Every finding on record at Hollidaysburg Veterans Home

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.Findings include:The facility's policy for food storage, dated January 1, 2026, revealed that all prepared items would be covered, labeled and dated clearly. Observations in the main kitchen on June 8, 2026, at 9:13 a.m. revealed that a stand up fan had a build up of black dust and debris on the cage and was blowing towards the food prep area; and at 9:33 a.m. in the walk-in freezer located in the basement, there were 11 birthday gobs that were not dated. Interviews with the Dietary Manager on June 8, 2026, at 9:13 a.m. and 9:33 a.m. confirmed that the dirty fan should not have been blowing towards the food prep area and needed cleaned, and the gobs should have been dated. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures. Findings include:The facility's policy regarding food temperatures, dated January 1, 2026, indicated that all hot foods were to be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F).Interview with a group of residents on June 10, 2026 at 2:00 p.m. revealed that the hot food is served warm or cold and that asking staff to reheat it in the microwave takes too much time. They stated that the residents that eat in their rooms are served first causing the food that sits in the dining room to cool down before the residents in the dining room are served. Interview with Resident 31 on June 8, 2026 at 12:14 p.m. revealed that the food is cold, the soup is always served cold, and that the plates are even cold. Interview with Resident 48 on June 8, 2026 at 12:19 p.m. revealed that the food is cold. She said that the food is barely warm when it reaches her and gets very cold before she has the chance to eat it. Interview with Resident 73 on June 8, 2026 at 12:10 p.m. revealed that the food is always cold. He stated that there are no plate warmers, no warm pallets for the plates to rest on, and no steam tables to keep the food warm. Interview with Resident 89 on June 8, 2026 at 12:15 p.m. revealed that the food is cold no matter if he eats in his room or in the dining room. He stated that he prefers to have hot food and especially hot soup. Observations in the North 1 dining room for the lunch meal service on June 10, 2026, at 11:53 a.m., revealed the lunch meal consisted of chicken tenders, mashed potatoes, corn, diced pears and a salad. The last resident to be served in the dining room was at 12:34 p.m. The test tray on June 10, 2026, at 12:35 p.m. revealed that the temperature of the chicken tenders was 141.0 degrees (F), mashed potatoes was 124.5 degrees (F) and the corn was 116.0 degrees (F). The mashed potatoes and corn were not hot and were not served at the appropriate temperatures. Interview with [NAME] 6 on June 10, 2026, at 12:45 p.m. confirmed that food should be served at a temperature of 140 degrees (F) or higher.28 Pa. Code 211.6(f) Dietary Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 56 residents reviewed (Resident 90).Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. For Enhanced Barrier Precautions, signage should clearly indicate the high-contact resident care activities that require the use of gown and gloves, and PPE, including gowns and gloves, and should be available immediately outside of the resident room. The facility's policy regarding EBP, dated January 1, 2026, indicated that EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents, and an order for EBP will be obtained for residents with any of the following: Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDR. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Clear signage would be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Gowns and gloves would be available immediately outside of the resident's room. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 90, dated May 13, 2026, indicated that the resident was cognitively impaired, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis of neurogenic bladder (bladder lacks control due to nerve or muscle problems) and obstructive uropathy (blockage in the urinary system). Physician's orders for Resident 90, dated February 4 and April 28, 2026, included an order for the resident to have EBP and a urinary (foley) catheter (an indwelling catheter). A care plan for Resident 90, dated May 21, 2026, revealed that the resident had an indwelling foley catheter and staff were to use PPE for EBP that included gowns and gloves while providing close contact care. Observations on June 10, 2026, at 9:18 a.m. revealed that Resident 90 was in bed and the wash basin that his urinary catheter bag was in was tipped on it's side, causing the urinary catheter bag to be in contact with the floor. There was no sign posted outside the resident's room to indicate the resident was on EBP and there was no PPE available outside of the resident's room. At 9:24 a.m. Nurse Aide 7 repositioned the resident's catheter and did not use proper PPE. An interview with Nurse Aide 7 at that time revealed that she thought Resident 90 was not on EBP. An interview with Licensed Practical Nurse 8 on June 10, 2026, at 9:29 a.m. confirmed that Resident 90 was to be on EBP and that there was no sign posted or PPE available outside of his room. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of the facility policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the appropriate instructions for administration for two of 56 residents reviewed (Resident 66, 83). Findings include: The facility's policy regarding medication administration and labeling, dated January 1, 2026, indicated that it is the purpose to provide guidance regarding medication administration to be in accordance with good nursing principles and practices and only by people legally authorized to do so. Labels for individual drug containers must include directions for use. Only the container in which a prescription drug or device is sold or dispensed to the ultimate consumer shall bear a label which shall be written in ink, typed or computer generated and shall contain full directions for the use of its contents. Manufacturer's directions for the use of Jardiance (used to manage diabetes) dated April 2026, revealed that Jardiance should not be split, broken or crushed, this may affect the medications absorption and stability. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated March 23, 2026, revealed that the resident was cognitively impaired, was dependent on staff for all his daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 66, dated July 24, 2025 included an order for the resident to receive 25 milligrams (mg) of Jardiance once a day. Observations of medication administration for Resident 66 on June 10, 2026, at 09:15 a.m. revealed that Licensed Practical Nurse 4 prepared the resident's medications, including Jardiance, by crushing it and then proceeded to administer the crushed medication to the resident. Interview with Licensed Practical Nurse 4 on June 10, 2026, at 11:20 a.m. revealed that she was unaware that she should not have crushed Jardiance, and that the medication package should have indicated do not crush if it was not supposed to be crushed and it did not. A quarterly MDS assessment for Resident 83, dated April 21, 2026, revealed that the resident was cognitively intact, required assistance with his daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 83, dated July 5, 2025, included an order for the resident to receive 10 mg Jardiance once a day. Observation of the [NAME] 2 medication cart June 10, 2026, at 11:20 a.m. revealed a medication card of 10 mg Jardiance for Resident 83. The medication card was not labeled with a do not crush label. Interview with Pharmacist 5 on June 11, 2026, at 2:08 p.m. confirmed that Jardiance should not be crushed and that that medication cards should contain a do not crush label to alert staff. Interview with the Nursing Home Administrator June 11, 2026, at 2:10 p.m. confirmed that the medication should not have been crushed and that medication cards should be labeled do not crush if the medication should not be crushed. 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to administer a resident's continuous oxygen as ordered for one of 56 residents reviewed (Resident 174).Findings include:The facility's policy regarding oxygen therapy, dated January 1, 2026, indicated that supplemental oxygen therapy is provided and monitored for residents as per the provider's order, or in emergency situations, for the ease and comfort of respiratory effort and disease symptom management.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 174 dated June 4, 2026, indicated that the resident was cognitively intact, required supervision with daily care needs, received oxygen therapy, and had a diagnosis of chronic obstructive pulmonary disease (COPD- a disease that causes airflow blockage and breathing-related problems).Physician's orders for Resident 174, dated May 28, 2026, included an order for the resident to receive continuous oxygen at a flow rate of 5 liters per minute (LPM) via nasal cannula (tubes that deliver oxygen into the nostrils) every shift.Observations of Resident 174 on June 9, 2026, at 10:22 a.m. revealed that the resident was using his wheelchair to go back to his room from the dining room with an oxygen tank on the back of his wheelchair. The oxygen tank was set at 5 LPM and the tank was reading empty. An interview with Registered Nurse 3 on June 8, 2026, at 12:41 p.m. confirmed that the resident's oxygen tank was empty. Interview with the Nursing Home Administrator on June 8, 2026, at 3:00 p.m. confirmed that Resident 174's oxygen tank should have been checked and replaced.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 56 residents reviewed (Resident 5) who had a feeding tube.Findings include: A facility policy for feeding tubes, dated January 1, 2026, indicated that feeding tube use occurs based on current clinical standards of practice with the intent to maintain the resident's nutrition and hydration status within acceptable parameter and decrease the risk of complications from use. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 20, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube. Physician's orders for Resident 5, dated March 27, 2026, included orders for the resident to receive Novasource (a tube feeding formula) at 250 milliliters/hour as needed if the resident ate less than 50% for breakfast, lunch and dinner. Review of Resident 5's meal intakes for March, April, May and June 2026 revealed that the resident did not eat breakfast on March 27; did not eat breakfast on March 28, 29, 30, 31, April 1, 2, 3, 5, 7, 8, 9, 11, 12, 13, 14, ate 1-25% of lunch on April 15; did not eat breakfast on April 16, 17, 18, 21, 23, 25, 29, 30, May 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 17, 18, 19, 21, 22, 23, 26, 27, 28; ate 1-25 % of lunch on May 29; did not eat breakfast on May 30, June 2, 4; did not eat dinner on June 5; did not eat breakfast on June 6; did not eat dinner on June 8; did not eat lunch on June 9, 10; and did not eat breakfast on June 11, 2026. There was no documented evidence in the resident's clinical record that the resident refused or was offered the Novasource via feeding tube as ordered by the physician. Interview with Registered Dietitians 1 and 2 on June 10, 2026, at 2:07 p.m. confirmed that there was no documentation that the resident refused or was offered the Novasource via feeding tube as ordered by the physician. Interview with the Nursing Home Administrator on June 10, 2026, at 3:00 p.m. confirmed that there was no documentation that the resident refused or was offered the Novasource via feeding tube as ordered by the physician. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of six residents reviewed (Resident 3) resulting in a fall with fracture. This deficiency is being cited as past non-compliance.Findings include: A facility policy regarding resident falls dated January 1, 2026, that all unwitnessed falls or a known strike to the head or neck required the neurological evaluation process. A significant change minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated May 1, 2026, revealed that the resident was cognitively impaired, was occasionally incontinent of urine, and required substantial assistance with toileting hygiene. The resident's care plan, updated April 20, 2026, revealed that the resident had potential for falls and required his urinal to be kept at the bedside. A nursing note following a fall, dated April 14, 2026, indicated that Resident 3 stated he was trying to use his urinal but could not get his fancy pants off, referring to his pull up brief. Resident 3 was noted to be without socks and was incontinent of urine. He had an area of abrasion/bruising noted to left knee measuring 2.0 centimeters (cm) long x 0.6 cm wide and multiple bruises noted to left arm. There was an area above the elbow 4.0 inches (in) long x 0.5 in wide, an area on the mid forearm 2.0 cm long x 1.0 cm wide, an area above the wrist 3.0 in long x 2.0 in wide, and on the wrist 3.5 inches in diameter. A fall investigation for Resident 3, dated April 14, 2026, at 10:30 p.m. revealed that the resident was getting up to use his urinal and was unable to get his pants down. The immediate intervention was to have staff offer toileting assistance on rounds and the resident was to start a bowel and bladder program. Staff would encourage Resident 3 to use his urinal at the bedside. A nursing note dated May 3, 2026, at 10:42 p.m. indicated that Resident 3 was found on the floor perpendicular to the bed. Resident stated he was trying to use the urinal and when he reached forward, he fell out of bed onto the floor, hitting his head. Resident 3 was noted to have urinated on himself. He was noted to have a purple quarter sized mark on the middle of his forehead. Resident 3 was sent to the hospital for evaluation and treatment. A fall investigation for Resident 3, dated May 3, 2026, at 11:07 p.m. revealed that the resident was attempting to use the bedside urinal, and as he was reaching for the urinal he fell out of bed. The immediate intervention was to send the resident to the emergency room for further evaluation due to him hitting his head when he fell out of bed. Neurological checks were started and Resident 3 would be placed on frequent checks (15 minute checks) upon return from the hospital. A witness statement by Licensed Practical Nurse (LPN) 6 on May 3, 2026, at 10:30 p.m. indicated that Resident 3's call bell was activated. He fell out of bed onto the floor, hitting his head. Resident 3 was wearing regular socks. A witness statement by Registered Nurse (RN) 1 on May 4, 2026, not timed, indicated that he was on break when Resident 3 fell and was sent to the hospital. Resident 3 left the facility at 10:52 p.m. for the hospital and returned on May 4, 2026 at approximately 1:40 a.m. There was no documented evidence in Resident 3's clinical record to indicate that 15 minute checks were initiated upon his return from the hospital. A nursing note for Resident 3, dated May 4, 2026, at 6:41 a.m. revealed that the resident was found on the floor at 4:30 a.m. The resident had his pants around his knees from apparently trying to stand to use his urinal. The resident had a 1.5 cm X 0.5 cm skin tear to his right elbow which was cleaned and dressed, he also reported right hip pain. The resident was sent to the hospital for further evaluation. Hospital records for Resident 3 dated May 4, 2026, revealed the diagnosis of a right hip fracture due to a ground level fall. A witness statement with Nurse Aide 2 on May 4, 2026 at 4:30 a.m., revealed while doing 15 minute rounds at approximately on May 4, 2026, 4:15 a.m. Resident 3 was heard moaning and was found on the floor. A witness statement with Nurse Aide 2 on May 7, 2026, indicated that she assisted the resident to the bathroom at 3:30 a.m. on May 4, 2026, at 4:15 p.m. the Resident 3 was sleeping, and then at 4:30 a.m. the resident was found on the floor. A subsequent witness statement by RN 1 on May 4, 2026, at 11:19 a.m. revealed that he only completed the neurological checks and the initial set of vitals upon Resident 3's return from the hospital. RN 1 couldn't find a neurological check sheet so he started a new one, starting with the time of 10:30 p.m. RN 1 left the neurological check sheet with the other time increments so other staff could fill them in. When Resident 3 came back from the hospital RN 1 started with the 1:30 a.m. slot. RN 1 only filled out the 1:30 a.m. time slot. Resident 4 was good, alert and talking, acting like his normal self. A witness statement by RNS 3 on May 6, 2026, at 2:58 p.m. revealed that he was not informed to add any interventions to Resident 3's plan of care when he returned. RNS 3 completed a neurological check at 4:30 a.m. after the second fall. The resident was not wearing an incontinent brief at the time and was only wearing pants, and he was not incontinent at the time of the fall. Resident 3 was confused and could not express what happened. An interview with Quality Assurance Registered Nurse on May 26, 2026 confirmed that there was no documented evidence of neurological checks and no documented evidence that frequent checks (15 minute checks) were initiated as fall interventions after Resident 3 returned from the hospital on May 4, 2026 at 1:30 a.m. Following the incident on May 4, 2026, the facility's corrective actions included: 1. On May 3rd and May 4, 2026 the resident experienced two falls in a short period of time, after the first fall an effective root cause analysis was not identified, and appropriate interventions were not put into place which put the resident at an increased risk to experience the second fall. 2. Any residents experiencing a fall has the potential to be affected by the same deficient practice. All resident falls that occurred 30 days prior to the identification of the deficient practice will be audited to verify that an appropriate root cause analysis (RCA) was identified and a corresponding immediate intervention and care plan update when appropriate. Corrective action completion date: May 11, 2026 3. Education records, dated May 8, 9, 10, 11, 12, 13, 14, 17, 20, 2026 revealed that 90 percent of the Registered Nurses received education regarding the Incident and Accident policy with and emphasis placed on the timely and accurate completion of RCAs and implementation of corresponding immediate interventions. Education also included requirements for completion and documentation of a post-fall RN assessment, as well as obtaining and reviewing staff witness statements. Additional education was provided regarding thorough review of resident care plans and appropriateness of interventions, ensuring care plans are updated with the date of review and/or care plan changes for residents returning from hospitalization related to falls or those experiencing frequent falls within a short period of time. The remaining two registered nurses will receive education prior to their next scheduled shift. Corrective action completion date: May 20, 2026 4. The Director of Nursing or designee will provide ongoing auditing to be completed following each resident fall to observe for identification of an appropriate RCA and implementation of corresponding immediate interventions, including care plan updates when appropriate. During completion of audit, any identified concerns will result in corrective action, with the concern documented and monitored through completion. These audits will continue for a period of 6 months, and the results will be reviewed during the Quality Assurance Committee Meeting to determine whether additional interventions and monitoring is necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on May 20, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of six residents reviewed (Resident 2). The facility's policy regarding changes in condition, dated January 1, 2026, indicated that when there was a change in the resident's condition, staff would notify the covering Registered Nurse who would then update the supervisor, physician, and family.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 29, 2026, revealed that the resident was cognitively intact, had diagnoses that included chronic obstructive pulmonary disease (a progressive, incurable lung disease that restricts airflow, making it difficult to breath, and used a CPAP (a Continuous Positive Airway Pressure) machine to provide pressured oxygen through a mask to keep his airway open.A progress note for Resident 2, dated May 18, 2026, at 1:19 a.m. indicated that the CPAP machine was observed to be unavailable.Interview with Resident 2, on May 26, 2026, at 11:51 a.m. indicated that when he was at home and the CPAP machine needed fixed/cleaned, the medical supply company gave him a replacement until his was repaired. He further indicted that it bothered him very much to not have his machine and that he could not sleep well. He indicated that he used his oxygen at night but that was not the same as his CPAP machine. At the time of the investigation the CPAP machine was in his room and functioning. Interview with Registered Nurse (RN) Supervisor 4 on May 26, 2026, at 12:25 p.m. indicated that she investigated the concern regarding Resident 2's CPAP machine being unavailable. She indicated that On May 13, 2026, the machine was taken by adaptive/maintenance to change the filters and fix a broken magnet on the strap of the appliance. Maintenance told Licensed Practical Nurse 5 that they were taking the residents CPAP machine to make repairs. There was no communication between the LPN and the RN regarding the removal of the CPAP machine from the residents room. She went on to say that there was some difficulty acquiring the correct filters and with adequately fixing the magnet on the strap. Therefore, the resident was without his CPAP machine from May 13, 2026, until approximately May 22, 2026. RN Supervisor 4 indicated that on May 18, 2026, the computer flagged a notice regarding the machine and that is how she became aware of the situation. At that time she made the physician aware of the situation. She indicated that if the appropriate staff would have been notified as per the procedure, then the provider may have made recommendations and/or a replacement CPAP machine may have been provided.There was no documented evidence that the physician was notified on May 13, 2026, regarding the resident's CPAP machine needing repairs and consequently becoming unavailable to Resident 2 for sleep.Interview with the Director of Nursing on May 26, 2026, at 3:00 p.m. confirmed that there was no documented evidence that the physician was notified timely when Resident 2's CPAP machine was unavailable for him to use, and he should have been.28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide scheduled toileting following a fall for one of six residents reviewed (Residents 3).Findings include:The facility policy for urinary catheter care, dated January 8, 2026, indicated that changing indwelling catheters or drainage bags at routine, fixed intervals, was not recommended. Rather it was suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised.An email was sent on March 11, 2026 for nursing supervisors to discuss incontinent care with no double briefing- toileting and changing residents every two hours documentation needs to be in point of care (POC) with all care, staff cannot block chart at the beginning of their shift and then the resident falls and it appears via documentation that the resident hasn't been changed all shift. The blue tile for incontinent care in POC changes to white after the first entry, but they can continue to add in rounds every two hours even though the tile is white.A significant change minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 3, dated May 1, 2026, revealed that the resident was always understood and always understood others, cognitively impaired, and was occasionally incontinent of urine, and required substantial assistance with toileting hygiene. The resident's care plan, dated September 22, 2025, revealed that the resident had a urinary incontinence and required to wears pull ups at all times for management of incontinence and dignity purposes. Check the pull up every two hours, and assist with perineal hygiene and management of incontinence products/clothing if noted to be soiled or wet. nursing note following a fall, dated April 14, 2026, indicated that Resident 3 stated he was trying to use his urinal but could not get his fancy pants off, referring to his pull up brief. Resident 3 was noted to be without socks and was incontinent of urine. He had an area of abrasion/bruising noted to left knee measuring 2.0 centimeters (cm) long x 0.6 cm wide and multiple bruises noted to left arm. There was an area above the elbow 4.0 inches (in) long x 0.5 in wide, an area on the mid forearm 2.0 cm long x 1.0 cm wide, an area above the wrist 3.0 in long x 2.0 in wide, and on the wrist 3.5 inches in diameter. A fall investigation for Resident 3, dated April 14, 2026, at 10:30 p.m. revealed that the resident was getting up to use his urinal and was unable to get his pants down. The immediate intervention was to have staff offer toileting assistance on rounds and the resident was to start a bowel and bladder program. Staff would encourage Resident 3 to use his urinal at the bedside. A nursing note dated May 3, 2026, at 10:42 p.m. indicated that Resident 3 was found on the floor perpendicular to the bed. Resident stated he was trying to use the urinal and when he reached forward, he fell out of bed onto the floor, hitting his head. Resident 3 was noted to have urinated on himself. He was noted to have a