Every finding on record at Holy Family Home

Based on a review of the clinical record, review of facility's policy and staff interviews, it was determined that the facility failed to ensure that re-weights were completed in a timely manner for one of 18 clinical records reviewed. (Resident R7). Findings include: Review of the facility policy, Weight, Loss or gain/re-weights, dated July 2, 2023, indicated that the physician, dietician, and MDS (Minimum Data Set- assessment of resident's care needs) Assessment Coordinator will be notified of the results of the monthly weights as indicated in the physician orders. Continued review of the order indicated that for significant weight loss, labs may be recommended to see if indicators of malnutrition are present. Review of the April 2025 orders for Resident R2 included the following diagnosis: anemia (a condition characterized by a deficiency of healthy red blood cells); chronic pain; diabetes (failure of the body to produce insulin); osteoarthritis (condition in which the protective cartilage that cushions the ends of the bones wears down over time) and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's weight record revealed than on October 17, 2025 the resident weight wa 168.6 pounds. Review of October 24, 2025 weight recorded by nursing staff was 148.8 pounds, totaling a 12.04-pound significant weight loss from October 17, 2025 to October 24, 2025. Continued review of Resident R7's clinical record did not show evidence that a re-weight was completed in a timely manner to ensure accuracy. Further review of the weight records revealed that a reweight was completed 5 days later on October 29, 2025. During an interview with the clinical dietician (Employee E3) on April 2, 2026, the -12.04 significant weight loss from the recorded weights of October 17, 2026 and October 24, 2026 was confirmed. The clinical dietician also reported that a weight discrepancy of 5 pounds or more from a resident's most recent requires a re-weight completed by nursing staff. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility's policy, staff interviews and the review of clinical records, it was determined that the facility failed to clarify a physician's order related to a resident's alcohol consumption for 1 out of 18 residents reviewed (Resident R7).Findings include: Review of the facility policy Alcohol Beverage Consumption, dated April 1, 2026, stated that upon admission, a licensed nurse will review the resident's medications and diagnosis, with the resident's physician, and that the physician will determine if the resident's medication of health status has any interaction of adverse effects with the consumption of alcoholic beverages per facility protocol. Continued review of the policy indicated that the facility has a two glass limit of alcohol beverage of choice to residents participating in any activities or special occasion events. The policy indicated that the two glass limit and the amount of alcoholic beverage that can be consumed will depend on the type of alcohol that the resident chooses (e.g. 12 ounces of beer, wines cooler; 8-9 ounces of malt liquor; 5 ounces of table wine; 3-4 ounces of fortified wine, 2-3 ounces of cordial liquer, Shnapps; 1.5 ounces of Brandy/Cognac/[NAME]/Courvoisier; 1.5 ounces of liquor such as a shot of vodka/gin/scotch/whiskey/[NAME]/tequila. Review of the clinical record for Resident R2 included the diagnoses of anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome); anemia (a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should); foot pain; hyperlipidemia (high cholesterol); migraine (a headache that can cause intense throbbing pain or a pulsing feeling, usually on one side of the head. It often happens with nausea, vomiting, and extreme sensitivity to light and sound); chronic pain syndrome (a long-term condition where persistent pain is accompanied by emotional and functional difficulties, affecting daily life). Review of Resident R2's April 2026 physician orders included a physician's order dated May 16, 2019, and monthly thereafter stating that the resident can have alcoholic beverages at activities or special occasions. Continued review of the physician orders did not include any parameters related to the consumption of alcohol such as the type of alcohol and the amount that the resident can consume in a specified period of time . Review of the resident physician orders included several medications that the resident is currently prescribed when mixed with alcohol due to the impact on the central nervous system or liver:Tramadol: As an opioid analgesic, tramadol can cause drowsiness, dizziness, and impaired coordination. Alcohol intensifies these effects, significantly increasing the risk of respiratory depression (slowed or stopped breathing), accidents, and falls. Pregabalin: Both the 150 mg and 75 mg capsules act on the CNS. Mixing this with alcohol can lead to severe sedation, cognitive impairment, loss of coordination, and an increased risk of falls. In severe cases, it can cause respiratory failure. Duloxetine: This medication is often used for anxiety and can cause dizziness or drowsiness. Alcohol can increase the risk of these side effects and impair judgment or coordination. Tylenol (Acetaminophen): Alcohol consumption while taking acetaminophen significantly increases the risk of severe or life-threatening liver damage. Eliquis (Apixaban): While there is no direct chemical interaction, alcohol can increase the risk of serious bleeding events, which is a critical concern for someone on an anticoagulant (blood thinner). Rimegepant: Alcohol is a known migraine trigger and may worsen the symptoms that the medication is treating, effectively counteracting the benefit of the medication. Protonix: While alcohol does not directly change how this medication works, it can stimulate stomach acid production, which may worsen the GERD symptoms the medication is intended to treat.During an interview with the Director of Nursing on April 1, 2026, at 2:30 p.m., it was discussed that physician orders for the consumption of alcohol were not clarified to document the amount of type, and frequency of consumption of alcohol to ensure continues resident can have. 28 Pa. Code:201.18(b)(1)(3) Management 28 Pa. Code:211.12(d)(1)(5) Nursing services

Based on a review of facility policies, clinical records, facility documentation, staff, resident and family interviews, it was determined the facility failed to ensure that Resident R1 was adequately secured in a transportation van. This failure resulted in actual harm for Resident R1 who fell while being transported in the van and sustained a fracture of the left distal femur and fracture of the right distal tibia, requiring transfer to the hospital and surgery for one of three residents reviewed. (Resident R1) Findings Include: Review of facility policy titled, Wheelchair Transport with revision date of June 2025 revealed, Policy- To move a resident who cannot move from one location to another without assistance. Further review of the policy indicates under, Purpose- to fulfill physical, social, psychological or spiritual needs. Review of Resident R1's clinical records revealed Resident R1 was admitted to the facility on [DATE] with the diagnoses of Chronic Pain (persistent or long-lasting pain that continues for more than three to six months), Drusen of Macula (small, yellow, waste-product deposits of lipids and proteins that accumulate under the retina, serving as a primary early indicator of Age-Related Macular Degeneration -AMD), Anxiety Disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), Major Depressive Disorder (serious, common mood disorder characterized by persistent sadness, low energy, and loss of interest in daily activities for at least two week), Muscle Weakness (decrease in the ability to exert force with your muscles, meaning they do not contract or move as expected) Osteoarthritis (chronic joint disease, occurring when protective cartilage at the ends of bones wears down over time, causing pain, stiffness, and reduced mobility), and Edema (swelling caused by excess fluid trapped in the body's tissues). Review of information submitted to the State Survey Agency on, dated February 21, 2026, revealed, [Resident R1], awake, alert, and oriented times three (people, places and situations), BIMS (Brief Interview for Mental Status) of 15 (cognitively intact), non-ambulatory for seven years and requires mechanical sit to stand life for transfers. Continued review of information submitted to the State Survey Agency, revealed at approximately 7:00 p.m., Resident R1 was returning to the facility after an outing with family member via wheelchair van transport. According to Resident R1's family member, who accompanied resident on the van, Resident R1 began sliding under the cross-body seatbelt, sliding down to the floor in front of the wheelchair. Resident's daughter and transport driver attempted to lift resident back up into chair but were unable to and proceeded back to the facility. RN (Registered nurse) notified, entered the van to see [Resident R1] seated on (his/her) right hip, legs together bending in front of (him/her) facing towards the left and was complaining of pain. RN notified 911(Emergency Medical Services) who arrived within 5 minutes. [Resident R1] transferred by EMTs (Emergency Medical Technicians) from van into the ambulance then transported to the hospital ER (Emergency Room). Review of Resident R1's nursing progress note dated February 21, 2026, revealed Called to the entrance of the house just before 7 p.m. When I arrived outside, I found resident sitting on the floor of the handicap van with (his/her) legs beneath (him/her), having slid out of the wheelchair during the ride home from the outing. Resident was with (his/her) daughter and the driver. Resident had been secured with the handicap van seat belt in the transport wheelchair which was secured in the handicap van with 4 straps to the floor. Daughter had attempted to keep (resident) from sliding out of the wheelchair but was unable due so. Resident was complaining of pain to (his/her) legs. According to daughter, resident did not hit (his/her) head as (he/she) slowly slid out of the wheelchair. Was unable to assess resident thoroughly or obtain vital signs due to (his/her) position inside the handicap van. Called 911 (Emergency Medical Services) immediately. First responders arrived shortly thereafter and assisted (resident) out of the van and onto a stretcher