3, 2026, at 2:00 PM and February 4, 2026, at 2:00 PM. The surveyor reviewed concerns regarding Resident 2's weight loss with Employee 1 (registered dietitian) on February 5, 2026, at 10:39 AM. Interview with Resident 6 on February 2, 2026, at 1:57 PM revealed that she denied knowledge of care plan meetings and denied that her son or daughter-in-law participated in care plan meetings. Clinical record review for Resident 6 revealed profile information that listed her son as her Care Conference Person. Care Plan Note documentation on December 1, 2025, at 1:34 PM; September 4, 2025, at 11:32 AM; June 4, 2025, at 8:45 AM; and March 6, 2025, at 1:56 PM revealed no evidence that the facility attempted to include Resident 6's son to participate with care planning. Interview with the Director of Nursing and the Nursing Home Administrator on February 3, 2026, at 2:00 PM confirmed that the facility could not provide evidence of Resident 6's representative participation in her care planning for the past year. Interview with Employee 3 (social services) on February 4, 2026, at 12:07 PM confirmed that she had no evidence that she attempted to involve Resident 6's son (designated as her care conference contact) when conducting care plan meetings. Social services documentation by Employee 3 dated February 4, 2026, at 4:10 PM (following the surveyor's questioning) revealed that she contacted Resident 6's son regarding care plan scheduling and he would be interested in attending meetings again following Resident 6's recent change in health status due to her surgery on her hip. 483.21 Comprehensive Care PlansPreviously cited deficiency 1/16/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide services to maintain or improve a resident's range of motion (ROM) and mobility for four of five residents reviewed (Resident 19, 48, 59, and 74). Findings include: Review of the facility policy entitled, Restorative Nursing Services, last reviewed without changes on August 15, 2024, revealed that residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Restorative goals and objectives are individualized and resident-centered and outlined in the resident's plan of care. Restorative goals may include but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities; developing, maintaining, or strengthening their physiological and psychological resources; maintaining their dignity, independence, and self-esteem; and participate in development and implementation of their plan of care. The policy does not speak to the expectations and frequency (how often) staff are to complete the resident's restorative nursing program interventions. Clinical record review for Residents 19 revealed a therapy restorative referral dated November 8, 2024, which identified they had a decrease in their active ROM (movement of the body to maintain a resident's ability). Therapy staff indicated nursing staff should provide PROM (passive range of motion) to their BLE's (bilateral [both] lower extremities [legs]) for 10 repetitions, all available planes, and ranges. Therapy staff did not indicate the frequency (how often) or specific shift(s) that nursing staff should complete Resident 19's restorative nursing program. Review of Resident 19's task documentation for Resident 19 revealed that nursing staff implemented their PROM restorative nursing program during each shift, however, opened the PROM task to be completed/documented only during day shift. There was no documentation that staff completed Resident 19's PROM restorative nursing program during evening or night shifts throughout the three months (November and December 2024, and January 2025) reviewed. Clinical record review for Residents 48 revealed a therapy restorative referral dated November 26, 2024, which identified they had a decrease in their independent ambulation. Therapy staff indicated nursing staff should ambulate Resident 48 up to 110 feet with a FWW (front wheeled walker) with assist of one and w/c (wheelchair) to follow for safety. Therapy staff did not indicate the frequency (how often) or specific shift(s) that nursing staff should complete Resident 48's restorative nursing program. Review of task documentation for Resident 48 revealed that nursing staff implemented their ambulation restorative nursing program during each shift, however, opened the ambulation task to be completed/documented only during day shift. There was no documentation that staff completed Resident 48's ambulation restorative nursing program during evening or night shifts throughout the three months (November and December 2024, and January 2025) reviewed. Further review revealed that staff noted NA (not applicable) for Resident 48's ambulation restorative nursing program on December 15, 2024, day shift. Further review for Residents 48 revealed a therapy restorative referral dated January 7, 2025, which identified they had a decrease in AROM active range of motion) for their right elbow. Therapy staff indicated nursing staff should perform slow, gentle, and sustained PROM to their right elbow into extension for 2 sets of 10 repetitions for joint integrity/mobility. Therapy staff did not indicate the frequency (how often) or specific shift(s) that nursing staff should complete Resident 48's restorative nursing program. Nursing staff initialed the therapy referral, which indicated that they acknowledged the information and implemented the therapist's restorative program. Review of task documentation for Resident 48 revealed that they had an AROM restorative nursing program for their RUE (right upper extremity) and right elbow, 2 sets of 10 repetitions in sitting position for every shift already implemented when therapy made the PROM restorative referral to nursing staff. There was no documentation that nursing staff discontinued Resident 48's AROM restorative nursing program and implemented their PROM restorative nursing program as indicated by therapy's restorative referral. Clinical record review for Residents 59 revealed a therapy restorative referral dated January 1, 2025, which identified they had a decrease in ROM for their BLE's and RUE (right upper extremity [arm]). Therapy staff indicated nursing staff should provide PROM to their BLE's and LUE (left upper extremity) for 10 repetitions, all available planes, and ranges to prevent decline in current ROM. Therapy staff did not indicate the frequency (how often) or specific shift(s) that nursing staff should complete Resident 59's restorative nursing program and indicated the decline was in Resident 59's RUE but implemented a restorative nursing program for their LUE. Therapy did not address the noted RUE decline in their restorative referral. Review of task documentation for Resident 59 revealed that nursing staff implemented that their PROM restorative nursing program during each shift, however, opened the PROM task to be completed/documented only during day and evening shift. Nursing staff also added with a.m. (morning) and p.m. (afternoon) care to the ROM task. Clinical record review for Residents 74 revealed therapy restorative referral dated September 23, 2024, which identified they had a concern with the flexion of their RUE. Therapy staff indicated nursing staff should perform slow, gentle, sustained PROM exercised right hand digits 2 - 5 into extension, positive wrist mobility, and place resting orthotic (splint) on the right hand for skin integrity, contracture management, and joint alignment. Therapy staff did not indicate the frequency (how often) or specific shift(s) that nursing staff should complete Resident 74's restorative nursing program. Review of task documentation for Resident 74 revealed that nursing staff implemented their PROM restorative nursing program during each shift, however, opened the PROM task to be completed/documented only during day shift. There was no documentation that staff completed Resident 74's restorative program on evening or night shifts. Further review revealed that staff indicated NA for the restorative program January 13, 2025, day shift. Further review of Resident 74's task documentation revealed that nursing staff implemented the therapy restorative referral for their right hand orthotic, with staff to apply a right palm roll and forearm splint on the AM (morning) and remove at HS (hour of sleep). Staff may remove for care and ambulation. There was no documentation in the therapy restorative referral or a physician's order, which indicated when staff were to apply and/or remove Resident 74's orthotic, place a palm roll, or that staff may remove for care and/or ambulation. Further review revealed that staff indicated NA or failed to document task completion on the following dates: Day Shift: October 5, 7 and 31, 2024 Evening Shift: December 7, 2024 The surveyor reviewed the above information on January 16, 2025, at 11:30 AM with the Nursing Home Administrator and the Director of Nursing. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide routine dental services related to partial dentures for one of two residents reviewed for dental concerns (Resident 86). Findings include: Interview with Resident 86 on January 14, 2025, at 11:37 AM revealed that she had partial dentures for her upper and lower jaw but they went missing. Resident 86 stated that they (the facility's consultant dental provider) are supposed to be making new ones. Resident 86 indicated that it was eight months to one year that she did not have her partial dentures. Observation of Resident 86 on the date and time of the interview revealed that she had natural teeth and was missing teeth. Clinical record review for Resident 86 revealed a plan of care created by the facility on Resident 86's admitted [DATE], to address her self-care deficits in her activities of daily living (ADL). The plan of care noted that Resident 86 had partial upper and lower dentures. Progress note documentation by the facility's consultant dental provider dated October 29, 2024, revealed that Resident 86 presented for an assessment of her bite for the casts (molds) of upper and lower partial dentures. The documentation indicated that it was the second assessment of Resident 86's bite. Interview with the Nursing Home Administrator and the Director of Nursing on January 15, 2025, at 12:20 PM confirmed that the facility did not have a concern form, grievance form, or clinical record documentation to indicate when Resident 86's partial dentures became missing; however, confirmed that the consultant dental provider documentation dated October 29, 2024, stipulated that Resident 86 presented for an assessment of her bite for the molds of upper and lower partial dentures. The surveyor requested that the facility provide their policy or procedure when resident property (including dentures) is determined missing. The facility did not provide a policy that stipulated the facility's responsibilities when there is loss or damage of resident dentures. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on resident interview, clinical record review, and staff and resident interview, it was determined that the facility failed to provide written notice regarding the facility's bed-hold policy for one of five residents reviewed for hospitalization concerns (Resident 63). Findings include: Interview with Resident 63 on January 13, 2025, at 12:12 PM revealed that he was hospitalized with symptoms that were questionably indicative of a stroke (cerebrovascular accident, interruption of blood flow or bleeding in the brain), but he returned to the facility after his hospitalization . Clinical record review for Resident 63 revealed nursing documentation dated October 12, 2024, at 12:24 PM that indicated Resident 63 was calling for help, had an elevated temperature, increased confusion, and agreed to transfer to the hospital for evaluation. Nursing documentation dated October 12, 2024, at 12:47 PM revealed that Resident 63 left the facility via an ambulance in route to the hospital. Nursing documentation dated October 12, 2024, at 1:25 PM revealed that staff spoke to Resident 63's sister to inform her of his transfer to the emergency department. The documentation did not indicate that staff forwarded written information to Resident 63's sister (resident representative) regarding the facility's bed-hold policy. Nursing documentation dated October 12, 2024, at 6:11 PM indicated that the emergency department admitted Resident 63 to the hospital. Review of a Bed Hold Notice (document that the facility utilizes to communicate the duration of the bed-hold policy) dated October 12, 2024, revealed that staff documented, Resident unable to sign, on October 14, 2024, on the signature line designated for the resident or resident representative name. The notice stipulated both that Resident 63 did not wish to authorize the facility to retain his bed and that he or his representative wanted to hold his bed for 15 days. The document did not indicate that staff forwarded written information to Resident 63's sister (resident representative) regarding the facility's bed-hold policy. The surveyor requested evidence that facility staff provided written information to Resident 63 and Resident 63's representative (sister) regarding the facility's bed-hold policy at the time of his October 12, 2024, hospitalization during an interview with the Nursing Home Administrator and the Director of Nursing on January 14, 2025, at 1:30 PM, and January 15, 2025, at 12:28 PM and 2:07 PM. The facility failed to provide evidence that Resident 63's responsible party received written information related to holding beds during absences from the facility within 24 hours of his emergency transfer. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one of 22 residents reviewed (Resident 34). Findings include: Review of Resident 34's clinical record revealed that the facility admitted her with a diagnosis of Schizophrenia. Further review revealed a PASRR (Pennsylvania Preadmission Screening Resident Review Identification Level 1 form) completed on May 22, 2019, that indicated the resident had a mental health condition or suspected mental illness that may lead to a chronic disability and the resident met the criteria (positive screen) to have a PASRR Level 2 evaluation done. A completed PASRR Level 2 by the Pennsylvania Department of Human Services Office on Mental Health and Substance abuse services dated August 1, 2019, indicated Resident 34 had evidence of a Mental Health condition that met the criteria, and the resident was determined as eligible for Mental Health services. Review of Resident 34's last comprehensive (annual) MDS (minimum Data set - an assessment completed at periodic intervals of time to determine resident care needs) completed on May 6, 2024, revealed facility staff assessed the resident as not being considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on January 15, 2025, at 2:00 PM. The Nursing Home Administrator confirmed on January 16, 2025, at 9:38 AM the MDS noted above for Resident 34 was not accurately completed and the facility submitted a corrected MDS after the information was reviewed as noted above. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident, family, and staff interview, it was determined that the facility failed to revise residents' care plans for three of 21 residents reviewed (Residents 79, 81, and 86). Findings include: Interview with Resident 79's daughter on January 13, 2025, at 10:29 AM indicated that she believed that her mother could become verbally and/or physically abusive to staff when she gets anxious. She stated that she believed that her mother has an anxious response when approached by two staff to perform care and that she suggested to the facility that her mother receive care by one staff. Resident 79's daughter also indicated that she provides soda for staff to give her mother to provide caffeine since she no longer smokes cigarettes or drinks coffee to lessen her behaviors and improve her compliance with care. Clinical record review for Resident 79 revealed social services documentation dated November 26, 2024, at 1:39 PM that during a care plan meeting, Resident 79's daughter expressed concerns that Resident 79 may be more combative in the morning with care because she no longer smokes cigarettes or drinks coffee. Resident 79's daughter provided diet soda for Resident 79 to have in the morning to provide some caffeine. Resident 79's daughter also suggested attempting care with only one staff member to see if Resident 79 would be less combative. The documentation indicated that staff updated resident 79's care plan. Plans of care developed by the facility to record Resident 79's problem areas, goals, and interventions revealed areas that addressed Resident 79's impaired cognitive function related to dementia (decline in cognitive function that affects memory, thinking, judgement, and behavior); psychotropic medication use to treat dementia, depression, and anxiety; behaviors that include physical aggression and resistance to care; and communication deficits due to dementia. The plans of care did not include an intervention to attempt care with one staff to minimize Resident 79's anxiety, aggression, and refusal to cooperate with care. Review of Task Documentation (electronic documentation by nurse aide staff to record care provided and the level of staff assistance utilized) dated November 2024, revealed that two staff provided assistance with dressing and transfers November 27 through 30, 2024. Two staff provided assistance with personal hygiene on November 27 and 28, 2024. The November 2024, documentation did not indicate that staff offered the diet soda to Resident 79. Review of Task Documentation dated December 2024, revealed that two staff provided Resident 79 assistance with dressing on 27 of the 31 days reviewed; with transfers on 22 of the 31 days reviewed; and with personal hygiene on 25 of the 31 days reviewed. The December 2024, documentation did not indicate that staff offered the diet soda to Resident 79. Review of Task Documentation dated January 1 through 16, 2025, revealed that two staff provided Resident 79 assistance with dressing on 12 of the 16 days reviewed; and with personal hygiene on 11 of the 16 days reviewed. The January 2025, documentation did not indicate that staff offered the diet soda to Resident 79. Interview with Employee 1 (nurse aide) on January 16, 2025, at 11:05 AM revealed that she often provides care to Resident 79. Employee 1 stated staff, typically go in with two (staff), to provide Resident 79's care. Employee 1 stated that two staff provide care because Resident 79 is combative. Employee 1 confirmed that staff do not document that care was unsuccessfully attempted by one staff before two staff attempt to provide care. Employee 1 also confirmed that there was no instruction in the nurse aide computer tablet (that is used to inform nurse aide staff of resident care needs) to provide Resident 79 a diet soda. Interview with the Nursing Home Administrator and the Director of Nursing on January 16, 2025, at 10:36 AM confirmed that Resident 79's plans of care did not include the new intervention to attempt care with one staff assistance. The interview also confirmed that the available documentation failed to indicate that staff offer Resident 79 a diet soda as part of her daily care. Interview with Resident 81 on January 14, 2025, at 11:54 AM revealed that he has a tooth that is bothering him. Clinical record review for Resident 81 revealed documentation by the facility's consultant dentist dated January 11, 2024, that Resident 81 had two missing teeth and retained roots (fragments of the tooth roots that remain in the jawbone after tooth loss or extraction) for three teeth (tooth number four, 17, and 32). Documentation by the facility's consultant dentist dated March 22, 2024, indicated that the facility referred Resident 81 for services due to a complaint of tooth pain. An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 8, 2024, assessed Resident 81 without any obvious or likely