purple quarter sized mark on the middle of his forehead. Resident 3 was sent to the hospital for evaluation and treatment. A fall investigation for Resident 3, dated May 3, 2026, at 11:07 p.m. revealed that the resident was attempting to use the bedside urinal, and as he was reaching for the urinal he fell out of bed. The immediate intervention was to send the resident to the emergency room for further evaluation due to him hitting his head when he fell out of bed. Neurological checks were started and Resident 3 would be placed on frequent checks (15 minute checks) upon return from the hospital. Resident 3 returned from the hospital on May 4, 2026 at approximately 1:40 a.m. A nursing note dated May 4, 2026, at 6:41 a.m. indicated that Resident 3 was found on the floor. The resident had his pants around his knees from apparently trying to stand to use his urinal. The resident had a 1.5 cm X 0.5 cm skin tear to right elbow which was cleaned and dressed, he also reported right hip pain. The resident was sent to the hospital for further evaluation. Hospital records for Resident 3 dated May 4, 2026, revealed that he was diagnosed with a right hip fracture due to a ground level fall. A witness statement by Licensed Practical Nurse (LPN) 6 on May 3, 2026, at 10:30 indicated the Resident 3's call bell was activated. He fell out of bed onto the floor, hitting his head. Resident 3 was wearing regular socks. Resident 3 left the facility at 10:52 p.m. for the hospital.A witness statement by Registered Nurse (RN) 1 on May 4, 2026, not timed, indicated that he was on break when Resident 3 fell and was sent to the hospital. A witness statement by RN 1 on May 4, 2026, at 11:19 a.m. revealed that he only completed the neurological checks and the initial set and vitals upon his return from the hospital. He completed the neurological checks and got his vitals when the resident came back from the hospital. RN 1 couldn't find a neurological sheet so he started a new one, and on the sheets it started with the time of 10:30 p.m. RN1 left the neurological check sheet with the other time increments so another staff could have filled them in. RN1 started with the 1:30 a.m. slot noting he came back from the hospital. I only filled out that 1:30 a.m. time slot. Resident 4 was good, alert and talking, acting like his normal self. Now when he fell on May 4,2026, at 4:40 a.m. Registered Nurse Supervisor (RNS) 3 started a new neurological check sheet, entering the one set, then Resident 3 was sent out to the hospital.A witness statement with Nurse Aide 2 on May 4, 2026 at 4:30 a.m., revealed while doing 15 minute rounds at approximately on May 4, 2026, 4:15 a.m. Resident 3 was heard moaning and was found on the floor. A witness statement with Nurse Aide 2 on May 7, 2026, not timed, indicated that she assisted the resident to the bathroom at 3:30 a.m. on May 4, 2026, at 4:15 p.m. the Resident 3 was sleeping, and then at 4:30 a.m. the resident was found on the floor.A witness statement by RNS 3 on May 6, 2026, at 2:58 p.m. revealed that frequent checks (15 minute checks) were started when he returned from the hospital at 1:40 a.m. on May 4, 2026. RNS 3 was no informed to add any interventions to Resident 3's plan of care when he returned. RNS 3 completed a neurological check at 4:30 a.m. after the second fall. The resident was not wearing an incontinent brief at the time and was only wearing pants, and he was not incontinent at the time of the fall. Resident 3 was confused and could not express what happened. A review of toileting documentation revealed that staff did not document every two hours as care planned, Some staff document when they toilet Resident 3 and others will only document once per shift. Interview with the Director of Nursing on May 26, 2026, at 4:55 p.m. confirmed that there was no documented evidence that Resident 3's was toileted every two hours as a fall intervention. This has been a problem and multiple educations have been sent out to staff with instructions on how to document toileting and care.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for assisting with Activities of Daily Living (ADL's) and preventing falls for one of seven residents reviewed (Resident 3), resulting in a fall and fracture for the resident. This deficiency was cited as Past Non-Compliance.Findings include: The facility's policy regarding resident abuse, dated January 5, 2026, revealed that the facility will provide protections for health, safety, welfare, and rights of each resident residing in the nursing home by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraints not required to treat a resident's medical condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 6, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was dependent with transfers, and had medical diagnoses that included Parkinsons, dementia, and orthostatic hypotension. A care plan, dated December 30, 2025, revealed that Resident 3 had a potential for falls related to new environment, adjustment to nursing home placement, presence of tremor, orthostatic hypotension, Parkinson's and impaired mobility. Transfer status was to use a full mechanical lift (a medical device designed to safely transfer individuals with limited mobility between position, such as bed to wheelchair or to the bathroom using manual hydraulic or electric power to reduce caregiver strain) for all transfers using a large sling size. A nursing note for Resident 3, dated January 19, 2026, at 8:36 p.m. revealed that the nurse was informed by staff that the resident had fallen from the mechanical body lift. The nurse entered the room, and the resident was observed lying on his right side between the legs of the mechanical body lift with his head located by the center post of the lift located at the doorway in the resident's room. The mechanical lift was safely pulled away from the resident while staff maintained proper head/neck alignment. The sling was observed in same position on hooks of lift while being moved. The mechanical body lift legs were observed in the closed position. The mechanical body lift arm was observed in high position. Blood was observed along the occipital region of Resident 3's head to the left ear and on the floor from a head laceration. Pressure was applied with gauze and bleeding was controlled. Resident 3 complained of headache, pain in the back of the head, neck pain, and back pain. A nursing note for Resident 3, dated January 19, 2026, at 8:59 p.m. revealed that the resident was admitted to the hospital with a diagnosis of scalp laceration requiring staples, closed head injury and a fracture at the sixth thoracic (middle of the back) vertebrae (spine). A statement completed by Nurse Aide 1, dated January 19, 2026, revealed that she was assisting another nurse aide to get the resident out of bed for a shower and he fell out of the sling backwards and hit the floor. The lift pad was positioned correctly and was up his back the proper way. A statement completed by Nurse Aide 2, dated January 19, 2026, revealed that she was assisting another nurse aide with transferring the resident out of bed and he fell out of the sling backwards hitting the floor. A statement completed by Registered Nurse 3, dated January 19, 2026, revealed that she observed the sling that was used to transfer the resident. The sling had long straps at the bottom that required the straps to be placed between the legs and crisscrossed then attached to the mechanical lift. The straps were connected to the lift, with the two right straps together and the two left straps together; they were not crisscrossed. She observed the size of the sling, and it was marked as extra-large. A statement completed by Registered Nurse Supervisor 4, dated January 21, 2026, revealed that he was notified of the fall. Upon his arrival he observed the mechanical lift outside the resident's room. The sling was not attached to the mechanical lift but was observed on the resident's bed. The sling was extra-large with legs, and the material and straps appeared to be in good condition. The sling was collected to get laundered as it was soiled and then collected to keep for the investigation. Investigative documents for Resident 3, dated January 29, 2026, revealed that on January 19, 2026, the Registered Nurse 3, was notified by staff that the resident had fallen from the mechanical body lift and was noted to be bleeding from his head. The resident was observed lying on his right side between the legs of the mechanical body lift with his head positioned by the post of the lift which was located at the doorway. The body mechanical lift was safely pulled away from the resident while staff were maintaining proper head and neck alignment. The resident was sent to the local emergency room and was admitted with fracture at the sixth vertebra. Investigation was initiated and included separate individual reenactments of the incident, verification of sling size and lift techniques utilized during the transfer. The facility's investigation revealed that the fall was caused by utilization of the wrong sling size. Interview with the Director of Nursing on February 11, 2026, at 2:51 p.m. confirmed that the facility's investigation substantiated neglect because Nurse Aide 1 and Nurse Aide 2 did not follow Resident 3's care plan requiring the resident to be transferred with a mechanical body lift using a large sling size. A review of the facility's plan of correction included the following:Reeducation on transporting residents with mechanical lifts and correct lift size per residents.Audits of residents require mechanical lifts for transfers and proper sling size per residents.Audits completed weekly on all staff transporting residents using a mechanical lift.Interviews with nursing staff on February 11, 2026, revealed that they had been educated on proper mechanical lift transfers and proper sling size per residents.A review of the facility's corrective actions revealed that they were in compliance with F600 on January 28, 2026. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as care planned and ordered for one of seven residents reviewed (Resident R2) who fell and suffered a fracture and failed to ensure that the residents' environment remained free of accident hazards for one of seven residents reviewed (Resident 3), who fell and suffered a fracture. Findings include:The facility's policy regarding incidents and accidents, dated January 5, 2026, revealed that the facility's purpose was to maintain the residents' safety and prevention of serious injury to the extent possible and to ensure a consistent and effective approach to the management and review of the fall itself. If the resident was determined to be high risk for falls, the interdisciplinary team (IDT) would initiate, individualized preventative measures on an individual basis which may include, but not limited to hip savers (a padded under garment to protect the hip area).A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R2, dated November 18, 2025, revealed that the resident was confused, had wandering behaviors, required maximum staff assistance with dressing, had a history of falls, and had diagnoses that included dementia. Physician's orders and a care plan for Resident 2, initiated on April 29, 2025, revealed that the resident was at risk for falls and was to wear hip savers at all times.A nursing note, dated January 22, 2026, revealed that at 3:25 p.m. Resident 2 was observed laying on his left side on the floor in between two nightstands. He had an open area to the left side of his head measuring 0.5 x 0.5 centimeters (cm), an abrasion noted to the left upper arm, and a skin tear to the left elbow measuring 1.0 x 0.5 cm. The resident yelled out in pain when his left leg was straightened. He had no shortening or deformity noted, but his external rotation was not assessed due to pain. The Certified Registered Nurse Practitioner (CRNP) was notified, and an order was received to send the resident to the hospital for further evaluation.A facility investigation, dated January 22, 2026, revealed Resident 2 had an unwitnessed fall and was found in another resident's room on the floor between two night stands. The report indicated that the resident had non-skin socks and hip savers on at the time of the fall, and was last observed by staff on January 22, 206, at 3:15 p.m. The last time the resident was toileted was on January 22, 2026, at 7:47 a.m. The resident had severe pain to his left hip, had an abrasion to his left upper arm, a skin tear to his left elbow, and he was unable to fully straighten his left leg due to pain. The resident was sent to the emergency room for further evaluation and was diagnosed with a left hip fracture.A witness statement from Licensed Practical Nurse 8 (11:00 p.m. to 7:00 a.m. shift), dated January 23, 2026, revealed that when she provided care to