in order to transport (him/her) to emergency room for further evaluation. Primary Care Physician notified of incident and transfer to Emergency Room. Resident left via ambulance around 7:25 pm. Chaplain present and gave blessing before resident left. Review of Resident R1's hospital record dated February 21, 2026, revealed, Eighty-five year old (female/male) with left periprosthetic distal femur (thigh) fracture. Right distal tibial (leg) shaft fracture status post slip forward under wheelchair seat belt from wheelchair. Review of Resident R1's nursing progress note dated February 27, 2026 revealed, Resident R1 returned from hospital post status- Left femur Open Reduction (surgical procedure used to stabilize and heal a fractured left femur by realigning the bone and securing it with internal hardware) and Internal Fixation (Weight Bearing As Tolerated) and Right tibial minimally displaced distal tibial fracture casted base of toes to below knee (Non-Weight Bearing). Left lateral thigh with dressings from hip extending to 8 inches above knee - dressing with moderate amount of strike through on dressings, treatment with wound dressing ointment twice a day. [Resident R1] indicated (he/she) does not want to be on any additional pain meds (he/she) was on in hospital, only wants the pain meds (he/she) was receiving at the facility. Review of facility investigation into the fall incident sustained by Resident R1 revealed a statement from (van driver) Employee E3 indicated, In person interview held with (van driver), Employee E3 witnessed by Director of Nursing Employee E2 and Nurse supervisor Employee E4 and (Director of Maintenance) Employee E5. I arrived at 2PM on Saturday [DATE], to pick up the resident and (his/her) daughter. I got (him/her) in the van facing forward and hooked the wheelchair to the four points anchor in the van and put on the seat belt. Daughter sat in the back passenger seat. Fifteen minutes into the ride, (she/he) said (she/he) was slipping, I stopped and re-adjusted (her/his) seat belt. (She/he) said (her/his) pants material and cushion is what causes the slipping. We arrived five minutes later and I wheeled (her/his) backwards out of the van. I gave (her/his) my number to text me when they were ready, but they said they would be ready around 6:00 p.m. or 6:30 p.m. I picked them up and wheeled (her/his) into the van and strapped (her/his) as I did earlier. (Resident) spoke about enjoying dinner, there was nothing different with (him/her). Five minutes into the ride (he/she) mentioned (he/she) was slipping again; I told (him/her) I was going to stop to re-adjust (his/her) seat belt. (He/she) said (he/she) was fine keep going. (His/her) daughter asked if (he/she) was sure and (he/she) said yes. I was focusing on the traffic; I don't know if the daughter did anything to help. I was going the speed limit, but at this point traffic was heavy, so I was moving about ten miles per hour. I turned on (he/she) said (he/she) was slipping again; I stopped and when I opened the door, (he/she) was sitting on the footrest. The daughter and I tried to put (him/her) back in (his/her) chair, but we couldn't. I said let's call for help. Daughter stated let's keep going. During interview held with Resident R1 on March 12, 2026, at 10:31 a.m. the resident was asked Did you apply your own seatbelt? the resident stated No the driver did, we started going, and it seems to me like he was going faster and it made me nervous he might have gotten nervous, I said I was slipping and my daughter was next to me, by the time he pulled over I was already on the ground and I don't remember much after that. I had the best time when I was out with my family. Interview held with Resident R1's daughter on March 12, 2026, at 10:55 a.m. revealed Resident R1's daughter met Resident R1 and (van driver) Employee E3 at the facility to ride over to their destination. Resident R1 was transferred to the van and there were no issues on the ride over. On the way back I thought he had strapped (him/her) in the same way as on the ride over but a few minutes in (he/she) started to say (he/she) felt a little loose. We were going through a busy nearby intersection, and as we were going through (he/she) slide down off of the chair. The driver then pulled over right away but [Resident R1] was already down on the floor of the van. Resident R1's daughter stated her and (Van driver) Employee E3 attempted to lift Resident R1 back into the chair but they were unable to, so she asked van driver, Employee E3 to go back to the facility. Review of facility investigation documents revealed a written statement from Licensed nurse, Employee E4, Called to the entrance of the house just before 7 pm. When I arrived outside, I found resident sitting on the floor of the handicap van with (his/her) legs beneath (him/her), having slid out of the wheelchair during the ride home from the outing. Resident was with (his/her) daughter and the driver. Resident had been secured with the handicap van seat belt in the transport wheelchair which was secured in the handicap van with 4 straps to the floor. Daughter had attempted to keep (him/her) from sliding out of the wheelchair but was unable do so. Resident was complaining of pain to (his/her) legs. According