cavity or broken natural teeth. The MDS assessment did not trigger facility staff to develop a plan of care to address Resident 81's potential for dental health concerns. Interview with Employee 2 (registered nurse assessment coordinator) on January 16, 2025, at 12:00 PM indicated that she did not review the dental progress notes when completing the MDS assessment. Employee 2 confirmed the June 8, 2024, annual MDS assessment was inaccurate and because the assessment did not note Resident 81's broken teeth, the assessment did not trigger a dental care area that required a plan of care. Documentation by the facility's consultant dentist dated July 8, 2024, indicated that Resident 81's thirteenth tooth was, non-restorable (tooth damage that cannot be fixed to prevent the tooth from removal); and that he recommended extraction of the tooth as needed. Resident 81 did not exhibit symptoms to warrant extraction at that time. Nursing documentation dated December 19, 2024, at 9:42 AM indicated that Resident 81 complained of a toothache, and the physician provided a new order to refer Resident 81 to a dentist. Nutritional staff documentation dated December 25, 2024, at 6:00 PM noted that Resident 81 complained of tooth pain. The writer indicated that it was difficult to see which tooth was symptomatic due to multiple decaying teeth. Interview with the Director of Nursing and the Nursing Home Administrator on January 15, 2025, at 12:28 PM confirmed that no plan of care was developed or revised to include the above available information that Resident 81 had episodes of tooth pain, had retained tooth roots, and had multiple decaying teeth. Interview with Resident 86 on January 14, 2025, at 11:37 AM revealed that she had partial dentures for her upper and lower jaw but they went missing. Resident 86 stated that they (the facility's consultant dental provider) are supposed to be making new ones. Resident 86 indicated that it was eight months to one year that she did not have her partial dentures. Progress note documentation by the facility's consultant dental provider dated October 29, 2024, revealed that Resident 86 presented for an assessment of her bite for the casts (molds) of upper and lower partial dentures. The documentation indicated that it was the second assessment of Resident 86's bite. Review of a plan of care created by the facility on Resident 86's admitted [DATE], to address her self-care deficits in her activities of daily living (ADL), revealed that she had partial upper and lower dentures. Facility staff did not revise this plan of care to reflect Resident 86's missing partial dentures. Interview with the Nursing Home Administrator and the Director of Nursing on January 15, 2025, at 12:20 PM confirmed that facility staff did not revise Resident 86's plan of care in response to Resident 86's missing partial dentures. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of two residents reviewed for rehabilitation concerns (Resident 12). Findings include: Interview with Resident 12 on January 13, 2025, at 12:58 PM revealed that she had a walker device in her room that is used when staff walk with her; however, that does not occur, too much because they (the facility) don't have too many people (staff). A discharge summary by physical therapy staff dated November 29, 2023, indicated that services included patient and caregiver training, and instruction regarding an in-home exercise program (HEP) to preserve Resident 12's current level of function and prevent functional decline. Resident 12's prognosis was assessed as good with consistent staff follow-through. Discharge recommendations included that Resident 12 was to continue with the HEP restorative nursing program for gait and independent transfers and wheelchair mobility. Review of Task Documentation (electronic documentation by nurse aide staff to record care provided and the level of staff assistance utilized) dated November 2024, revealed that staff documented Resident 12's program to ambulate for 100 feet was not applicable (NA) on November 12 and 27, 2024. Staff documented that Resident 12 refused to ambulate on eight days; however, there was no indication that staff re-approached Resident 12 to give her an opportunity to complete the program after her initial refusal on seven of the eight occasions. Nursing documentation dated December 3, 2024, at 10:55 AM revealed that staff reviewed Resident 12's nursing ambulation program and made no changes at that time. Review of Task Documentation dated December 2024, revealed that staff documented Resident 12's program to ambulate for 100 feet was, NA, on December 9, 10, and 24, 2024. Staff documented that Resident 12 refused the program on December 1, 6, 8, 17, 19, 23, 25, 30, and 31, 2024; however, there was no indication that staff re-approached Resident 12 to give her an opportunity to complete the program after her initial refusal on those nine days. Staff documented that Resident 12 completed the program on only 19 of the 31 days reviewed for December 2024. Review of Task Documentation dated January 1 through 15, 2025, revealed that staff documented Resident 12's program to ambulate for 100 feet was, NA, on January 2, 4, 9, and 13, 2025. Staff documented that Resident 12 refused the program on January 5, 6, 12, and 15, 2025; however, there was no indication that staff re-approached Resident 12 to give her an opportunity to complete the program after her initial refusal on those four days. Staff documented that Resident 12 completed the program on only seven of the 15 days reviewed for January 2025. The surveyor reviewed the above concerns regarding Resident 12's restorative nursing program for ambulation during an interview with the Nursing Home Administrator and the Director of Nursing on January 16, 2025, at 10:36 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement physician ordered supplemental oxygen consistent with professional standards of practice for one of one resident reviewed for supplemental oxygen concerns (Resident 63). Findings include: Clinical record review for Resident 63 revealed a physician's order dated November 11, 2024, for staff to administer supplemental oxygen at two liters per minute as needed to keep oxygen saturation levels above 90 percent, use as needed for oxygen saturations of less than 90 percent. Review of Resident 63's medication administration records and treatment administration records (MAR and TAR, electronic documentation completed by staff to record the completion of medications and treatments) dated November 2024, December 2024, and January 2025, revealed that staff did not obtain routine assessments of Resident 63's oxygenation saturations to determine the need for supplemental oxygen. Observation of Resident 63 on January 13, 2025, at 12:20 PM revealed no supplemental oxygen in use. Review of Resident 63's clinical record revealed no evidence that staff obtained an assessment of Resident 63's oxygen saturation to determine that he did not need supplemental oxygen. The surveyor reviewed the above concern that Resident 63's supplemental oxygen was ordered to maintain an oxygenation saturation greater than 90 percent; however, staff are not obtaining oxygenation saturation assessments regularly during an interview with the Nursing Home Administrator and the Director of Nursing on January 14, 2025, at 2:15 PM. The facility provided a revised physician order dated January 15, 2025, at 10:45 AM that would prompt staff every shift to evaluate Resident 63's need for supplemental oxygen. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 43). Findings include: Clinical record review for Resident 43 revealed the facility admitted her on October 31, 2024, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 43's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 6, 2024, indicated that the facility assessed Resident 43 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 43's care plan entitled impaired cognitive function related to dementia revealed that there was no indication that the facility had implemented an individualized person-centered care plan to address the resident's dementia and cognitive loss needs, until the surveyor brought it to their attention on January 15, 2025, at 11:30 AM. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on January 15, 2025, at 2:30 AM. The facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss for Resident 43. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of select policy and procedures, observation, clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent falls resulting in injuries for two of two sampled residents (Residents 54 and CR1). Findings include: The "Fall Prevention and Risk Identification," identified by the Director of Nursing as the facility's most recent policy, revealed that whenever a resident has a history of falls, nursing staff should evaluate the pattern of the falls. Based on the resident's "fall history," the team should look for underlying causes so a proactive approach can be taken to prevent further falls. Clinical record review for Resident 54 and review of incident investigations revealed that Resident 54 has had 13 falls in the last 10 months. An investigation into the fall dated October 23, 2012, at 6:50 AM, indicated that the staff found Resident 54 on the floor in her room beside her overturned bedside commode saying, "I have to go to the bathroom." The staff initially assessed her with no injury but later they sent her to the emergency room when she complained of shortness of breath and presented with decreased breath sounds. The emergency room physician diagnosed her with two fractured vertebrae and pneumonia. An investigation into the fall dated November 24, 2012, at 12:00 PM, revealed that the staff found Resident 54 on the floor bedside her bed. The personal alarm was attached to the resident, but there is no indication whether it activated. According to the report, the chair alarm was not on. Review of nursing notes, witness statements, and