Every finding on record at Kadima Rehabilitation & Nursing at New Wilmington

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for three of four medication carts reviewed (North two, South, and [NAME] medication carts).Findings include: Review of facility policy entitled Vials and Ampules of Injectable Medications dated 2/24/26, indicated The beyond use date. are recorded on the multidose vials. And Medications in multidose vials may be used for twenty-eight days. Review of facility policy entitled Storage of Medications dated 2/24/26, indicated medications and biologicals are stored. following manufacturer's recommendations or those of the supplier. And Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of. Review of manufacturer's guidelines revealed that an open pen of Humalog Insulin must be used within 28 days after opening or be discarded. Manufacturer's guidelines for Trelegy Ellipta (medication used to treat Chronic Obstructive Pulmonary Disease [COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing] and Asthma [a long-term inflammatory disease of the airways that cause the airways to narrow and swell causing symptoms such as wheezing, coughing, chest tightness, and shortness of breath], indicated that Trelegy should be discarded six weeks after opening the foil tray or when the counter read 0, whichever comes first. Manufacturer's guidelines for Serevent Diskus (a medication used to treat asthma and COPD), indicated that Serevent should be discarded six weeks after opening the foil tray or when the counter read 0, whichever comes first. Manufacturer's guidelines for Fluticasone Propionate/Furoate Diskus (medication used to treat asthma), indicated that Serevent should be discarded six weeks or two months after opening the foil pouch or when the counter read 0, whichever comes first. Observation of drug storage on 3/3/26, at 1:27 p.m. of the North two medication cart revealed a Serevent Diskus out of the foil package and lacking an open date. During an interview on 3/3/26, at the time of observation Licensed Practical Nurse (LPN) Employee E1 confirmed that the Serevent lacked an open date, and staff were unable to determine the discard date. He/she also confirmed that the Serevent should have been discarded. Observation of drug storage on 3/3/26, at 1:35 p.m. of the South medication cart revealed three Trelegy Ellipta Diskus out of the foil packages, and lacking open dates. During an interview of 3/3/26, at the time of observation LPN Employee E2, confirmed that the three Trelegy Ellipta Diskus lacked open dates, and staff were unable to determine the discarded dates. He/she also confirmed that the three Trelegy Ellipta Diskus should have been discarded. Observation of drug storage on 3/3/36, at 3:05 p.m. of the [NAME] medication cart revealed two Trelegy Ellipta Diskus out of the foil package and in use, one with an open date of 12/1/25, and the other one lacking an open date; two Fluticasone Propionate Diskus out of the foil packages and in use with open dates of 12/12/25; a Fluticasone Furoate Diskus out of the foil package, in use and lacking an open date; and an open, in use insulin pen of Humalog with an expiration date of 2/26/26. During an interview on 3/3/26, at the time of observations LPN Employee E3 confirmed that one of the Trelegy Ellipta Diskus was beyond its use by date and the other one lacked an open date and staff were unable to determine the discarded date; the two Fluticasone Propionate Diskus were beyond their use by dates; and the Fluticasone Furoate Diskus lacked an open date and staff were unable to determine the discarded date and that the Humalog insulin pen had an expiration date of 2/26/26. He/she also confirmed that the Trelegy Ellipta Diskus, Fluticasone Propionate/Furoate Diskus, and the Humalog insulin pen should have all been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for two of six residents reviewed (Residents R23 and R51).Findings include:A facility policy entitled Use of Psychotropic Medication dated 2/24/26, indicated that Non-pharmacological approaches must be attempted unless clinically contraindicated, to minimize the need for psychotropic medications. Review of Resident R23's clinical record revealed an admission date of 10/25/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R23's physician's orders revealed an order dated 9/26/25, to administer Lorazepam (anti-anxiety) 0.5 milliliter (ml) by mouth every four hours PRN for anxiety. Review of Resident R23's January 2026, February 2026, and March 2026 Medication Administration Records (MARs) revealed that the PRN Ativan was used on 1/2/26, 1/3/26, 1/6/26, 1/7/26, 1/9/26, 1/10/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/20/26, 1/24/26, 2/3/26, 2/6/26, 2/7/26, 2/8/26, 2/10/26, 2/11/26, 2/16/26, 2/17/26, 2/19/26, and 3/4/26. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the administrations listed above in January 2026, February 2026, and March 2026. Review of Resident R51's clinical record revealed an admission date of 4/4/25, with diagnoses that included dysphagia (difficulty swallowing), hypertension (high blood pressure), and anxiety. Review of Resident R51's physician's orders revealed an order dated 1/22/26, to administer Vistaril (anti-anxiety) 50 milligrams (mg) by mouth every eight hours PRN for anxiety. Review of Resident R51's January 2026, February 2026, and March 2026 MARs revealed that the PRN Vistaril was used on 1/27/26, 2/1/26, 2/9/26, 2/18/26, 2/23/26, 2/2526, and 3/5/26. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Vistaril for the administrations listed above in January 2026, February 2026, and March 2026. During an interview on 3/5/26, at 3:37 p.m. the Director of Nursing confirmed that Resident R23 and Resident R51's clinical records lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of five residents reviewed (Residents R67 and R71).Findings include: Review of facility policy entitled Transfer Form Instructions dated 2/24/26, indicated Should it become necessary to transfer a resident. a transfer form will be executed and forwarded., The transfer form will be completed. and will include: Current medical findingsDiagnosisSummary of the course of treatment followedPertinent administrative and social informationOther as necessary and appropriate Review of Resident R67's clinical record revealed an admission date of 7/8/25, with diagnoses that included heart failure, anxiety disorder (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia (high cholesterol). Review of Resident R67's progress notes revealed notes dated 11/18/25, and 12/17/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R71's clinical record revealed an admission date of 12/10/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R71's progress notes revealed notes dated 1/7/26, 1/11/26, 1/16/26, 1/27/26, 2/2/26, and 2/6/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 3/6/26, at 2:37 p.m. the Director of Nursing confirmed that Resident R67 and Resident R71's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and that when the transfers occurred clinical information should have been provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate treatment to prevent potential complications related to a gastrostomy tube (g-tube - a tube inserted through a small incision in the abdomen into the stomach, used for the administration of liquid nutrition and medications) for one of three residents reviewed (Resident R64). Findings include: Review of facility policy entitled Enteral Tube Feeding Care dated 2/24/26, indicated Nursing staff will follow physician orders and acceptable clinical standards to. reduce the risk of infection. Enteral feeding. tubing must be changed every 24 hours. And Label feeding bags with the date and time they are hung. Review of feeding label and manufacturer's guidelines revealed Hang product up to 48 hours after initial connection when clean technique and only one feeding set are used. Otherwise, hang no longer than 24 hours. Review of Resident R64's clinical record revealed an admission date of 12/21/26, with diagnoses that included anorexia (a serious eating disorder that causes a fear of weight gain, an how one's body looks leading to a significant weight loss), eating disorder (is a serious mental health condition that causes unhealthy eating behaviors because of how one sees their body and weight), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R64's physician's orders dated 1/23/26, revealed orders for Jevity 1.5 (feeding) at 75 ml (milliliters) per hour and another order to change piston syringe (a needleless syringe that is used to flush water through a g-tube) every day on the midnight shift for tube feed water flushes dated 2/11/26. Observations on 3/3/26, at 11:20 a.m. and again at 1:00 p.m. revealed Resident R64's feeding hanging on an IV pole connected to Resident R64's g-tube, the feeding and tubing lacked dates indicating when the tubing and feeding were initiated. Further observations revealed a piston syringe hanging on the IV pole that was dated 2/22/26. During an interview on 3/3/26, at 1:20 p.m. the Director of Nursing (DON) confirmed that the feeding and the tubing lacked dates indicating when they were initiated and that the piston syringe had a date of 2/22/26. The DON also confirmed that the date should be written on the feeding and tubing when they are initiated and that the piston syringe should have been changed per physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician's orders for two of three residents reviewed for respiratory care (Residents R18 and R23). Findings include: Review of facility policy entitled Oxygen Tubing, Nasal Cannula and Oxygen Mask dated 2/24/26, indicated Nursing staff will verify the ordered oxygen flow rate., Oxygen tubing, nasal cannulas. must be replaced at least once every seven days., and New oxygen tubing, cannulas, and mask must be stored in a clean, dry area, open supplies must be protected from contamination. Review of facility policy entitled Oxygen Concentrator-Preventative Maintenance dated 2/24/26, indicated Air filter. will need to be cleaned on a weekly basis. Review of facility policy entitled Oxygen Administration dated 2/24/26, indicated Change pre-filled humidification system at least weekly. Review of Resident R18's clinical record revealed an admission date of 10/11/25, with diagnoses that include respiratory failure (a condition where your lungs don't exchange air properly), chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R18's physician's orders revealed an order for supplemental oxygen via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) at two liters/minute every shift dated 10/11/25. Review of Resident R18's care plans revealed a care plan for COPD with intervention of oxygen therapy as ordered by the physician. Another care plan for respiratory distress with intervention of oxygen continuous per order two liters via nasal cannula. Observations on 3/3/26 at 12:55 p.m. and again at 1:05 p.m., revealed Resident R18 lying in his/her bed with supplemental oxygen in place via nasal cannula and the oxygen concentrator (machine used to deliver concentrated oxygen to patients) flow rate set at one and a half liters/minute. The nasal cannula lacked a date and the humidification water bottle was empty. Review of Resident R23's clinical record revealed an admission date of 10/25/24, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), respiratory failure (a condition where your lungs don't exchange air properly), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R23's physician's orders revealed an order for oxygen to keep SpO2 (oxygen saturations) at or above 90 percent dated 4/28/25. Review of Resident R23's care plans revealed a care plan for pneumonia with an intervention that staff will ensure oxygen equipment care/tubing is changed per physician's orders. Observations on 3/3/26, at 12:54 p.m. and again at 1:05 p.m., revealed an oxygen concentrator sitting next to Resident R23's bed. A filter on the back of his/her oxygen concentrator had a large amount of fluffy white substance covering the filter. During an interview on 3/3/26, at 1:20 p.m. the Director of Nursing (DON) confirmed that Resident R18's humidification bottle was empty, the nasal cannula lacked a date, and his/her oxygen flow rate was set at one and a half liters per minute and was not in accordance with physician's orders. The DON also confirmed that Resident R23's oxygen concentrator filter was covered with a large amount of fluffy white substance and should be clean. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination (transfer of germs from one location to another) during medication administration (West Wing medication cart) and failed to prevent cross-contamination for one resident (Resident R122) receiving nebulizer treatments ( a treatment that delivers medication directly to the lungs to treat respiratory conditions). Findings include: Review of facility policy entitled Medication Administration dated 2/24/26, revealed that If breaking tablets. hands are washed with soap and water or alcohol gel prior to handling tablets. Review of facility policy entitled Nebulizer Equipment Management dated 2/24/26, revealed The facility will ensure that nebulizer used for medication administration is maintained. with infection control standards to prevent cross-contamination. and Nebulizer. mouthpiece must be replaced at least once every seven days (weekly). Equipment must also be replaced immediately if: It becomes visibly soiled or contaminated. Observations during medication administration on 3/4/26, at 8:00 a.m. revealed Licensed Practical Nurse (LPN) Employee E3 preparing medications from the [NAME] Wing medication cart. LPN Employee E3 touched a pill from a bottle without sanitizing/washing his/her hands or applying gloves. He/she then proceeded to place the pill into the medication cup with other pills. Further observations revealed that LPN Employee E3 dropped pills onto the floor and then proceeded to pick the pills up and placed them into the medication cup. During an interview on 3/4/26, at the time of observations LPN Employee E3 confirmed that he/she did not sanitize/wash his/her hands or apply gloves before touching a pill and he/she picked pills up off the floor and placed them in the medication cup. LPN Employee E3 also confirmed that he/she should not touch medications without sanitizing/washing his/her hands or applying gloves or place medications off the floor into the medication cup. Review of Resident R122's clinical record revealed an admission date of 2/26/26, with diagnoses that included coronary artery bypass graft (an open-heart surgery that creates a new path for blood flow), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R122's physician's orders revealed an order Ipratropium Albuterol (a liquid medication) solution 3 mg per ml every four hours. Observations on 3/3/26, at 11:00 a.m. and again at 1:03 p.m. revealed a nebulizer machine (a medical device that turns liquid medication into a fine mist) sitting on the bedside stand next to Resident R122's bed with a hand held mouth piece (a device that is connected to a nebulizer machine allowing a person to inhale medication directly into their lungs) lying on the floor and lacking a date. During an interview on 3/3/36 at 1:20 p.m. the Director of Nursing (DON) confirmed that the mouthpiece was lying on the floor and lacked a date. The DON also confirmed that the mouthpiece should not be on the floor and that it should have a date indicating when it was placed. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding personal hygiene, oral hygiene, toileting, and dressing for three of three residents reviewed (Residents R1, R2, and R3).Findings include: Review of facility policy entitled Flow of Care dated 3/27/25, indicated The provision of targeted care needs shall be documented on Care Tracker/Point of Care/ADL [activities of daily living] Flow Records. Review of Resident R1's clinical record revealed an admission date of 12/12/25, with diagnoses that included fracture of neck of left femur (broken bone of the hip), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of resident R1's clinical record under tasks (area in the clinical record where nursing assistant's document) for the month of December 2025, revealed oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing lacked evidence of documentation on 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/18/25, and 12/19/25, that oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing had been completed. Review of Resident R1's physician's orders revealed an order dated 12/14/25, to turn and reposition every two hours dated. Resident R1's clinical record lacked evidence that he/she was turned and repositioned every two hours per physician's orders. Review of Resident R2's clinical record revealed an admission date of 11/15/25, with diagnoses that included heart failure (a condition where the heart cannot supply the body with enough blood), hypertension, and need for assistance with personal care. Review of resident R2's clinical record under tasks for the month of December 2025, revealed oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing lacked evidence of documentation on 12/1/25, 12/3/25, 12/4/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/22/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25, 12/30/25, and 12/31/25, that oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing had been completed. Review of Resident R3's clinical record revealed an admission date of 11/26/25, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), respiratory failure (a condition where your lungs don't exchange air properly), and hypertension. Review of resident R3's clinical record under tasks for the month of December 2025, revealed oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing lacked evidence of documentation on 12/1/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/15/25, 12/16/25, 12/27/25, 12/31/25, that oral hygiene, personal hygiene, toileting hygiene, and upper and lower body dressing had been completed. During an interview on 1/23/26, at 10:15 a.m. the Nursing Home Administrator and Director of Nursing confirmed that Residents R1, R2 and R3's clinical records did not have complete documentation regarding turning and repositioning, personal hygiene, oral hygiene, toileting, and dressing. They also confirmed that turning and repositioning, personal hygiene, oral hygiene, toileting, and dressing should be documented in the clinical record after it is completed. 28 Pa. Code 211.5(f) Medical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of four nursing units (West Hall Nursing Unit). Findings include: Review of the facility policy entitled, Call Light Response with a revision date of 11/1/24 , revealed that a call bell or alternative device will be placed within the reach of each resident while in their room, toilet or bathing area. The resident will be instructed in the use of the call bell or alternative device. Staff will respond to the call bell in a timely manner. Staff will be alert to signals that the call bell is on by the following: Flashing light on intercom Beeping of intercom Lighted call signal over the resident's door Sounding of tap bell Observation of the [NAME] Hall Nursing Unit, revealed the call bell system in the corridors did not illuminate when resident call bells in their rooms had been activated. Upon review of maintenance records, it was confirmed that the call bell system on the [NAME] Hall Nursing Unit had not been functioning since 4/22/25, and a temporary call bell system was installed on 4/29/25. A price quote for a new call bell system was obtained but was not completed. Upon observation of the temporary call bell system on the [NAME] Hall Nursing Unit, it was confirmed that residents can call, but no visible overhead light system illuminates. Requests by residents go to a screen located in center hall at the time of call. It was observed that if another resident uses their call bell before staff becomes aware, the previous resident's call is not visible and there is no way to review previous calls and those calls get missed. During interviews with residents at the time and date of the investigation revealed the following: Resident R1 stated that there are long wait times always, on all shifts; you will wait hours to get assistance sometimes; the system does not have a light system over the door and employees don't know you call; wait times have been worse since the original system stopped working. Resident R2 stated that there are consistent wait times of one to two hours for assistance after you call for help on all shifts; it is concerning. Resident R3 stated that assistance is always slow after you call for help on all shifts; you will wait over one hour sometimes. Resident R4 stated that there are always long wait times after you call on the call bell for help or needs; thirty to sixty minute wait times are not uncommon and it upsets him/her. Resident R5 stated that there are always 30 minute wait times or longer and sometimes employees don't know there was a call; Resident R5 also stated I wait too long to go to the bathroom when I call, so I just get up by myself if I cannot wait. Resident R6 stated that there are constantly long wait times when he/she calls for help of over 30 minutes and staff doen't know the call system was used. During an interview on 6/10/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the central call bell system on the [NAME] Hall Nursing Unit was not fully functioning to provide visual communication of which room the call bell activation was coming from. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy and manufacturer's instructions, observations and staff interview, it was determined that the facility failed to label one multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD-testing solution for tuberculosis) injection with the date it was opened and date it should be used by in one of three medication storage rooms observed (North Two Nurse Station medication room). Findings include: Review of manufacturer's instructions for Aplisol- tuberculin PPD Vials revealed Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of facility policy entitled Storage of Medications, with a policy review date of 3/26/24, revealed that Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Observations of the North Two Nurse Station medication room on 3/12/25, at approximately 1:15 p.m. revealed that one multi-dose vial of Aplisol-Tuberculin PPD was opened and was currently in use, but not labeled with the opened date or the use by date. At the time of the observation, the Assistant Director of Nursing confirmed that the one undated multi-dose vial of Aplisol was opened, in use daily, and should have been labeled with the date opened and use by date. 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 and clinical records and staff interviews, it was determined that the facility failed to appropriately monitor a resident identified with a significant weight loss for one of 20 residents reviewed (Resident R42). Findings include: Review of the facility policy related to weight monitoring and weight loss intervention dated 3/27/23, indicated that weight loss intervention will be implemented to prevent further weight loss and to maintain/improve the resident's nutritional status. It also indicated when there is a 5% weight loss in 30 days to follow up with Dietitian recommendations and to keep records of interventions implemented and the progress made. The Registered Dietitian (RD) job description indicated the purpose of the job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility. Resident R42's clinical record revealed an admitted [DATE], with diagnoses including heart disease, kidney disease, and gastrointestinal bleed. Documentation related to Resident R42's weekly weights revealed the following: Admission weight documented - 2/03/23 - 227.9 pounds; next weight documented on 2/20/23 - 227.2 pounds 3/01/23 - 236.2 pounds 3/02/23 - 230.1 pounds 3/06/23 - 247.0 pounds - 20 pound weight gain in 14 days 3/20/23 - 247.0 pounds 3/27/23 - 161.4 pounds - 74.8 pound weight loss in 26 days, from 3/01/23 3/29/23- 161.6 pounds 4/02/23 -173.5 pounds 4/10/23- 178.2 pounds 5/15/23-183.2 pounds Review of Resident R42's Discharge Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated March 21, 2023, revealed that the resident had a weight gain of 5% or more in the last month. Review of Resident R42's Quarterly MDS assessment dated [DATE], revealed Resident R42 had a weight loss of 5% or more in the last month. The clinical record revealed no evidence that Resident R42 was reassessed by the RD, since the initial admission Nutrition Data Collection dated 2/16/23, until 5/18/23, a period of three months. During an interview on 5/18/23, at 2:00 p.m. the Director of Nursing confirmed that Resident R42's clinical record lacked evidence of any dietitian notes or recommendations since the initial admission Nutrition Data Collection dated, 2/16/23, until 5/18/23, a period of three months. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to monitor a resident's personal refrigerator for temperatures for one of one residents reviewed with personal refrigerators (Resident R8). Findings include: Review of facility policy entitled, Personal Refrigerators with a policy review date of 3/27/23, revealed Personal refrigerators will be subject to the same monitoring as other facility refrigerators. The food stored in the personal refrigerator must meet the same standards as food stored elsewhere in the facility. The policy also revealed Inform resident that refrigerator must include a thermometer and will be monitored regularly for temperature compliance. Establish a temperature and contents monitoring process. Initiate temperature monitoring and content inspection for food labeling and dating. Observation on 5/16/23, at 1:30 p.m. revealed that Resident R8 had a personal refrigerator in the room that contained food and beverage items. The observation also revealed that there was no thermometer in the refrigerator and no temperature log sheets in order to monitor the resident's personal refrigerator and food/beverage items for proper storage. During an additional observation of Resident R8's personal refrigerator on 5/16/23, at 4:25 p.m. with the Director of Nursing it was confirmed that there was no thermometer in the refrigerator and no temperatures recorded to ensure the safe storage of resident food/beverage items. 28 Pa Code 201.14 (a) Responsibility of Licensee

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update and/or individualize a care plan for one of 20 residents reviewed (Resident R42). Findings include: Review of facility policy entitled, Participation in Planning Care and Treatment dated 3/27/23, indicated that the resident care plan shall be reviewed, evaluated and updated, as necessary, by professionals involved in the care of the resident. Resident R42's clinical record revealed an admitted [DATE], with diagnoses including heart disease, kidney disease, and gastrointestinal bleed. Documentation related to Resident R42's weekly weights revealed the following: Admission weight documented - 2/03/23 - 227.9 pounds; next weight documented on 2/20/23 - 227.2 pounds 3/01/23 - 236.2 pounds 3/02/23 - 230.1 pounds 3/06/23 - 247.0 pounds - 20 pound weight gain in 14 days 3/20/23 - 247.0 pounds 3/27/23 - 161.4 pounds - 74.8 pound weight loss in 26 days, from 3/01/23 3/29/23- 161.6 pounds 4/02/23 -173.5 pounds 4/10/23- 178.2 pounds 5/15/23-183.2 pounds Review of Resident R42's Discharge Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated March 21, 2023, revealed that the resident had a weight gain of 5% or more in the last month. Review of Resident R42's Quarterly MDS assessment dated [DATE], revealed Resident R42 had a weight loss of 5% or more in the last month. The clinical record revealed a nutritional problem care plan related to dysphagia (difficulty swallowing) dated 2/13/23. As of 5/18/23, there was no evidence that Resident R42's care plan had been updated to reflect Resident R42's weight loss. During an interview on 5/18/23, at 2:18 p.m. the Director of Nursing confirmed that Resident R42's nutrition care plan was not updated to reflect weight loss and their current status. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and manufacturer's instructions, observation, and staff interviews it was determined that the facility failed to label pre-filled insulin pens with the date they were opened and discard multi-dose insulin bottle within the use by timeframe for one of two medication carts observed (South Hall) Findings include: Review of facility policy dated 3/27/23, entitled Labeling of Medications indicated that multi-dose medications must be dated when opened for determination of discard date based on manufacturer's instructions. Review of manufacturer's instructions for the Novolog (type of insulin) multi-dose vial directed that once open, they were to be used within 28-days, then discarded. Observation of South Hall medication cart on 5/16/23, at 4:33 p.m. revealed that Resident R15's Basaglar Kwik Pen (type of insulin), R41's Insulin Aspart Flex Pen, and Resident R28's Insulin Glargine and Insulin Lispro Pens were currently in use, but not labeled with an open date. Further observation revealed Resident R23's Novolog multi-dose bottle was open, dated for 4/15/2023, and was currently in use, or 31-days past the open date. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that Resident R15, R41, and R28's insulin pens were in use and not labeled with an open date and that Resident R23's multi-dose insulin vial was being used past the 28-days. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of information submitted by the facility, facility policies, state laws, professional licenses, and staff time records, and staff interview, it was determined that the facility failed to ensure that professional staff were licensed in accordance with applicable state laws for two of two licensed employees reviewed (Agency Licensed Practical Nurses (LPN) Employee E1 and LPN Employee E2). Findings include: Review of Pennsylvania's Professional Nursing Law, Section 8 (a) indicated that each person who met the professional nursing licensure requirements would be issued a certificate setting forth that the person was licensed to practice professional nursing. Section 11 (a) indicated that the license issued expired on the date established by the State Board of Nursing. Review of facility policy entitled Use of Outside Resources, dated [DATE], indicated that the facility may utilize outside sources for services and will obtain copies of current licensure and keep them current. Review of facility policy entitled License and Registration of Nursing Personnel, dated [DATE], indicated that a current license or copy will be on file during the length of employment. Review of information submitted by the facility, dated [DATE], revealed that Agency LPN Employee E1 and Agency LPN Employee E2 had been working with an expired license since [DATE]. Review of the Pennsylvania professional nurse licenses for Agency LPN Employee E1 and Agency LPN Employee E2 revealed that they both expired on [DATE]. Nursing schedules from [DATE] through [DATE], revealed that LPN Employee E1 worked a total of 19 shifts after his/her license expired and LPN Employee E2 worked a total of six shifts with an expired license. Interview with the Director of Nursing on [DATE], at 2:00 p.m. confirmed that Agency LPN Employee E1 worked 19 shifts with an expired license and that Agency LPN Employee E2 worked six shifts with an expired license. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from non-consensual sexual contact and observation of masturbation for five of 18 residents (Residents R1, R16, R30, R49 and R50) resulting in sexual abuse and psychosocial harm. Findings include: Review of the facility policy entitled, Abuse: Protection From Abuse, with a revision date of 8/2016, and a Policy Review date of 3/18/22, revealed a policy statement that reads The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The Facility shall have a process in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The policy interpretation stated, Sexual abuse includes, but is not limited to, sexual harrassment, sexual coercion, or sexual assault. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) Section C0500 dated 5/26/22, indicated that Resident R1's Basic Interview of Mental Status (BIMS- test is used to get a quick snapshot of how well you are functioning cognitively) was 15 (intact cognition). Review of Resident R16's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS Section C0500 dated 3/20/22, indicated that Resident R16's BIMS was eight (moderately impaired). Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section C0500 dated 4/09/22, indicated that Resident R30's BIMS was 15. Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section C0500 dated 5/05/22, indicated Resident R49's BIMS was 13 (intact cognition). Review of Resident R50's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section C0500 dated 5/05/22, indicated that Resident R50's BIMS was 13. Review of Resident R33's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section C0500 dated 3/09/22, indicated that Resident R33's BIMS was 9 (moderately impaired). Further review of Resident R33's clinical record revealed a physician's orders dated 6/01/22, to administer [MEDICATION(S)] (medication to treat anxiety) 1 milligram three times a day, 5/19/22, for [MEDICATION(S)] (antipsychotic medication) 100 mg monthly on the 19th for behaviors, and a care plan to address his/her sexually inappropriate behaviors that included interventions to: avoid conversation to encourage behavior, document episodes, intermittent supervision, redirect to a private area, and set limits for acceptable behavior. Resident R33's clinical record contained the following progress notes: - 1/02/22, 9:12 a.m. upset about smoking, verbally abusive toward staff at nurse's station - 1/13/22, reviewed by psychoactive drug committee - 1/20/22, 12:00 a.m. masturbating in lounge, encouraged to go to room - 1/21/22, psychiatrist notified of refusing medications and increased behaviors, [MEDICATION(S)] ordered monthly - 1/22/22, 1:37 a.m. wandering in and out of various female rooms while they are sleeping, exposing his penis and masturbating in the hallway, 1:1 provided for remainder of shift - 1/22/22, 1:54 a.m. found in room [ROOM NUMBER], reported by resident in room [ROOM NUMBER] to be touching his/her leg, exposing penis at West nurse's station - 1/22/22, 4:19 a.m. exposing himself and masturbating in his doorway during 1:1 - 1/22/22, 4:30 a.m. at bedside masturbating - 1/24/22, 3:37 p.m. verbally abusive toward staff - 1/26/22, 10:30 a.m. seen by Primary Care Physician - 2/08/22, 1:57 p.m. seen by psychiatrist - 2/11/22, 1:30 a.m. verbally abusive to staff - 2/13/22, 4:16 p.m. exposing self/masturbating in doorway of his room, female resident reported he entered her room and exposed himself (told by staff to scream), and Nurse Aide found him in the same female resident's room masturbating next to her bed while she slept (staff informed him if behavior continued there would be consequences) - 2/14/22, 7:51 p.m.: upset about smoking, pacing halls, verbally abusive to staff and raising arm as if to swing at staff, Certified Registered Nurse Practitioner in building and notified - 2/15/22, 8:16 a.m.: upset about smoking, at nurse's station swearing at staff - 2/15/22, 8:33 a.m.: psychiatrist faxed, returned order for [MEDICATION(S)] at 2:18 p.m. - 2/16/22, 2:48 a.m.: swearing at staff - 2/18/22, 1:08 p.m. upset about smoking, charge nurse reported resident puncher her, police called, [MEDICATION(S)] given - 2/19/22, 4:18 p.m. upset about smoking, swearing at staff - 2/20/22, q 15 min checks - 2/28/22, 1:22 p.m. verbally abusive and making threats of physical harm and burning the building down, [MEDICATION(S)] given - 2/28/22, 1:48 p.m. Social Worker conversation with Power of Attorney, confirmed that resident's behaviors can be a lot to handle - 2/28/22, 2:22 p.m. struck staff - 2/28/22, 2:50 p.m. psychiatrist notified - 3/04/22, 8:35 a.m. reviewed by psychoactive drug committee - 3/06/22, 1:13 p.m. exposed and masturbating in dining room - 3/08/22, 11:49 a.m. seen by psychiatrist, continue [MEDICATION(S)] and [MEDICATION(S)] - 3/13/22, 7:30 p.m. upset about smoking, verbally abusive to staff - 3/15/22, 1:08 a.m. verbally abusive to staff - 3/15/22, 4:26 a.m. in hallway nude, yelling at female resident across the hall - 3/25/22, 9:02 a.m. upset about smoking, verbally abusive toward staff, swung arm toward aide and missed, hitting glass door - 3/25/22, 10:00 a.m. verbally aggressive, threatening to kill staff, tried to punch female staff - 3/30/22, 8:20 p.m. upset about smoking, verbally abusive toward staff, fabricated stories to obtain other resident's cigarettes, approached staff with raised fist and retreated when other staff arrived - 3/31/22, psychiatrist notified of behaviors, new orders for [MEDICATION(S)] - 4/04/22, 3:30 a.m. found in hall masturbating - 4/05/22, 7:09 a.m. late entry of female resident reported that Resident R33 was masturbating outside of her room at 3:00 a.m. - 4/06/22, 4:52 a.m. exposing penis at West nurse's station - 4/06/22, 8:30 a.m. exposing penis in dining room - 4/12/22, 2:00 p.m. seen by psychiatrist, increased [MEDICATION(S)] doses - 4/17/22, 8:14 a.m. upset about smoking, threatened to kill staff - 4/28/22, 3:47 p.m. yelling at two female residents in the common area, screamed profanities, threatened staff - 5/10/22, 4:10 p.m. seen by psychiatrist, increased [MEDICATION(S)] - 5/30/22, 1:40 a.m. masturbating in dining room - 5/31/22, 2:56 p.m. kissed a blind female resident and rubbed her back, told by staff that he could not kiss other residents without their permission, became angry and pulled his fist back twice as if to strike staff, told by staff that if he kisses anyone without their permission or punches anyone that police will be notified - 5/31/22, 3:02 p.m. psychiatrist notified - 5/31/22, 4:18 p.m. statement received from female resident revealed that Resident R33 approached her in the smoking gathering place and attempted to take her back to her room to take her clothes off, he reapproached her 15 minutes later and kissed her on the lips without her permission, she told him to leave her alone, when he was approached by staff to discuss the incident, he became aggressive, used profanity, and pulled his arm back as if to swing at staff - 6/01/22, 12:09 new [MEDICATION(S)] order from psychiatrist - 6/05/22, 10:45 p.m. verbally confrontational with staff Resident R33's clinical record revealed a care plan entitled Problematic manner characterized by inappropriate sexual behavior related to exposing self/masturbating dated 4/05/22, and lacked evidence that the facility evaluated/updated the care plan following the above stated incidents. Further review of the clinical record revealed that Resident R33 refuses his medications [MEDICATION(S)] and [MEDICATION(S)], frequently. Review of facility documents including incident investigations and progress notes, revealed that the facility was aware of the incidents involving Resident R33's behaviors on 1/22/22, 3/30/22, 2/13/22, 2/14/22, and 5/31/22. Observation on 6/09/22, at 1:30 p.m. revealed that the doorway to Resident R33's room was not visible to staff located at the South Wing nurse's station and that on 10 occasions Resident R33 was able to exit his room to masturbate in common areas and/or in female resident rooms during the 11:00 p.m. to 7:00 a.m. shift without being noticed by staff until he was found by staff in common areas and female resident rooms. Resident interviews on 6/09/22, between 1:00 p.m. and 2:00 p.m. included the following: - Resident R1, confirmed that he/she was kissed and rubbed from his/her shoulders down to his/her buttocks by Resident R33 without giving permission, and that he/she is blind, and is afraid to be alone in case he comes back, so he/she does not wait in the common area alone either. - Resident R16, resides across the hall from Resident R33 and confirmed that he/she has observed Resident R33 standing out in the hallway near his doorway exposing himself and masturbating, and that he/she is afraid that Resident R33 will come into the room while he/she is in bed, and that he/she tries not to be in the room alone. - Resident R30, confirmed that he/she is non-ambulatory and that he/she has observed Resident R33 exposing himself and masturbating in the common area, and is afraid he will come in his/her room while he/she is sleeping. - Resident R49, confirmed that he/she has seen Resident R33 standing outside his/her doorway exposing himself and masturbating while he/she was in bed. Resident R49 also confirmed that he/she is afraid of Resident R33. - Resident R50, who is aphasic (unable to speak), indicated with a head nod that Resident R33 has been in his/her room while he/she was in bed and that Resident R33 has touched him/her. Resident R50's facial expression closed down and he/she refused to answer any further questions related to details of the encounters. During an interview on 6/9/22, at approximately 3:00 p.m., Nursing Employee E10 disclosed for the past several months, Resident R33 frequently masturbated in public areas and in the doorways of female resident's rooms and that the female residents were very fearful of him. During an interview on 6/10/22, at approximately 10:30 a.m. the Director of Nursing confirmed that he/she personally follows-up on resident and staff reports of violent and sexual behaviors exhibited by Resident R33. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations and staff interviews it was determined that the facility failed to store food and food containers in a safe and sanitary manner in the main kitchen and in the designated resident refrigerator. Findings include: Observation on 6/07/22, at 11:05 a.m. revealed clear plastic drink cups and metal baking pans nested together with moderate/dripping amount of water between surfaces. During an interview at that time, the Dietary Manager confirmed the plastic cups and metal pans were nested together while wet and that the items should be dry before stacking them. Observation on 6/8/22, at 10:43 a.m. revealed clear plastic drink cups nested together with moderate/dripping amount of water between surfaces. During an interview on 6/08/22, at 11:05 a.m. the Regional Dietary Manager confirmed the plastic cups were nested together while wet and that staff should not stack the wet cups together. Observation on 6/08/22, at 1:30 p.m. of the resident snack refrigerator/freezer in the unit kitchenette (signage indicated that the refrigerator was for resident use only) revealed the following items labeled with resident names and lacked a date: unsealed Kentucky Fried Chicken sandwich, a container of macaroni and cheese, a container of chili, a half of stick of butter, a container of cut watermelon, blue Gatorade, bottle of water, yogurt, ½ gallon of cherry vanilla ice cream, and orange ice cream bars. The following items lacked a name or a date: blue container of sauerkraut, orange Gatorade, baggie with three slices of ham, half full protein drink in a cup, bottle of water, opened jar of sweet pickle relish, open bottle of chocolate syrup, open bottle of caramel sauce, open bottle of ketchup, three open bottles of mustard, four vanilla ice cream cups, two blueberry snack muffins, and assorted popsicles. There were also eight containers of yogurt with an expiration date of 5/18/22. During an interview on 6/08/22, at 1:30 p.m. the Regional Dietary Manager confirmed that the above stated foods and drinks should have been labeled with a name and date, and that the eight outdated yogurts should have been discarded. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(1) Management

Based on review of facility records, job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that female residents were protected from a resident with sexually inappropriate behaviors. Findings include: Review of job description entitled, Administrator that was signed by the Nursing Home Administrator on 1/19/2021, stated The primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state and local standards, guidelines, and regulations that govern long term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of job description entitled, Director of Nursing stated, The purpose of your job position is to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Based on the findings in this report that identified that the facility failed to implement their job duties due to not protecting residents from a sexually inappropriate resident on multiple occasions as confirmed by documentation and concerns from residents, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. Refer to F600 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide care of each resident in an environment that promotes maintenance or enhancement of his/her quality of life for three of 18 residents reviewed (Residents R16, R49, and R50). Findings include: Review of Resident R16's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS- standardized assessment tool that measures health status in nursing home residents) Section C0500 dated 3/20/22, indicated that Resident R16's Basic Interview of Mental Status (BIMS- BIMS test is used to get a quick snapshot of how well you are functioning cognitively) was eight (moderately impaired cognition). Resident R16's clinical record lacked evidence of informed consent/acknowledgement of shared bathrooms with the opposite gender. Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section C0500 dated 5/05/22, indicated Resident R49's BIMS was 13 (intact cognition). Resident R49's clinical record lacked evidence of informed consent/acknowledgement of shared bathrooms with the opposite gender. Review of Resident R50's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Section C0500 dated 5/05/22, indicated that Resident R50's BIMS was 13. Resident R50's clinical record lacked evidence of informed consent/acknowledgement of shared bathrooms with the opposite gender. Observations of Residents R16, R50 (roommates) and R49's bathrooms revealed that both bathrooms were being shared with residents of the opposite gender. There were locks on each door in both bathrooms on the inside of the doors to enable residents to lock the bathrooms when in use. During an interview on 6/07/22, at 12:05 p.m. Resident R49 confirmed that he/she has to share a bathroom with two residents of the opposite gender in the next room and that the housekeeper has to clean it several times a day because they are messy when they use it, he/she does not like using it because there is urine all over the floor and he/she has a new partial amputation of his/her right foot with a bandage on it and is concerned with germs. Resident R49 also confirmed that when he/she was admitted to the facility he/she shared the bathroom with members of the same gender and the facility moved residents of the opposite gender into the room and didn't ask if he/she minded and he/she was not informed ahead of time. Resident R49 confirmed that he/she expressed displeasure of the current situation and was told by staff that the facility is allowed to do that and there isn't anything they can do about it and that if he/she wanted to move to another room, that was their right. During an interview on 6/09/22, at 11:30 a.m. the Admissions Coordinator/Social Worker confirmed that the facility's admission packet lacked evidence that the potential residents and/or their representatives were informed of and agreed to the possibility of sharing bathrooms with the opposite gender. During an interview on 6/09/22, at 12:20 p.m. Residents R16 and R50 (roommates) confirmed that they were not informed upon admission that they may have to share bathrooms with residents of the opposite gender and are uncomfortable doing so, and that they were not asked by the facility about the arrangements, however they were told that this is the way it is. Residents R16 and R50 also confirmed that a male resident who lives in the adjoining room has walked into their room to enter the bathroom from their door. 28 Pa. Code 201.18(a)(2)(3)(d) Management 28 Pa. Code 201.29 (a)(b)(i)(j) Resident Rights 28 Pa. Code 211.10 (a)(d) Resident Care Policies

Based on review of clinical records and facility policy and staff interviews, it was determined the facility failed to report an allegation of abuse to the State Survey Agency in a timely manner for one of 18 residents reviewed (Resident R1). Findings include: Review of the facility policy entitled, Abuse Reporting, with a revision date of 8/2016, and an Annual Policy Review date of 3/18/2022, revealed that, this facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. Injuries of unknown origin will be investigated to rule out potential abuse. The facility shall notify the Department of Health, Department of Aging, Area Agency on Aging, Adult Protective Services, local law enforcement and licensing agencies depending on the circumstances of the allegation or actual event in compliance with Federal and state regulations, including Act 13. Review of a facility investigation report dated 5/31/22, revealed that staff was made aware of a female resident's allegation of sexual abuse involving unwanted kissing and touching from a known male resident, and follow up/investigations dated 1/22/22, and 2/13/22, revealed that staff observed the same male resident wandering in and out of various female resident rooms while they slept, and female residents reported that the same male resident was in their rooms touching them and exposing his penis and masturbating. There was no evidence to indicate that the Department of Health was notified regarding the allegation of abuse of Resident R1 as required at the time of the reported allegation. Refer to F600 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records and facility policies and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 16 residents (Resident R59). Findings include: Review of the facility policy entitled, Hand Hygiene/Handwashing dated 3/18/22, indicated that staff are to perform hand hygiene/handwashing after removing their gloves. Review of Resident R59's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/08/22, at 9:40 a.m. revealed that Licensed Practical Nurse (LPN) Employee E1 set up a tray table with supplies, donned (put on) clean gloves, removed the existing dressing (contained moderate amount of drainage), changed his/her gloves, and failed to perform hand hygiene, cleansed wounds on the sacrum and left hip/buttock area, changed his/her gloves, and failed to perform hand hygiene, applied clean dressings to both wounds, disposed of trash and gloves. Interview on 6/08/22, at 9:56 a.m. LPN Employee E1 confirmed that he/she failed to perform hand hygiene when he/she changed gloves, that proper procedure is to be perform hand hygiene after removing gloves, and that he/she should have brought hand sanitizer into the room prior to beginning wound care. During an interview on 6/09/22, 10:45 a.m. the Director of Nursing confirmed that hands should be cleansed when gloves are changed. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12 (d)(2) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policies, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that residents were free of neglect during care which resulted in actual harm of a fracture of the neck of the right humerus (long bone in the arm that runs from the shoulder to the elbow) for one of 24 residents reviewed (Resident R19). This deficiency is cited as past non-compliance. Findings include: A review of facility policy titled, Abuse: Protection from Abuse, dated 3/08/21, revealed that, Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A review of Resident R19's clinical record revealed an admitted [DATE], and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R19's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 8/28/20, revealed that Resident R19 required extensive two person assist with transfers. A review of Resident R19's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, originally dated 8/05/19, revealed under the category, Transfer: hoyer lift and sling with the Bedside Kardex Report [computer information for nurse aides], dated as of 9/22/20, revealed that Resident R19 was to be transferred using a hoyer lift and sling. The Transfer of Residents policy, dated 3/08/21, revealed, if a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling). is determined to be the best method of transfer, a minimum of two persons is required. A review of Resident R19's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E4, dated 9/18/20, at 12:55 a.m. that when the staff attempted to move Resident R19's arm, the resident yelled. When the nurse inquired what was wrong, Resident R19 stated that when they were lifted into bed at bedtime, his/her right shoulder hurt. The nursing note also documented that the resident was assessed and Resident R19 stated that the pain originated at the shoulder and extended down the right arm to the hand. Plan to notify doctor in the morning of the right shoulder pain. An x-ray was ordered in house, at 1:21 p.m. by the Certified Registered Nurse Practioner per the nursing notes and the results from the in house x-ray revealed a humerus neck fracture with angulation (distal portion of the bone points off in a different direction). The facility physician was notified and Resident R19 was sent to the emergency room (ER). The ER x-ray revealed an acute comminuted (breakage of the bone into more than two fragments) fracture of the neck or the right humerus. Review of information submitted by the facility, dated 9/19/20, revealed Resident R19 was a transfer by hoyer lift (mechanical lift needing two person for a transfer). Nurse aide (NA) Employee E5 had transferred the resident to bed without the use of the hoyer lift or two persons. A statement from Resident R19 signed by RN Employee E6 revealed his/her injury occurred somehow when Resident R19 was transferred. Resident R19 stated that NA Employee E5 picked me up and put me to bed then my arm hurt and I could not figure out why. A review of the investigation revealed that NA Employee E5 reported that he/she transferred Resident R19 independently without the use of a lift on 9/17/20, and the resident seemed okay when the NA left the room. A review of documentation submitted by the facility, dated 9/19/20, revealed that the facility initiated an investigation and NA Employee E5 was suspended during the investigation. During an interview on 8/06/21, at 2:21 p.m. the Regional Nurse Employee E7 confirmed that the NA Employee E5 had transferred Resident R19 independently and did not use a lift as reported. The facility failed to ensure that Resident R19 was free from neglect resulting in actual harm of a right humeral neck fracture from an improper transfer without the use of the appropriate lift and done independently and not with the required two person assistance. This deficiency is cited as past non-compliance. On 8/05/21, the facility included the initiated plan of correction at the time of the incident which started on 9/19/20, to include: The NA Employee E5 was re-educated on transfers, notification to supervisors for trouble shooting, and the abuse policy. The facility initiated re-educating all staff beginning 9/19/20, 9/21/20 and 9/23/20 regarding transfers, notification to supervisors for trouble shooting, and the abuse policy. Random audits were conducted between 9/24/20 and 10/14/20 to assure staff were performing transfers appropriately. Interviews on 8/06/21, with Licensed Practical Nurse (LPN) Employee E10, and NA's Employee E8, E9 and E11 confirmed that they knew where to find the information related to a resident's transfer status and that if a resident should be transferred using a mechanical lift that two persons must always be utilized. Abuse is reviewed during orientation of all new employees. Abuse interviews were conducted during the survey process with no issues identified. The facility has demonstrated compliance with the mechanical lift procedure and transfers since 10/14/20. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, facility documentation and review of clinical records and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care and in accordance with facility policy which resulted in actual harm of a fracture of the neck of the right humerus (long bone in the arm that runs from the shoulder to the elbow) for one of 24 residents reviewed (Resident R19). This deficiency is cited as past non-compliance. Findings include: The Transfer of Residents policy, dated 3/08/21, revealed, if a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling). is determined to be the best method of transfer, a minimum of two persons is required. A review of Resident R19's clinical record revealed an admitted [DATE], and included diagnoses of heart problems, [CONDITION(S)] (abnormal development or damage to parts of the brain that control movement, balance and posture) and cancer of the rectum. A review of Resident R19's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 8/28/20, revealed that Resident R19 required extensive two person assist with transfers. A review of Resident R19's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, originally dated 8/05/19, revealed under the category, Transfer: hoyer lift and sling with the Bedside Kardex Report [computer information for nurse aides], dated as of 9/22/20, revealed that Resident R19 was to be transferred using a hoyer lift and sling. A review of Resident R19's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E4, dated 9/18/20, at 12:55 a.m. that when the staff attempted to move Resident R19's arm, the resident yelled. When the nurse inquired what was wrong, Resident R19 stated that when they were lifted into bed at bedtime, his/her right shoulder hurt. The nursing note also documented that the resident was assessed and Resident R19 stated that the pain originated at the shoulder and extended down the right arm to the hand. Plan to notify doctor in the morning of the right shoulder pain. An x-ray was ordered in house, at 1:21 p.m.by the Certified Registered Nurse Practioner per the nursing notes and the results from the in-house x-ray revealed a humerus neck fracture with angulation (distal portion of the bone points off in a different direction). The facility physician was notified and Resident R19 was sent to the emergency room (ER). The ER x-ray revealed an acute comminuted (breakage of the bone into more than two fragments) fracture of the neck or the right humerus. Review of information submitted by the facility, dated 9/19/20, revealed Resident R19 was a transfer by hoyer lift (mechanical lift needing two person for a transfer). Nurse aide (NA) Employee E5 had transferred the resident to bed without the use of the hoyer lift or two persons. A statement from Resident R19 signed by RN Employee E6 revealed his injury occurred somehow when Resident R19 was transferred. Resident R19 stated that NA Employee E5 picked me up and put me to bed then my arm hurt and I could not figure out why. A review of the investigation revealed that NA Employee E5 reported that they transferred Resident R19 independently without the use of a lift on 9/17/20 and the resident seemed okay when the NA left the room. A review of documentation submitted by the facility, dated 9/19/20, revealed that the facility initiated an investigation and NA Employee E5 was suspended during the investigation. During an interview on 8/06/21, at 2:21 p.m. the Regional Nurse Employee E7 confirmed that the NA Employee E5 had transferred Resident R19 independently and did not use a lift as reported. The facility failed to ensure that Resident R19 was provided adequate assistance in accordance with their care plan to utilize a mechanical lift, causing a right humeral neck fracture from an improper transfer. This deficiency is cited as past non-compliance. On 8 /05/21, the facility included the initiated plan of correction put into place at the time of the incident which started on 9/19/20 to include: The NA Employee E5 was re-educated on transfers, notification to supervisors for trouble shooting, and the abuse policy. The facility initiated re-educating all staff beginning 9/19/20, 9/21/20 and 9/23/20 regarding transfers, notification to supervisors for trouble shooting, and the abuse policy. Random audits were conducted between 9/24/20 and 10/14/20 to assure staff were performing transfers appropriately. Interviews on 8/06/21, with Licensed Practical Nurse (LPN) Employee E10, and NA's Employee E8, E9 and E11 confirmed that they knew where to find the information related to a residents transfer status and that if a resident should be transferred using a mechanical lift that two persons must always be utilized. The facility has demonstrated compliance with the mechanical lift procedure since 10/14/20. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services