to daughter, resident did not hit (his/her) head as (he/she) slowly slid out of the wheelchair. Was unable to assess resident thoroughly or obtain vital signs due to (his/her) position inside the handicap van. Called 911immediately. First responders arrived shortly thereafter and assisted (him/her) out of the van and onto a stretcher in order to transport (him/her) to the emergency room for further evaluation. Primary Care Physician notified of incident and transfer to Emergency Room. Daughter followed resident to Emergency Room. Resident left via ambulance around 7:25 pm. Chaplain present and gave blessing before resident left. Review of map directions revealed from the destination to the nursing facility was a total distance of 5.4 miles which would take approximately 19 minutes to drive. Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing (DON), Employee E2 at 9:50 a.m. on March 12, 2026. were asked what occurred with Resident R1 having a fall in the transportation van. The Director of Nursing Employee E2 stated, Resident R1 had a requested to go out with family to celebrate (his/her) birthday with (his/her) family. Resident R1 went with no issues but on the way back slide out of (his/her) chair, the driver and daughter attempted to get resident back in but couldn't, they proceeded back to the facility and at that point 911 was called and Resident R1 was taken to the hospital. When asked what type of van and chair it was DON, Employee E2 revealed it was a facility transport van and a standard wheelchair. When asked who fastened Resident R1's seatbelt DON Employee E2 stated van driver, Employee E3 did. DON, Employee E2 revealed when the van driver, Employee E3's statement was taken they described fastened the seat belt but when asked to demonstrate the belting it was determined by the facility that Employee E3 failed the ensure the wheelchair was properly belted under the arms of wheelchair to obtain and maintain maximum securement. Interview held with the licensed nurse supervisor, Employee E4 who was the nurse supervisor the night the incident occurred, I was informed (he/she) was back and that there was trouble, so I immediately went to the entrance, found (him/her) half sitting and half lying. It was obvious (he/she) had slid and (he/she) was saying that (he/she) just wanted to go to bed but it hurts. I immediately called 911 due to me completing an initial assessment and realizing it was a situation that needed emergent attention. Interview held on March 12, 2026 at 12:44 p.m. with the Director of Maintenance, Employee E5. revealed I have experience with driving vehicles, securing people, moving people and stuff like that is why I was designated to be the trainer to teach, to re-educate and make sure everybody knew what was going on and make sure all the vehicles were safe and see if there was anything that was missing or needed to happen. When asked how many vehicles the facility uses for transport Director of Maintenance, Employee E5 revealed, there's three vans that could be used and a car that could be used but that's for ambulatory people. Director of Maintenance, Employee E5 was asked, how did you do an evaluation of the vans to make sure everything was still working properly and then how did you come up with the training that you were using to retrain the staff? When asked if anything was changed or modified in the vans Director of Maintenance, Employee E5 stated, I didn't want to modify I just went straight to all new equipment basically new everything, as far as like lap belts or well I noticed that the handicapped van is set up with a use of the existing cross strap and the van has been modified for handicapped. they put the brackets in the floor and it's got the bracket the receiving actually and but it's primarily mounted so you use the seat belt that's in there. Because of the way it goes on some of the chairs I said we needed to get a different kind of an additional lap belt for chairs that don't that have the armrests attached to the back; you would have to go under and across, thus losing the cross strap if you're going to lose the chest strap let's put it down where it's better so we got the lap belt that attaches to the anchor points. I ordered those for the handicapped van and I installed them, for training there is a manufacturer nineteen minute video we'll make the staff/drivers watch the video and we take them to the van we show them how it's done and then we make the drivers actually do it. Continued interview with the Director of Maintenance, Employee E5 on March 12, 2026, revealed the facility van driver was still employed and was re-in serviced and re-trained with a hands-on training on how to proper securely individuals in facility vans. The training included reviewing a 19-minute video and hands on skills testing. Interview held on March 12, 2026, with Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 at 2:20 p.m. confirmed the facility van driver did not properly secure Resident R1 in the transportation van. The facility failed to ensure that Resident R1 was adequately secured in the transportation van. This failure resulted in actual harm for Resident R1 who fell while being transported in the van and sustained a fracture of the left distal femur and fracture of the right distal tibia and required a transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management