the incident investigation revealed that there was no indication whether Resident 54 fell from her bed or the wheelchair. There were no known injuries. An investigation into the fall dated December 11, 2012, at 11:30 AM, revealed that the staff found Resident 54 lying on the floor in the hallway outside of her room. Resident 54 indicated that she had been attempting to go to the bathroom. The measures that the facility implemented, a sensor (device mounted on the wall that detects motion) and body (personal) alarm were on but not activated. The staff assessed the resident and found a lump on the right side of her head. The fall dated February 1, 2013, at 10:45 AM, revealed that the staff found Resident 54 lying on the floor next to her bed saying, "I need to pee." The bed alarm sounded. The personal alarm was not in place. The staff determined that Resident 54 had removed it. The sensor alarm was turned off. Interviews with the staff revealed that the motion (sensor) alarm was turned off due to numerous "false alarms." The staff indicated that they were going to change the clip of the personal alarm to deter Resident 54 from removing it. An investigation into the fall dated March 14, 2013, at 4:30 AM, revealed that the staff responded to Resident 54's alarm, and found her on the floor at the foot of her bed. Resident 54 indicated, "I was going to the bathroom." The staff indicated that Resident 54's personal alarm clip was not attached to her person and that she has a history of removing it. There was no indication that the clip alarm had been changed per the intervention after Resident 54's fall on February 1, 2013. The bed alarm was sounding at half volume. Resident 54 complained of upper back and shoulder pain and was medicated with Tylenol. The fall dated April 17, 2013, at 4:45 AM, revealed that the staff responded to Resident 54's alarm sounding. She was sitting beside her bed saying, "I had to pee" and "I slid and fell on my butt." There was no indication whether the sensor alarm activated or was turned off. It was not listed under the "list of safety alarms present," and it was not listed as a current care planning intervention. An investigation into the fall dated May 2, 2013, at 9:15 PM, revealed that the staff found Resident 54 on the floor beside her bed saying, "I was going to the bathroom." The staff assessed her and found a 5 centimeter (cm) hematoma (bruise) on top of her head. The motion (sensor) alarm was not turned on. It was also noted that Resident 54 closes her door making it hard to hear the alarm. Upon review, the staff determined a need to evaluate the effectiveness of her alarms. There is no documented evidence that the staff ever evaluated the effectiveness of the alarms. The fall dated May 3, 2013, at 9:10 PM, revealed that the staff responded to an alarm (no designation of which alarm) and found Resident 54 on the floor in the dining room. The report indicated that both the personal and chair alarms were on and activated. The resident sustained [REDACTED]. A physician's progress note dated May 9, 2013, revealed that Resident 54 recently had two falls again because she independently gets out of the chair. Resident 54 forgets that she has to call for help. The physician wrote, "We are not getting over this and I am sure she is going to break her hip soon." "She is very feeble, weak, and very confused." An investigation into the fall dated May 22, 2013, at 9:30 PM, revealed that Resident 54 was reaching for a paper on the floor when she slid out of bed. Resident 54 sustained a skin tear (size not noted) on her left arm. The report indicated that she sustained an injury, first aid was provided and she was transferred to the emergency room . The fall dated June 7, 2013, at 6:15 AM, revealed that the staff found Resident 54 seated on the floor in her room behind the door saying, "I slipped." The alarms were sounding. The staff completed a "3 day Bowel and Bladder Pattern Record" and a "Bowel and Bladder Continence Evaluation" and found that she was at moderate restorative potential. According to the Bowel and Bladder Evaluation form, moderate restorative potential, which is habit/prompted is a score of 6 to 11. According to the Bowel and Bladder policy, this toileting plan is relatively more dependent on staff involvement and assistance as opposed to resident function. An investigation into the fall dated July 6, 2013, at 7:30 PM, revealed that the staff found Resident 54 sitting on her buttocks, leaning against the corner of the wall. She had a 6 cm by 3 cm raised area on the left side of her head. She had activated her call bell and the alarms were functioning. Nursing documentation revealed that Resident 54 had been attempting to take herself to the bathroom when she fell . She was continent of bowel and bladder but was unable to follow a scheduled toileting plan. Resident 54 was adamant about using the bathroom frequently. On July 10, 2013, Resident 54's physician examined her and found that she was having increased frequency and urgency with urination. A urinalysis indicated no urinary tract infection. A physician's orders [REDACTED]." The staff started the "Bladder Tracker" on July 14, 2013, but did not complete it. The staff recommended to request a physician's orders [REDACTED]. A urologist is unable to see Resident 54 until August 30, 2013. The fall dated July 12, 2013, at 9:20 PM, revealed that the staff found Resident 54 on the floor in her room. The report indicated that Resident 54 had activated her call light and the bed and body alarms were present and activated. The staff indicated that Resident 54 was, "responding to bladder urgency." The report indicated that the staff initiated a 3 day bladder tracker; however, it was incomplete and there was no evidence that the staff utilized the information that they did gather to determine any patterns in Resident 54's incontinence (see above). The staff assessment revealed an abrasion on her left shoulder and a 1 cm laceration above her left eye. The emergency room staff evaluated Resident 54 and notified the facility that all tests were negative. On July 17, 2013, the hospital informed the facility that Resident 54's x-ray completed on July 12, 2013, showed an acute fracture of the carpal navicular bone (wrist). An x-ray completed on July 18, 2013, revealed a nondisplaced fracture of her sixth and seventh ribs. The orthopedist (physician specializing in muscular and skeletal ailments) saw Resident 54 on July 24, 2013, and indicated that the x-ray of her left wrist showed, "no obvious fracture." An investigation into the fall dated July 22, 2013, at 11:04 AM, revealed that the staff left Resident 54 unattended in the bathroom and she fell attempting to ambulate back to her bed. The report indicated that the staff did not follow Resident 54's care plan because they left her unattended. An observation of Resident 54 on July 23, 2013, at 9:30 AM, revealed that she was lying in her bed asleep. Her left eye and the surrounding area were bruised. Re-entry of the room at 9:45 AM, revealed the motion (sensor) alarm sounded. The sensor alarm did not activate on the first entry. Closed clinical record review for Resident CR1 and review of incident investigations revealed that Resident CR1 has had 13 falls in the last eight months. An investigation into a fall dated November 20, 2012, at 7:00 AM, revealed that the staff found Resident CR1 on the floor at the bottom of his bed saying, "I slid." His personal alarm was sounding. The fall dated December 11, 2012, at 12:30 PM, revealed that when the staff went in to pick up his lunch tray, they found him on the floor between the beds. The staff indicated that they would place him in a wheelchair and they received a new order for a personal alarm. According to the investigation into the fall on November 20, 2012, he already had a personal alarm. An investigation into the fall dated January 28, 2013, at 7:30 PM, revealed that the staff heard Resident CR1's alarm sounding, and found him lying on the floor in the dining room. The staff indicated that they would toilet him after supper and provide supervision. The fall dated February 14, 2013, at 6:25 AM, revealed that Resident CR1's alarm was sounding and the staff found him on the floor in his room. The staff indicated that they would complete a bowel and bladder assessment. There is no documented evidence that the staff completed the bowel and bladder assessment. An investigation into the fall dated February 25, 2013, at 7:15 AM, revealed that the staff found Resident CR1 on the floor in his room. His alarm was sounding. The staff determined that morning care should be at 6:00 AM because Resident CR1 was an early riser (after sustaining two morning falls). The fall dated March 7, 2013, at 4:10 PM, revealed that the staff found Resident CR1 lying on the dining room floor. The incident report indicated that the chair alarm was "present, on, and activated," however, the Licensed Practical Nurse (LPN) did not indicate that the alarm was on in her statement. If the alarm was activated, there was no indication that the staff responded to the alarm. The LPN indicated that another resident came to the nurses' station and reported that a resident was on the floor. When the staff arrived in the dining room, Resident CR1 was noted to be on the floor in front of his wheelchair. An investigation into the fall dated March 21, 2013, at 8:05 AM, revealed that the staff found Resident CR1 in front of his wheelchair with the alarms sounding. The staff indicated that they would toilet him when he was restless and complete a bowel and bladder evaluation. There was no documented evidence that the staff completed the bowel and bladder assessment. The fall dated March 26, 2013, at 8:55 AM, revealed that while Resident CR1 was in the dining room, he pulled his chair over to a table, put his hands on the table, and sat slowly on the floor. An investigation into the fall dated May 24, 2013, at 5:40 AM, revealed that the staff found Resident CR1 