Every finding on record at Homewood Living Martinsburg, Inc

Based on review of clinical records as well as staff interviews, it was determined that the facility failed to notify the resident and resident representative in writing regarding the reason for hospitalizations, for four of 37 residents reviewed (Resident's R9, R37, R76 and R110). Findings include: The facility's policy for Admission, Transfer and Discharge Notification, dated January 8, 2025, did not indicate that upon transfer to the hospital the resident and legal guardian would be notified in writing. An admission MDS for Resident 9, dated October 19, 2025, indicated that the resident was cognitively impaired and had an indwelling urinary catheter (tube placed in the bladder to drain urine). A nurse's note for Resident 9, dated October 29, 2025, at 7:53 a.m. revealed that the resident was sent to the emergency room for an evaluation related to not being able to urinate and unsuccessful attempts to straight catheterize (medical device used to temporarily drain urine from the bladder) him. There was no documented evidence that written notification of transfer to the hospital was provided to Resident 9 or his representative. A quarterly MDS assessment for Resident 37, dated October 9, 2025, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included congestive heart failure. A nursing note for Resident 37, dated July 3, 2025, revealed the resident was transferred to the hospital following a change in condition. There was no documented evidence in Resident 37's clinical record to indicate that the resident and resident's representative were notified in writing of the purpose for the transfer to the hospital. A quarterly Minimum Data Set assessment for Resident 76, dated October 31, 2025, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included Alzheimer's disease. Review of Resident 76's clinical record revealed the resident was transferred to the hospital on March 20, 2025 following a fall with injury. There was no documented evidence in Resident 76's clinical record to indicate that the resident and resident representative were notified in writing of the reason for the resident's transfer to the hospital on March 20, 2025. An admission Minimum Data Set assessment for Resident 110, dated September 7, 2025, indicated that the resident was cognitively intact, required assistance from staff for his daily care needs and had diagnoses that included a total hip replacement. Review of Resident 110's progress notes revealed that the resident was transferred to the hospital on September 21, 2025, when he developed a temperature, cough and shortness of breath. There was no documented evidence in Resident 110's clinical record to indicate that the resident and resident representative were notified in writing of the purpose for the resident's transfer to the hospital on September 21, 2025. Interview with the Director of Admissions on December 11, 2025 at 10:45 a.m. confirmed that the facility is not automatically sending written notification to the resident and resident representative when a resident is transferred to the hospital. Interview with the Director of Nursing on December 11, 2025 at 16:30 a.m. confirmed that there is no documentation that the resident and resident representative were notified in writing of Resident 9, 37, 76 and 110's transfers to the hospital, and there should have been. 28 Pa Code: 201.25 Discharge policy. 28 Pa Code: 201.29 (f) Resident rights. 28 Pa Code: 201.29 (g) Resident rights

Based on observations and staff interviews, it was determined that the facility failed to provide a homelike environment for one of 37 residents reviewed (Resident 14). Findings include: The facility's policy entitled Homelike Environment, dated January 8, 2025, indicated that residents will be provided with a safe, clean comfortable and homelike environment. Observations of Resident 14's Broda Chair (a specialized chair designed primarily for individuals with mobility challenges and physical disabilities) on December 8, 2025 at 10:42 a.m.; December 9, 2025 at 1:19 p.m.; and December 10, 2025, at 2:20 p.m. revealed that the resident was resting in her chair and the left armrest had an area approximately 12 inches by 6 inches that was torn and shredded. Interview with Registered Nurse Supervisor 1 on December 10, 2025, at 2:37 p.m. confirmed that the left armrest cover on Resident 14's Broda chair had a large area that was torn and shredding off, and it should not be. Interview with the Director of Nursing on December 10, 2025, at 2:55 p.m. confirmed that Resident 14's Broda chair should not have armrests and/or headrests that are torn or shredded. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 39 residents reviewed (Resident 17).Findings include: The facility's laboratory and diagnostic test policy, dated January 8, 2025, indicated that the physician would identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated November 17, 2025, revealed that the resident was moderately cognitively impaired and had diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Physician's orders for Resident 17, dated November 25, 2025, included an order for staff to obtain a TSH (Thyroid Stimulating Hormone - test used to identify the amount of hormones secreted by the thyroid).There was no documented evidence that staff obtained Resident 17's TSH as ordered on November 25, 2025. Interview with the Director of Nursing on December 11, 2025, at 11:29 a.m. confirmed that there was no documented evidence that Resident 17's TSH level was obtained as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as interviews with staff, it was determined that the facility failed to develop individualized care plans for two of 44 residents reviewed (Residents 28, 105). Findings include: A facility policy for Comprehensive, person-Centered Care Plans, dated January 10. 2024, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated August 15, 2024, revealed that the resident was rarely/never understood, could rarely/never understand, was cognitively impaired, required assistance with care needs, and had diagnoses that included heart failure and dementia. Observations of Resident 28 on November 18, 2024, at 11:26 a.m. revealed that the resident was asleep in bed. He had intravenous access in his right forearm. A nursing note for Resident 28, dated November 20, 2024, at 9:05 p.m. revealed that Resident 28's midline (an intravenous catheter used to administer medications or fluids for up to 30 days) had good blood return and flushed well. There were no signs of midline complications. The dressing was clean, dry and intact. Dextrose five percent (fluid injected into a vein through an IV to replace lost fluids and provide carbohydrates to the body) was running at 75 milliters per hour. Resident 28's current care plan did not include any information or interventions related to the resident's care needs for the use of a midline catheter. Interview with the Director of Nursing on November 21, 2024, at 2:18 p.m. confirmed that there was no information in Resident 28's care plan related to the care and use of his midline catheter. A nursing note for Resident 105, dated November 12, 2024, at 11:44 a.m. revealed that the resident had two seizure episodes in the therapy gym. The physician was notified and gave an order to send the resident to the hospital, and he was admitted with a diagnosis of seizure. After treatment he was discharged from the hospital on November 15, 2024, with a diagnosis of epilepsy (a chronic brain disease that causes seizures). Resident 105's current care plan did not include any information or interventions related to the resident's care needs for a seizure disorder. Interviews with the Director of Nursing on November 18, 2024, at 1:19 p.m. confirmed that there was no information in Resident 105's care plan related to his seizure disorder. 28 Pa. Code 201.24(e)(4) Admission Policy.