Based on clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records related to fall investigation for one of eight records reviewed (Resident R6). Findings include: Review of facility reported incidents revealed that resident R6 sustained an unwitnessed fall on January 17, 2025. A request was made to employee E2, the Director of Nursing, at 1:30 p.m. on April 9, 2025, to provide the surveyors with the fall investigation report. On April 10, 2025, at 9:30 a.m. the facility provided the report. Employee E2 stated that they could not find the original report and that she had recapitulated it to a new form. Review of the form revealed that the document was dated as 4-9-25 for event 1-17-25. Interview with employee E2 on April 10, 2025, at 12:00 p.m. confirmed that because the facility was unable to locate the original document, the records for resident R6 were incomplete. 28 Pa. Code 211.12(c) Nursing service 28 Pa. Code 211.12(d)(1) Nursing service 28 Pa. Code 211.12(d)(2) Nursing service 28 Pa. Code 211.12 (d)(5) Nursing service

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure foods were stored in accordance with professional standards for food service safety and that dishes were cleaned under sanitary conditions. Findings Include: Review of undated facility policy titled, Labeling and Dating, revealed the facility staff is to label and date all stored foods. Review of facility policy titled, Dishwashing Machine Operation- High Temperature, dated April 7, 2006, revealed staff is to check and record temperatures of wash and rinse water. Wash temperatures should reach 160 degrees Fahrenheit and rinse temperatures must reach at least 180 degrees Fahrenheit. Further review revealed staff is to record was and rinse temperatures on the dishwasher Temperature Log form and temperatures are checked throughout the dishwashing cycle. A tour of the Food Service Department conducted on July 25, 2023, at 10:27 a.m. with the Food Service Manager (FSM), Employee E4, and the facility Chief Executive Officer (CEO), Employee E5, revealed the following concerns: Observations in the dishwashing machine room area revealed clumps of dust all throughout the right side of the wall, exposing clean dishes to physical contamination. A blowing fan was observed moving the dust clump particles on the wall making dust particles unstable. Review of the dish machine temperature log revealed temperatures were not monitored throughout the month; the temperature log was blank. Interview with Employee E4 and E5 on July 25, 2023 at approximately 10:30 p.m. confirmed there was no dish machine temperature log monitoring for the months of April, May, June, and July of 2023. Observations in the walk-in freezer revealed the following foods were opened, undated, unlabeled, and without proper sealing to prevent freezer burn: french fries, waffle sweet potato fries, meatballs, chicken patties, breakfast waffles, and ravioli. Observations in the main kitchen area revealed very dirty stove top. Further observation revealed a layer of dust on the oven top and water leakage. Observations in the receiving/dumpster area revealed multiple clumps of plastic wrap, plastic sandwich bags, large clear trash bags, and leaves next to the green garbage can. Observations were confirmed by FSM, Employee E4, and CEO, Employee E5, along the duration of the tour. 28 Pa. Code 211.6 (f) Dietary Services

Based on observation, clinical record review and staff/resident interviews it was determined that the facility failed to provide food in a form to meet a resident's individual needs for one of 11 residents reviewed. (Resident R17). Findings include: Observation of Resident R17's lunch meal on August 10, 2015 at 12:30 p.m. revealed that the resident's lunch included a ham slice. The resident refused to eat the ham slice and asked for the ham to be chopped. Review of Resident R17's physician's orders [REDACTED]. Review of a speech therapy progress note dated July 17, 2015 revealed that a recommendation for a mechanical soft diet and on July 29, 2015 revealed that the resident is unable to swallow related to the [MEDICAL CONDITION] and requires a tube feeding. An interview with Employee E3, dietitian, on August 11, 2015 at 11:30 a.m. revealed that a ham slice was not an appropriate food for this resident. 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on observation, clinical record review, interviews with staff and review of facility policy and procedure, it was determined that the facility failed to provide a safe and sanitary environment to prevent potential transmissions of infections for three of 11 residents reviewed. (Resident R10, R5, and R32). Findings include; Observation of blood sugar testing using a glucometer (blood sugar monitoring device) for Resident R10, on August 11, 2015 at 12:10 p.m. with Employee E4, licensed nurse, revealed that the employee did not clean the glucometer prior to use or after use, after contact with a blood sample, and then placed the the glucometer back in the community medication cart, contaminating the cart. Employee E4 then took the glucometer out of the medication