lying on the fall mat beside his bed. The mat was soiled with urine. He had removed his brief. The bed alarm did not sound even though the staff checked it and found that it was functional. The staff revealed that they added a personal alarm but previous documentation indicated that a personal alarm was already in place. The staff indicated they would do a bowel and bladder assessment. There was no documented evidence that the staff completed the bowel and bladder assessment. The fall dated May 31, 2013, at 2:00 AM, revealed that the staff responded to a sounding alarm and found Resident CR1 lying on the mat beside his bed. The staff assessed him and found a 2.5 cm superficial abrasion on his forehead and a reddened area on his right outer eyelid. An investigation into the fall dated July 11, 2013, at 5:30 PM, revealed that the staff tried to redirect Resident CR1 because he was bothering another resident, who threatened to throw coffee on him. He was on the edge of the chair and when the staff member turned, he fell to the floor. Resident CR1 sustained a 5 cm abrasion on his right side. The fall dated July 13, 2013, at 7:10 PM, revealed that Resident CR1's alarm was sounding. A staff member responded and saw him stand and then fall in the dining room. The staff indicated that they would put him near a supervised area and check him every 15 minutes. Resident CR1 sustained a 2 cm by 2 cm reddened area on top of his head. An investigation into the fall dated July 14, 2013, at 7:55 PM, revealed that Resident CR1 fell from his wheelchair while trying to stand, striking his left lateral forehead on the floor in the hallway. A nurse revealed that she was standing outside the dining room when she heard a thud. The staff assessed him and found a 1.5 inch abrasion with swelling to his forehead. He was transported to an acute care hospital where he was diagnosed with [REDACTED]. During a meeting with the Nursing Home Administrator, Director of Nursing, and Employee 1 (Assistant Director of Nursing) on July 23, 2013, at 2:30 PM, each fall was discussed and all information available was presented and reviewed as previously stated. The facility failed to provide interventions and supervision to prevent falls for Residents 54 and CR1, resulting in major injuries. 483.25(h) Accidents. Previously cited 1/4/13 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/2/12, 11/1/12, and 1/4/13 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/2/12, 12/6/12, and 1/4/13 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/2/12, 12/6/12, 1/4/13, and 1/25/12 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/2/12, 11/1/12, 12/6/12, 1/4/13, and 1/25/13

Based on clinical record review and staff interview, it was determined that the facility failed to maintain adequate supervision for resident safety for one of four sampled residents (Resident 18). Findings include: Clinical record review for Resident 18 revealed that the facility admitted him on September 27, 2012, with a [DIAGNOSES REDACTED]. A physician's progress note dated October 3, 2012, revealed that Resident 18 lived with his wife at home. "His wife noticed an increased change in his mental status and he became more demented, paranoid, delusional, and aggressive. The resident's agitation increased to the point where his wife's life was in danger and he threatened to hurt her and kill her. Neighbors saw what was happening and called police and EMS. The resident was evaluated at the hospital and determined that he should be put in a Geriatric Psychiatric Ward, which resulted in his placement in the facility." Clinical record review for Resident 18 revealed nursing documentation starting on September 28, 2012, indicating that Resident 18 presented with increased aggression, agitation, and physical behavioral symptoms directed towards others. Nursing documentation revealed that Resident 18's aggressive, agitated, and physical behavioral symptoms continued until December 23, 2012, when he aggressively shoved Resident 25 while she ambulated in her merry walker (a device to aide in ambulation). Resident 25 sustained a fractured left elbow as a result of Resident 18's aggression. Review of Resident 18's nursing documentation revealed the following: September 28, 2012, at 2:00 AM, Found Resident 18 naked in another residents room yelling at a sleeping resident. October 14, 2012, at 9:40 PM, Resident 18 observed attempting to urinate in the wastebasket in the TV room. When another resident yelled at him to stop it and get out, he reportedly raised his hand above her head to strike her. November 19, 2012, at 5:00 AM, Resident 18 up most of the night continues to go into other resident rooms. Shows signs of frustration when redirected. November 22, 2012, at 4:00 AM, Resident 18 awake pacing the halls all shift, continues go into other resident rooms. Shows signs of frustration and anger when redirected. Also tried to direct another resident into his room but was stopped by staff. November 22, 2012, at 6:00 AM, Resident 18 was in another resident's room, when staff tried to redirect him he pushed staff and gestured that he was going to punch her. November 23, 2012, at 4:30 AM, Resident 18 awake this shift wandering hallways. Became angry with staff, pounded his hands on the nurse's station counter with increased frustration when staff did not know what he was trying to say. November 26, 2012, at 5:15 AM, Resident 18 awake walking the halls. Continues to go into others rooms. Takes others belongings. When staff try to redirect Resident 18, he is becoming more aggressive with increased frustration. November 30, 2012, at 5:30 AM, Resident 18 is becoming more bold and aggressive making fists and threating gestures. Note given to Social Service. December 8, 2012, at 9:50 AM, Resident 18 continues with increased behaviors. Ambulating in and out of other resident rooms. Wheeling others around the unit. December 9, 2012, at 2:00 AM, Resident 18 was antagonizing his roommate. Resident 18 was sitting on his roommate's bed with his roommate on it and Resident 18 was mimicking grunting sounds. Resident 18 is more difficult to redirect, and pushed staffs hand away as staff was attempting to escort him from his roommate's bed. December 10, 2012, at 3:00 AM, Resident 18 awake, OOB (out of bed) in and out of other resident room. Difficult to redirect. Was in room 212A trying to pull feeding tube (an artificial means of receiving nutrition by medically placing a tube in the stomach to receive nutrition) out. Aggressive with staff. Arguing with roommate. December 10, 2012, at 10:30 PM, Resident 18 was in and out of others rooms. Difficulty with redirection. Combative with staff in dining room. Refused to eat. December 11, 2012, at 6:00 AM, Resident 18 was very difficult to redirect. Arguing with roommate. Aggressive with staff. December 11, 2012, at 9:00 PM, Resident 18 combative with staff at 3:45 PM, unable to redirect. Resident jumping and skipping, pushing nurse's medication cart, trying to take medication book, cups, and straws off cart. December 12, 2012, at 11:15 PM, nursing staff were called to the shower room due to Resident 18 dancing on the wet floor in the shower room. The nurse aide was encouraging him to sit down in the shower chair and Resident 18 pushing back at the nurse aide's chest. At 9:30 PM Resident 18 was in the dining room picking at things that are not there. Resident 18 was found near a table using the bathroom on the floor in the dining room. When redirected to his room Resident 18 started laughing at staff. Change in behavior noted, acting childish and hard to redirect. December 14, 2012, at 1:58 PM, Aide (nurse aide) needed help in AM (morning) trying to get Resident 18 dressed and he pushed aide against the wall in the bathroom. December 15, 2012, at 6:00 AM, Resident 18 is trying to take papers off the nurse's desk when trying to redirect, Resident 18 raised fist to nurse. He is wandering into other resident rooms, verbal with roommate. December 15, 2012, at 10:00 AM, Resident 18 continues with behaviors, aggression, running down hall, pushing dining room chair down hall. Increased difficulty to redirect. December 15, 2012, at 8:45 PM, Resident 18 exhibiting childish acts, ambulating backwards in the hallway. Redirected with much difficulty. Resident 18 observed to have increased change in behavior and mental status. December 16, 2012, at 6:30 PM, Resident 18 combative when nurse asked to take temperature. The nurse showed resident what was going to be done. Resident 18 agreeable with stating OK. Resident 18 turned his head, when LPN (licensed practical nurse) tried to take his temperature Resident 18 resident swung his arms, pulled up his foot, and kicked the LPN in stomach. After dinner, Resident 18 started pushing trays off the table onto the floor, with redirection Resident 18 became combative pushing staff in the chest. With the assistance of three staff, Resident 18 was redirected to a safe place in the hallway. December 17, 2012, at 2:25 PM, Resident 18 observed with increased aggression and agitation. Resident 18 grabbed a hold of the railing at the nurse's station and ripped the railing off the wall. Resident 18 continued to grab the counter of the nurse's station and pull, attempting to tear it apart. Resident 18 pushing hands at staff, no contact made thus far, unable to redirect without difficulty. RN (registered nurse) made aware. December 18, 2012, at 11:20 AM, Resident 18's behavior continues to be erratic. He is hopping down the hall. Resident 18 will move at staff and residents quickly then spins around and goes the other way. December 19, 2012, at 6:25 PM, Resident 18 ambulating down the hallway with trash can in hand. Trash can taken away by nursing staff. Resident 18 observed skipping and dancing in the hallway. December 20, 2012, at 10:30 PM, found in Resident 18's room observed to be picking on resident in Bed-A, throwing hands at Bed-A, and pulling on curtain between beds. Resident 18 was observed to be jumping and