Based on review of facility polices and 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 44 residents reviewed (Resident 25). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated January 10, 2024, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated October 15, 2024, indicated that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, received a diuretic (a medication used to treat fluid build-up), received oxygen, and had diagnoses that included respiratory failure (blood does not have enough oxygen and causes difficulty breathing) and hypertension (high blood pressure). Current physician's orders for Resident 25 included an order for the resident to receive 40 milligrams (mg) of Furosemide (a diuretic medication) daily for hypertension and cerebrovascular disease (conditions that affect blood flow to your brain). A review of Resident 25's Medication Administration Record (MAR) for September, October, and November 2024 revealed that the resident received Furosemide as ordered; however, there was no documented evidence that the resident's care plan was revised to reflect her need for diuretic medication. Interview with the Director of Nursing on November 21, 2024, at 11:02 a.m. confirmed that there was no documented evidence that Resident 25's care plan was revised to reflect her need for diuretic medication and it should have been. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure medications were administered correctly for one of 44 residents reviewed (Resident 89). This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated September 4, 2024, revealed that the resident was understood, could understand, was cognitively impaired, required assistance with care needs, and had diagnoses that included renal failure and dementia. A nursing note for Resident 89, dated October 21, 2024, at 10:15 p.m., revealed that Resident 89 was given another resident's medication. The staff member became distracted and accidently gave the medication to the wrong resident. A nursing note for Resident 89, dated October 21, 2024, at 10:18 p.m., revealed that Resident 89 was sent to the emergency room for further evaluation and treatment to monitor for any possible drug interactions. The medications that Resident 89 received included 650 milligrams of Tylenol (pain reliever), 5 mg of Zyprexa (antipsychotic medication), 200 mg of Atorvastatin (cholesterol lowering medication), 40 mg of Famotidine, 750 mg of Levetiracetam (anticonvulsant), 300 mg of Lithium (psychotropic medication), 200 mg of Hydroxychloroquine (antimalarial), and 75 mg of Effexor (Serotonin and norepinephrine reuptake inhibitors). Interview with the Director of Nursing on November 19, 2024, at 11:03 a.m. confirmed Resident 89 received the wrong medication and was sent to the hospital for evaluation. A system change was implemented that included a review of the resident impacted, other residents that could be impacted by medication errors, training for all licensed staff about the five rights of medication, and audits of medication passes. A plan was developed on October 22, 2024, for random audits to be conducted The results of the audits were to be discussed during the monthly QA meeting.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for two of 44 residents reviewed (Residents 25, 45). Findings include: Observations in the main dining room on November 18, 2024, at 11:26 a.m. revealed that there was a hot plate in use to keep coffee pots warm. The hot plate was sitting on the counter at waist height and was accessible by the residents. At 11:26 a.m. Resident 3 was observed pouring a cup of hot water and making hot chocolate at the counter where the hot plate was located. Interview with Resident 3 on November 18, 2024, at 1:06 p.m. revealed that she did get her own hot water today; however, she has not done that before. She stated that staff always get the hot water or coffee for them, and she is not sure why she did it herself today. Interview with Family Member 1 on November 18, 2024, at 12:08 p.m. revealed that she eats lunch with her family member everyday in the dining room. She stated that she has never seen any residents approach the coffee, hot water, or hot plate and that staff always get the residents their coffee and hot water. Interview with Dietary Aide 2 revealed that the residents do not get themselves coffee, the staff always do, but that the hot plate is within the residents' reach. Interview with the Director of Nursing on November 18, 2024, at 3:25 p.m. revealed that she was not aware there was a hot plate in the dining room that was within the residents' reach. She stated that it would be removed immediately. A facility policy for wheelchairs, dated January 10, 2024, indicated that it was the policy of the facility to provide transportation with safety and comfort and that residents transported in a wheelchair by staff should have their leg rests on and feet on the foot pedals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated October 15, 2024, indicated that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, used a wheelchair, was dependent on staff for mobility in her wheelchair, and had a diagnosis of dementia. Observations of Resident 25 on November 18, 2024, at 11:17 a.m. revealed that the resident was transported in her wheelchair down the hallway from her room to the dining room by Nurse Aide 3. The wheelchair had no leg rests on it to prevent the resident from dragging her feet. Nurse Aide 4 was observed walking with Nurse Aide 3 as she transported Resident 25 to the dining room. An interview with Nurse Aide 4 at that time revealed that she did not see the leg rests in the resident's room and did not believe the resident had leg rests for her chair. Nurse Aide 4 went to the resident's room and found a set of leg rests and put them on her wheelchair. Nurse Aide 4 and Nurse Aide 3 confirmed that they should not have transported the resident in her wheelchair without leg rests. Interview with the Director of Nursing on November 19, 2024, at 11:02 a.m. confirmed that leg rests should have been used when transporting Resident 25 in her wheelchair. Facility policy for the safe lifting and moving of residents, dated January 10, 2024, indicated that manual lifting of residents should be eliminated when feasible and that staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts) and mechanical lifting devices. An annual MDS for Resident 45, dated October 23, 2024, indicated that the resident had moderate cognitive impairment, required partial to moderate assistance from staff for moving from sitting to standing position, and had diagnoses that included