Resident 2 on the night shift of January 21, 2026, into the morning of January 22, 2026, the resident's hip savers were in place during the last check.A witness statement from Nurse Aide 9, (11:00 p.m. to 7:00 a.m. shift), dated January 23, 2026, revealed Resident 2's hip savers were in place during incontinent care in the morning. A witness statement from Licensed Practical Nurse 10, (7:00 a.m. to 3:00 p.m. shift), dated January 24, 2026, revealed Resident 2's hip savers were on him during the morning skin checks.A witness statement from Nurse Aide 11, (7:00 a.m. to 3:00 p.m. shift), dated January 24, 2026, revealed Resident 2's hip savers were put on him after being showered.A witness statement from Nurse Aide 12, (7:00 a.m. to 3:00 p.m. shift), dated January 23, 2026, revealed Resident 2's hip savers were in place when he was changed after lunch.A witness statement from Registered Nurse 5, (7:00 a.m. to 3:00 p.m. shift), dated January 22, 2026, revealed that she was at the nurse's station and was notified that Resident 2 was on the floor, and she did not witness the event.Interview with Registered Nurse 5, on February 11, 2026, at 3:14 p.m. confirmed that when she responded to Resident 2 being found on the floor and assessed him, he did not have his hip savers on as care planned and ordered. She stated that she reported this finding to Registered Nurse Supervisor 6. She also reported that she did not notice on the incident report that hip savers were checked as being in place at the time of the fall and confirmed that this was not correct. Interview with Registered Nurse Supervisor 6 on February 11, 2026, at 3:59 p.m. confirmed that Registered Nurse 5 did report to her that Resident 2 did not have his hip savers on at the time of the fall, and she also observed the resident without the hip savers on as care planned and ordered. She stated that when she was reviewing the resident's clinical record for the fall investigation, she saw that hip savers were care planned and ordered and should have been on. She stated that she did report this. Interview with Assistant Director of Nursing 7 and the Director of Nursing on February 11, 2026, at 5:15 p.m. confirmed that they were not aware that Resident 2 did not have his hip savers on at the time of the fall that resulted in a fracture. A quarterly MDS assessment for Resident 3, dated January 6, 2026, revealed that the resident cognitively impaired, requires assistance from staff for daily care needs, dependent with transfers, and had medical diagnoses that included Parkinsons, dementia, and orthostatic hypotension. A care plan, dated December 30, 2025, revealed that the resident had a potential for falls related to new environment, adjustment to nursing home placement, presence of tremor, orthostatic hypotension, Parkinson's and impaired mobility. Transfer status was to use a full mechanical lift for all transfers with large sling size. A nursing note for Resident 3, dated January 19, 2026, at 8:36 p.m. revealed that the nurse was informed by staff that the resident had fallen from the mechanical body lift. The nurse entered the room, and the resident was observed lying on his right side between the legs of the mechanical body lift with his head located by the center post of the lift located at the doorway in the resident's room. The mechanical lift was safely pulled away from the resident while staff maintaining proper head/neck alignment. The sling was observed remaining in same position on hooks of lift while being moved. The mechanical body lift legs observed being in closed position. The mechanical body lift arm was observed in high position. Blood was observed along the occipital region of head to the left ear and on the floor from a head laceration. Pressure was applied with gauze and bleeding was controlled. Resident complained of headache, pain in the back of the head, neck pain, and back pain. A nursing note for Resident 3, dated January 19, 2026, at 8:59 p.m., revealed that the resident was admitted to the hospital with a diagnosis of scalp laceration requiring staples, closed head injury and a fracture at the sixth thoracic (middle of the back) vertebrae (spine). A statement completed by Nurse Aide 1, dated January 19, 2026, revealed that she was assisting another nurse aide to get the resident out of bed for a shower and he fell out if the sling backwards and hit the floor. The lift pad was positioned correctly and was up his back the proper way. A statement completed by Nurse Aide 2, dated January 19, 2026, revealed that she was assisting another nurse aide with transferring the resident out of bed and he fell out of the sling backwards hitting the floor. A statement completed by Registered Nurse 3, dated January 19, 2026, revealed that she observed the sling that was used to transfer the resident. The sling had long straps at the bottom that required the straps to be placed between the legs and crisscrossed then attached to the mechanical lift. The straps were connected to the lift incorrectly. The two right straps were together and two left straps were together and they were not crisscrossed. She observed the size of the sling, and it was marked as extra-large. A statement completed by Registered Nurse Supervisor 4, dated January 21, 2026, revealed that he was notified of the fall. Upon his arrival he observed the mechanical lift outside the resident's room. The sling was not attached to the mechanical lift but was observed on the resident's bed. The sling was extra-large with legs, and the material and straps appeared to be in good condition. The sling was collected to get laundered as it was soiled and then collected to keep for the investigation. Investigative documents for Resident 3, dated January 29, 2026, revealed that on January 19, 2026, the Registered Nurse 3, was notified by staff that the resident had fallen from the mechanical body lift and was noted to be bleeding from his head. The resident was observed lying on his right side between the legs of the mechanical body lift with his head positioned by the post of the lift which was located at the doorway. The body mechanical lift was safely pulled away from the resident while staff were maintaining proper head and neck alignment. The resident was sent to the local emergency room and was admitted with fracture at the sixth vertebra. Investigation was initiated and included separate individual reenactments of the incident, verification of sling size and lift techniques utilized during the transfer. The facility's investigation revealed that the fall was caused by utilization of the wrong sling size. Interview with the Director of Nursing on February 11, 2026, at 2:51 p.m. confirmed that the facility's investigation substantiated that the nurse aides used the incorrect sling size per the resident's care plan. In addition, the facility's investigative documents confirmed that the sling was connected incorrectly due to not having the leg straps crisscrossed. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect as the cause of a fracture for one of seven residents reviewed (Resident 2).Findings include:The facility's policy regarding falls, dated January 5, 2026, revealed that upon observation of a resident on the floor/lower level or witnessing a fall, if able, staff were stay with the resident and call for assistance. The Registered Nurse Supervisor was to be notified immediately. Staff were to document complete fall information, to include how the resident was found, environment around the resident, possible reason for fall, any applicable immediate interventions placed, any alteration in skin integrity, changes in prior known condition, and above notifications in the resident's electronic health record.The facility's policy regarding resident abuse/neglect, dated January 5, 2026, revealed that the facility would conduct a thorough investigation to determine facts specific to the case for any and all types of alleged violations, and identify and interview all involved persons including the alleged victim(s), alleged perpetrator(s), witnesses, and any others who may have knowledge of the allegations. The supervisor and Commandant were to be notified immediately of any and all types of alleged violations.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R2, dated November 18, 2025, revealed that the resident was confused, had wandering behaviors, required maximum staff assistance with dressing, had a history of falls, and had diagnoses that included dementia. Physician's orders and a care plan for Resident 2, initiated on April 29, 2025, revealed that the resident was at risk for falls and was to wear hip savers (a padded under garment to protect the hip area) at all times.A nursing note, dated January 22, 2026, revealed that at 3:25 p.m. Resident 2 was observed laying on his left side on the floor in between two nightstands.He had an open area to the left side of his head measuring 0.5 x 0.5 centimeters (cm), an abrasion noted to the left upper arm, and a skin tear to the left elbow measuring 1.0 x 0.5 cm. The resident yelled out in pain when his left leg was straightened. He had no shortening or deformity noted, but his external rotation was not assessed due to pain. The Certified Registered Nurse Practitioner (CRNP) was notified, and an order was received to send the resident to the hospital for further evaluation.A facility investigation, dated January 22, 2026, revealed Resident 2 had an unwitnessed fall and was found in another resident's room on the floor between two nightstands. The report indicated that the resident had non-skin socks and hip savers on at the time of the fall, and was last observed by staff on January 22, 206, at 3:15 p.m. The last time the resident was toileted was on January 22, 2026, at 7:47 a.m. The resident had severe pain to his left hip, had an abrasion to his left upper arm, a skin tear to his left elbow, and he was unable to fully straighten his left leg due to pain. The resident was sent to the emergency room for further evaluation and was diagnosed with a left hip fracture.A witness statement from Registered Nurse 5 (7:00 a.m. to 3:00 p.m. shift), dated January 22, 2026, revealed that she was at the nurse's station and was notified that Resident 2 was on the floor, and she did not witness the event.Interview with Registered Nurse 5 on February 11, 2026, at 3:14 p.m. confirmed that when she responded to Resident 2 being found on the floor and assessed him, he did not have his hip savers on as care planned and ordered. She stated that she reported this finding to Registered Nurse Supervisor 6. She also reported that she did not notice on the incident report that hip savers were checked as being in place at the time of the fall and confirmed that this was not correct.Interview with Registered Nurse Supervisor 6 on February 11, 2026, at 3:59 p.m. confirmed that Registered Nurse 5 did report to her that Resident 2 did not have his hip savers on at the time of the fall, and she also observed the resident without the hip savers on as care planned and ordered. She stated that when she was reviewing the resident's clinical record for the fall investigation, she saw that hip savers were care planned and ordered and reported this.The facility's investigation information revealed no documented evidence that a thorough investigation was conducted, as there was no documented evidence that the investigation included witness statements from Registered Nurse 5 and Registered Nurse Supervisor 6 that included observations of Resident 2 without hip savers on at the time of the fall on January 22, 2026.Interview with Assistant Director of Nursing 7 and the Director of Nursing on February 11, 2026, at 5:15 p.m. confirmed that they were not aware that Resident 2 did not have his hip savers on at the time of the fall that resulted in a fracture.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for three of 59 residents reviewed (Residents 53, 136, 171). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated March 26, 2025, indicated that the resident was cognitively intact, was independent for care, and received enteral feeding. Physician's orders, dated April 9, 2025, included an order for the resident to receive Isosource 1.5 (a tube feeding formula) at 250 milliters (ml) per hour over one hour three times a day, provide 85 ml flush before and after feeding, and document the amount of feed and flush administered. A review of Resident 53's Medication Administration Record (MAR), dated April, May, June 2025, indicated that staff were not correctly documenting the amount of feeds and flushes. On April 10, 2025, at 9:00 a.m. 100 ml was documented, and there was do documented evidence if the resident received pre and post-administration flushes; 250 ml was documented on April 11, at 9:00 a.m. and 1:00 p.m.; April 12, at 9:00 a.m. and 6:00 p.m.; April 13, at 9:00 a.m. and 1:00 p.m.; April 14, at 9:00 a.m.; April 17, at 6:00 p.m.; April 19, at 1:00 p.m.; April 21, at 6:00 p.m.; April 23, at 6:00 p.m.; April 24, at 9:00 a.m.; April 25, at 9:00 a.m. and 1:00 p.m.; April 30, at 1:00 p.m.; and no documented evidence of pre and post-administration flushes; 335 ml was documented as administered on April 15, at 9:00 a.m., 1:00 p.m. and 6:00 p.m.; April 16, at 9:00 a.m. and 1:00 p.m.; April 18, at 9:00 a.m. and 1:00 p.m.; April 19, at 6:00 p.m.; April 20, at 9:00 a.m., 1:00 p.m., and 6:00 p.m.; April 27, at 9:00 a.m., 1:00 p.m., and 6:00 p.m.; 250 ml feeding and 85 ml flush was documented for May 2, at 6:00 p.m.; 250 ml was documented as administered on May 3, at 1:00 p.m.; May 4, at 9:00 a.m.; May 7, at 6:00 p.m.; May 10, at 1:00 p.m.; May 17, at 9:00 a.m.; May 20, at 9:00 a.m.; May 22, at 1:00 p.m. and 6:00 p.m.; May 23, at 1:00 p.m. and 6:00 p.m.; May 24, at 1:00 p.m.; May 26, at 2:50 p.m.; May 29, at 1:00 p.m. and 6:00 p.m.; May 30, at 9:00 a.m., 1:00 p.m., and 6:00 p.m.; May 31, at 1:00 p.m.; 390 ml was documented as administered on May 17, at 6:00 p.m.; 240 ml was documented as administered on May 11, at 1:00 p.m.; 157 ml was documented as administered on May 20, at 6:00 p.m.; 500 ml was documented as administered on May 26, at 1:00 p.m.; 247 ml was documented as administered on May 27, at 1:00 p.m.; 370 ml was documented as administered on May 28, at 6:00 p.m.; and 380 ml was documented as administered on May 31, at 6:00 p.m. The documentation did not indicate how much was feeding and how much was pre and post-flushes. Interview with the Director of Nursing on June 12, 2025, at 1:16 p.m. confirmed that the nurses were to follow the physician's orders for Resident 53's enteral feeding to document the correct amount of flush and Isosource administered at the time of administration. A quarterly MDS assessment for Resident 136, dated March 4, 2025, revealed that the resident was cognitively impaired, was independent with most care needs, and had a diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event). A physician's progress note for Resident 136, dated April 23, 2025, at 1:41 p.m., indicated that the resident was seen for a 60-day assessment and had a diagnosis of ongoing chronic PTSD. Review of the resident's clinical records, including psychiatric progress notes, the resident's plan of care, and the trauma assessment revealed no documented evidence that the resident had a diagnosis of PTSD. Interview with the Social Service Director on June 12, 2025, at 2:20 p.m. indicated that she had reviewed Resident 136's clinical records dating back to his admission and that there was no prior documentation in the resident's clinical records that indicated he had a diagnosis of PTSD. She indicated that there was a psychiatric note that indicated he had no signs of PTSD, and she believed that the PTSD diagnoses may have been documented in error. She reached out to the Certified Registered Nurse Practitioner (CRNP) to clarify the PTSD diagnosis. She indicated that the resident was a civil war re-enactor and was care planned as such with no signs of PTSD. There was no active care plan for the resident related to PTSD. A physician's progress note for Resident 136, dated June 12, 2025, at 2:45 p.m., revealed that the resident's chart was reviewed secondary to his PTSD diagnosis. Upon review, there was no diagnosis of PTSD noted as per multiple psychiatrist documentation and follow up evaluations. The PTSD diagnosis was therefore not warranted based on their evaluations. Interview with the Social Service Director on June 12, 2025, at 3:07 p.m. confirmed that Resident 136 did not have a diagnosis of PTSD as confirmed by the CRNP per review of the resident's clinical record. A significant change MDS assessment for Resident 171, dated May 27, 2025, revealed that the resident was understood, could understand others, was independent with transfers, had a diagnosis of dementia, and had a history of falls. A nursing note for Resident 171, dated May 20, 2025, revealed that the resident had an unwitnessed fall. The resident sustained a 3 centimeter (cm) by 4 cm abrasion to the center of the neck. The CRNP was made aware and a new order was received to have the resident screened by speech therapy. A speech therapy note for Resident 171, dated May 20, 2025, indicated that the resident had a screening and it was recommended to have vocal rest due to recent trauma. Speech therapy would follow-up in a few days to assess voice further; however, there was no documented evidence in Resident 171's clinical record that speech therapy followed up as recommended. A late entry speech therapy note, recorded on June 11, 2025, for May 20, 2025, indicated that speech therapy followed up with Resident 171, who was improving, had a gargled voice, and recommended to continue with light vocal use and rest. Interview with the Speech Therapist on June 12, 2025, at 12:14 p.m. revealed that therapy screenings are documented in the medical record. She confirmed that she did follow up with Resident 171 but forgot to document it. She entered a late entry in the clinical record after she was made aware that there was no documentation. Interview with the Nursing Home Administrator on June 12, 2025, at 4:15 p.m. confirmed that Resident 171's clinic record should have been complete and accurate. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 59 residents reviewed (Resident 140). Findings include: Review of the facility's current dialysis policy, dated July 1, 2024, revealed that when the resident returns from dialysis the resident will be assessed by a registered nurse with a complete set of vital signs and the dialysis access permacath (a catheter used for dialysis access) or fistula (a surgically created access point for dialysis) would be assessed for bleeding every 15 minutes for two hours. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 140, dated April 25, 2025, indicated that the resident was cognitively impaired, had a diagnosis of kidney failure, and received dialysis. The current care plan revealed that Resident 140 goes to dialysis early in the morning on Tuesdays, Thursdays, and Saturdays. A review of Resident 140's clinical record for April, May, and June 2025 revealed no documented evidence that a registered nurse assessed the dialysis site for bleeding every 15 minutes for two hours on April 15 and 17, 2025; May 1, 17, 31, 2025; and June 7, 2025; and no documented evidence that vital signs were completed upon return from dialysis on April 5, 8, 10, 12, 24, 26, 2025; May 6 , 15, 24, 27, 29, 2025; and June 5 and 7, 2025. Interview with the Director of Nursing on June 11, 2025, at 9:53 a.m. confirmed that there was no documented evidence that the facility's policy for after dialysis assessment, care and monitoring was completed for Resident 140 on the above dates. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared under sanitary conditions. Findings include: Observations in the main kitchen on June 9, 2025, at 9:20 a.m. revealed that the large plastic flour container, the large plastic sugar container, and the large plastic thickening powder container, located in the preparation area, was still in the original paper containers of flour, sugar, and powder thickener while stored inside each of the plastic containers. Interview with Dietary Manager on June 9, 2025, at 9:20 a.m. revealed that she was not aware of any reason that the original paper containers should not be inside the large plastic containers. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain confidentiality of residents' personal health information during medication administration for one of 59 residents reviewed (Resident 78). Findings include: The facility policy regarding privacy of health information, dated July, 1 2024, indicated that the facility was to protect the confidentiality of a resident's health information. Observations of the [NAME] building's North Hall on June 11, 2025, at 12:21 p.m. revealed a medication cart at the end of the hallway, the computer on top of the medication cart was on, and Resident 78's personal information was visible on the screen. Interview with Licensed Practical Nurse 1 on June 11, 2025, at 12:27 p.m. confirmed that she should have covered Resident 78's personal information on the computer screen when leaving the medication cart. Interview with the Director of Nursing on June 11, 2025, at 1:41 p.m. confirmed that the computer screen with Resident 78's personal health information should have been covered when the nurse was not at the medication cart. 28 Pa. Code 211.5(b) Clinical Records.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one 59 residents reviewed (Resident 139). Findings include: The facility's abuse policy, dated July 1, 2024, indicated that each resident had the right to be free from abuse, neglect and misappropriation of resident property. Abuse is defined as, the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being, which includes verbal, sexual, physical and mental abuse. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 139, dated January 7, 2025, indicated that the resident was moderately cognitively impaired, required moderate assistance from staff with activities of daily living, and had diagnoses that included glaucoma (weakening of the eyesight) and Parkinson's disease (a brain disorder resulting in tremors and slowness of movement). Resident 139's urinary incontinence care plan, dated January 5, 2023, indicated that staff members were to assist the resident with toileting, perineal hygiene, and management of incontinence products/clothing upon resident request and as needed. A written statement from Nurse Aide 3, dated March 2, 2025, revealed that she saw Nurse Aide 2 go into the Resident 139's room and heard her say, Stop ringing your bell you're not going to get anyone else but me to help you. You can change your own underwear. She further indicated that Nurse Aide 2 left the room and the resident rang again. Nurse Aide 3 answered the call bell and he complained about Nurse Aide 2 and asked to speak to the supervisor. A written statement from Registered Nurse Supervisor 4, dated March 2, 2025, revealed Resident 139 reported that Nurse Aide 2 came into his room, turned his bell off, and walked out of his room several times. He reported that she told him to, Stop ringing your bell, and You can do it yourself. He also reported that she was mean to him, he was afraid of her, and wished for her not to care for him again. He stated that she argued with him about his vision. He told her that he was partially blind due to his glaucoma and she told him, You're not blind, you can see just fine. He indicated he was fearful of retaliation. Facility investigation documents, dated March 2, 2025, revealed that Nurse Aide 2 went into Resident 139's room and turned his call bell off and walked out of his room several times. The last time she answered his bell he asked the nurse aide for help and she replied, Stop ringing your call bell. You can do it yourself. A call bell report was run, which indicated that the resident had rung his call bell several times in a short time frame. A statement provided by Resident 139, dated March 7, 2025, indicated that Nurse Aide 2 refused to provide care for him saying we don't do that. For example, she will not make sure his private areas are clean and other areas like that. The resident stated this was not the first time this has happened with her, and that he gets the feeling she does not care. He also stated that he feels nervous when she answers his call bell, and that she sometimes just stands there and cocks her hips staring at him. Interview with the Assistant Director of Nursing 5 on June 12, 2025, at 2:03 p.m. confirmed that the facility substantiated neglect and mental abuse, and that Nurse Aide 2 was terminated. He further indicated that he would expect nursing staff to answer a resident's call bell and provide the care/assistance asked by the resident. An interview with the Nursing Home Administrator on June 12, 2025, at 16:50 p.m. confirmed that the facility substantiated abuse of Resident 139 by Nurse Aide 2. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 59 residents reviewed (Resident 169). Findings include: A facility policy regarding interdisciplinary care plans, dated July 1, 2024, indicated that each resident has an individualized interdisciplinary care plan. Proper documentation was required in the care plan for discontinued or added interventions, changes in problems, goals, and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 169, dated February 4, 2025, revealed that the resident was understood, could understand others, was moderately cognitively impaired, required supervision for showering and bathing, was independent with all other care needs, and had diagnoses that included heart failure and Alzheimer's disease. Nursing notes, dated February 16, 2025, indicated that Resident 169 fell at his daughter's home, was admitted to the hospital with a brain bleed, and had five sutures in the back of his head. A care plan regarding falls, dated May 5, 2024, indicated that the resident was at risk for falls related to antidepressant use. A care plan intervention for the resident, dated February 24, 2025, revealed that staff were to monitor staples to the head related to a fall while on a leave of absence. Staff were to notify the medical provider with worsening condition of the site. A nurse practitioner note for Resident 169, dated February 27, 2025, indicated that five staples were removed from the back of his head. Observations of Resident 169 on June 11, 2025, at 12:35 p.m. in the dining room revealed that he did not have any staples on the back of his head. Interview with Assistant Director of Nursing 6 on June 11, 2025, at 3:09 p.m. confirmed that Resident 169's care plan needed updated to discontinue staple care needs, as they were removed in February 2025. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of 59 residents reviewed (Resident 140). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 140, dated April 25, 2025, indicated that the resident was cognitively impaired and had diagnoses that included kidney failure and received dialysis. A care plan for nutritional status, dated January 26, 2024, revealed that the resident goes to dialysis at 6:00 a.m. on Tuesdays, Thursdays, and Saturdays. Physician's orders for Resident 140, dated January 26, 2024, included an order for the resident to receive at 9:00 a.m. 1 milligram (mg) of bumetanide (a medication to treat edema), 25 microgram (mcg) of vitamin D3, 2.5 mg of Eliquis (a blood thinner), one 50 mcg spray per nostril of Flonase (a medication to treat allergies), 0.5 mg of lorazepam (a medication to treat anxiety), 10 mg of midodrine, 75 mg of Plavix (a medication to help prevent blood clots from forming), 10 mg of Protonix (a medication to treat acid reflux), 800 mg of renvela (a medication to treat high phosphorus levels), 25 mg Vistaril (a medication to treat anxiety and itchiness). A review of Resident 140's Medication Administration Records (MAR) for May and June 2025 revealed that the resident received his medications at 9:00 a.m. on Tuesdays, Thursdays, and Saturdays; however, a review of the resident's clinical record revealed that the resident was at dialysis on those dates and time, and was unavailable to receive his medication. There was no documented evidence to indicate that the physician was notified for clarification of the orders for Resident 140's dialysis days. Nursing notes for Resident 140 on dialysis days for the months of May and June 2025 revealed that the resident received his 9:00 a.m. medication by the third shift licensed practical nurse before leaving for dialysis at 6:00 a.m. on dialysis days. Interview with the Director of Nursing on July 7, 2025, at 11:37 a.m. confirmed that Resident 140's orders for his 9:00 a.m. medication on dialysis days should have been clarified with the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that fall interventions were in place for one of 59 residents reviewed (Resident 9) who had a history of a fall from his bed, and failed to lock the wheels on a hoyer lift during use per manufacturer's instructions for one of 59 residents reviewed (Resident 186). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated March 25, 2025, revealed that the resident was cognitively intact, was dependent for most daily care needs including bed mobility, and had a diagnoses that included hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury) of the left side following a stroke. The current fall care plan for Resident 9 revealed that the resident was at risk for falls. Interventions for Resident 9 included the use of a long positioning wedge to the left side at all times when in bed. Physician's orders for Resident 9, dated December 24, 2024, included an order for the resident to use a long positioning wedge to his left lateral side at all times when in bed. Observations on June 11, 2025, at 2:38 p.m. and June 12, 2025, at 11:16 a.m. revealed that Resident 9 was lying in bed and he did not have his long positioning wedge in place to his left lateral side. Interview with Licensed Practical Nurse 7 on June 12, 2025, at 11:24 a.m. indicated that she was not sure if Resident 9 was to have a wedge to his left side when in bed, but she would check with the nurse aide to see if she recalled him having one and where it was at. Licensed Practical Nurse 7 verified the orders and confirmed that the resident was to have the long positioning wedge to his left lateral side when in bed and it was not in place. Interview with Nurse Aide 8 on June 12, 2025, at 11:28 a.m. indicated that she did recall Resident 9 having a left lateral wedge in bed but could not locate it in his room. Interview with the resident at that time indicated that he had a wedge to his left side but did not know when he had it last. Interview with the Assistant Director of Nursing 6 on June 12, 2025, at 3:09 p.m. confirmed that Resident 9's long positioning wedge to his left lateral side should have been in place and it was not. The facility's policy for using a lifting machine, dated July 1, 2024, revealed that staff must be competent in the use of mechanical lifts per manufacturer's instructions. Manufacturer's instructions for the Vikking Hoyer lift revealed that the breaks were to be engaged when lifting a patient from the floor to decrease the risk of the lift moving into the patient. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 186, dated April 2, 2025, revealed that the resident was cognitively impaired and required extensive assistance with daily care needs including transfers. A fall care plan, dated May 21, 2025, revealed that the resident was to be transferred by two staff using a Hoyer mechanical lift with the model 350 size medium sling. Observations of Nurse Aide 9 and Registered Nurse 10 on June 9, 2025, at 1:21 p.m. using the mechanical lift to transfer Resident 186 from the floor to his bed revealed that the brakes on the lift were not engaged during the transfer causing the lift to roll slightly. Interview with Nurse Aide 9 and Registered Nurse 10 on June 9, 2025, at 1:30 p.m. confirmed that they should have had the brakes on while raising Resident 186 from the floor and lowering him into the bed. Interview with the Director of Nursing on June 10, 2025, at 2:13 p.m. confirmed that the brakes should have been engaged when using the mechanical lift to transfer Resident 186 from the floor to his bed. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident did not display decreased social interaction, and/or withdrawn, angry or depressive behaviors, unless unavoidable, for one of 50 residents reviewed (Resident 49), resulting in physical and mental decline and hospitalization for the resident. Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated July 15, 2021, indicated that the resident was cognitively intact. A nursing note, dated March 31, 2021, indicated that the resident was capable of making her own decisions, and an admission note, dated April 13, 2021, and authored by the facility's physician, indicated that the resident was capable of making medical decisions. A nursing note, dated May 25, 2021, indicated that Resident 49 was observed giving her husband, Resident 27, thin liquids when he was ordered thickened liquids. A nurse practitioner's note, dated May 26, 2021, indicated that Resident 49 was having [CONDITION(S)] related to anxiety, with accompanying hallucinations that appeared to be related to a lack of sleep/abrupt awakening in the middle of the night, and that the resident was aware that the hallucinations were not real. A psychiatrist's note, dated June 4, 2021, revealed that Resident 49 had no depression, her thought process was good, and her insight and judgement were fair. A nursing note, dated June 11, 2021, revealed that Resident 49 returned from a hospital stay and that she was alert and oriented to person, place and time. A nursing note, dated June 15, 2021, indicated that Resident 49 was aware and capable and did not want her family called regarding new orders for herself. A nursing note, dated June 18, 2021, indicated that Resident 49 attempted to feed Resident 27 a cinnamon roll while he was lying in bed. Staff attempted to educate Resident 49 about her husband's diet and that he should not be fed in bed; however, Resident 49 was upset and stated that she wanted to have a snack with her husband and he deserved to eat with her. Resident 49 was upset because she wanted her husband to have a cinnamon roll and staff would not allow her to feed him. She stated that she took care of him at home for five years after a stroke and before they were placed in long-term care. She fed him before this placement and she knew what he needed. A note on June 18, 2021, indicated that Resident 49 was upset because staff yelled at her for trying to feed her husband, and that she was also upset because she could not have her bed close to her husband's bed. She was educated by the speech therapist and agreed to have her husband in an upright position prior to feeding him. She also agreed to feed him items within his diet restrictions and nectar thick liquids. A nursing note, dated June 19, 2021, indicated that nurse aides were providing care for Resident 27 and they pulled the privacy curtain between him and his wife, Resident 49, which upset Resident 49. She told the nurse aide that Resident 27 was her husband and there was no need for the privacy curtain as they had been married for over [AGE] years; however, staff educated her that there was a necessity for the privacy curtain between them. The facility completed behavior logs each shift to keep track of any attempts that Resident 49 made to feed Resident 27. A nursing note, dated June 22, 2021, indicated that Resident 49 was referred to psychiatry for the behavior of feeding her husband and demanding that staff keep the privacy curtain open between her and her husband. A nursing note, dated June 22, 2021, indicated that Resident 49 asked nursing staff to leave the privacy curtain open between her and her husband, who she was power of attorney for; however, they refused and stated they would pull it for his privacy. A nursing note, dated June 23, 2021, indicated that Resident 49 had new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notes from an Interdisciplinary Team meeting on June 24, 2021, indicated that Resident 49 was observed feeding her husband in the past, and that she was capable and was his power of attorney. The interdisciplinary team decided that if her behaviors continued, they would further ensure Resident 27's safety as necessary. A nursing note, dated June 25, 2021, indicated that Resident 49 became upset when staff were providing care for her husband and pulled the curtain between them. She again stated that she had been married to him for a long time and that there was no reason for the curtain. She was then upset because staff removed him from their room for dinner and she was afraid they would not feed him and he would starve. A nurse practitioner note, dated June 27, 2021, indicated that Resident 49 was aware of Resident 27's food restrictions and that she did not want to harm her husband, just feed him foods she knew he liked and was told he could have. She again stated that she took care of him for years prior to their placement. A nursing note, dated June 28, 2021, indicated that Resident 49 was upset because she did not want her husband to be taken to the dining room for supper. She wanted him to stay with her for meals, and she was again upset that staff continued to pull the curtain during his care. A nurse practitioner's note, dated June 29, 2021, indicated that Resident 49 was not capable of making sound decisions. An Interdisciplinary Team (IDT) meeting note, dated June 29, 2021, revealed that Resident 49 was threatening her husband's safety and dignity by continuing to feed him and insist that the privacy curtain be open between them. The note indicated that the resident continues to dictate the care that she believes her husband wants to receive, by instructing staff not to take him to the dining room for meals, and insisting that she is able to safely supervise her husband independently for meals. Despite education, she has not had a change in her behavior (of feeding her husband) and does not appear to comprehend the risk associated with her continued behaviors. In addition to the behaviors noted above, she is intrusive to her husband's care. She frequently will pull the privacy curtain back during incontinent care/dressing and yell at staff that she wants to be able to directly observe her