dancing. December 21, 2012, at 10:50 AM, Resident 18 was pushing other resident's and staff in AM. Nursing staff able to get Resident 18 into bed in AM. Sleeping at that time. Resident 18 and roommate continue with yelling at each other. Roommate agitated in AM, hollering, complaints of wanting to get out of here. Resident 18 observed to have increased agitation when roommate agitated. Resident 18 appears tired. December 21, 2012, at 7:00 PM, Resident 18 observed getting out of his chair in the dining room, walked over to another table and stood up on the chairs. Resident 18 then started hopping from one chair to another chair when staff tried to redirect him. Resident 18 came down from the chair when there were no other chairs to hop onto. Resident 18 ambulated in the hallway, and then was observed going in and out of rooms. Resident 18 was lying on the floor in the dining room. "Laid self down, crawled around picking things (up) from (the) floor that were not there." December 22, 2012, at 6:00 AM, Resident 18 attempts to run in hallways, attempts to stand on chairs. He is not able to follow a simple request such as, "please sit down." Resident 18 is intrusive into others rooms. December 22, 2012, at 10:45 AM, Resident 18 showing increased behaviors, grabbing at staff, pulling at lights, walking fast down the hallway. Nursing staff able to redirect Resident 18 with moderate difficulty. RN made aware. Will monitor. December 23, 2012, at 9:45 AM, Resident 18 continues with increased behaviors. He is ambulating fast down hallways, and skipping down hallways. December 23, 2012, at 2:20 PM, Resident 18 is alert and was ambulating down east hallway around 1:30 PM. "Resident 18 aggressively pushed Resident 25 over in her merry walker. Resident 25 fell to floor. Resident 18 was removed from the situation and placed in a supervised area. RN made aware. MD notified." Resident 18 had 29 documented incidents of aggressive, agitated, and/or physical behavioral symptoms with staff or other residents prior to aggressively pushing Resident 25 over in her merry walker and causing her to fracture her left elbow. Clinical record review of Resident 18's chart revealed that during November 28, 2012 until December 23, 2012 the facility made five medication changes. Review of physician orders [REDACTED]. 11/28/12 Depakote 500 milligram (mg) twice a day for seizure disorder. 12/11/12 Seroquel 25 mg twice a day for behavioral disturbances. 12/18/12 Increase Seroquel to 100 mg twice a day. 12/20/12 Discontinue Aricept and Namenda. 12/23/12 Haldol 2 mg IM (intramuscularly) every 6 hours PRN (as needed) Continued review of Resident 18's clinical record revealed a physician's orders [REDACTED]. Clinical record review revealed that the facility initiated 15 minute checks on Resident 18 from December 8, 2012 through December 15, 2012 at which time the 15 minute checks were discontinued even though Resident 18 continued to exhibit behaviors of aggression, agitation, and physical behaviors. Review of the document entitled, "15 minute checks," dated December 10, 2012, at 3:00 AM indicated that Resident 18 was in the TV room sitting. Review of nursing documentation of Resident 18 dated December 10, 2012, at 3:00 AM revealed that "Resident (18) (was) awake, OOB (out of bed) in and out of other resident rooms. Difficult to redirect." Resident 18 was observed in room 212A trying to pull feeding tube out. Resident 18 was aggressive with staff, and arguing with his roommate. The nursing note entry and the entries on the 15 minute checks were conflicting. Continued review of the "15 minute check" sheet dated December 15, 2012, at 10:00 AM revealed that Resident 18 was in his bedroom, in bed. Review of nursing documentation dated December 15, 2012, at 10:00 AM revealed that Resident 18 "continues with behaviors, aggression, running down (the) hall, and pushing dining room chair down (the) hall. Increased difficulty to redirect Resident (18)." Again, the nursing documentation and the entries on the 15 minute checks were conflicting. Review of a document entitled, "Event Reporting Checklist for Resident to Resident Contact-Guardian Elder Care Event Report," dated December 23, 2012, indicated that corrective action for Resident 18 was to remove him from the situation and place him in a supervised area. Additional comments revealed that Resident 18 was to be placed on 15 minute checks for 3 days to evaluate further episodes of resident to resident contact. Clinical record review revealed that the facility re-initiated the 15 minute checks on Resident 18 on December 24, 2012, at 11:00 AM; 21 hours after Resident 18 aggressively pushed Resident 25 and her merry walker over, causing her to fall and fracture her left elbow. Nursing documentation dated December 23, 2012, at 4:00 PM revealed that Resident 18 continues with angry, aggressive behaviors. Resident 18 pushed another resident who was seated in a chair. Resident 18 was banging and attempting to get into the nurse's station and ambulating throughout the unit. Resident 18 entered other resident's rooms and when attempting to redirect, Resident 18 lashes out, and attempted to lunge towards staff. Resident 18's physician was notified and a new order for Haldol (antipsychotic medication) 2 mg IM (intramuscular) to be given every six hours whenever necessary for aggressive behavior. Clinical record review revealed that the facility initiated 15 minute checks on Resident 18 from December 24, 2012 through December 27, 2012 at 3:00 AM, at which time the 15 minute checks were discontinued, even though Resident 18 continued to exhibit behaviors of aggression, agitation, and physical behaviors. The physician added another medication change on December 24, 2012, to increase Resident 18's Seroquel (antipsychotic medication) to 200 mg twice a day. Nursing documentation dated December 27, 2012, at 2:05 PM revealed that Resident 18 "lunged (him) self at another resident, attempting to wrap (his) arms around the other residents neck." Staff intervened and Resident 18 fell to his knees behind the other resident's wheelchair. One on one observation was initiated. The RN and physician were notified. The physician ordered an increase in the Seroquel to 300 mg twice a day. The physician also discontinued the previous Haldol order and added a new order for Haldol 4 mg NOW and start Haldol 4 mg IM every 6 hours as needed. Nursing documentation dated December 28, 2012, at 5:15 PM revealed that Resident 18 had increased agitation. Resident 18 was swinging at staff and other residents. "Moved away from other residents. Resident still was swinging fists at staff and kicking at staff. Resident 18 grabbed the supper tray, and was throwing food. Resident 18 then grabbed at the dinner plate but the staff got the plate away from him before he threw it. Resident 18 was still swinging at staff, grabbing at chairs, and shoving tables." Clinical record review of Resident 18's Social Service documentation dated December 28, 2012, revealed that the facility initiated alternative placement for Resident 18 but was unsuccessful for placing him elsewhere. The physician order [REDACTED]." On December 28, 2012, the physician again wrote, "May have psych consult." There was no evidence that Resident 18 saw a psychiatrist until December 31, 2012. Nursing documentation for Resident 18 dated December 30, 2012, at 7:00 AM revealed that he became agitated towards his roommate. "PRN (as needed) med given." Nursing documentation dated December 30, 2012, at 5:00 PM revealed that at 3:40 PM Resident 18 was given Haldol 4 mg IM (intramuscular injection) because he came out of his room with his roommate's cane in his hand. Resident 18 was swinging the cane as he came down the hallway. Nursing staff was able to take the cane away from him and he was redirected back to his room. Nursing documentation dated December 31, 2012, at 7:30 AM revealed that Resident 18 was ambulating in the hallway in a brief and T-shirt. Resident 18 was observed to be incontinent of his bowels. Resident 18 was redirected back to his room, swinging at staff and running away from staff, eventually staff got him to the shower room where three nurse aides changed his brief. During this time, Resident 18 was swinging, kicking, and trying to punch staff. After Resident 18 was cleaned and dressed he was assisted to his room, and IM Haldol was injected. Nursing documentation indicated it required three nursing staff to assist with the administration of the Haldol. Clinical record review for Resident 18 revealed a document entitled, "Section D/E Mood and Behavior," care plan initiated September 27, 2012. Resident 18 is identified as having physical behavior towards others and behaviors that put residents and others, at significant risk for physical illness and injury. Aggressive behaviors such as pushing wheelchairs, getting into the nurse's station, etc. It also identifies wandering behavior in and out of other resident rooms. The goal for Resident 18 is not to have episodes of behavioral occurrences increase through the next review and to have a positive adjustment to facility and staff. Interventions include: Encouraging resident to verbalize feelings and concerns. Staff will breakdown tasks into steps to permit the resident to complete activities and activities of daily living. Remove resident from source of stimulation, which increases behavioral occurrences Leave resident, reapproach 10 minutes if increased anxiety is noted during care. Approach in a calm manner. Encourage to participate in diversion activities of resident's interest. Staff will provide as many opportunities as possible for resident to make choices regarding care. Monitor for changes in resident behavior and report findings to MD if noted. Secure unit. Redirect prn with snack and/or drink. Medications per order. When addressing him use positive facial expressions, and open posture to convey friendly demeanor. 10/19/12 Medications prn. 10/22/12 To see psychiatrist (this never happened until December 31, 2012) Put in supervised area, residents separated, MD notified, med ordered. 12/24/12 Every 15 minute checks for 72 hours. Resident 18's plan of care did not target identified behavior as it related to other residents safety as his behaviors escalated and he presented with increased aggression, agitation, and physical behavioral symptoms directed towards others. Interview on January 4, 2012, at 12:45 PM with the Administrator and Employee 1 (Social Service) confirmed that Resident 18 received an order for [REDACTED]. They also confirmed that alternative placement was not initiated until December 28, 2012. Interview on January 4, 2012, at 1:30 PM with the Administrator and Employee 2 (Corporate QA Nurse) confirmed the above interventions for Resident 18's behavior; however, there were not able to indicate that the facility consistently ensured adequate supervision to keep other residents of the facility safe. The facility failed to protect the safety and security of other residents, resulting in Resident 25 sustaining a fractured left elbow. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/2/12 and 11/1/12 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/2/12 and 12/6/12 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/2/12 and 12/6/12 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/2/12, 11/1/12, and 12/6/12