dementia. Observations of Resident 45 on November 18, 2024, at 11:02 a.m. revealed the resident was lying in her bed ringing her call bell to go to the bathroom. Registered Nurse 1 entered the room and assisted the resident to sit on the edge of her bed so she could walk to the bathroom in her room. While Resident 45 was sitting on the edge of the bed, Registered Nurse 1 leaned forward and placed her arm under the resident's right arm attempting to assist the resident to a standing position. The resident was unable to stand upright, and Registered Nurse 1 again placed her arm under the right arm of Resident 45 and helped to pull her to a standing position. The resident was walked to the bathroom and care was provided. The resident was again assisted to the standing position from the toilet with the support of Registered Nurse 1 pulling under the resident's left arm. No gait/transfer belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around) was used. Interview with Registered Nurse 1 on November 18, 2024, at 11:16 a.m. confirmed that she should have used a gait belt when assisting Resident 45 from the sitting to standing position and walking her to the bathroom. Interview with the Director of Nursing on November 19, 2024, at 9:03 a.m. confirmed that a gait belt should have been used when Registered Nurse 1 assisted Resident 45 with transferring out of bed to a standing position. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain weights as ordered by the physician for one of 44 residents reviewed (Resident 25) who had weight loss. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated October 15, 2024, indicated that the resident was cognitively impaired, was understood and able to understand others, required supervision assist with eating, holds food in mouth/cheeks, was on a mechanically altered diet, had a significant weight loss, received a diuretic medication (a medication used to treat fluid build-up), received oxygen, and had a diagnosis of dementia, depression, anxiety, and respiratory failure (blood does not have enough oxygen and causes difficulty breathing). Physician's orders for Resident 25, dated August 7, 2024, included an order for the resident to be weighed weekly for four weeks with a start date of August 12, 2024, and an end date of September 16, 2024. Review of Resident 25's clinical record revealed no documented evidence that the resident's weight was obtained on August 19, 2024. Physician's orders for Resident 25, dated September 4, 2024, included an order for the resident to be weighed weekly for four weeks with a start date of September 9, 2024, and an end date of October 1, 2024. Review of Resident 25's clinical record revealed no documented evidence that the resident's weight was obtained on September 9, 2024. Physician's orders for Resident 25, dated October 14, 2024, included an order for the resident to be weighed weekly for four weeks with a start date of October 18, 2024, and an end date of November 9, 2024. Review of Resident 25's clinical record revealed no documented evidence that the resident's weight was obtained on October 18, 2024. Physician's orders for Resident 25, dated November 10, 2024, included an order for the resident to be weighed weekly for four weeks with a start date of November 14, 2024, and an end date of December 6, 2024. Review of Resident 25's clinical record revealed no documented evidence that the resident's weight was obtained on November 14, 2024. Interview with the Director of Nursing on November 21, 2024, at 11:02 a.m. confirmed that Resident 25's weights were not obtained as ordered on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the required information was obtained from the contracted hospice provider (provider of end-of-life services) for one of 44 residents reviewed (Resident 94) who was receiving hospice services. Findings include: A facility policy regarding the Hospice Program, dated January 10, 2024, indicated that the hospice agency maintains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions and includes all communication between the hospice and facility when any changes are indicated or made to the plan of care. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 94, dated October 28, 2024, indicated that the resident was cognitively impaired, required assistance for her daily care needs, had diagnoses that included dementia and Alzheimer's disease, and was receiving hospice services. Physician's orders for Resident 94, dated October 25, 2024, included an order for a hospice consult. A nursing note for Resident 94, dated October 26, 2024, at 7:22 p.m. indicated that the resident was admitted to Gentiva Hospice. The hospice plan of care, dated October 26, 2024, indicated that the home health aide was to see Resident 94 twice weekly starting October 27, 2024, and a registered nurse was to see the resident weekly. As of November 21, 2024, at 12:36 p.m. there was no documented evidence readily available in Resident 94's clinical record, or in the hospice provider's clinical record, of progress notes by the hospice registered nurse since October 27, 2024, or the hospice nurse aide since the start of hospice services on October 26, 2024. Interview with the Director of Nursing on November 21, 2024, at 12:36 p.m. confirmed that the hospice communication records should have been readily accessible in Resident 94's clinical record and they were not. She indicated that it was the facility's practice to obtain paperwork from hospice agencies weekly to put in their hospice binders. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection during incontinent care for one of 44 residents reviewed (Resident 45). Findings include: Facility policy for handwashing/hand hygiene, dated January 10, 2024, indicated that the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated after contact with blood, body fluids, or contaminated surfaces, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 45, dated October 23, 2024, indicated that the resident had moderate cognitive impairment, required partial to moderate assistance from staff for toileting and personal care needs, and had diagnoses that included dementia. Observations of Resident 45 on November 18, 2024, at 11:02 a.m. revealed that Registered Nurse 1 entered the resident's room and assisted the resident to walk to the bathroom. The resident was noted to be continent and incontinent of urine at the time. Registered Nurse 1 removed a soiled brief from the resident and changed the resident's pants that were soiled. She then assisted Resident 45 to a standing position and cleansed the resident's buttocks area and pulled her brief and pants up. Registered Nurse 1 did not remove her gloves and perform hand hygiene prior to assisting the resident to walk to her recliner. Registered Nurse 1 was observed rubbing the resident's back while she walked beside her, then assisted the resident to sit in a recliner with her feet elevated, positioned her over-bed table, and placed a pillow under the resident's feet prior to removing her gloves. Interview with Registered Nurse 1 on November 18, 2024, at 11:16 a.m. confirmed that she should have removed her gloves and completed hand hygiene after providing toileting care to the resident and prior to touching the resident's belongings. Interview with the Director of Nursing on November 19, 2024, at 9:03 a.m. confirmed that Registered Nurse 1 should have removed her gloves and completed hand hygiene after providing toileting care to Resident 45 and prior to touching the resident's belongings. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of four residents reviewed (Resident 1), and failed to transcribe physician's orders for one of four residents reviewed (Resident 4). Findings include: A policy regarding medication administration, dated January 10, 2024, revealed that individuals administering medication will verify the resident's identity before giving the resident their medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 16, 2024, revealed that the resident rarely understands and is rarely understood, was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included Alzheimer's disease. A nursing note for Resident 1, dated May 29, 2024, at 7:30 a.m., revealed that the resident had been given another resident's medication. The crushed medication included 50 milligrams (mg) of Lopressor (used to treat high blood pressure), 8.6 mg of Senna (treats constipation), 120 mg of Cardizem (used to treat high blood pressure), 100 mg of Gabapentin (a medication to treat seizures), and 50 mg of Seroquel (an antipsychotic medication). Vital signs were checked, and the medical doctor was notified. A nursing note for Resident 1, dated May 29, 2024, at 7:32 a.m., revealed new orders to check the resident's vital signs in one hour and to monitor the resident. A nursing note for Resident 1, dated May 29, 2024, at 8:16 a.m., revealed a blood pressure of 82/44 mmHg, a heart rate of 63 beats per minute, and respirations of 12 per minute. Resident 1 was not easy to wake up, and the medical doctor was notified. A nursing note for Resident 1, dated May 29, 2024, at 8:16 a.m., revealed that the medical doctor was notified and new orders were received to send the resident to the hospital. A nursing note for Resident 1, dated May 29, 2024, at 3:15 p.m., revealed that a report was received from the hospital and the resident was being admitted into ICU for observation for bradycardia (low heart rate), hypotension (low blood pressure), and nosocomial overdose (an overdose that did not happen in the hospital). A nursing note for Resident 1, dated May 30, 2024, revealed an update. The resident is on dopamine (a medication that regulates blood flow) to keep vital signs regulated. A nursing note for Resident 1, dated May 31, 2024, revealed that the resident returned to facility. Interview with the Director of Nursing on June 18, 2024, at 11:10 a.m. confirmed that Resident 1 received another resident's medication and that the medication nurse did not identify the resident prior to administering the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 21, 2024, revealed that the resident understands and is understood, was cognitively impaired, required extensive assistance with daily care needs, had diagnoses that included Alzheimer's disease. Physician's orders for Resident 4, taken verbally by Registered Nurse 1 on April 24, 2024, included an order for 50 mg of Zoloft (a medication to treat depression) with a start date of April 24, 2025. A nursing note for Resident 4, dated May 8, 2024, revealed that the resident's Zoloft had been discontinued in error and upon reorder the incorrect date was written. The resident did not receive the Zoloft for two weeks. Interview with the Director of Nursing on June 18, 2024, at 11:10 a.m. confirmed that the registered nurse should have verified the medication transcription for Resident 4 to ensure the correct start date. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans that included specific and individualized interventions to address specific care needs for two of 33 residents reviewed (Residents 3, 35). Findings include: The facility's policy regarding care plans, dated January 12, 2023, indicated that individualized, comprehensive, person-centered care plans would be developed and implemented based on the resident's rights, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the resident's comprehensive assessment. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 26, 2023, revealed that the resident was cognitively impaired was understood and could understand others. Physician's orders for Resident 3, dated December 13, 2023, included an order for the resident to be on a 1500 milliliter (ml) fluid restriction per day. There was no documented evidence in Resident 3's clinical record that a comprehensive care plan was developed that included a 1500 ml per day fluid restriction. Interview with the Director of Nursing on December 19, 2023, at 2:00 p.m. confirmed that a care plan to address Resident 3's specialized care needs related to a fluid restriction was not created and that it should have been. An admission MDS assessment for Resident 35, dated October 15, 2023, revealed that the resident was cognitively impaired. Physician's orders for Resident 35, dated December 13, 2023, included an order for the resident to have the midline catheter (a form of intravenous access that is used for a prolonged period of time) flushed with 3 milliliters of normal saline solution before and after each IV medication administration. There was no documented evidence in Resident 35's clinical record to indicate that a comprehensive care plan was developed that included the care needs for a midline catheter. Interview with the Director of Nursing on December 20, 2023, at 1:26 p.m. confirmed that a care plan to address Resident 35's specialized care needs related to having a midline catheter was not created and that it should have been. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(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 care plans were updated to reflect changes in residents' care needs for two of 34 residents reviewed (Residents 14, 101). Findings include: The facility's policy regarding care plans, dated January 12, 2023, indicated that nursing staff and/or the interdisciplinary team were to initiate and/or update care plans for the resident as warranted. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated August 21, 2023, revealed that the resident was understood and could understand others, had no cognitive impairment, and was dependent on staff for daily care needs. Current physician's orders for Resident 14 revealed an order for a 1500 milliliter (ml) fluid restriction per day. A care plan for Resident 14, most recently updated November 2, 2023, indicated the resident was on a 2000 ml per day fluid restriction. Interview with the Director of Nursing on December 19, 2023, at 9:28 a.m. confirmed that Resident 14 was on a 1500 ml fluid restriction per day and that the care plan was not updated. An annual MDS assessment for Resident 101, dated December 10, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, had a care plan that indicated the resident was at risk for infection due to her indwelling catheter, and had diagnoses that included chronic kidney disease and acute kidney failure. Physician's orders for Resident 101, dated December 4, 2023, included an order for the resident to have the foley catheter changed every month. However, a care plan, dated December 19, 2023, indicated that the catheter was to be changed every three months. Interview with the Director of Nursing on December 19, 2023, at 2:40 p.m. confirmed that Resident 101's care plan was not updated to reflect the catheter was to be changed every month. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(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 34 residents reviewed (Resident 93). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 93, dated November 23, 2023, revealed that the resident was understood, could understand others, and had diagnoses that included heart disease. Physician's orders for Resident 93, dated November 28, 2023, included orders for the resident to receive 25 milligrams (mg) of Metoprolol Tartrate (treats high blood pressure) once a day, to be held if her systolic blood pressure (top number in a blood pressure reading) was less than 100 mm/Hg and held if her heart rate was less than 60 beats per minute (bpm). A review of the December 2023 Medication Administration Record (MAR) for Resident 93 revealed that on December 5 the resident's blood pressure was 86/51 mm/Hg. The Metoprolol Tartrate dose was administered on the above date when it should have been held, according to the physician's orders. In addition, there was no documented evidence in the clinical record to indicate that Resident 93's pulse was taken as ordered during the month of December 2023. Interview with the Director of Nursing on December 20, 2023, at 2:47 p.m. confirmed that Metoprolol Tartrate was administered to Resident 93 on the above-mentioned date when it should not have been given, and that the pulse should have been taken and recorded per the physician's orders but was not. 28 Pa. Code 211.12(d)(1)(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 central venous catheters were flushed as ordered by the physician for one of 34 residents reviewed (Resident 35). Findings include: The facility's policy regarding flushing central venous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated January 12, 2023, indicated that the catheter was to be flushed before and after each intravenous (IV) medication administration and after each blood draw. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated October 15, 2023, revealed that the resident was cognitively impaired, needed extensive assistance for daily care needs, had diagnoses that included wound infection, a diabetic foot ulcer, and was receiving IV medication. Physician's orders for Resident 35, dated December 13, 2023, included and order for the central catheter to be flushed with 3 milliliters (ml) of normal saline solution (NSS) after medication. There was no documented evidence in the clinical record that Resident 35's central catheter was flushed as ordered and per facility policy on December 13, 2023; December 14, 2023; and December 16, 2023. An interview with the Director of Nursing on December 20, 2023, at 12:20 p.m. confirmed that there was no documented evidence that Resident 35's midline was flushed as ordered or per the facility's policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 34 residents reviewed (Resident 3). Findings include: The facility's policy regarding medication administration, dated January 12, 2023, indicated that staff were to document that medication was given on the appropriate line of the resident's Medication Administration Record (MAR). Physician's orders for Resident 3, dated November 20, 2023, included an order for the resident to receive one 5 milligram (mg) tablet of Oxycontin (a controlled narcotic pain medication) every four hours three times daily. Resident 3's controlled drug records for December 2023 revealed that a 5 mg dose of Oxycontin was signed-out for administration once on December 9, 2023; however, the resident's clinical record, including the MAR, contained no documented evidence that the Oxycontin was actually administered to the resident. Interview with the Director of Nursing on December 19, 2023, at 2:00 p.m. confirmed that there was no documented evidence that the dose of Oxycontin signed-out by the nurse was actually administered to Resident 3 on the above date. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility's plans of correction from previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending January 6, 2023, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending December 21, 2023, identified repeated deficiencies regarding care plan development, care plan timing and revision, quality of care, and ensuring that parenteral fluids were administered consistent with professional standards of practice. The facility's plan of correction for deficiencies regarding the development of resident-centered care plans, cited during the survey ending January 6, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the development of resident-centered care plans. The facility's plan of correction for deficiencies regarding the timing and revision of resident care plans, cited during the survey ending January 6, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the timing and revision of resident care plans. The facility's plan of correction for deficiencies regarding quality of care, cited during the surveys ending on January 6, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plan of correction for deficiencies regarding ensuring that parenteral fluids were administered consistent with professional standards of practice, cited during the survey ending on January 6, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that parenteral fluids were administered consistent with professional standards of practice. Refer to F656, F657, F684, F694. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on the review of the facility policies, clinical records and facility investigation records, as well as staff interviews, it was determined that the facility failed to ensure that an allegation of abuse was reported timely for one of six residents reviewed (Resident 1). Findings include: The facility's policy regarding abuse, dated January 2, 2023, indicated that all allegations of abuse shall be reported immediately to the charge nurse/Registered Nurse supervisor, Director of Nursing, and resident physician for investigation into the incident. The staff member who discovers the incident, suspected abuse situation, or has initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The executive Director and/or the Director of Nursing must immediately report, or no later than 24 hours, the incident to the state survey agency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 12, 2023, indicated that the resident was confused, required extensive assistance of two staff for hygiene and required total assistance of two staff for bed mobility and transfers. Facility investigation documents, dated July 25, 2023, included a statement from Nurse Aide 1 that indicated there was an incident she witnessed 10 to 11 months ago regarding Resident 1. Nurse Aide 1 and Nurse Aide 2 were providing care and while wiping the resident's buttocks the resident was yelling out. Nurse Aide 2 stated that she felt it would be funny to put her two fingers into the resident's butt to shut him up. Nurse Aide 1 physically saw Nurse Aide 2 putting her fingers in and he screamed then went back to his yelling. Nurse Aide 2 then laughed. Nurse Aide 1 thought of reporting the incident but she did not want to get in trouble. Information reported by the facility revealed that the above incident occurred approximately ten to eleven months ago but was not reported to the Director of Nursing until July 25, 2023, at 5:00 p.m. A follow-up interview with Nurse Aide 1 during the on-site investigation revealed that she would not confirm seeing the actual abuse, only that Nurse Aide 2 made the threat. Interview with the Director of Nursing on July 21, 2023, at 9:35 a m. confirmed that Nurse Aide 1 did not report the allegation of abuse immediately and that she should have. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28177 Based on the review of the facility policies, clinical records and facility investigation records, as well as staff interviews, it was determined that the facility failed to ensure that an allegation of abuse was reported timely for one of six residents reviewed (Resident 1). Findings include: The facility's policy regarding abuse, dated January 2, 2023, indicated that all allegations of abuse shall be reported immediately to the charge nurse/Registered Nurse supervisor, Director of Nursing, and resident physician for investigation into the incident. The staff member who discovers the incident, suspected abuse situation, or has initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The executive Director and/or the Director of Nursing must immediately report, or no later than 24 hours, the incident to the state survey agency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 12, 2023, indicated that the resident was confused, required extensive assistance of two staff for hygiene and required total assistance of two staff for bed mobility and transfers. Facility investigation documents, dated July 25, 2023, included a statement from Nurse Aide 1 that indicated there was an incident she witnessed 10 to 11 months ago regarding Resident 1. Nurse Aide 1 and Nurse Aide 2 were providing care and while wiping the resident's buttocks the resident was yelling out. Nurse Aide 2 stated that she felt it would be funny to put her two fingers into the resident's butt to shut him up. Nurse Aide 1 physically saw Nurse Aide 2 putting her fingers in and he screamed then went back to his yelling. Nurse Aide 2 then laughed. Nurse Aide 1 thought of reporting the incident but she did not want to get in trouble. Information reported by the facility revealed that the above incident occurred approximately ten to eleven months ago but was not reported to the Director of Nursing until July 25, 2023, at 5:00 p.m. A follow-up interview with Nurse Aide 1 during the on-site investigation revealed that she would not confirm seeing the actual abuse, only that Nurse Aide 2 made the threat. Interview with the Director of Nursing on July 21, 2023, at 9:35 a m. confirmed that Nurse Aide 1 did not report the allegation of abuse immediately and that she should have. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that gastrostomy tube care was provided as ordered by the physician for one of 32 residents reviewed (Resident 50). Findings include: The facility's policy regarding gastric residual volume (GRV), dated January 31, 2022, revealed that staff were to check the GRV when the resident was not tolerating the enteral feedings, had a marked position change of the tube, the appearance and pH (a measure of the acidity) of the aspirate suggest the tube was misplaced, or when ordered by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated December 30, 2022, indicated that the resident was rarely or never understood or understands; was severely impaired; required extensive assistance from staff for bed mobility, toileting, and dressing; was fully dependent on staff for transfers, eating, hygiene and bathing; and had a feeding tube for nutrition. A care plan, dated December 22, 2022, indicated that the resident was a nutritional risk related to a current status of nothing by mouth (NPO), requiring enteral feeding to meet nutrition and hydration needs with an intervention to notify the physician if the gastric residual volume was 100 milliliters (ml) or over. The resident received a continuous enteral feeding from 12:00 p.m. to 6:00 a.m. daily. Physician's orders for Resident 50, dated June 11, 2022, included an order for the resident to receive a flush of 200 milliliters of free water prior to starting the enteral feeding at 12:00 p.m. and after the feeding is stopped at 6:00 a.m., check for a gastric residual volume before each flush. There was no documented evidence in the clinical record to indicate that Resident 50's gastric residual volume was checked as ordered from June 11, 2022, through December 22, 2022. Interview with the Director of Nursing on January 6, 2023, at 12:27 p.m. confirmed that there was no documented evidence that Resident 50's gastric residual volumes were checked as ordered. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to implement its abuse prohibition policies regarding verifying new employees' standing with the Pennsylvania Nurse Aide Registry or the State Board of Nursing for two of five new employees reviewed (Registered Nurse 1, Nurse Aide 2), and failed to complete a Federal Bureau of Investigations (FBI) background clearance prior to hire for one of five employees reviewed (Nurse Aide in Training 3). Findings include: The facility's policy regarding abuse prevention and prohibition, dated January 31, 2022, indicated that all employees would be screened and have background checks completed; licensed staff will have their appropriate licensing boards checked for any history of abuse, neglect, mistreatment of residents or misappropriation of resident property; and that nurse aides will have their registry checked for past incidents of abuse, neglect, exploitation, mistreatment of residents, and misappropriation of resident property prior to hiring for employment. The personnel file for Registered Nurse 1 revealed that she was hired on September 7, 2022; however, there was no documented evidence that her professional license was verified with the State Board of Nursing prior to being hired. The personnel file for Nurse Aide 2 revealed that she was hired on November 2, 2022; however, her enrollment on the Pennsylvania Nurse Aide Registry was not verified prior to being hired. The personnel file for Nurse Aide in Training 3 revealed that she was hired September 14, 2022, and that she had not resided in the state of Pennsylvania for two years prior to employment; however, there was no documented evidence that there was a FBI check verified prior to her being hired. Interview with the Director of Nursing on January 5, 2023, at 2:20 p.m. confirmed that Registered Nurse 1's licensure verification, Nurse Aide 2's enrollment in the Nurse Aide Registry, and Nurse Aide in Training 3's FBI check should have been completed prior to employment. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, by failing to follow a resident's care plan while providing care for one of two residents reviewed (Resident 1), resulting in harm due to a fall from the bed with a fracture. This deficiency was cited as past non-compliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 24, 2021, revealed that the resident had severe cognitive impairment; had impaired hearing; required the extensive assistance of two staff for bed mobility, transfers and toilet use; and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall report for Resident 1, dated July 10, 2021, at 6:25 a.m. revealed that staff was providing incontinent care when the resident rolled off the right side of her bed. A hematoma (collection of blood under the skin) was noted to left side of her head. A statement by Nurse Aide 1, dated July 10, 2021, revealed that while doing morning care for Resident 1, the resident fell off the bed. The nurse aide indicated that she rolled the resident toward her to change her, and she thought she had the resident well braced. The resident's weight shifted and the nurse aide was not able to catch/roll her back in time. Nursing notes for Resident 1, dated July 10, 2021, revealed that during a fall that morning, the resident bumped her head on the nightstand and had bruising and a small open area to the head. Resident 1's fall risk care plan was updated on July 10, 2021, to include that the resident required the assistance of two staff for incontinent care, and staff were educated to have two people assist with incontinent care to prevent such an incident from happening in the future. A fall report for Resident 1, dated September 22, 2021, at 7:50 a.m. revealed that the resident had a fall in her room. Nurse Aide 2 was providing morning care to the resident and rolled her onto her left side. The nurse aide took her hand away from the resident for a second when reaching for a wash cloth, and the resident rolled forward off the side of the bed before the nurse aide could reach her. A statement by Nurse Aide 2, dated September 22, 2021, at 7:50 a.m. revealed that she was providing morning care for Resident 1 and rolled her onto her side. She was reaching for the wash cloth and the resident rolled out of bed. A nursing note for Resident 1, dated September 22, 2021, at 11:04 a.m., and marked as a late entry for 7:50 a.m., revealed that the resident was lying on her right side between her bed and the wall with a pillow under her head. A nurse aide reported that while she was providing care to the resident, and had her rolled onto her left side, she took her hand off the resident for a second to reach the a wash cloth that was out of reach. The resident rolled forward, fell out of the bed, and landed on her right side before she could reach her. The resident complained of right shoulder pain. The physician was updated and gave orders for x-rays of the resident's right shoulder and arm. An x-ray report for Resident 1, dated September 22, 2021, at 11:31 p.m. revealed an acute displaced fracture (a bone break in which two ends of a fractured bone are separated and out of their normal positions) mid-shaft of the right clavicle (collarbone). A reenactment of the incident by Nurse Aide 2 on September 22, 2021, revealed that she pulled Resident 1 to the resident's right side of the bed and positioned her on her left side, in the middle of bed. Nurse Aide 1 rolled the resident away from her to perform morning care to the resident's back, and stated that she left the resident's legs on top of each other. Nurse Aide 2 stated her supplies were at the foot of the bed at the level of the resident's knees to ankle. Nurse Aide 2 demonstrated that she removed her hand from the resident's hip to turn and reach for the supplies at the end of the bed. When she reached for the supplies, the resident fell face first onto the edge of the bed and rolled out onto floor. Nurse Aide 2 denied having the resident's top knee bent or having her hand positioned on the bed to prevent the resident from rolling. An investigation follow-up for Resident 1, dated September 30, 2021, revealed that on September 29, 2021, during a review of incident reports, the facility identified a similar incident for Resident 1 in July, 2021. Her care plan was updated at that time to include that two staff persons were necessary while providing care to the resident in bed. Nurse Aide 2 was re-interviewed and stated that she did not review Resident 1's care plan and was not aware of changes. An employee statement by Nurse Aide 2 on September 29, 2021, confirmed that she did not review Resident 1's care plan prior to providing care and was not aware that two staff persons were required while providing care in bed. Interview with the Director of Nursing on October 14, 2021, at 9:30 a.m. confirmed that Resident 1 should have had two staff present while care was provided in bed on September 22, 2021. Following the incident on September 22, 2021, the facility's corrective actions included: On September 28, 2021, the facility's policy regarding identification of a resident's assistance level was changed. The registered nurse completing a new resident admission was to identify residents who required the assistance of two staff with bed mobility, which was to be documented in the resident's care plan and the facility's electronic care record system. The therapy department was to evaluate all new residents on admission to establish the resident's bed mobility requirements. Residents were to be reevaluated quarterly, upon request, or with a decline in condition. Two hands were to be placed on the resident's door by therapy staff if the resident required the assistance of two with bed mobility. Bed mobility was to be documented in the care plan and the electronic care records by therapy or nursing staff. Education regarding this system was to be included in new hire orientation. On September 29, 2021, staff education was initiated regarding accident hazards, abuse, neglect, resident assistance level, repositioning and bed mobility. Review of the facility's education sign-in sheets revealed that 98 percent of the staff education was completed as of October 3, 2021. Interviews on October 14, 2021, with Nurse Aide 3 at 1:33 p.m., Nurse Aide 4 at 1:51 p.m., Nurse Aide 5 at 2:13 p.m., and Licensed Practical Nurse 6 at 2:15 p.m. confirmed that they were aware that they had to check a resident's care plan prior to care, and if there were two hands located on the resident's door, this indicated the need for assistance from two staff with care. The facility's daily audit sheets for October 4, 5, 6, 7 and 8, 2021, revealed that new residents and current residents with a change in condition were assessed by therapy staff, their assistance levels were placed on the residents' doors, and care plans and electronic care documents were updated appropriately. A plan was developed on September 29, 2021, to do weekly audits for four weeks, then monthly audits for two months. The results of the audits were to be discussed during the monthly Quality Assurance meeting. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and investigation reports, as well as staff interviews, it was determined that the facility failed to develop fall/injury prevention interventions for residents who were at risk for falls for one of 48 residents reviewed (Resident 160), resulting in a fall with fracture(s) for the resident. Findings include: Resident 160's care plan, initiated (MONTH) 16 and 17, (YEAR), indicated that the resident was at risk for falls related to a history of frequent falls and impaired judgement, and staff were to involve her in restorative ambulation, ensure that adaptive equipment was within reach and in good repair, encourage her to participate in activities of choice, remind her to lock her wheelchair brakes and to ring for assistance when needed for transfers, provide a tab alarm (alarm that alerts staff when the resident attempts to transfer without assistance) for safety, and provide physical therapy as indicated. The resident was to be in a low bed with fall mats for safety, have a defined perimeter mattress, use leg rests on her wheelchair, and staff were to encourage/assist her to use the bathroom and provide incontinent care at least every two hours and as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 160, dated (MONTH) 12, (YEAR), indicated that the resident had severe cognitive impairment, required extensive assistance from staff for daily care tasks, including transfers and walking, was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, and had no recent falls. physician's orders [REDACTED]. A revision to Resident 160's care plan, dated (MONTH) 8, 2019, indicated that the resident was at risk for falls related to a history of falls, impaired judgement, decreased mobility and balance, occasional incontinence of bladder, use of anti-anxiety and anti-depressant medications, and staff were to ensure that her call light was within reach in her room, that her walker was within reach and in good repair, to remind her to lock her wheelchair brakes and to ring for assistance when she needed transferred, and to provide physical therapy as indicated. The resident was to be in a low bed with floor mats for safety, use elevated leg rests on her wheelchair, have a sign placed in her bathroom to remind her to use the call bell to request assistance before attempting to ambulate unassisted, and staff were to encourage her to use her call bell and wait for assistance with ambulation, and to join in activities outside of her room. physician's orders [REDACTED]. A revision to the resident's care plan, dated (MONTH) 12, 2019, indicated that the resident had a history of [REDACTED]. She was compulsive with this behavior and frequently rang for assistance to use the bathroom and required maximum assistance, and staff were to provide comfort, reassurance and privacy as needed. A fall investigation report for Resident 160, dated (MONTH) 18, 2019, indicated that the resident was found sitting on the floor at the end of her bed. The resident was unable to state what happened due to her [DIAGNOSES REDACTED]. The investigation revealed that the resident requested to go to the bathroom multiple times in a short period of time and continued to attempt to self-transfer despite the call bell being within reach, there being a sign reminding her to ring for assistance, traction strips beside her bed, and non-skid footwear. The resident declined the use of a bedside commode and staff were to continue with the current interventions and provide one-to-one care as needed, redirection, toileting, and to re-orient the resident to the situation and encourage her to use the call bell for assistance. A fall risk assessment for Resident 160, dated (MONTH) 18, 2019, indicated that the resident had a recent fall, was assessed as being high risk for falls, and it was recommended to encourage more one-to-one supervision and remind the resident to use the call bell for assistance. A behavior tracking note, dated (MONTH) 18, 2019, at 12:25 p.m. indicated that Resident 160 kept taking herself to the bathroom and walking in her room by herself, redirection was tried but nothing worked, and at 9:50 p.m. staff were one-to-one with the resident. However, there was no documented evidence that a plan was developed for how to increase one-to-one supervision, and no documented evidence that any changes or new interventions to prevent further falls and/or injury were initiated following the fall on (MONTH) 18, 2019. Nursing notes for Resident 160, dated (MONTH) 18, 2019, at 11:01 p.m. revealed that the resident was very confused during the shift, was up and down from her recliner, was self-ambulating in the room without using a walker, and walked out into the hallway twice during the shift without using a walker. The resident was redirected back to her room each time and reminded to ring the call bell for assistance and to not ambulate without using the walker; however, this was not effective, and the resident continued to get up and ambulate in the room with no assistance. Nursing notes for Resident 160, dated (MONTH) 20, 2019, at 9:16 p.m. revealed that the resident was restless and was attempting to self-ambulate. The resident was offered snacks and television and was toileted, which were not effective. The resident was offered clean towels to fold, which she enjoyed. A fall investigation report for Resident 160, dated (MONTH) 21, 2019, indicated that the resident was on the floor beside her bed, closest to the window, and the bathroom was on her right side. The resident stated, I was trying to go to the bathroom and tried grabbing the bottom bed post and my hand slipped and I fell . The investigation determined that the resident had a history of [REDACTED]. The resident was very restless and rarely rang for assistance. She was seen recently coming to the doorway multiple times during the shift to check what was going on down the hallway, she was reminded repeatedly to ring for assistance, staff increased their checks on the resident, and medication changes were made due to urgency and complaints of gas. The resident had a sign to ring for assistance, which she was able to read without any problems, had non-skid strips to her bathroom floor, and had fall mats. However, following the fall on (MONTH) 18, 2019, there was no documented evidence that a plan was developed for increased supervision and no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury. Nursing notes dated (MONTH) 21, 2019, at 2:02 p.m. revealed that the physician was notified about Resident 160's falls, and an order was received to X-ray the resident's right hip. Nursing notes dated (MONTH) 21, 2019, at 7:40 p.m. revealed that the physician was notified about the X-ray results and that the resident had shortening, external rotation of the right leg, and continued complaints of pain (symptoms of a [MEDICAL CONDITION]), and an order was received to obtain a CT scan (diagnostic imaging test) of the resident's right hip. A nursing note dated (MONTH) 22, 2019, at 5:13 p.m. revealed the physician was notified that the CT scan was positive for a [MEDICAL CONDITION]. Interview with the Director of Nursing on (MONTH) 28, 2019, at 3:53 p.m. confirmed that there were no new interventions developed to prevent falls and/or injury for Resident 160 following her fall on (MONTH) 18, 2019. She indicated that a bedside commode was offered, but the resident refused, and staff were to continue using the current interventions. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 1/11/18, 2/2/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 9/11/18, 1/11/18, 2/2/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/11/18, 1/11/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/11/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/11/18, 1/11/18, 2/2/17.