husband's care. The IDT team decided that Resident 49 should not room with Resident 27, her husband, because of her behaviors. A nursing note, dated June 29, 2021, indicated that staff attempted to move Resident 27 out of the shared room, and Resident 49 became upset and started to raise her voice and stated that he was not going anywhere and that she was in charge of her husband. Because Resident 49 was so upset, the staff stopped trying to move him at that time. When staff attempted to move him at dinner time, Resident 49 barricaded herself in front of the room and would not let them. Again staff tried to move Resident 27 and Resident 49 adamantly refused. Staff attempted to contact a family member of Residents 27 and 49, to have the family member try to talk to Resident 49. The family member told staff that she tried to talk to Resident 49, who was very angry and did not want Resident 27 moved from the room. A social services note, dated June 30, 2021, indicated that the social worker attempted to tell Resident 49 that her husband was being moved out of her room because of her behaviors and Resident 49 insisted that she was in charge of Resident 27's care and he was not going to move. It also stated that Resident 49 was upset that the facility would not permit her and her husband to have beds near one another, and that there had to be a privacy curtain between them. A subsequent social services note on June 30, 2021, indicated that Resident 27 was moved from Resident 49's room while Resident 49 was off the unit, and that when she returned to the unit she was angry and going room to room looking for her husband. When she found where he was and entered his room, he started to yell out when he saw her. She was upset and called her family to complain that they took him from her room without her consent. She informed staff that she was in charge of his care and that she would sleep on the floor in his room to be near him. A nursing note, dated June 30, 2021, indicated that Resident 49 was sitting near Resident 27 in the dining room, holding his arm, and was reluctant to let it go when it was time to part. She was angry and upset that they were separated. She told activities staff that she was mad at nursing staff for separating them and did not want to speak to nursing staff. She then refused her medications from the licensed practical nurse. She then approached her husband's room, but was reminded she wasn't to go into his room because there were other male roommates and she was told to say goodnight to her husband from the doorway and she became argumentative. She then entered his room and took a picture, and he began to yell out when he saw her. A nursing note, dated July 1, 2021, indicated that Resident 49 was upset that her husband was moved. She refused her health assessments at that time. A nurse practitioner's note, dated July 1, 2021, indicated that Resident 49 was crying with the recent move of her husband to another room, that she had depression, situational, due to her husband being moved from her room. A nursing note, dated July 1, 2021, indicated that Resident 49 was tearful, refused all medication and treatments, and refused to eat breakfast and lunch. She was very upset and stated that she was told they would reside together or she never would have went there in the first place. She refused ice water as well, stating staff were trying to poison her. On July 1, 2021, Resident 49's family member stated that she was aware of everything, and that the family would like for Residents 27 and 49 to be together. Later on July 1, 2021, Resident 49 again refused medications, treatments and her supper. She ignored all staff and refused all care. Nursing notes on July 2, 2021, indicated that Resident 49 refused all care, all assessments, all meals and all medications because she was upset that her husband was removed from her room. A nursing note on July 2, 2021, indicated that Resident 49 was refusing her meals and medications because she believed, They'll bring my husband back to my room. On July 2, 2021, the nurse practitioner noted that Resident 49 was having chest pain, increased shortness of breath and difficulty breathing while lying down. The nurse practitioner noted that, Due to recent events of moving her husband to another room, she has been depressed and anxious. She has been refusing to eat or take her medication. Her shortness of breath is worsening. The note indicated that the resident's [CONDITION(S)] was likely due to her medication refusal for the past two days. She was sent to the emergency room and was admitted to the hospital. A nursing note, dated July 7, 2021, indicated that Resident 49 was readmitted to the facility from the hospital, she was alert and oriented to person, place and time. A nurse practitioner's note, dated July 8, 2021, indicated that the resident had not been taking her medications prior to hospitalization because her husband was moved out of her room, and although her mood had improved, she was still angry and had sadness with the situation. A psychiatrist note, dated July 10, 2021, indicated that Resident 49 was upset about the separation from her husband and that she protested by refusing medications, which lead to her physical health issues. She was asking to see her husband. An activity note, dated July 15, 2021, indicated that Resident 49 was able to have a video call with her husband. A social services note, dated July 19, 2021, indicated that Resident 49 had a Brief Interview for Mental Status score of 13, suggesting that her cognition was intact and consistent with prior assessments. Resident 49's clinical record revealed that she was admitted to the hospital for medical reasons on July 21, 2021, and was readmitted to the facility on [DATE]. A nursing note on July 27, 2021, indicated that Resident 49 was critically ill, anxious, and was asking to see her husband. She was told she could not see him because she would have to isolate due to COVID rules. A nurse practitioner's note, dated July 28, 2021, indicated that Resident 49 returned from the hospital where she was again critically ill, and that she was wanting to see her husband who she had not seen in several weeks. The nurse practitioner indicated that the resident appeared capable and that she should be re-evaluated by psychiatry. A nursing note, dated July 28, 2021, indicated that Resident 49 wished to be able to talk to her husband and that the registered nurse was aware. A nursing note, dated July 29, 2021, indicated that Resident 49 was able to have a video call with Resident 27. A social services note, dated August 4, 2021, indicated that Resident 49 requested to be in the same room as her husband. She indicated that if that was not permitted, she wanted to leave the facility. She expressed anger that she had only had one video call with her husband in the week. A nursing note on August 5, 2021, indicated that Resident 49 had a video call with her husband. A nurse practitioner's note, dated August 9, 2021, indicated that Resident 49 was physically ill, but refused hospitalization because of the requirement to isolate upon return from the facility due to COVID. She was short of breath, pale, fatigued, and had notable swelling in both legs. She was adamantly refusing hospitalization because of the isolation upon return to the facility. A nursing note, dated August 13, 2021, indicated that Resident 49 became short of breath with difficulty breathing and was transferred to the hospital where she was admitted . Resident 49 was readmitted to the facility on [DATE]. A nurse practitioner note, dated September 3, 2021, indicated that Resident 49 was physically declining and depressed. She was very depressed and requested to see her husband. An activity note, dated September 3, 2021, indicated that Resident 49 could not have a video call with her husband because the phone did not work. A social services note, dated September 7, 2021, indicated that the social worker attempted to call a family member in order to fix the phone so that Resident 49 could have a video call with her husband, but there was no answer. A social services note, dated September 9, 2021, indicated that the resident's phone was still not working and they would give it to a family member to try to fix so that she could have a video call with her husband. An interdisciplinary team meeting note, dated September 16, 2021, indicated that Resident 27 was moved back into a room with Resident 49 because it would be beneficial for both residents' psychosocial well-being. Interview with Director of Nursing on September 23, 2021, at 8:25 p.m. revealed that the facility moved Resident 27 out of Resident 49's room against Resident 49's wishes, and that Resident 49 was angry and upset. Resident 49 refused medications, food and drinks after Resident 27 was moved out of the room, and she was hospitalized and depressed as a result. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.10(a)(b)(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies, clinical records, a police report, and investigation documentation, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of hazards created by a resident who displayed sexually inappropriate behaviors toward other residents (Resident R2) for one of 14 residents reviewed (Resident R1), which resulted in the sexual assault of Resident R1. Findings include: The facility's behavior management policy, revised August 2016, revealed that a behavioral management program was to be implemented to identify problematic behaviors, provide resident assessment, identify specific systematic behavioral interventions, and make necessary adjustments based on observed results. A care plan was to be initiated and updated to manage targeted behaviors and include suggested effective interventions. A quarterly Minimum Data Set assessment (MDS-a mandated assessment of a resident's abilities and care needs) for Resident R1, dated August 17, 2016, revealed that the resident had moderately impaired cognition, that her range of motion was impaired to one side of her upper extremities, and that she required the assistance of two staff for much of her care, including bed mobility, transfers and dressing. The resident's care plan, most recently updated on August 1, 2016, revealed that the resident was at risk for falls and the staff were to make sure that she called for help with all transfers and to keep the call bell within reach at all times when in and out of bed. Nursing notes for Resident R1, dated April 22, 2016, revealed that at 7:55 a.m. she was seated in her wheelchair across from the office when Resident R2 walked by and stopped, reaching out his hand toward her hand. Resident R2 then reached out and squeezed Resident R1's left breast two times. Resident R1 confirmed that Resident R2 touched her breast. The Registered Nurse Supervisor and social services were notified, and the residents were kept separated in the dining room. The note indicated that the staff would continue to monitor for any further behaviors. A social services note for Resident R1, dated April 22, 2016, revealed that Resident R1 felt that Resident R2 was trying to get fresh with her but was met with her disapproval. A quarterly MDS assessment for Resident R2, dated July 27, 2016, revealed that he had moderately impaired cognition, was independent with ambulation (walking) and had [DIAGNOSES REDACTED]. Nursing notes, dated April 22, 2016, revealed that Resident R2 inappropriately touched Resident R1 on the breast two times. Resident R2's care plan, dated April 22, 2016, revealed that the resident was educated that touching women was inappropriate and unacceptable, was to be kept away from Resident R1 and re-directed away as needed, and was to be monitored closely when the resident was around women. However, the care plan did not include specific and individualized approaches for how the staff were to keep Resident R2 away from Resident R1, for how the staff were to monitor Resident R2 when he was around women, and there was no documented evidence that the staff monitored Resident R2 when he was around women. A nursing note for Resident R1, dated August 21, 2016, at 8:45 a.m. revealed that she was sitting in the hallway next to the nursing station and Resident R2 was hovering and very close to her. Resident R2 was advised to leave Resident R1 alone and stay away from her. Resident R2 walked down the hallway from her but did not respond to the nurse re-directing him. A nursing note for Resident R1, dated August 21, 2016, at 3:26 p.m. and completed by Registered Nurse 2, revealed that at 9:30 a.m. that morning she heard the nurse aide yelling for her. The nurse was in the medication room, which was two doors down from Resident R1's room, and when she exited the medication room she saw Resident R2 exiting Resident R1's room with his pants unzipped, his penis hanging