Based on clinical record review and staff interview, it was determined that the facility failed to maintain adequate supervision for resident safety for one of four sampled residents (Resident 18). Findings include: Clinical record review for Resident 18 revealed that the facility admitted him on September 27, 2012, with a [DIAGNOSES REDACTED]. A physician's progress note dated October 3, 2012, revealed that Resident 18 lived with his wife at home. His wife noticed an increased change in his mental status and he became more demented, paranoid, delusional, and aggressive. The resident's agitation increased to the point where his wife's life was in danger and he threatened to hurt her and kill her. Neighbors saw what was happening and called police and EMS. The resident was evaluated at the hospital and determined that he should be put in a Geriatric Psychiatric Ward, which resulted in his placement in the facility. Clinical record review for Resident 18 revealed nursing documentation starting on September 28, 2012, indicating that Resident 18 presented with increased aggression, agitation, and physical behavioral symptoms directed towards others. Nursing documentation revealed that Resident 18's aggressive, agitated, and physical behavioral symptoms continued until December 23, 2012, when he aggressively shoved Resident 25 while she ambulated in her merry walker (a device to aide in ambulation). Resident 25 sustained a fractured left elbow as a result of Resident 18's aggression. Review of Resident 18's nursing documentation revealed the following: September 28, 2012, at 2:00 AM, Found Resident 18 naked in another residents room yelling at a sleeping resident. October 14, 2012, at 9:40 PM, Resident 18 observed attempting to urinate in the wastebasket in the TV room. When another resident yelled at him to stop it and get out, he reportedly raised his hand above her head to strike her. November 19, 2012, at 5:00 AM, Resident 18 up most of the night continues to go into other resident rooms. Shows signs of frustration when redirected. November 22, 2012, at 4:00 AM, Resident 18 awake pacing the halls all shift, continues go into other resident rooms. Shows signs of frustration and anger when redirected. Also tried to direct another resident into his room but was stopped by staff. November 22, 2012, at 6:00 AM, Resident 18 was in another resident's room, when staff tried to redirect him he pushed staff and gestured that he was going to punch her. November 23, 2012, at 4:30 AM, Resident 18 awake this shift wandering hallways. Became angry with staff, pounded his hands on the nurse's station counter with increased frustration when staff did not know what he was trying to say. November 26, 2012, at 5:15 AM, Resident 18 awake walking the halls. Continues to go into others rooms. Takes others belongings. When staff try to redirect Resident 18, he is becoming more aggressive with increased frustration. November 30, 2012, at 5:30 AM, Resident 18 is becoming more bold and aggressive making fists and threating gestures. Note given to Social Service. December 8, 2012, at 9:50 AM, Resident 18 continues with increased behaviors. Ambulating in and out of other resident rooms. Wheeling others around the unit. December 9, 2012, at 2:00 AM, Resident 18 was antagonizing his roommate. Resident 18 was sitting on his roommate's bed with his roommate on it and Resident 18 was mimicking grunting sounds. Resident 18 is more difficult to redirect, and pushed staffs hand away as staff was attempting to escort him from his roommate's bed. December 10, 2012, at 3:00 AM, Resident 18 awake, OOB (out of bed) in and out of other resident room. Difficult to redirect. Was in room 212A trying to pull feeding tube (an artificial means of receiving nutrition by medically placing a tube in the stomach to receive nutrition) out. Aggressive with staff. Arguing with roommate. December 10, 2012, at 10:30 PM, Resident 18 was in and out of others rooms. Difficulty with redirection. Combative with staff in dining room. Refused to eat. December 11, 2012, at 6:00 AM, Resident 18 was very difficult to redirect. Arguing with roommate. Aggressive with staff. December 11, 2012, at 9:00 PM, Resident 18 combative with staff at 3:45 PM, unable to redirect. Resident jumping and skipping, pushing nurse's medication cart, trying to take medication book, cups, and straws off cart. December 12, 2012, at 11:15 PM, nursing staff were called to the shower room due to Resident 18 dancing on the wet floor in the shower room. The nurse aide was encouraging him to sit down in the shower chair and Resident 18 pushing back at the nurse aide's chest. At 9:30 PM Resident 18 was in the dining room picking at things that are not there. Resident 18 was found near a table using the bathroom on the floor in the dining room. When redirected to his room Resident 18 started laughing at staff. Change in behavior noted, acting childish and hard to redirect. December 14, 2012, at 1:58 PM, Aide (nurse aide) needed help in AM (morning) trying to get Resident 18 dressed and he pushed aide against the wall in the bathroom. December 15, 2012, at 6:00 AM, Resident 18 is trying to take papers off the nurse's desk when trying to redirect, Resident 18 raised fist to nurse. He is wandering into other resident rooms, verbal with roommate. December 15, 2012, at 10:00 AM, Resident 18 continues with behaviors, aggression, running down hall, pushing dining room chair down hall. Increased difficulty to redirect. December 15, 2012, at 8:45 PM, Resident 18 exhibiting childish acts, ambulating backwards in the hallway. Redirected with much difficulty. Resident 18 observed to have increased change in behavior and mental status. December 16, 2012, at 6:30 PM, Resident 18 combative when nurse asked to take temperature. The nurse showed resident what was going to be done. Resident 18 agreeable with stating OK. Resident 18 turned his head, when LPN (licensed practical nurse) tried to take his temperature Resident 18 resident swung his arms, pulled up his foot, and kicked the LPN in stomach. After dinner, Resident 18 started pushing trays off the table onto the floor, with redirection Resident 18 became combative pushing staff in the chest. With the assistance of three staff, Resident 18 was redirected to a safe place in the hallway. December 17, 2012, at 2:25 PM, Resident 18 observed with increased aggression and agitation. Resident 18 grabbed a hold of the railing at the nurse's station and ripped the railing off the wall. Resident 18 continued to grab the counter of the nurse's station and pull, attempting to tear it apart. Resident 18 pushing hands at staff, no contact made thus far, unable to redirect without difficulty. RN (registered nurse) made aware. December 18, 2012, at 11:20 AM, Resident 18's behavior continues to be erratic. He is hopping down the hall. Resident 18 will move at staff and residents quickly then spins around and goes the other way. December 19, 2012, at 6:25 PM, Resident 18 ambulating down the hallway with trash can in hand. Trash can taken away by nursing staff. Resident 18 observed skipping and dancing in the hallway. December 20, 2012, at 10:30 PM, found in Resident 18's room observed to be picking on resident in Bed-A, throwing hands at Bed-A, and pulling on curtain between beds. Resident 18 was observed to be jumping and dancing. December 21, 2012, at 10:50 AM, Resident 18 was pushing other resident's and staff in AM. Nursing staff able to get Resident 18 into bed in AM. Sleeping at that time. Resident 18 and roommate continue with yelling at each other. Roommate agitated in AM, hollering, complaints of wanting to get out of here. Resident 18 observed to have increased agitation when roommate agitated. Resident 18 appears tired. December 21, 2012, at 7:00 PM, Resident 18 observed getting out of his chair in the dining room, walked over to another table and stood up on the chairs. Resident 18 then started hopping from one chair to another chair when staff tried to redirect him. Resident 18 came down from the chair when there were no other chairs to hop onto. Resident 18 ambulated in the hallway, and then was observed going in and out of rooms. Resident 18 was lying on the floor in the dining room. Laid self down, crawled around picking things (up) from (the) floor that were not there. December 22, 2012, at 6:00 AM, Resident 18 attempts to run in hallways, attempts to stand on chairs. He is not able to follow a simple request such as, please sit down. Resident 18 is intrusive into others rooms. December 22, 2012, at 10:45 AM, Resident 18 showing increased behaviors, grabbing at staff, pulling at lights, walking fast down the hallway. Nursing staff able to redirect Resident 18 with moderate difficulty. RN made aware. Will monitor. December 23, 2012, at 9:45 AM, Resident 18 continues with increased behaviors. He is ambulating fast down hallways, and skipping down hallways. December 23, 2012, at 2:20 PM, Resident 18 is alert and was ambulating down east hallway around 1:30 PM. Resident 18 aggressively pushed Resident 25 over in her merry walker. Resident 25 fell to floor. Resident 18 was removed from the situation and placed in a supervised area. RN made aware. MD notified. Resident 18 had 29 documented incidents of aggressive, agitated, and/or physical behavioral symptoms with staff or other residents prior to aggressively pushing Resident 25 over in her merry walker and causing her to fracture her left elbow. Clinical record review of Resident 18's chart revealed that during November 28, 2012 until December 23, 2012 the facility made five medication changes. Review of physician orders [REDACTED]. 