Every finding on record at Holy Family Manor

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in one of three resident dining rooms. (Second floor)Findings include: Observation in the Second Floor resident dining room on May 31, 2026, at 1:30 p.m., revealed areas of dark red discoloration along the length of the bottom shelf of the reach-in refrigerator, in addition to a puddle of water and soaked dish cloth. There was a carafe with water that was not dated. There was a carton of chocolate milk with a use by date of May 30, 2026. There was a plastic container with tartar sauce packets in it that had a thick layer of a dried white substance on the outside of the container. There was a bread knife directly touching a shelf in the cooler. In an interview on May 31, 2026, at 1:30 p.m., the Food Operations Manager confirmed that the water should have been dated, the expired milk removed, and that the knife was used to cut sandwiches and left in the reach-in cooler and should have been sent to the for washing and sanitizing. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 19 sampled residents. (Resident 60)Findings include: Review of facility policy entitled, Self-Administration of Medications/Bedside Medication Storage, last reviewed April 28, 2026, revealed that a resident may exercise the right to self-administer medications when determined that this practice is safe. It was the responsibility of the Interdisciplinary Team to determine the following issues with regards to resident self-administration of medications: resident safety to self-administer medications, location of medication administration, determine who will be responsible for storage, and documentation of medication administration. If the resident indicated a desire to self-administer his or her medications, the Interdisciplinary Team would complete the Self-Administration of Medications UDA (User Defined Assessment) to determine the resident's ability to safely self-administer medications. The Care Plan will document interventions to support self-administration of medications by the residents. Clinical record review revealed that Resident 60 was admitted to the facility on [DATE], and had diagnoses that included heart failure, diabetes, depression, and high blood pressure. Review of the Minimum Data Set (MDS) assessment, dated April 21, 2026, revealed that Resident 60 was alert and oriented. Observation of the scheduled medication administration on May 31, 2026, at 10:06 a.m., revealed the licensed practical nurse (LPN 1) placed a medication cup with five pills on Resident 60's bedside table and left the room. LPN 1 confirmed that she left the medications on the resident's bedside table for her to take later. There was no documentation to support that the resident had a physician's order to self-administer medications or that the interdisciplinary team had assessed the resident to self-administer medications. In an interview on June 1, 2026, at 1:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed that Resident 60 did not have a physician's order to self-administer medications and the resident was not assessed to self-administer the medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition for one of 19 sampled residents. (Resident 67)Findings include: Review of the facility policy entitled, Change in Condition- Notification of Change, dated April 28, 2026, revealed the resident and the resident's legal representative/family, would be notified of any change in condition which included a change in behavior, medications, activities of daily living, a new onset of pain, and a change in treatment. Clinical record review revealed that Resident 67 had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and muscle weakness. Review of a nurse's note dated May 13, 2025, revealed the physician was notified and made aware that the resident was incontinent, had a change in behavior, and complained of pain when urinating. The nurse further noted that the physician directed staff to obtain a stat (immediate) urine sample for urinalysis to rule out an infection. In addition, a physician's order dated May 14, 2026, directed staff to administer an increased dosage of an anti-depressant medication (sertraline) from 25 milligrams (mg) to 50 mg. There was no documentation to support that the resident's responsible party was notified of the physician's order for a urinalysis and increased dose of medication. In an interview on June 2, 2026, at 2:20 p.m., the Director of Nursing confirmed that the responsible party was not notified of the resident's changes in condition, including prescribed treatments. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for one of 19 sampled residents. (Resident 67)Findings include: Review of the facility policy entitled, Change in Condition- Notification of Change, dated April 28, 2026, revealed the resident and the resident's legal representative/family, would be notified of any change in condition which included a change in behavior, medications, activities of daily living, a new onset of pain, and a change in treatment. Clinical record review revealed that Resident 67 had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and muscle weakness. Review of a nurse's note dated May 13, 2025, revealed the physician was notified and made aware that the resident was incontinent, had a change in behavior, and complained of pain when urinating. The nurse further noted that the physician directed staff to obtain a stat (immediate) urine sample for urinalysis to rule out an infection. In addition, a physician's order dated May 14, 2026, directed staff to administer an increased dosage of an anti-depressant medication (sertraline) from 25 milligrams (mg) to 50 mg. There was no documentation to support that the resident's responsible party was notified of the physician's order for a urinalysis and increased dose of medication. In an interview on June 2, 2026, at 2:20 p.m., the Director of Nursing confirmed that the responsible party was not notified of the resident's changes in condition, including prescribed treatments. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for three of five newly hired employees. (Employees 3, 4, 5)Findings include:A review of the facility policy entitled, Resident Abuse Prevention and Reporting Reasonable Suspicion of a Crime, dated April 28, 2026, revealed that the facility was to conduct screenings for potential hires for a history of abuse, neglect, or mistreatment of residents, which included checking the appropriate licensing boards and registries for verification of license/certification to ensure the license was in good standing. Employee 3 (E3) had been working in the facility as a license practical nurse since April 15, 2026. There was no evidence that the facility submitted an inquiry to the state licensure board prior to E3 working among residents in the facility. Employee 4 (E4) had been working in the facility as a license practical nurse since April 6, 2026. There was no evidence that the facility submitted an inquiry to the state licensure board prior to E4 working among residents in the facility. Employee 5 (E5) had been working in the facility as the Administrator since April 27, 2026. There was no evidence that the facility submitted an inquiry to the state licensure board prior to E5 working among residents in the facility. In an interview on June 3, 2026, at 9:28 a.m., the Administrator confirmed there was no documented evidence that the license verifications were done prior to start of employment for E3, E4, and E5.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 24)Findings include:A review of the facility policy entitled, Dialysis, last reviewed April 28, 2026, revealed that staff were to complete the pre-dialysis portion of the dialysis communication form that provided information regarding the resident's ongoing status to send with the resident to dialysis, including the resident's pre-dialysis weight and vital signs. Clinical record review revealed that Resident 24 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis and had a physician's order for the facility to provide dialysis three days per week. There was a lack of evidence to support that Resident 24's pre-dialysis weight was obtained and documented on the dialysis communication forms that were to be completed before leaving for dialysis on 24 of 36 occasions from March 2, 2026, through June 1, 2026. Additionally, there was no documented evidence that the facility obtained Resident 24's vital signs on May 20, 2026.During an interview on June 3, 2026, at 1:48 p.m., the Administrator confirmed that the pre-dialysis weight and vital signs were to be obtained prior to leaving for dialysis and documented on the dialysis communication form and that there was no evidence that this was done on the previously mentioned days. 28 Pa. Code 211.12(1)(3)(5) Nursing services.

Based on a review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to inform a resident and/or responsible party, in advance, of a treatment and treatment options prior to receiving psychotropic medication for one of 19 sampled residents. (Resident 67)Findings include: Review of facility documentation entitled, Informed Consent for Psychotropic Medication Use, revealed that before receiving any psychotropic medication, an informed consent must be obtained. The resident or responsible party was to receive information and education regarding the benefits and potential side effects of the psychotropic medication. Clinical record review revealed that Resident 67 was admitted to the facility on [DATE], and had diagnoses that included metabolic encephalopathy (brain dysfunction), dementia, and anxiety. The Minimum Data Set assessment dated [DATE], indicated that the resident had cognitive impairment and displayed symptoms of feeling depressed and hopeless. Physician's orders dated April 22, 2026, and May 5, 2026, directed staff to administer an anti-anxiety medication, lorazepam, every six hours as needed. In addition, a physician's order dated May 7, 2026, directed staff to administer an antidepressant medication, sertraline, once a day. There was no documentation to support that the resident and resident's responsible party were provided with information and education regarding the benefits and potential side effects of the psychotropic medications or that consent was obtained prior to the administration of the psychotropic medications. In an interview on June 2, 2026, at 2:20 p.m., the Director of Nursing confirmed that an informed consent was not obtained and that the resident and resident's responsible party were not educated on the risks and benefits of the psychotropic medications. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review, resident interview, and observation, it was determined that the facility failed to provide timely assistance with care in a manner that maintained dignity for two of 24 sampled residents. (Residents 30, 86) Findings include: Clinical record review revealed that Resident 30 had mild cognitive impairment and required assistance from staff to get out of bed. According to the care plan, she also had depressed mood and would call out at times. The care plan indicated that staff was to respond to her requests for care and allow the resident to make decisions about her activities. On June 4, 2024, at 10:09 a.m., the resident was observed in bed and her call light was on. The resident stated, I want to get out of bed. Between 10:09 and 10:38 a.m., the call light remained on, and several staff members walked by the room without assisting the resident. At 10:38 a.m., a staff member turned off the call light and left the room without assisting the resident. The resident began to call out, Help me! until staff assisted her at 11:07 a.m. Clinical record review revealed that Resident 86 was incontinent of urine, was able to communicate her needs, and required assistance to use the toilet. According to the care plan, staff was to assist the resident to the toilet frequently and upon request. On June 5, 2024, at 10:49 a.m., the resident turned on her call light. At that time she stated, I need to use the bathroom. At 10:52 a.m., a nurse entered the room and turned off her call light without assisting her to the bathroom. Staff did not assist the resident until 11:30 a.m. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to implement physician's orders for one of 24 sampled residents. (Resident 45) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included muscle weakness, dementia, and Parkinson's disease. Review of the Minimum Data Set assessment, dated May 15, 2024, revealed that the resident had cognitive impairment. Review of the care plan revealed the resident has a potential for impaired skin integrity and staff was to apply Dermasaver gloves (gloves for skin protection) to both arms while the resident was in the wheelchair. On June 18, 2023, a physician ordered that staff to apply a Tubigrip (an elastic bandage for support) to the right hand under the Dermasaver glove. On June 4, 2024, at 1:12 p.m. and 2:07 p.m., and again on June 5, 2024, at 10:47 a.m. and 12:25 p.m., Resident 45 was observed in a wheelchair without the Dermasaver gloves or Tubigrip in place. There was no documented evidence that the resident had refused application of the Dermasaver gloves or Tubigrip. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the LPN (Licensed Practical Nurse) Act, clinical record review and staff interviw, it was determined that the facility failed to ensure that professional standards of quality regarding the administration of physician prescribed medications was followed for one of four residents that received medication. (Resident 1) Findings include: Pa. Code Title 49 Professional and Vocational Standards Department of State Chapter 21, State Board of Nursing 21.145 Function of the Licensed Practical Nurse states that the LPN is prepared to functions as a member of the health care team based on preparation, knowledge, skills and understanding of past experiences in nursing situations and the LPN administers medications and carries out the therapeutic treatments ordered for the patient. Clinical record review revealed that Resident 1 had diagnoses that included COPD (chronic obstructive pulmonary disease), anxiety and hypotension. Clinical record review revealed that on January 31, 2024, at 9:40 p.m. LPN 1 failed to identify Resident 1 by name band identification, photo identification or verbal confirmation prior to the administration of medications. As a result, Resident 1 received another resident's medications in error including a medication to treat hypertension (Lisinopril),a medication for schizophrenia (Quetiapine), a medication for tremors (Ropinirole) and a medication for depression (Mirtazapine). In an interview on February 6, 2024, at 11:10 a.m., the Director of Nursing confirmed that LPN 1 failed to follow the accepted standard of identifying a resident prior to the administration of medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 24 sampled residents. (Resident 20) Findings include Clinical record review revealed that Resident 20 had diagnoses that included spina bifida, paraplegia, muscle weakness, and debility. A physician's order dated November 1, 2019, directed staff to apply a knee abduction cushion and check for alignment throughout the day. Review of the care plan revealed that the resident was at risk for skin breakdown. The intervention was for staff to apply a knee abduction cushion per the orders. Multiple observations on July 19, 2023, between 11:10 a.m., and 1:28 p.m., revealed Resident 20 sitting in a wheelchair, the knee abduction cushion was not in place. In an interview on July 20, 2023, at 8:20 a.m., the Director of Nursing confirmed that staff did not apply the knee abduction cushion and that it should have been applied per the care plan and physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to ensure that proper care was provided for one of two sampled residents who used a urinary catheter (a flexible tube that drains urine from the bladder). (Resident 20) Findings include: Review of facility policy entitled, Urinary Catheters, last reviewed January 2023, revealed that a catheter drainage bag was never to be elevated to or above bladder level. Clinical record review revealed that Resident 20 had diagnoses that included paraplegia, spina bifida, dementia, and dysfunction of the bladder. Review of the care plan revealed that the resident had an indwelling catheter. The intervention was for staff to position the catheter bag and tubing below the level of the bladder. Multiple observations on July 18, 2023, between 11:30 a.m. and 1:13 a.m., revealed Resident 20 was seated in a wheelchair. The tubing of the catheter was arranged such that it extended down the resident's pants leg and out the bottom to the drainage bag. The catheter bag was positioned inside the seat of the wheelchair, between the arm rest and the resident's hip. Neither the tubing nor the drainage bag were maintained below the level of the resident's bladder. Urine was observed in the tubing. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review it was determined that the facility failed to notify the resident's representative in four of five residents sampled who were transferred to the hospital. (Residents 19, 56, 61, 112) Findings include: Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on April 24, 2023, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 56 was transferred and admitted to the hospital on April 24, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 61 was transferred to the hospital on April 24 and June 1, 2023, after changes in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfers to the hospital. Clinical record review revealed that Resident 112 was transferred and admitted to the hospital on June 30, 2023, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. 28 Pa. Code 201.29(c.3)(2) Resident rights.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and failed to maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Sanitation and Infection Control, Receiving and Storage, dated [DATE], revealed that food items were to be dated and rotated using the First in-First out system. Upon opening a food item, it was to be dated with the opened date. Observations made during the initial tour of the kitchen on [DATE], at 10:15 a.m., revealed in the walk-in cooler there were mandarin oranges with a use by date of [DATE], navy beans in liquid with a use by date of [DATE], and an uncovered container of romaine lettuce not dated. In the prep freezer there were two aluminum wrapped items without identification to contents, and no date. In dry storage, one opened bag of rice with a use by date of [DATE], four bottles of fish sauce with an expiration date of [DATE], one jar of tamarind paste with no expiration date and no received date, one opened bottle of snow cone cotton candy liquid with a use by date of February 18, 2022, two opened lemon bar crust mixes with a use by date of [DATE], three packages of butterscotch pudding bags with no received by date or expiration date, five bags mini marshmallows with an expiration date of [DATE], one opened container of [NAME] chocolate fudge frosting with no use by date, one opened bag of walnut halves with a use by date of [DATE], one opened bottle of food color with a use by date of [DATE], one opened bag of Krusteaz gluten free flour with a use by date of [DATE], one opened bag of Hershey's cocoa with no use by date, one opened container Sysko double acting baking powder with no use by date, a plastic storage box containing two opened containers of black decorating icing with a use by date of [DATE], two opened containers of sprinkles with use by dates of [DATE] and 17, 2021, and four opened containers of sprinkles with a use by date of [DATE]. In an interview on [DATE], at 10:15 a.m., the Assistant Food Service Director confirmed the identified food items in the dietary department were to have been covered, clearly identified and dated and were not and the expired items should have been removed. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 211.6 (c) Dietary Service.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for one of 23 sampled residents. (Resident 299) Findings include: Clinical record review revealed that Resident 299 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 6, 2022, the physician ordered that the resident be weighed daily and to notify the physician of any weight changes. Review of Resident 299's weight record revealed there was no documented evidence that the weights were obtained as ordered on August 8, 9, 10, 12, 13, 14 and 15, 2022. In an interview on August 18, 2022, at 11:00 a.m., the Director of Nursing confirmed there was no documentation to support that Resident 299 was weighed in accordance with the physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to reassess and review the need for continued use of side rails for one of 23 sampled residents. (Resident 3) Findings include: Review of the facility policy entitled, Transfer Bars/Bedrails/Enablers, last reviewed January 18, 2022, revealed that staff was to review the necessity of continued use of transfer bars quarterly and document in the progress notes. Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on August 16, 2022, at 10:43 a.m., and August 17, 2022, at 10:20 a.m., revealed transfer bars were attached to Resident 3's bed on both sides. Clinical record review revealed that the resident had an initial transfer bar assessment completed on October 21, 2021. There was no documented evidence that the resident was reassessed quarterly for the continued use of the transfer bars per facility policy. In an interview on August 18, 2022, at 11:05 a.m., the Director of Nursing confirmed she had no documented evidence to support that Resident 3 was reassessed quarterly for the continued need for transfer bars. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess and document the status of a pressure ulcer for one of three sampled residents with pressure ulcers. (Resident 6) Findings include: Review of the facility policy entitled, Pressure Ulcer Assessment and other Skin Conditions, last reviewed June 8, 2021, revealed that the wound team would do rounds weekly on residents with skin breakdown and document wound status in the clinical record. Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment, dated June 4, 2021, revealed that the resident had cognitive impairment and required extensive assistance with activities of daily living including bed mobility. On July 28, 2021, a nurse noted that the resident developed a wound on her right fourth toe, measuring 0.2 centimeters (cm) x 0.2 cm x 0.1 cm, that was classified as a stage two pressure ulcer. There was no documented evidence that Resident 6's right toe pressure ulcer was assessed after July 28, 2021, until September 7, 2021. In an interview on September 9, 2021, at 12:12 p.m., the Director of Clinical Operations confirmed there was no documented evidence that the area was measured or assessed from July 28, 2021, until September 7, 2021. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that pain medication was administered in accordance with physicians' orders and policy standards. In addition, the facility failed to attempt non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for two of 19 sampled residents. (Residents 16, 21) Findings include: Review of the facility policy entitled, Pain Management, revised January 9, 2021, revealed that residents were to be screened every shift using pain scales to determine pain intensity. Then pain scale assigned a numerical range to determine the resident's level of pain and was identified as follows: one through four was mild pain, five through nine was severe pain, and 10 was very severe/horrible pain. Clinical record review revealed that Resident 16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On November 27, 2020, the physician ordered that staff administer a narcotic pain medication (oxycodone five milligrams) every four hours as needed for severe pain. Review of medication administration records revealed that the resident received the narcotic medication six times in August 2021, for mild pain only. In addition, there was a lack of documentation to support that non-pharmacological interventions were provided when the as needed pain medication was administered in August and September 2021. Clinical record review revealed that Resident 21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 25, 2021, the physician ordered that staff administer a narcotic pain medication (oxycodone two and one-half milligrams) every six hours as needed for severe pain. Review of medication administration records revealed that the resident received the narcotic medication four times in August 2021, and one time in September 2021, for mild pain only. In addition, there was a lack of documentation to support that non-pharmacological interventions were provided when the as needed pain medication was administered in August and September 2021. During an interview on September 9, 2021, at 1:55 p.m., the Director of Nursing confirmed there was a lack of documentation to support that non-pharmacological interventions were provided prior to or in conjunction with the administration of as needed pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that skin assessments were performed weekly for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission skin assessment revealed that the resident had a skin tear of the right shin. There was no documentation to support that the resident had any other area of skin impairment. The facility policy for new admissions indicated that staff was to perform weekly skin assessments on shower/ bath days and report to the nurse any areas of impaired skin . There was a lack of documentation in the clinical record to indicate the resdient's skin was assessed weekly. The resident was sent to the emergency roiagnom on [DATE]. In an interviw on January 4, 2021, at 11:30 a.m., the Nursing Home Administrator confirmed that there was no documented evidence of Resident 1's weekly skin assessments. The resident had a sacral ulcer on admission to the hospital. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to develop care plan interventions for identified psychosocial needs for two of 26 sampled residents. (Residents 87, 136) Findings include: Clinical record review revealed that Resident 87 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], identified that the resident displayed no behavioral symptoms at that time. Review of the resident's subsequent quarterly MDS assessment dated [DATE], identified that the resident was displaying physical and verbal behavioral symptoms towards others and was rejecting care. Nursing documentation supported that the resident displayed behaviors such as hitting, kicking, cursing at, and running his chair into staff (noted August 24, 2020), sexually inappropriate comments to staff (noted August August 27, 2020), and escalating behavioral symptoms (noted August 27, 2020). Review of the current care plan revealed a lack of psychosocial interventions to address management of the resident's aggressive behaviors. Closed clinical record review revealed that Resident 136 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], identified that the resident had no mood problems, however a subsequent MDS assessment dated [DATE], revealed that the resident was experiencing symptoms such as feeling down, depressed, and/or hopeless two to six days per week. A note by the dietician dated June 15, 2020, indicated that the resident was teary and requested communion. Review of the care plan at that time revealed that the resident's mood symptoms were not addressed. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review, interview, and review of facility documentation submitted to the Department, it was determined that the facility failed to ensure that staff provided sufficient safety and supervision to prevent a fall that resulted in serious injuries (fracture) for one of three residents reviewed (Resident 184). Findings include: Clinical record review revealed that Resident 184 had [DIAGNOSES REDACTED]. Review of documentation initially submitted by the facility to the Department on (MONTH) 5, 2019, revealed that on (MONTH) 3, 2019, at 1:30 p.m. Employee 6, a nurse aide, attempted to transfer the resident off the toilet alone. Documentation reflected that during the transfer the resident began to fall and Employee 6 lowered the resident to the floor. In a written statement dated (MONTH) 5, 2019, Employee 6 noted that duing the transfer the resident's right leg gave out and the left leg was a little to the side so I straighten (sic) it out and put her on the floor. Nurses' notes reflected that about 15 hours later on (MONTH) 4, 2019, at 4:47 a.m. the resident began to complain of leg pain. Nurses' notes indicated that at 11:00 a.m. that day, the resident's left leg was sore and swollen with bruising. Staff notified the physician who ordered X-rays which revealed fractures of the left tibia and fibula (two bones in the lower leg). On (MONTH) 5, 2019, the resident was admitted to the hospital for evaluation and treatment of [REDACTED]. Review of the Minimum Data Set (MDS - a mandated assessment of resident care needs) annual assessment dated (MONTH) 21, 2019, revealed that the resident had an ability to express ideas and wants if prompted and comprehends most conversation. The assessment also noted that the resident could not walk and was totally dependent on the assistance of two staff for toileting and transfers. Both the resident Care Area Assessment (CAA) and the revised care plan dated (MONTH) 26, 2019, revealed that the resident had balance problems, was at risk for falls and was to be free from injuries. Clinical record documentation revealed that since (MONTH) 8, (YEAR), the resident had a physician's orders [REDACTED]. In addition, physical therapy documentation dated (MONTH) 1, 2019, reflected that the resident continued to require two staff for all transfers. In an interview conducted on (MONTH) 14, 2019, at 1:35 p.m. the resident confirmed that she broke her left leg because one nurse aide transferred her from the toilet to the wheelchair. The resident further stated that she has pain and my body will never be the same. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 3/23/18 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 3/23/18, 6/24/17, 4/6/17

Based on clinical record review, incident investigation review and staff interview, it was determined that the facility failed to provide adequate monitoring and supervision to prevent a fall in a stairwell for one of two residents sampled. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had memory impairment, impaired decision making, and was independently mobile in his wheelchair. A current physician's orders [REDACTED]. Review of a form entitled "Elopement/wandering assessment" dated February 20, 2015, revealed that the resident wandered on a daily basis and often was observed aimlessly wheeling himself about the care unit throughout the day. Review of an event submitted by the facility to the Department of Health, via the electronic Event Reporting System (ERS) on February 20, 2015, at 6:20 p.m., revealed that staff had found Resident CR1 on the floor at the bottom of steps with wheelchair beside him, in a non-resident care area. The resident was without respirations, grey in color and his head was in a puddle of blood. The resident was pronounced deceased at the scene. Review of facility incident investigation report revealed that the resident had exited the north wing by way of an activity/lounge area (Spanish Room) on the unit. There was a ramp area in this lounge that led to the chapel. The resident was able to open the gate to the ramp that led to the chapel. The gate was alarmed, but the alarm did not sound. Once down the ramp, the resident opened the door to the vestibule of the chapel. He then opened the door to the stairwell instead of the door to the chapel. The door to the stairwell was unlocked and unalarmed, because it was an emergency exit route. Staff found the resident at the bottom of the steps in the stairwell, face down and his wheelchair along side of him. Two dietary employees heard the sound from the alarm on the resident's wheelchair and summoned nursing to the scene. In an interview on February 24, 2015, at 11:50 a.m., the Nursing Home Administrator confirmed that staff failed to provide adequate supervision to enure that this known wandering resident was kept safe and injury free. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE]