Every finding on record at John J Kane Regional Center-Sc

Based on clinical record review, select facility policy, review of resident financial records, and resident and staff interviews, the facility failed to safeguard, manage, or accurately account for the resident's personal funds deposited with the facility for five of 38 residents sampled (Residents 21, R31, R246, R11, R46).Findings include: A review of the facility policy titled Resident Rights dated 2/1/26, with a previous review date of 11/24/25, indicated that upon written authorization of a resident, the facility must hold, safeguard, manage and account for personal funds of the resident deposited with the facility. Funds more than fifty dollars must be deposited in an interest-bearing account separate from the facility's operating account. Review of the facility's Trial Balance Report dated from 4/1/26, through 6/30/26, listed multiple residents who had their funds deposited in the facility. The five residents randomly chosen identified the facility as the Rep Payee for their accounts were Residents R21, R31, R246, R11 and R46. Review of Residents R21, R31, R246, R11 and R46 provided personal account information did not identify interest in each account for two of three quarters provided. During an interview on 8/31/26, at approximately 2:00 p.m., the Business Office Manager (BOM) Employee E5 stated that his access to the accounts was limited and he had to reach out to the Revenue Manager. During an interview on 9/126, at approximately 10:00 a.m., the Deputy Director of [NAME] Facilities confirmed that the facility had not applied the interest into each resident account for two of three quarters. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, review of resident fund reports, and staff interviews, it was determined that the facility failed to provide accurate quarterly resident trust fund (resident funds account with current accounts open and holding resident monies) statements for five of 38 residents (Residents R21, R31, R246, R11 and R46).Findings include: Review of the facility policy Resident Rights, dated 2/1/26, with a previous review date of 11/24/25, indicated that the facility must establish and maintain a system that assures a full and complete and separate according to generally accepted accounting principles of each resident's personal funds entrusted to the facility on the resident's behalf and assure that a fully accounting of a resident's personal funds is given in writing to the resident or responsible person at least quarterly. During a review of the copy of the mailed Savings Statement provided to Residents R21, R31, R246, R11 and R46 did not include interest applied to each account for statements from the last two of three quarters indicating the statements accuracy of monies available. During an interview on 8/31/26, at approximately 2:00 p.m., the Business Office Manager (BOM) Employee E5 stated that his access to the accounts was limited and he had to reach out to the Revenue Manager. During an interview on 9/126, at approximately 10:00 a.m., the Deputy Director of [NAME] Facilities confirmed that the facility had not applied the interest into each resident account for two of three quarters. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a) Resident rights.

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of five residents (Resident R94).Findings include: Review of facility's policy Assessment-Comprehensive Person-Centered Care Planning dated 2/1/26, indicated to assure documentation, development, and implementation of a comprehensive person-centered care plan for all residents to attain or maintain the highest practicable physical, mental and psychosocial well-being. Practitioner orders, medication administration records, treatment administration records, progress notes which include treatment plans, and skilled therapy treatment plans are part of the whole resident's comprehensive person-center care plan. Review of the clinical record indicated Resident R94 was admitted to the facility on [DATE]. Review of Resident R94's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/3/26, indicated diagnoses of obstructive sleep apnea (muscles in the back of your throat relax and block your airway during sleep, your breathing repeatedly stops and starts), hypothyroidism (body doesn't make enough thyroid hormones), and diabetes (body does not use insulin effectively). Review of Resident R94's physician orders dated 2/20/26, indicated Continuous Positive Airway Pressure machine (CPAP, helps sleep apnea patients breathe easily and safely while they sleep) to be worn at night. Review of Resident 94's physician orders dated 3/5/26, indicated oxygen continuous 2-3 liters via nasal cannula, may titrate to keep oxygen saturation above 92%. Review of Resident R94 's care plan started on 3/3/26 and last updated 8/24/26, did not reveal evidence of the oxygen or CPAP having been part of the resident's care planning. Review of a providers' note on 8/11/26, indicated Resident R94 using CPAP at night. During an interview and observation on 8/31/26, at approximately 11:00 a.m. Resident R94 was asked by the surveyor if she uses oxygen and a CPAP and the resident replied yes. Resident 94 stated she uses the oxygen all the time and the CPAP every night, I probably wouldn't be breathing if I didn't use my CPAP every night. CPAP was observed at resident's bedside and the resident was using oxygen. During an interview on 9/3/26, at approximately 8:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed facility failed to develop care plans that included instructions to provide person centered care. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to complete a restorative nursing program for one of four residents reviewed for ADLs (activities of daily living) concerns (Residents R7).Findings include: Review of the facility policy Rehabilitative/Restorative Programs: dated 2/1/26, indicated residents will receive rehabilitative services designed to improve or restore functioning. During an interview on 9/1/26 at 2:50 p.m., Registered Nurse (RN) Unit Manager Employee E1 revealed that restorative activities are documented on the daily Point of Care electronic record. Clinical record review for Resident R7 revealed a diagnoses list that included respiratory failure and lack of coordination and abnormalities of gait and mobility. Review of the current care plan for Resident R7 revealed the resident requires assistance with walking and transferring. An intervention included maximum assistance with all ADLs. Review of the physical therapy Discharge summary dated [DATE], indicated highest practical level achieved. Review of the current After Therapy Care status indicated Resident R7 will perform assisted range of motion exercises (hip, knee, and ankle exercises 3 sets of 15 repetitions) to the right and left lower extremities, and passive range of motion exercises (stretching to the thighs and calves 3 sets of 30-60 seconds hold each) to the right and left lower extremities. Review of the daily Point of Care electronic record dated July through August 2026 did not include documentation that the restorative task was completed. During an interview on 9/1/16 at 3:00 p.m., The Director of Nursing confirmed the above findings and that the facility failed to complete a restorative nursing program for ADLs concerns for Resident R7. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of two residents reviewed (Residents R9).Findings include: Review of the facility policy Dialysis; Hemodialysis dated 2/1/26. The policy indicates to provide optimal care to residents receiving hemodialysis at an outpatient clinic, including physical monitoring and assessment of the fistula site, residents' response to treatment, and ongoing communication with the clinic. Practitioner Reviews Dialysis Communication form (MR 248) when there is a recommendation made by the clinic and enters a progress note addressing the recommendation. Nurse Pre-Dialysis Treatment:Completes Dialysis Communication form (MR 248) and sends form with resident to dialysis. Nurse Post-Dialysis Treatment:Reviews Dialysis Communication form (MR 248) for changes, complications, and recommendations and notifies practitioner promptly of any recommendations. Review of the clinical record indicated Resident R9 was originally admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS-a periodic assessment of care needs) dated 7/22/26, indicated diagnoses of chronic respiratory failure (lungs cannot move enough oxygen into the blood or remove enough carbon dioxide), diabetes (body does not use insulin effectively), and end stage renal disease (kidneys fail to filter waste and balance fluids). Review of Resident R9's physician order dated 7/23/26, indicated dialysis: Monday, Wednesday, and Friday at [dialysis center]. Transport time scheduled for 11:15 a.m . Review of Resident R9's current care plan dated 7/12/26, indicated review follow-up recommendations from dialysis log upon return. Resident R9 had thirteen dialysis treatments between the dates of 8/3/26 and 8/31/26. Review of dialysis communication forms, maintained in the resident's logbook, that accompanies the resident to and from dialysis, revealed incomplete communication forms on the following dates: 8/3/26 Dialysis form dated 8/3/26 and has a post it note on it with pre and post vitals dated 8/10/26. 8/3/26 post-dialysis section not completed by the facility nurse upon residents return from dialysis. 8/5/26 Dialysis form was not in the resident's dialysis logbook and could not be found.8/7/26 Dialysis form was not in the resident's dialysis logbook and could not be found.8/10/26 Dialysis form was not in the dialysis logbook and could not be found.8/12/26 Dialysis form was not in the dialysis logbook and could not be found.8/14/26 Dialysis form was not in the dialysis logbook and could not be found.8/18/26 Dialysis form not signed by the facility nurse pre-dialysis or dialysis center post dialysis. 8/20/26 Dialysis form not signed by facility nurse and post-dialysis section not completed by the facility nurse upon residents return from dialysis. 8/21/26 Dialysis form not signed by the facility nurse or dialysis center nurse and post-dialysis section not completed by the facility nurse upon residents return from dialysis.8/24/26 Dialysis form was not in the dialysis logbook and could not be found.8/26/26 Dialysis form was not in the dialysis logbook and could not be found.8/28/26 Dialysis form was not in the dialysis logbook and could not be found.8/31/26 Dialysis form was not in the dialysis logbook and could not be found.Unknown Date: Dialysis form with no date on the form, unsigned by facility staff and post-dialysis section not completed by the facility nurse upon residents return from dialysis. During an interview on 9/3/26, at 8:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained. 28 Pa. Code: 211.5(f) Clinical records28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations for five of five nursing staff (Nurse Aide (NA) Employees E7, E8, E9, E10 and E11). Findings include: Review of facility policy Facility assessment dated [DATE], with a previous review date of 1/14/26, indicated that all personnel who provide services will have annual evaluations. Review of NA Employee E7's personnel record indicated a hire date of 6/1/15. Review of NA Employee E7's current employee file failed to reveal an annual employee performance evaluation for 6/1/25, through 6/1/26. Review of NA Employee E8's personnel record indicated a hire date of 5/20/24. Review of NA Employee E8's current employee file failed to reveal an annual employee performance evaluation for 5/20/25 and 5/20/26. Review of NA Employee E9's personnel record indicated a hire date of 3/7/05. Review of NA Employee E9's current employee file failed to reveal an annual employee performance evaluation for 3/7/25, through 3/7/26. Review of NA Employee E10's personnel record indicated a hire date of 2/23/15. Review of NA Employee E10's current employee file failed to reveal an annual employee performance evaluation for 2/23/25 and 2/23/26. Review of NA Employee E11's personnel record indicated a hire date of 5/5/14. Review of NA Employee E11's current employee file failed to reveal an annual employee performance evaluation for 5/5/25 and 5/5/26. During an interview 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations for five of five nursing staff personnel records (NA Employees E7, E8, E9, E10 and E11). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for one of five employees (Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Dementia and Psychosocial Needs.Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee's current personal file failed to reveal annual in-service training on Dementia and Psychosocial Needs from 4/23/25, through 4/23/26.During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Dementia and Psychosocial Needs for one of five staff members (contracted PT Employee E12). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for one of five employees (Physical Therapist (PT) Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Corporate Compliance and Ethics. Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee E12's current personal file failed to reveal annual in-service training on Corporate Compliance and Ethics from 4/23/25, through 4/23/26.During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Corporate Compliance and Ethics for one of five staff members (PT Employee E12). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members (Physical Therapist (PT) Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included QAPI. Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee's current personal file failed to reveal annual in-service training on QAPI from 4/23/25, through 4/23/26. During an interview on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for one of five staff members (contracted PT Employee E12). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interview, it was determined that the facility failed to provide annual training on Effective Communication for one of five staff members (Physical Therapist Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated all personnel, including contracted staff will have annual trainings provided including content and competency and will be monitored by facility designated Managers/ Supervisors for attendance. Training requirements identified included Effective Communication as mandatory training for direct care staff including contracted staff. Review of contracted Physical Therapy (PT) Employee E12's personnel record indicated a hire date of 4/23/18. Review of PT Employee E12's current personal file failed to reveal annual in-service training on Effective Communication 4/23/25 through 4/23/26. During an interview completed on 9/2/26, at approximately 11:23 a.m., the Nursing Home Administrator confirmed that the facility failed to provide annual training on Effective Communication for one of five staff members (PT Employee E12). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, Pennsylvania Code Title 49. Professional and Vocational Standards, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to follow nursing standards of practice for safe medication administration for one of eight residents reviewed for medication administration (Resident R1). Findings include: Review of the Facility Policy, Medication Administration General Guidelines dated 2/1/26, indicated it is the policy to safely administer medications to residents as prescribed by the practitioner and in accordance with current standards of practice and regulatory requirements. Review of the facility policy Medication Error Reporting, Analysis and Correction (MERF) indicates a medication error is observed or identified preparation or administration of medication or biological which is not in accordance with practitioner orders, manufactures specification, and accepted professional standards and principles. Review of the Pennsylvania Code Title 49. Professional and Vocational Standards Chapter 21, State Board of Nursing: A. Registered Nurses (RN), revealed the following:21.11 General Functions (a)(4) Carries out nursing care and actions which promote, maintain and restore the well-being of individuals. (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice.21.14 Administration of Drugs (a) A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed. Review of the facility Registered Nurse job description Duties and Responsibilities 28. Indicated the RN accurately carries out physician orders per facility nursing policies and procedures, transcribes and administers medications, treatments, and therapies.Review of facility personnel records on 6/16/26, indicated Registered Nurse (RN) Employee E1 is issued an active Pennsylvania State License in good standing. Review of Resident R1's clinical record indicated an admission date of 10/2/24, with diagnoses that included dementia, left hip replacement, high blood pressure, diabetes, asthma, and osteoporosis. Review of the Minimum Data Set (MDS) resident assessment and care screening dated 3/5/26, indicated Resident R1 is cognitively impaired with confusion at baseline. Review of nurse progress notes dated 5/22/26, indicated Resident R1 took another resident's medications v.s.s. (vital signs stable) no noted adverse effects at this time, however, will be sent to the hospital to be monitored. 911 called and transported. Review of a practitioner note dated 5/22/26, indicated able to review medications that patient grabbed and took with risk of hypotension (low blood pressure), hypoglycemia (low blood sugar), lethargy, delirium, bleeding. Will send to ER (emergency room) for evaluation and treatment. Review of a physician note dated 5/23/26, indicated Resident R1 was sent to the ER for evaluation after taking another patient's medication. Patient was clinically stable and had no complaints. The patient returned to facility after 24-hour review. Review of a facility Event Report Medication Error document dated 5/22/26, indicated Resident R1 took another resident's medication to include amlodipine (lowers blood pressure) 10 mg (milligrams), atenolol (lowers blood pressure and heart rate) 50 mg, Eliquis (blood thinner) 5 mg, Jardiance ( antidiabetic) 12.5 mg, Lisinopril (antihypertensive) 20 mg, olanzapine (antipsychotic) 2.5 mg, Lexapro (antidepressant) 10 mg, Ativan (anti-anxiety medication) 0.5 mg, metformin (anti diabetic) 500 mg, Certavite (a supplement) and Zyrtec (antihistamine). The RN put another resident's medications in a med cup on a breakfast tray. The breakfast tray was then put in front of Resident R1, and she took the other resident's medications. Review of RN Employee E1's witness statement dated 5/22/26, indicated pulled patient 1's medication and placed it on a tray that is used to pass other trays. I went to assist another patient and when I returned the NA (nursing assistant) informed me that she (pt 2) (Resident R1) had taken the medication on the tray. Review of Resident R1's hospital Service and Length of Stay documentation dated 5/23/26, indicated the patient was admitted for accidental medication error. The resident was monitored and remained stable. Resident R1 returned to the facility on 5/23/26 in stable condition. During an interview on 6/16/26, at approximately 10:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that RN Employee E1 failed to follow nursing standards of practice for safe medication administration for Resident R1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls for one of four residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the facility policy, Resident Falls dated 11/24/25, indicated it is the policy of the facility to take all precautions to minimize the risk of falling for all residents and if a fall does occur, to implement appropriate measures to prevent reoccurrence. Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/28/25, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and muscle weakness. Review of Section G: indicated that Resident R1 required substantial/maximal assistance to roll left and right. Review of Resident R1's current plan of care initiated on 7/24/25, indicated At risk for injury related to falls due to decreased mobility and generalized weakness. Assist x2 for transfers and bed mobility. Review of a progress note dated 12/23/25, at 2:40 p.m. indicated, This ADON (Assistant Director of Nursing) was called to unit by LPN (licensed practical nurse) regarding a fall from bed. Upon arriving to unit, resident was found on the floor lying on her back. Resident was alert and oriented and able to answer questions appropriately. Bleeding also noted to previous left leg wound. Pressure applied to both areas. Review of a progress note dated 12/23/25, at 3:09 p.m. indicated, Resident c/o (complained of) pain in head area. 911 called. Resident remained on floor until paramedics arrived. Resident fell out of bed during care. Order to send out to hospital. Family notified. Review of a progress note dated 12/23/25, at 6:41 p.m. indicated, Received report from [hospital] and spoke to RN. Resident is said to be stable from the fall. Review of facility submitted information dated 12/23/25, indicated, CNA (nurse aide), [Employee E1] was providing care to [Resident R1]. CNA had slightly turned resident onto her right side then walked away from the resident to obtain supplies to provide incontinence care. Resident fell out of bed. RN assessed: Moderate amount of blood noted on left lower extremity from prior wound. No changes in ROM (range of motion), Neurochecks (systematic assessments of the nervous system (brain, spinal cord, nerves) evaluating mental status, cranial nerves, motor strength, sensory function, coordination, and reflexes to detect issues with movement, feeling, balance, awareness, or cognition) WNL (within normal limits). Resident did complain of neck pain when paramedics arrived. Review of emergency room physician documentation dated 12/23/25, at 6:53 p.m. [Resident R1] presents to the ED (emergency department) from skilled facility after she had a fall out of bed with head injury. She is complaining of pain in her head, neck, shoulder, back, also has bleeding through the bandages on her chronic left wound. Review of the facility provided unit assignment sheet in use on 12/23/25, indicated Resident R1: BED MOBILITY: 2 ASST. Review of an employee statement written by NA Employee E1 dated 12/23/25, indicated, I was doing care on resident. I went to slid her toward me then roll her towards the door. I roll her halfway towards the window then I went for a wash rag and towel then I hard to resident fell on the floor. I ran to check on the resident then ran to the door the other aide came in that's when I went to call the nurse. Review of a facility provided interview completed with NA Employee E1 on 12/23/25, indicated: -(Facility) How did [Resident R1] fall out of bed? -(NA Employee E1) I was providing care, I went to slide the resident towards me so I could turn her the window, I turned her a little bit and pushed her towards the window. Then I forgot the washcloths and soap so I stopped to go to her bathroom to get the supplies. And then I heard her fall while I was in the bathroom and I came out of the bathroom as soon as I heard. -(Facility) Did you receive an assignment sheet? -(NA Employee E1) Yes, I didn't realize she was a 2 assist with bed mobility but I did know she was a 2 assist with transfers. -(Facility) Did you change her earlier today? -(NA Employee E1) I just checked her brief and it wasn't wet so I didn't need to change her earlier, I did find it odd that she wasn't wet in the beginning of the shift but she is alert and oriented and rings when she needs changed. -(Facility) Did you look at your assignment sheet that was given to you at the beginning of the shift? -(NA Employee E1) Yes and I didn't notice she was a 2 assist with bed mobility. -(Facility) Did find it odd that if she was a 2 assist with transfers she wouldn't be a 2 assist with bed mobility.-(NA Employee E1) Yes, now I recognize. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 12/23/25, included the information: -Findings of Facility Investigation: CNA failed to follow residents plan of care with 2 assist for bed mobility. CNA walked away from resident while resident was slightly turned to the right to obtain supplies. This resulted in resident falling out of bed. Resident was sent to [hospital] ER. -Conclusions: CNA failed to follow resident's plan of care which resulted in injury to resident. Review of facility provided information indicated that on 12/23/25, at 5:04 p.m. the facility notified NA Employee E1's employing agency that he was not longer able to work at any facility in their system due to non-compliance with the resident plan of care, which resulted in resident injury. On 12/23/24, the facility initiated a plan of correction that included: Physical and occupational therapy consulted upon return of Resident R1 for bed positioning and safety. NA Employee E1 excluded from further agency employment at the facility or its sister facilities. Resident R1's care plan updated to reflect Resident R1's current status.Staff in-service education related to bed mobility, positioning, and following the plan of care, completed on 12/28/25.Audits completed for safe bed positioning and mobility direct observation of care, daily for one week, three times per week for one week, twice per week for one week, and one time per week for one week. During interviews of eight direct care staff on 1/16/25, confirmed that all staff interviewed were aware of how to learn a resident's appropriate assistance level from the nurse aide assignment sheet and where to find the assistance level in the electronic medical records, and further confirmed that they had received staff in-service education on bed mobility, positioning, and following the plan of care after 12/23/25. Facility was in compliance as of 12/23/25. During an interview on 1/16/25, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to implement interventions to prevent falls for one of four residents. This was identified as past noncompliance. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the facility policy, Abuse - Resident and Reasonable Suspicion of a Crime dated 11/24/25, defined neglect as the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/28/25, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and muscle weakness. Review of Section G: indicated that Resident R1 required substantial/maximal assistance to roll left and right. Review of Resident R1's current plan of care initiated on 7/24/25, indicated At risk for injury related to falls due to decreased mobility and generalized weakness. Assist x2 for transfers and bed mobility. Review of a progress note dated 12/23/25, at 2:40 p.m. indicated, This ADON (Assistant Director of Nursing) was called to unit by LPN (licensed practical nurse) regarding a fall from bed. Upon arriving to unit, resident was found on the floor lying on her back. Resident was alert and oriented and able to answer questions appropriately. Review of a progress note dated 12/23/25, at 3:09 p.m. indicated, Resident c/o pain in head area. 911 called. Resident remained on floor until paramedics arrived. Resident fell out of bed during care. Review of a progress note dated 12/23/25, at 6:41 p.m. indicated, Received report from [hospital] and spoke to RN. Resident is said to be stable from the fall. Review of facility submitted information dated 12/23/25, indicated, CNA (nurse aide), [Employee E1] was providing care to [Resident R1]. CNA had slightly turned resident onto her right side then walked away from the resident to obtain supplies to provide incontinence care. Resident fell out of bed. RN assessed: Moderate amount of blood noted on left lower extremity from prior wound. No changes in ROM (range of motion), Neurochecks (systematic assessments of the nervous system (brain, spinal cord, nerves) evaluating mental status, cranial nerves, motor strength, sensory function, coordination, and reflexes to detect issues with movement, feeling, balance, awareness, or cognition) WNL (within normal limits). Resident did complain of neck pain when paramedics arrived. Review of emergency room physician documentation dated 12/23/25, at 6:53 p.m. [Resident R1] presents to the ED (emergency department) from skilled facility after she had a fall out of bed with head injury. She is complaining of pain in her head, neck, shoulder, back, also has bleeding through the bandages on her chronic left wound. Review of the facility provided unit assignment sheet in use on 12/23/25, indicated Resident R1: BED MOBILITY: 2 ASST. Review of an employee statement written by NA Employee E1 dated 12/23/25, indicated, I was doing care on resident. I went to slid her toward me then roll her towards the door. I roll her halfway towards the window then I went for a wash rag and towel then I hard to resident fell on the floor. I ran to check on the resident then ran to the door the other aide came in that's when I went to call the nurse. Review of a facility provided interview completed with NA Employee E1 on 12/23/25, indicated: -(Facility) How did [Resident R1] fall out of bed? -(NA Employee E1) I was providing care, I went to slide the resident towards me so I could turn her the window, I turned her a little bit and pushed her towards the window. Then I forgot the washcloths and soap so I stopped to go to her bathroom to get the supplies. And then I heard her fall while I was in the bathroom and I came out of the bathroom as soon as I heard. -(Facility) Did you receive an assignment sheet? -(NA Employee E1) Yes, I didn't realize she was a 2 assist with bed mobility but I did know she was a 2 assist with transfers. -(Facility) Did you change her earlier today? -(NA Employee E1) I just checked her brief and it wasn't wet so I didn't need to change her earlier, I did find it odd that she wasn't wet in the beginning of the shift but she is alert and oriented and rings when she needs changed. -(Facility) Did you look at your assignment sheet that was given to you at the beginning of the shift? -(NA Employee E1) Yes and I didn't notice she was a 2 assist with bed mobility. -(Facility) Did find it odd that if she was a 2 assist with transfers she wouldn't be a 2 assist with bed mobility.-(NA Employee E1) Yes, now I recognize. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 12/23/25, included the information: -Findings of Facility Investigation: CNA failed to follow residents plan of care with 2 assist for bed mobility. CNA walked away from resident while resident was slightly turned to the right to obtain supplies. This resulted in resident falling out of bed. -Conclusions: CNA failed to follow resident's plan of care which resulted in injury to resident. Review of facility provided information indicated that on 12/23/25, at 5:04 p.m. the facility notified NA Employee E1's employing agency that he was not longer able to work at any facility in their system due to non-compliance with the resident plan of care, which resulted in resident injury. On 12/23/24, the facility initiated a plan of correction that included: Physical and occupational therapy consulted upon return of Resident R1 for bed positioni9ng and safety. NA Employee E1 excluded from further agency employment at the facility or its sister facilities. Resident R1's care plan updated to reflect Resident R1's current status.Staff in-service education related to bed mobility, positioning, and following the plan of care, completed on 12/28/25.Staff in-service education related to abuse and neglect, completed on 1/4/26.Audits completed for safe bed positioning and mobility direct observation of care, daily for one week, three times per week for one week, twice per week for one week, and one time per week for one week. During interviews of eight direct care staff on 1/16/25, confirmed that all staff interviewed had received staff in-service education on abuse and neglect after 12/23/25. Facility was in compliance as of this date. During an interview on 1/16/25, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to protect residents from neglect one of four residents. This was identified as past noncompliance. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on a review of facility policy, observations and staff interview it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness in one of six coolers (cooler #6). Findings Include: Review of the facility policy Food Safety Manual last reviewed on 7/23/25, indicated to store team member food separately from any food prepared for the business unit and do not store personal items in the kitchen, service or storage areas. During an observation tour of the main kitchen on 9/5/25, at 12:20 p.m., revealed that cooler #6 contained employee drinks and food items with resident food items. During an interview on 9/5/25, at a.m.,12:30 p.m. Food Service Director Employee E1 confirmed that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness.During an interview on 9/5/25, at 3:00 p.m. the Director of Nursing confirmed the above findings, and the facility failed to properly store food products in the Main Kitchen. Pa. 28 Code: 211.6(c)(d)(f) Dietary services.

Based on facility document review and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition on five of five nursing units (2A, 3A, 3B, 4A, and 4B).Review of facility submitted information dated 7/16/25, indicated that on 7/15/25, At 7:11pm, During a scheduled facility power outage, the maglock (electrified magnetic locking mechanism) door batteries became disengaged. While monitoring CCTV (closed-circuit television, a type of video surveillance system), Security saw resident enter the stairwell on unit 4A. Resident was identified as [Resident R1]. Security witnessed on camera her carefully safely walk down the stairwell and exit on unit 2A. Total Time 2 mins and 20 seconds. Nursing Supervisor immediately notified by Security and met resident on unit 2A. Resident returned to the unit safely. Resident had no injury. No emotional distress noted. MD (Doctor of Medicine) and NOK (next of kin) notified. Review of an employee statement dated 7/15/25, written by Security Employee E1, indicated, While reviewing CCTV I noticed a resident enter the stairwell 1 entry on 4A. She was identified as [Resident R1]. I witnessed her walk down the stairwell and exit on 2A middle hall. She walked to the nurses station. I then called [Employee E2] and she and [Employee E3] responded to 2A and addressed it. She was returned to her unit right away. Subsequently upon further investigation the maglocks failed during the planned power outage. Review of an employee statement dated 7/15/25, written by Security Director Employee E4 indicated, At 1930 hrs (7:30 p.m.) on the above date (7/15/25) during a scheduled facility wide power shutdown, I received a call from Security Employee E1 reporting that a resident identified as [Resident R1] had entered stairwell #1 from unit 4A proceeding down to unit 2A. Security Employee E1 stated that the house supervisor was immediately notified of the incident. The resident was assessed by staff and returned to the unit. Under my direction, Security Employee E1 was instructed to check all maglocks on all stairwells, as an extra precaution all mechanical alarm boxes were to be tested and engaged. I advised Security Employee E1 that I was responding to the facility with a 20-30 min ETA (estimated time of arrival). Upon my arrival at 8pm Security Employee E1 informed me that all nursing unit maglocks were down. Nursing had placed a staff member at each door as an extra precaution. Upon investigation found that the battery backups for these doors had failed. Further investigation showed that the power supplies for these doors were not on generator power. ESM (Environmental Service Manager) Employee E5 was notified of the issue. Upon Employee E5's direction the facility electrician [Maintenance Employee E6] rewired the power supplied to a generator electric panel, restoring power to the affected doors at 2130 hrs (9:30 p.m.). the A side maglocks were fully functional. I made a sweep of the A side of the facilty and confirmed that all A side maglocks were again operating as designed. At 2230 (10:30 p.m.) power was restored to all B side maglocks. I again made a sweep of the B side to confirm all doors were working as designed. Upon review of the guard log book these doors were last tested at 1530 hrs (3:30 p.m.) and fully functional. I departed the facility at 2230 hrs (10:30 p.m.). All doors were fully functional. Review of a statement written by Environmental Service Manager Employee E5 stated that:7/15/25, (approximate times):8:00 a.m.: with Electric Maintenance Vendor V1 and V2 onsite, the local power provider terminated outside power and the facility converted to generator power. 4:00 - 4:30 p.m.: Electric Maintenance Vendor V2 advised that the Main Transfer Switch was faulty. At that time Facility Executive Employee E7, Director of Facilities Employee E8, and the County Electrician Employee E9 were contacted about the failed switch and the need to replace it immediately. 5:00 p.m. - Electric Vendor V2 was able to find a replacement switch, located approximately 90 miles away. The part was picked up and delivered at 8:00 p.m. Installation was begun at that time. 8:00 p.m. - Security Employee E1 notified that the maglock doors had failed and a resident got out of 4A. Battery backups were found to be low on power, and replace with new batteries. The decision was made change the maglocks from battery backup to generator power. 10:30 p.m. - All power to the maglock doors on the resident units was converted to generator emergency power. 7/16/25, (approximate times):12:00 a.m. - Electric Maintenance Vendor V2 completed the installation of the replacement part. The local power provider was called to restore service. The local power provider would not send anyone to restore power, due to confusion regarding the work order, with a work order from a sister facility. 2:00 a.m. - Power was restored by the local power provider. 7/17/25:Confirmed that all resident and non-resident area maglocks have backup generator power supply. During an interview on 7/17/25, at approximately 10:40 a.m. ESM Employee E5 confirmed that the facility had been unprepared for the maglock batteries to become too low on power during an extended power outage, and had not planned to have replacements used prior to the batteries completely failing. During an interview on 7/15/25, at approximately 1:00 p.m. the Assistant Director of Nursing confirmed the facility failed to ensure that essential equipment was in safe operating condition on five of five nursing units.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of 41 residents (Resident R1). Review of the facility policy Elopement - Missing Resident dated 1/8/25, indicated the facility will provide to each resident adequate monitoring and interventions to maintain safety. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/30/25, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and a seizure disorder. Review of Section E: Behavior indicated Resident R1 had displayed wandering behaviors. Review of an Elopement Evaluation completed on 6/18/25, indicated Resident R1 was at risk for elopement. Review of the physician's order dated 6/18/25, indicated Resident R1 was ordered a security bracelet that alerts when an identified resident approaches a monitored door. Review of Resident R1's plan of care for Risk for Elopement initiated 6/18/25, indicated Resident R1 is at risk for elopement due to Alzheimer's disease and a history of wandering. Review of a progress note dated 7/7/25, at 8:43 a.m. indicated Resident R1 was testing door handles and keypads. When lobby door is open, she will start to run for the door. Review of a progress note dated 7/10/25, at 12:59 p.m. indicated Resident R1 was trying to open dining room windows this morning. Any time there is an open door and she notices, she will sprint towards it. Review of a progress note dated 7/15/25, at 11:18 p.m. indicated, At 7:13 p.m. resident was found on the 2nd floor walking up the middle hall from the stairwell. Nursing supervisor notified by security that the resident had gotten out of the locked unit. Upon investigation it was found that the maglocks (electrified magnetic locking mechanism) on the stairwell doors were not engaged due to planned power outage. Resident returned to locked unit without difficulty. Resident had no injury of any kind, did not fall or hurt herself in any way. No s/s (signs or symptoms) of emotional distress upon return to unit. Review of facility submitted information dated 7/16/25, indicated that on 7/15/25, At 7:11pm, During a scheduled facility power outage, the maglock door batteries became disengaged. While monitoring CCTV (closed-circuit television, a type of video surveillance system), Security saw resident enter the stairwell on unit 4A. Resident was identified as [Resident R1]. Security witnessed on camera her carefully safely walk down the stairwell and exit on unit 2A. Total Time 2 mins and 20 seconds. Nursing Supervisor immediately notified by Security and met resident on unit 2A. Resident returned to the unit safely. Resident had no injury. No emotional distress noted. MD (Doctor of Medicine) and NOK (next of kin) notified. During an interview on 7/17/25, at approximately 1:00 p.m. the Assistant Director of Nursing confirmed the facility failed to provide adequate supervision to prevent elopement for one of 41 residents (Resident R1).

Based on a review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls and an injury, resulting in actual harm of a leg fracture for one of three residents reviewed (Resident R91) and a head laceration for one of three residents (Resident R3). Findings include: Review of the facility policy All Policy and Procedure: General Guidelines last reviewed on 1/5/24, indicated that the facility will provide necessary care and services to each resident to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. Staff must properly position the resident [NAME] position of comfort during and after any procedure. All care and services must be provided a prescribed by the practitioner, and according to the resident's person-centered plan of care. Review of the facility policy Fall Risk Evaluation Policy last reviewed on 1/5/24, indicated that residents who are identified as at risk for falls are provided safety measures that would deter falls and provide a safe environment. Review of the American Congress of Rehabilitation Medicine (ACRM) - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the clinical record indicated Resident R91 was admitted to the facility on [DATE], with diagnoses which included right sided (dominant side) hemiplegia and hemiparesis (paralysis of one side of body) due to a stroke, morbid obesity and difficulty swallowing. Review of the Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 7/13/24, indicated the diagnoses remained current, Section GG 0170 Mobility identified Resident R91 as dependent (which requiring one staff to do all the effort or two staff ) for bed mobility. Review of an incident report dated 7/30/24, at 12:30 a.m., indicated that Resident R91 was being provided incontinence care by Nurse Aide (NA) Employee E9 and redness was identified on Resident R91's buttocks. This report stated NA Employee E9 turned away from Resident R91 to get cream and Resident R91 slid off of the bed (away from NA Employee E9) and onto the floor causing a fractured left distal femur (thigh bone closest to the knee bone). Review of the statement that was attached to the investigation dated 7/30/24, from NA Employee E9 stated that I came into the room and Resident R91 told me she needed to be changed. As I am changing her brief and wiping her backside, I noticed redness in the area I asked her did she have any cream her response was yes, I asked her where was it she told me as I turned my left side to grab the cream she started to roll herself out of bed. I ran over to the other side of bed and sat with her until the ambulance came. Review of the facility investigation dated 7/31/24, contained the Staff Development Referral process dated 12/28/2022, that was signed by NA Employee E9. This document includes the statement for resident bed mobility: Residents to be rolled towards you, not away from you (2 staff members present when indicated on the assignment sheet). During an interview on 9/23/24, at 1:00 p.m., Resident R91 stated that she recalled the event that resulted in this fall and injury. Resident R91 reported she was rolled away from NA Employee E9 onto her right side that has limited mobility, and she verbalized I am sliding a couple of times before she fell out of the bed. Resident R91 stated the bed was raised to a higher position so that NA Employee E9 could provide care, as Resident R91 tried to reach out with her left arm to stop the slide there was nothing within reach and she fell . During an interview on 9/23/24, at 1:10 p. m., Resident R91's roommate Resident R125 confirmed the details of Resident R91's detail of the fall. During an interview on 9/25/24, at 1:30 p.m. with NA Employee E10, indicated that resident care is identified on the care sheets received at the start of the shift. Employee E10 indicated report is received between shifts for any changes to the resident's care. Employee E10 indicated additional staff is available to assist when requested. Employee E10 indicated the facility policy is to roll a resident toward staff when providing care. During an interview on 9/25/24, at 1:45 p.m. with NA Employee E11, indicated that resident care is identified on the care sheets received at the start of the shift. Employee E11 indicated report is received between shifts for any changes to the resident's care. Employee E11 indicated additional staff is available to assist when requested. Employee E11 indicated Resident R91 had been an assist of one and now is requires two. Employee E11 indicated the facility policy is to roll a resident toward staff when providing care. During an interview on 9/25/24, at 2:00 p.m. with NA Employee E12, indicated that resident care is identified on the care sheets received at the start of the shift. Employee E12 indicated report is received between shifts for any changes to the resident's care. Employee E12 indicated additional staff is available to assist when requested. Employee E12 indicated the facility policy is to roll a resident toward staff when providing care. During an interview on 9/26/24, at 10:22 a.m., the Director of Nursing confirmed NA Employee E9 rolled Resident R91 away from her to provide care then turned away from Resident R91 during this care causing the resident to roll out of bed which resulted in actual harm for Resident R91 when a fractured left distal femur was sustained. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness and dementia. A MDS dated [DATE], indicated the diagnoses remained current, Section GG 0170 Mobility indicated functional abilities of the resident identified resident R3 required dependent care with rolling left to right which is indicated the helper does all the effort or two staff are required. Review of Resident R3's Physican orders dated 10/31/23, prior to the incident and remained current, indicated Resident R3 required bed mobility of assist of two. Review of Resident R3 plan of care, prior to incident and remained current, indicated Resident R3 had behaviors of resistant with care. Review of an incident report dated 8/28/24, indicated that Resident R3 developed a 1.5 c.m. x 2.0 c.m. x 0.1 c.m. head laceration with a bruise requiring steri strips (tape that is used in place of sutures) to close when NA Employee E8 attempted to readjust a sheet around his waist to keep him from picking at his brief with no additional assistance when turning Resident R3 who cannot hold himself or stop himself from rolling, NA Employee E8 hit Resident R3s head off of the overbed table causing the laceration. During an interview on 9/25/24, at 8:15 a.m., NA Employee E5 stated that Resident R3 is rigid and required two staff since he becomes combative with care. NA Employee E5 stated that he frequently is assigned to Resident R3. The Nurse Aides use a care sheet (a sheet shown to the surveyor and is on each nursing unit as a quick reference for each residents care needs for the Nurse Aides to utilize) but they also get report between shifts in case there are any changes to determine the assistance required by the residents. During an interview on 9/25/24, at 8:40 with NA Employee E6 and E7 indicated that resident care is identified on the care sheets but they also get report between shifts in case there are any changes. During an interview on 9/26/24, at 10:22 a.m., the Director of Nursing confirmed that the facility failed to provide appropriate assistance to prevent falls and an injury, resulting in actual harm of a leg fracture for one of three residents reviewed (Resident R91) and a head laceration for one of three residents (R3). 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights

Based on review of facility policy, resident clinical records, documentation provided by the facility, facility investigation, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect, which resulted in actual harm as evidenced by a left distal femur (thigh bone closest to the knee bone) fracture for one of three residents (Resident R91) and a head injury for one of three residents (Resident R3). Findings include: Review of the facility policy Abuse- Resident last reviewed on 1/5/24, indicated that the facility treat every resident with respect and dignity. The failure of the facility to provide goods and services to a resident that are necessary to avoid or may result in physical harm is identified as neglect. All complaints/allegations of resident abuse/neglect shall be promptly reported to the administration and investigated. Alleged violations whether or not confirmed, must be reported. Review of the clinical record indicated Resident R91 was admitted to the facility on [DATE], with diagnoses which included right sided (dominant side) hemiplegia and hemiparesis (paralysis of one side of body) due to a stroke, morbid obesity and difficulty swallowing. An Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 7/13/24, indicated the diagnoses remained current, Section GG 0170 Mobility identified Resident R91 as dependent (which requiring one staff to do all the effort or two staff ) for bed mobility. Review of an incident report dated 7/30/24, at 12:30 a.m., indicated that Resident R91 was being provided incontinence care by Nurse Aide (NA) Employee E9 and redness was identified on Resident R91's buttocks. The statement further indicated NA Employee E9 turned away from Resident R91 to get cream and Resident R91 slid off of the bed (away from NA Employee E9) and onto the floor causing a fractured left distal femur. Review of the statement that was attached to the investigation dated 7/30/24, from NA Employee E9 stated that I came into the room and Resident R91 told me she needed to be changed. As I am changing her brief and wiping her backside, I noticed redness in the area I asked her did she have any cream her response was yes, I asked her where was it she told me as I turned my left side to grab the cream she started to roll herself out of bed. I ran over to the other side of bed and sat with her until the ambulance came. Review of the facility investigation dated 7/31/24, contained the Staff Development Referral process dated 12/28/22, that was signed by NA Employee E9. This document includes the statement for resident bed mobility: Residents to be rolled towards you, not away from you (two staff members present when indicated on the assignment sheet). During an interview on 9/23/24, at 1:00 p.m., Resident R91 stated that she recalled the event that resulted in this fall and injury. Resident R91 reported she was rolled away from NA Employee E9 onto her right side that has limited mobility, and she verbalized I am sliding a couple of times before she fell out of the bed. Resident R91 stated the bed was raised to a higher position so that NA Employee E9 could provide care, as Resident R91 tried to reach out with her left arm to stop the slide there was nothing within reach and she fell . During an interview on 9/23/24, at 1:10 p.m., Resident R91's roommate Resident R125 confirmed the details of Resident R91's detail of the fall. During an interview on 9/25/24, at 1:30 p.m. with NA Employee E10, indicated that resident care is identified on the care sheets received at the start of the shift. Employee E10 indicated report is received between shifts for any changes to the resident's care. Employee E10 indicated additional staff is available to assist when requested. Employee E10 indicated the facility policy is to roll a resident toward staff when providing care. During an interview on 9/25/24, at 1:45 p.m. with NA Employee E11, indicated that resident care is identified on the care sheets received at the start of the shift. Employee E11 indicated report is received between shifts for any changes to the resident's care. Employee E11 indicated additional staff is available to assist when requested. Employee E11 indicated Resident R91 had been an assist of one and now is requires two. Employee E11 indicated the facility policy is to roll a resident toward staff when providing care. During an interview on 9/25/24, at 2:00 p.m. with NA Employee E12, indicated that resident care is identified on the care sheets received at the start of the shift. Employee E12 indicated report is received between shifts for any changes to the resident's care. Employee E12 indicated additional staff is available to assist when requested. Employee E12 indicated the facility policy is to roll a resident toward staff when providing care. During an interview on 9/26/24, at 10:22 a.m., the Director of Nursing confirmed NA Employee E9 rolled Resident R91 away from her to provide care then turned away from Resident R91 during this care not providing actual positioning assistance which resulted in actual harm for Resident R91 when a fractured left distal femur was sustained. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness and dementia. A MDS dated [DATE], indicated the diagnoses remained current, Section GG 0170 Mobility indicated functional abilities of the resident identified Resident R3 required dependent care with rolling left to right which is indicated the helper does all the effort or two staff are required. Review of Resident R3's physican orders dated 10/31/23, prior to the incident and remained current, indicated Resident R3 required bed mobility of assist of two. Resident R3 has no use of his hands or arms due to brain injury and contractures. Review of Resident R3's plan of care, prior to incident and remained current, indicated Resident R3 had behaviors of resistant with care. Review of an incident report dated 8/28/24, indicated that Resident R3 developed a 1.5 c.m. x 2.0 c.m. x 0.1 c.m. head laceration with a bruise requiring steri strips (tape that is used in place of sutures) to close when NA Employee E8 attempted to readjust a sheet around his waist to keep him from picking at his brief with no additional assistance when turning Resident R3 who cannot hold himself or stop himself from rolling, NA Employee E8 hit Resident R3s head off of the overbed table causing the laceration. During an interview on 9/25/24, at 8:15 a.m., NA Employee E5 stated that Resident R3 is rigid and required two staff since he becomes combative with care. NA Employee E5 stated that he frequently is assigned to Resident R3. The Nurse Aides use a care sheet but they also get report between shifts in case there are any changes to determine the assistance required by the residents. During an interview on 9/25/24, at 8:40 with NA Employee E6 and E7 indicated that resident care is identified on the care sheets but they also get report between shifts in case there are any changes. During an interview on 9/26/24, at 10:22 a.m., the Director of Nursing confirmed that the facility failed to make certain that a resident was free from neglect, which resulted in actual harm as evidenced by a left distal femur (thigh bone closest to the knee bone) fracture for one of three residents (Resident R91) and a head injury for one of three residents (Resident R3). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, review of facility incident/accident reports, clinical records, and staff interviews, it was determined that the facility failed to identify and/or investigate potential abuse and/or neglect for one of three residents (Resident R3). Findings include: Review of the facility policy Abuse- Resident last reviewed on 1/5/24, indicated that the facility treat every resident with respect and dignity. The failure of the facility to provide goods and services to a resident that are necessary to avoid or may result in physical harm is identified as neglect. All complaints/allegations of resident abuse/neglect shall be promptly reported to the administration and investigated. Alleged violations whether or not confirmed, must be reported. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included anoxic brain injury, quadriplegia, schizoaffective disorder, contractures, anxiety, blindness and dementia. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/18/24, indicated the diagnoses remained current. Section GG 0170 Mobility indicated functional abilities of the resident identified resident R3 required dependent care with rolling left to right which is indicated the helper does all the effort or two staff are required. Review of Resident R3's physican orders dated 10/31/23, prior to the incident and still current, indicated Resident R3 required bed mobility of assist of two. Review of Resident R3 plan of care, prior to incident and current, indicated resident R3 had behaviors of resistant with care. Review of an incident report dated 8/28/24, indicated that Resident R3 developed a 1.5 c.m. x 2.0 c.m. x 0.1 c.m. head laceration with a bruise requiring steri strips (tape that is used in place of sutures) to close when NA Employee E8 attempted to readjust a sheet around his waist to keep him from picking at his brief with no additional assistance when turning Resident R3 who cannot hold himself or stop himself from rolling, NA Employee E8 hit Resident R3s head off of the overbed table causing the laceration. During an interview on 9/25/24, at 8:15 a.m., NA Employee E5 stated that Resident R3 is rigid and required two staff since he becomes combative with care. NA Employee E5 stated that he frequently is assigned to Resident R3. During an interview on 9/25/24, at 8:40 with NA Employee E6 and E7 indicated that resident care is identified on the care sheets (a sheet shown to the surveyor and is on each nursing unit as a quick reference for each residents care needs for the nurse aides to utilize) but they also get report between shifts in case there are any changes. During an interview on 9/26/24, at 10:22 a.m., the Director of Nursing confirmed that the facility failed to identify and/or investigate potential abuse and/or neglect for one of three residents (Resident R3). 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1)(3) Management. 28 Pa Code: 211.10 (d) Resident care policies. 28 Pa Code: 211.12 (d)(3) Nursing services.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on abuse, neglect, and exploitation prevention for two of ten staff members (Employee E3 and E4). Findings include: Review of the Facility Assessment most recently reviewed 7/12/24, included in the list of training topics, Abuse, Neglect, and Exploitation. Review of facility provided documents and training records revealed the following staff members did not have documented training on abuse, neglect, and exploitation prevention. Unit Clerk Employee E3 had a hire date of 4/16/07, failed to have abuse, neglect, and exploitation prevention in-service education between 4/16/23, and 4/16/24. Nurse Aide Employee E4 had a hire date of 5/19/14, failed to have abuse, neglect, and exploitation prevention in-service education between 5/19/23, and 5/19/24. During an interview on 9/26/24, at approximately 1:09 p.m. the Assistant Director of Nursing confirmed that the facility failed to provide training on abuse, neglect, and exploitation prevention for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policies, clinical records and facility documents, and resident and staff interviews, it was determined that the facility failed to provide adequate assistance during a transfer that resulted in actual harm (a fractured tibia) for one of five residents reviewed (Resident R3). Findings include: The facility's policy Lifting and Moving Residents, Mechanical Lift Transfers last reviewed 1/19/19, indicated there must always be at least two staff members when using a mechanical lift (a device with a sling attached to a C shaped frame that lifts the resident mechanically from point to point) for transfers. A review of the Admission Face Sheet indicated that Resident R3 was admitted to the facility on [DATE]. A review of the Annual Minimum Data Set assessment (MDS- a resident assessment of care and screening) dated 1/16/19, indicated that Resident R3 was re-admitted to the facility on [DATE], was cognitively intact (alert and oriented), and had current [DIAGNOSES REDACTED]. The MDS also indicated Resident R3 transferred from surface to surface (bed to chair) with total dependence of two persons, did not walk in the room or the corridor, and required one person assist with locomotion on the unit (in wheelchair). A review of the physician order [REDACTED]. The plan of care dated 4/2/18, indicated Resident R3 required a mechanical lift for transfers due to immobility and to use two or more staff persons. A review of the (MONTH) 2019, Activities of Daily Living (ADL) care sheet indicated two people were to assist Resident R3 out of bed with a mechanical lift. A review of the facility's reported incident indicated that on 2/10/19, at 10:45 a.m. a Nurse Aide (NA) Employee E7, was transferring Resident R3 via a Hoyer lift, without assistance of a second person, and the lift tipped, sending Resident R3 to the floor. A review of the X-Ray report dated 2/10/19, indicated that Resident R3 had a nondisplaced oblique (a fracture at an angle or diagonally) [MEDICAL CONDITION] tibia (lower leg bone). A review of a statement dated 2/10/19, and signed by NA Employee E7, indicated NA Employee E7 was aware that residents of the facility are to have assistance of two persons for a mechanical lift. A review of the facility's investigation of Resident R3's fall on 2/10/19, indicated NA Employee E7, failed to follow the physician order [REDACTED]. A review of the physician order [REDACTED]. A review of the (MONTH) 2019, Medication Administration Record [REDACTED]. After the fall Resident R3 received [MEDICATION NAME]-[MEDICATION NAME] for pain twenty-one times from 2/14/19 until 2/27/19. During an interview on 2/27/19, at 10:20 a.m. Resident R3 indicated that they must keep their leg straight, have had increased pain from the left leg fracture and now take a pain pill, and they are afraid of the mechanical lift which is used to get out of bed. During an interview on 2/27/19, at 2:15 p.m. the Director of Nursing confirmed the facility failed to make certain that Resident R3 was provided adequate assistance during a mechanical lift transfer which resulted in a fall and actual harm to the resident (left tibia fracture). The facility failed to make certain that Resident R3 was provided adequate staff assistance during a mechanical lift transfer to prevent an accident resulting in harm. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 7/9/18. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 7/9/18.

Based on review of facility policies, clinical records and facility documents, and resident and staff interviews, it was determined that the facility failed to make certain that residents were free from neglect, which resulted in actual harm (a fractured tibia) for one of five residents reviewed (Resident R3). Findings include: The facility's policy Lifting and Moving Residents, Mechanical Lift Transfers last reviewed 1/19/19, indicated there must always be at least two staff members when using a mechanical lift (a device with a sling attached to a C shaped frame that lifts the resident mechanically) for transfers. A review of the Admission Face Sheet indicated that Resident R3 was admitted to the facility on [DATE]. A review of the Annual Minimum Data Set assessment (MDS-a periodic assessment of care needs) dated 1/16/19, indicated that Resident R3 was re-admitted to the facility on [DATE], was cognitively intact (alert and oriented), and had current [DIAGNOSES REDACTED]. The MDS also indicated Resident R3 transferred from surface to surface (bed to chair) with total dependence of two persons, did not walk in room or corridor, and required one person assist of locomotion on the unit (in wheelchair). A review of the physician order [REDACTED]. The plan of care dated 4/2/18, indicated Resident R3 required a mechanical lift for transfers due to immobility and to use two or more staff persons. A review of the (MONTH) 2019, Activities of Daily Living (ADL) care sheet indicated two people were to assist Resident R3 out of bed with a mechanical lift. A review of the facility reported incident indicated that on 2/10/19, at 10:45 a.m. Nurse Aide (NA) Employee E7, was transferring Resident R3 via a Hoyer lift, without assistance of a second person, and the lift tipped, sending resident R3 to the floor. A review of the X-Ray report dated 2/10/19, indicated that Resident R3 had a nondisplaced oblique (at an angle or diagonally) [MEDICAL CONDITION] tibia (lower leg bone). A review of a statement dated 2/10/19, and signed by NA Employee E7, indicated NA Employee E7 was aware that residents of the facility are to have assistance of two persons for a mechanical lift and I know I should have waited. A review of the facility's investigation of Resident R3's fall on 2/10/19, indicated NA Employee E7, failed to follow the physician order [REDACTED]. A review of the physician order [REDACTED]. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. After the fall Resident R3 received [MEDICATION NAME]-[MEDICATION NAME] twenty-one times for pain from 2/14/19 until 2/27/19. During an interview on 2/27/19, at 10:20 a.m. Resident R3 indicated that they must keep their leg straight, have had increased pain from the left leg fracture and now takes a pain pill and that they are afraid of the mechanical lift which is used to get out of bed. During an interview on 2/27/19, at 2:15 p.m. the Director of Nursing confirmed the facility failed to make certain that Resident R3 was free from neglect during a transfer from the bed to the chair which resulted in actual harm (left tibia fracture) to Resident R3. The facility failed to make certain that Resident R3 was protected from neglect while transferring a resident from the bed to the chair. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 7/9/18. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 7/9/18.