11/28/12 Depakote 500 milligram (mg) twice a day for seizure disorder. 12/11/12 Seroquel 25 mg twice a day for behavioral disturbances. 12/18/12 Increase Seroquel to 100 mg twice a day. 12/20/12 Discontinue Aricept and Namenda. 12/23/12 Haldol 2 mg IM (intramuscularly) every 6 hours PRN (as needed) Continued review of Resident 18's clinical record revealed a physician's orders [REDACTED]. Clinical record review revealed that the facility initiated 15 minute checks on Resident 18 from December 8, 2012 through December 15, 2012 at which time the 15 minute checks were discontinued even though Resident 18 continued to exhibit behaviors of aggression, agitation, and physical behaviors. Review of the document entitled, 15 minute checks, dated December 10, 2012, at 3:00 AM indicated that Resident 18 was in the TV room sitting. Review of nursing documentation of Resident 18 dated December 10, 2012, at 3:00 AM revealed that Resident (18) (was) awake, OOB (out of bed) in and out of other resident rooms. Difficult to redirect. Resident 18 was observed in room 212A trying to pull feeding tube out. Resident 18 was aggressive with staff, and arguing with his roommate. The nursing note entry and the entries on the 15 minute checks were conflicting. Continued review of the 15 minute check sheet dated December 15, 2012, at 10:00 AM revealed that Resident 18 was in his bedroom, in bed. Review of nursing documentation dated December 15, 2012, at 10:00 AM revealed that Resident 18 continues with behaviors, aggression, running down (the) hall, and pushing dining room chair down (the) hall. Increased difficulty to redirect Resident (18). Again, the nursing documentation and the entries on the 15 minute checks were conflicting. Review of a document entitled, Event Reporting Checklist for Resident to Resident Contact-Guardian Elder Care Event Report, dated December 23, 2012, indicated that corrective action for Resident 18 was to remove him from the situation and place him in a supervised area. Additional comments revealed that Resident 18 was to be placed on 15 minute checks for 3 days to evaluate further episodes of resident to resident contact. Clinical record review revealed that the facility re-initiated the 15 minute checks on Resident 18 on December 24, 2012, at 11:00 AM; 21 hours after Resident 18 aggressively pushed Resident 25 and her merry walker over, causing her to fall and fracture her left elbow. Nursing documentation dated December 23, 2012, at 4:00 PM revealed that Resident 18 continues with angry, aggressive behaviors. Resident 18 pushed another resident who was seated in a chair. Resident 18 was banging and attempting to get into the nurse's station and ambulating throughout the unit. Resident 18 entered other resident's rooms and when attempting to redirect, Resident 18 lashes out, and attempted to lunge towards staff. Resident 18's physician was notified and a new order for Haldol (antipsychotic medication) 2 mg IM (intramuscular) to be given every six hours whenever necessary for aggressive behavior. Clinical record review revealed that the facility initiated 15 minute checks on Resident 18 from December 24, 2012 through December 27, 2012 at 3:00 AM, at which time the 15 minute checks were discontinued, even though Resident 18 continued to exhibit behaviors of aggression, agitation, and physical behaviors. The physician added another medication change on December 24, 2012, to increase Resident 18's Seroquel (antipsychotic medication) to 200 mg twice a day. Nursing documentation dated December 27, 2012, at 2:05 PM revealed that Resident 18 lunged (him) self at another resident, attempting to wrap (his) arms around the other residents neck. Staff intervened and Resident 18 fell to his knees behind the other resident's wheelchair. One on one observation was initiated. The RN and physician were notified. The physician ordered an increase in the Seroquel to 300 mg twice a day. The physician also discontinued the previous Haldol order and added a new order for Haldol 4 mg NOW and start Haldol 4 mg IM every 6 hours as needed. Nursing documentation dated December 28, 2012, at 5:15 PM revealed that Resident 18 had increased agitation. Resident 18 was swinging at staff and other residents. Moved away from other residents. Resident still was swinging fists at staff and kicking at staff. Resident 18 grabbed the supper tray, and was throwing food. Resident 18 then grabbed at the dinner plate but the staff got the plate away from him before he threw it. Resident 18 was still swinging at staff, grabbing at chairs, and shoving tables. Clinical record review of Resident 18's Social Service documentation dated December 28, 2012, revealed that the facility initiated alternative placement for Resident 18 but was unsuccessful for placing him elsewhere. The physician order [REDACTED]. On December 28, 2012, the physician again wrote, May have psych consult. There was no evidence that Resident 18 saw a psychiatrist until December 31, 2012. Nursing documentation for Resident 18 dated December 30, 2012, at 7:00 AM revealed that he became agitated towards his roommate. PRN (as needed) med given. Nursing documentation dated December 30, 2012, at 5:00 PM revealed that at 3:40 PM Resident 18 was given Haldol 4 mg IM (intramuscular injection) because he came out of his room with his roommate's cane in his hand. Resident 18 was swinging the cane as he came down the hallway. Nursing staff was able to take the cane away from him and he was redirected back to his room. Nursing documentation dated December 31, 2012, at 7:30 AM revealed that Resident 18 was ambulating in the hallway in a brief and T-shirt. Resident 18 was observed to be incontinent of his bowels. Resident 18 was redirected back to his room, swinging at staff and running away from staff, eventually staff got him to the shower room where three nurse aides changed his brief. During this time, Resident 18 was swinging, kicking, and trying to punch staff. After Resident 18 was cleaned and dressed he was assisted to his room, and IM Haldol was injected. Nursing documentation indicated it required three nursing staff to assist with the administration of the Haldol. Clinical record review for Resident 18 revealed a document entitled, Section D/E Mood and Behavior, care plan initiated September 27, 2012. Resident 18 is identified as having physical behavior towards others and behaviors that put residents and others, at significant risk for physical illness and injury. Aggressive behaviors such as pushing wheelchairs, getting into the nurse's station, etc. It also identifies wandering behavior in and out of other resident rooms. The goal for Resident 18 is not to have episodes of behavioral occurrences increase through the next review and to have a positive adjustment to facility and staff. Interventions include: Encouraging resident to verbalize feelings and concerns. Staff will breakdown tasks into steps to permit the resident to complete activities and activities of daily living. Remove resident from source of stimulation, which increases behavioral occurrences Leave resident, reapproach 10 minutes if increased anxiety is noted during care. Approach in a calm manner. Encourage to participate in diversion activities of resident's interest. Staff will provide as many opportunities as possible for resident to make choices regarding care. Monitor for changes in resident behavior and report findings to MD if noted. Secure unit. Redirect prn with snack and/or drink. Medications per order. When addressing him use positive facial expressions, and open posture to convey friendly demeanor. 10/19/12 Medications prn. 10/22/12 To see psychiatrist (this never happened until December 31, 2012) Put in supervised area, residents separated, MD notified, med ordered. 12/24/12 Every 15 minute checks for 72 hours. Resident 18's plan of care did not target identified behavior as it related to other residents safety as his behaviors escalated and he presented with increased aggression, agitation, and physical behavioral symptoms directed towards others. Interview on January 4, 2012, at 12:45 PM with the Administrator and Employee 1 (Social Service) confirmed that Resident 18 received an order for [REDACTED]. They also confirmed that alternative placement was not initiated until December 28, 2012. Interview on January 4, 2012, at 1:30 PM with the Administrator and Employee 2 (Corporate QA Nurse) confirmed the above interventions for Resident 18's behavior; however, there were not able to indicate that the facility consistently ensured adequate supervision to keep other residents of the facility safe. The facility failed to protect the safety and security of other residents, resulting in Resident 25 sustaining a fractured left elbow. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/2/12 and 11/1/12 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/2/12 and 12/6/12 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/2/12 and 12/6/12 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/2/12, 11/1/12, and 12/6/12