out the pants, and with an erection. She entered Resident R1's room and found her reclined back in her chair with her pants unzipped, slightly pulled down, and her shirt was lifted up. The Licensed Practical Nurse and the nurse aide remained with Resident R1 so she (Registered Nurse 2) could stop Resident R2 from leaving the unit. She returned Resident R2 to his room and assigned staff to remain with him. An assessment of Resident R1 revealed that there was a 0.5 x 1.0 centimeter (cm) abrasion to her abdominal fold and a 2.0 x 1.0 cm abrasion to her right pubic fold with a small amount of bleeding. A police report, dated August 21, 2016, revealed that around 9:30 a.m. Resident R2 entered the room of Resident R1 while she was sitting in her recliner and pulled the top of her pants down. He then placed his hand down the front of her pants and placed his finger in her vagina. He began to move his finger around when it was inside her vagina, and with his finger still in her vagina he exposed his penis and began masturbating. Resident R1 told Resident R2 to stop; however, he continued until Nurse Aide 1 entered the room and discovered Resident R2. Resident R1 indicated that Resident R2 did not have her permission to have any contact with her. The report revealed that Resident R1 had an abrasion in the center of her abdominal fold that was irregular and bleeding as a result of Resident R2 rubbing her body with his fingers and fingernails. Resident R1 was examined at the hospital and had a small cut on the inside of her leg where the leg and groin meet. The facility's investigation report, dated August 21, 2016, revealed that Resident R1's eyes were big, and she was scared and very upset at the time of the incident. Resident R1 stated that she did not want Resident R2 to be doing what he did and that she asked him to stop. She indicated that she did not ring the call bell for help because she was scared. There was no documented evidence that the facility's investigation included interviews with the nursing staff who worked various shifts and interviews with other disciplines to determine if they ever observed any sexually inappropriate behaviors from Resident R2. The facility's investigation also did not include interviews with other female residents who resided on the same floor as Resident R2 or with female residents from other units to determine if Resident R2 ever sexually assaulted them. An interview with Registered Nurse 2 on August 29, 2016, at 2:25 p.m. revealed that she was aware that Resident R2 was to be kept away from Resident R1 and the staff were to re-direct Resident R2 when he was around Resident R1. She indicated that on the morning of August 21, 2016, Resident R2 was too close to Resident R1 and was told to stay away from her. An interview with Licensed Practical Nurse 6 on August 29, 2016, at 2:35 p.m. revealed that Resident R2 liked to push female residents out of the dining room, and she thought that Resident R1 and Resident R2 were to be kept separated. Interview with Nurse Aide 7 on August 29, 2016, at 2:45 p.m. revealed that she was unaware of any plan to keep Resident R2 from being around Resident R1. Interview with Nurse Aide 5 on August 29, 2016, at 2:47 p.m. revealed that Resident R2 was quick and ambulated independently. She indicated that she once chased Resident R2 out of another female resident's room because she did not feel that it was appropriate for him to be in a female's room. Interview with Nurse Aide 4 on August 29, 2016, at 2:55 p.m. revealed that she was aware that Resident R2 grabbed Resident R1's breast (in April 2016) and the only plan was to keep an eye out for Resident R2 in order to re-direct him when needed. She indicated that Resident R2 liked to push women to the dining room. Interview with Nurse Aide 8 on September 1, 2016, at 6:19 a.m. revealed that she saw Resident R2 intentionally grab Resident R1's breast twice in April and after that he was to be kept away from Resident R1. Interview with Nurse Aide 11 on September 1, 2016, at 6:20 a.m. revealed that she was familiar with Resident R2 , and that she was aware that there was a previous incident where Resident R2 touched a female resident inappropriately a couple of months ago, and as a result, staff were to keep Resident R2 away from women. When asked what type of interventions were used to keep Resident R2 away from female residents, the nurse aide stated that staff would tell Resident R2 to Leave them alone. Interview with Nurse Aide 9 on September 1, 2016, at 6:55 a.m. revealed that Resident R2 always helped female residents back to the dining room. Interview with Housekeeper 10 on September 1, 2016, at 7:30 a.m. revealed that Resident R2 would bring female residents to the dining room for lunch on a daily basis, but she was unaware that Resident R2 was to be monitored when around female residents. Interview with Nurse Aide 12 on September 1, 2016, at 9:25 a.m. revealed that Resident R2 frequently wheeled female residents to the dining area for meals and would help them to put on clothing protectors prior to meals. Nurse Aide 12 stated that she was not aware that Resident R2 was to be kept away from the female residents. Interview with Nurse Aide 13 on September 1, 2016, at 9:50 a.m. revealed that she was aware that staff were to try and keep Resident R2 away from the female residents, but he liked to push the ladies in their wheelchairs to and from the dining room at mealtime. She stated that at times Resident R2 became angry when staff tried to redirect him from doing that. Interview with Licensed Practical Nurse 14 on September 1, 2016, at 3:20 p.m. revealed that Resident R2 was always very friendly with the female residents, particularly with female Residents R1 and R3, and would wheel them back and forth to meals. Interview with Nurse Aide 15 on September 1, 2016, at 3:05 p.m. revealed that she was aware of an incident a couple of months ago where Resident R2 fondled Resident R1's breasts, and that staff were to try and keep the two residents apart. Interview with Nurse Aide 1 on September 1, 2016, at 8:59 a.m. revealed that she found Resident R2 in Resident R1's room on August 21, 2016, and that Resident R1 was terrified. She stated that Resident R1 was asked if she wanted Resident R2 to do that to her and she stated, No. The nurse aide was aware that Resident R2 was not to be around Resident R1. Interview with Registered Nurse Assessment Coordinator 3 on August 30, 2016, at 12:46 p.m. revealed that Resident R2's care plan was reviewed on August 8, 2016, and the plan for Resident R2 to be kept away from Resident R1 and to be monitored when around women was still current. An interview with the Director of Nursing on August 30, 2016, at 1:00 p.m. confirmed that re-direction was the only intervention in place to prevent Resident R2 from having contact with Resident R1, which was ineffective. She confirmed that there was no documented evidence that following the incident that occurred on April 22, 2016, the staff monitored Resident R2 when he was around female residents. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 7/20/16, 2/25/16. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 5/19/16, 2/25/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/20/16, 5/19/16, 2/25/16, 3/26/15.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that an individualized care plan was developed that described the services to be furnished for three of 20 residents reviewed (Residents CR1, CR4, R12) who were at risk for aspiration and/or choking, resulting in harm for Resident CR1 who choked on food. Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR1, dated December 1, 2015, revealed that the resident had short-term memory problems and required set-up and supervision for meals. A nursing note, dated November 1, 2015, indicated that the resident had a choking episode while eating his meal and required the [MEDICATION NAME] maneuver (an emergency technique used when a person's windpipe becomes blocked by an object) to be preformed to dislodge food particles. An incident report, dated November 1, 2015, revealed that the resident's spouse indicated that he was always stuffing his mouth and was always in such a hurry to eat. physician's orders [REDACTED]. The safe swallowing strategies and techniques listed on the discharge summary included rate modification (slowing down how fast a person eats), alternation of food and fluids, bolus size modifications (taking smaller bite sizes), chin tuck (tucking to chin to the chest when swallowing to help prevent aspiration (inhalation of foreign material into the respiratory tract)), and hard swallow/reswallow (swallowing hard multiple times to clear the mouth). Following the resident's choking episode and speech therapy evaluation and recommendations, there was no documented evidence on Resident CR1's clinical record that an individualized care plan was developed to ensure safe eating related to the resident's history of choking, his swallowing problems, and his risk for aspiration. physician's orders [REDACTED]. The therapy evaluation indicated that the resident had decreased safety awareness and poor self-monitoring skills. It also indicated that he was unable to safely masticate (chew) the food to an appropriate bite size, and that he had increased coughing with a regular consistency diet trial. Speech therapy's recommendations at that time were to keep the resident on a mechanical soft diet, provide close supervision with his meals, and reinforce the swallowing strategies due to his risk for aspiration. There was no documented evidence on Resident CR1's clinical record that an individualized care plan was developed to ensure safe eating related to the resident's history of choking, swallowing problems, and his risk for aspiration. physician's orders [REDACTED]. A nursing note, dated May 14, 2016, indicated that the resident had a choking episode while eating, the [MEDICATION NAME] manuver was performed without success, and the resident ceased to breath. Interview with Nurse Aides 2 and 3 on May 17, 2016, at 12:40 p.m. and 12:45 p.m., respectively, revealed that they were not aware that Resident CR1 had any swallowing strategies that were to be followed when he was eating. physician's orders [REDACTED]. A nursing note, dated September 12, 2015, at 7:03 p.m., revealed that the resident was in the dining room eating supper when his face turned red and his lips turned blue, and the nurse was required to perform the [MEDICATION NAME] manuver, which produced pieces of salmon. physician's orders [REDACTED]. An initial speech evaluation and plan of treatment for [REDACTED]. consistency and his liquids as nectar thick liquids (fluids thin enough to be sipped through a straw or from a cup but thick enough to fall off a tipped spoon slowly). Speech therapy also recommended swallowing strategies and techniques that included rate modification, alternation of food and fluids, bolus size modifications, chin tuck, and hard swallow/reswallow. Following the resident's choking episode and speech therapy evaluation and recommendations, there was no documented evidence on Resident CR4's clinical record that an individualized care plan was developed regarding his history of choking, his swallowing problems, and his risk for aspiration. A speech therapy discharge summary for Resident CR4, dated October 13, 2015, indicated that the resident should receive his solids as a mechanical soft/ground texture and his liquids as nectar thick liquids. Speech therapy also recommended swallowing strategies and techniques that included rate modification, alternation of food and fluids, bolus size modifications, chin tuck, and hard swallow/reswallow. Following the resident's discharge from speech therapy with recommendations for his diet and swallowing strategies, there was still no evidence that an individualized care plan was developed regarding his history of choking, swallowing problems, and risk for aspiration. physician's orders [REDACTED]. Following the resident's discharge from speech therapy with recommendations for safe swallowing strategies, there was no documented evidence that an individualized care plan was developed related to the resident's swallowing problems and risk for aspiration. Interview with the Director of Nursing on May 17, 2016, at 10:10 a.m., confirmed that the speech therapy recommendations were not on the care plans for Residents CR1, CR4 and R12. Interview with Speech Therapist 4 on May 17, 2016, at 2:00 p.m., revealed that speech therapy's recommendations regarding swallowing techniques were very important for residents who were at risk for aspiration. 42 CFR 483.20(d); 483.20(k)(1) Develop Comprehensive Care Plans. Previously cited 2/25/16. 28 Pa. Code 211.11(d) Resident care plans. Previously cited 2/25/16. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 2/25/16.