cart and went into the medication room and cleansed the glucometer with a spray disinfectant solution labeled AIRX 44 ACE, that was under the sink. Observation during a medication pass on August 11, 2015 at approximately 8:00 a.m., employee E 5 stated R32's blood sugar is checked before receiving insulin. E5 wiped the glucometer device with alcohol and checked the Resident's blood sugar. The device indicated, the resident required insulin. Following the administration of the insulin, employee E5 was observed cleaning the glucometer with alcohol and returned the device to the drawer in the medicine cart. Review of the manufacturer's recommendations for cleaning the EVENCareG2 revealed that the disinfectant used by the facility for cleaning the glucometers was not on the list of disinfectants to be used to cleanse the glucometer. An interview with Employee E2, infection control licensed nurse, on August 12, 2015 at 11:45 a.m. confirmed that the facility staff were not using the correct disinfectant cleaner for the glucometer. E5 failed to properly cleaned the glucometer device with a bleach disinfecting wipe as required by the Department of Health and Human Services. The faciliy failed to follow the infection control Standards for Nursing Homes 483.65-F441 dated August 27, 2010, Department of Health and Human Services, Center for Medicare and Medicaid Services, that a bleach only disinfecting wipe is used to clean the glucometer following resident's blood sugar check. Based on observation, review of clinical records and facility policy and procedures and staff interiews, the facility failed to maintain an effective infection control program. The facility did not establish a secure and safe field for prepartion and disposal of items during a dressing change of an infectious wound. E3 failed to change gloves after removing the soiled dressing and applying the clean. The facility failed to maintain a safe and santitary environment to help prevent the transmission of infectious disease. 28 Pa. Code: 201.18 (b)(1) Management. 28 Code: 211.12 (d)(1)(5) Nursing services.

Based on observations, review of facility documentation and interview with facility staff, it was determined that the facility failed to consistently monitor the safe use of therapeutic equipment and failed to maintain doors and safety rails in order to provide a safe and functional environment for residents on two of two nursing units. findings include: Observation of the Physical Therapy room on August 10, 2011, at approximately 10:15 a.m., accompanied by the Director of Maintenance revealed the presence of a [MEDICATION NAME] (metal tank filled with very hot water to heat and store hot packs for therapeutic use) located in the main therapy room. A review of logs titled Physical Agent Modality Temperature Cleaning Log for the [MEDICATION NAME] indicated that for temperatures above 165 degrees discontinue use immediately and notify facility staff. The logs for the months of December 2010, through June, 2011, revealed many dates that had no entries. The entry for June 2, 2011, indicated that the temperature had reached 170 degrees. Employee E4, physical therapist, reported in an interview on August 10, 2011, at approximately 10:00 a.m. that the log sheet was to be used to keep a record of the daily temperatures of the water in the [MEDICATION NAME]. During the interview with the employee, it was confirmed that temperatures had not been consistently monitored or recorded and that she had just learned that the temperatures had to be done daily not weekly. Observations during the environmental tour of the second and third floor nursing units on August 10, 2011, at approximately 10:30 a.m., accompanied by the Director of Maintenance, revealed the corners on the doors for resident rooms 2A-8, 2A-14, 3A-2, 3A-5 and both fire doors in the hallway outside of room 3A-2 to have splintered laminate, gouges and sharp edges from the bottom of the doors up to approximately 6 to 11 inches. Safety handrails were noted to be loose and easily moved in the second floor hallway between the wheelchair closet and the community tub room, resident rooms 2A-1 and 2A-2; also in the third floor hallway on both sides of the elevator doors, resident rooms 3A-8 and 3A-9. These observations were confirmed by the Director of Maintenance. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on observation and staff interview, it was determined that the facility failed to post the required information regarding the facility's name, nurse staffing and census for two of two nursing units. Findings include: Observations on the second and third floor nursing units on all days of the survey failed to reveal the required nurse staffing information including the resident census, total number licensed registered nurses and licensed practical nurses or total number of hours worked by licensed registered nurses, licensed practical nurses, and nurse aides. Observation of both units accompanied by facility Administrator on August 10, 2011, at approximately 11:15 a.m. and 11:30 a.m. confirmed that the nurse staffing postings were not posted on either unit. The Administrator stated at that time that she had not been aware that they had to be. 28 Pa. Code 201.18(e) Management.

Based on reviews of clinical records/facility documentation/facility policy, procedures and interviews with facility staff, it was determined that the facility failed to consistently assess, monitor and supervise a resident with multiple serious medical conditions for one of two residents reviewed, resulting in neglect and actual harm to one resident. (Resident: R2). Findings include: Clinical record review of Resident R2 revealed [DIAGNOSES REDACTED]. A review of facility documentation for January 15, 2011 revealed that after lunch, Resident R2 was transferred to the resident's bed from a standing position, with assistance of Employee E1, a nursing assistant and use of a rolling walker. It was documented that the resident had let herself fall back on the bed while holding onto the walker. Resident R2's legs came up and hit the crossbar of the underside of the rolling walker. The incident was not reported to the charge nurse at that time. At 4:45 p.m., Employee E2, a nursing assistant, dressed Resident R2 who informed the nursing assistant that she had a broken leg. Employee E3, called the charge nurse who assessed Resident R2 and identified bleeding from the right distal lower extremity with open [MEDICAL CONDITION] tibia and the right foot was turned inward. A review of the physician's orders [REDACTED]. The facility staff neglected to report the initial injury to the supervisor. The facility staff had failed to follow the facility policy and procedure for Incident Reporting dated July 2005, to ensure an adequate initial assessment for the resident. A review of the facility investigation report revealed that the initial injury occurred during the provision of care earlier in the day. The physical evidence suggests movement during provision of care on 3-11 shift which may have caused the open fracture to occur. There was evidence of a discrepancy between the verbal and written reports by the 3-11 nursing assistant and the observation of the nurse and administration. Interview with the Director of Nursing, on March 8, 2011, at 3:00 p.m., confirmed that Resident R2 had sustained the initial injury during the provision of care in the afternoon and later while providing further physical movement during care, an open fracture occurred. 28 Pa Code: 211.12 (d)(1)(3)(5) Nursing services

Based on observations, reviews of clinical record, facility documentation and interviews with facility staff, it was determined that the facility failed to prevent injury to one of 11 residents by adequately assessing and monitoring the use of hot packs resulting in actual harm to Resident R11. Findings include: Clinical record review of Resident R11 revealed [DIAGNOSES REDACTED]. documentation dated March 11, 2008. The resident assessment of June 15, 2010, indicated that Resident R11 was independent with decision making, exhibited behaviors, received extensive assistance with personal hygiene and received skilled therapies for self feeding, ambulation, pain and transfers skills. A review of facility documentation noted that Resident R11 was assessed with [REDACTED]. A review of physician's orders [REDACTED]. A review of occupational therapist documentation for August 31, 2010, revealed that Resident R11 participated in receiving hot packs which were placed in six towels, at 10:12 a.m. to 10:27 a.m. that day. During this treatment, the resident was described as exhibiting accusatory and paranoid thoughts and the occupational therapist provided redirection. Review of nursing documentation for August 31, 2010, at 4:30 p.m., six hours later, indicated that the restorative aide identified Resident R11 with blisters on the tips of the 2nd, 3rd and 4th fingers of the right hand and the resident did not voice any pain concerns. The resident was unaware of how the blisters developed. The physician ordered a dry dressing to be applied and for staff to observe for other areas that blisters may appear. Facility documentation dated September 1, 2010, indicated the resident had an increase in the fluid filled blisters and the physician ordered for Resident R11 to be transferred to the hospital for evaluation of these blisters that were identified as second degree burns. A review of the facility investigation revealed that the occupational therapist had noted on the day of the last treatment (August 31, 2010) that the resident's fingers were "a little pruny looking" and did not think that this was unusual at the time. An observation during treatment of [REDACTED]. The third finger tip had been debrided by the wound care specialist and was approximately one centimeter by one centimeter. The facility failed to adequately monitor this Resident R11 identified with decreased sensations in the bilateral hands. This condition would place the resident at high risk for burns. Resident R11 was unable to feel if the modality was too hot due to lack of peripheral circulation. The facility failed to provide the resident with more frequent skin checks during the modality treatment to ensure skin integrity resulted in actual harm for Resident R11. Interview with Employee E2, on September 9, 2010, at 2:00 p.m., concluded in the facility investigation that Resident R11 sustained the burn after the application of the hot packs. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services