Every finding on record at Kadima Rehabilitation & Nursing at Washington

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that its residents who require dialysis receive such services consistent with professional standards of practice for one of three residents reviewed for dialysis services (Resident R1).Findings include: Review of the facility policy Peritoneal Dialysis Policies and Procedures, dated 7/1/26, indicated that supplies must be available and used per manufacturer's guidelines. Physician orders are needed for all APD (Automated Peritoneal Dialysis) procedures. Aseptic technique is used when performing APD procedures including proper personal protective equipment. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal disease requiring peritoneal dialysis daily, heart flutter, diabetes and a fracture of his left talus (serious break of the bone that connects lower leg to the foot) due to a fall. A Minimum Data Set- a periodic assessment of resident care needs) dated 7/20/26, indicated the diagnoses remained current. Review of the clinical record identified a progress note dated 7/19/26, indicating Resident R1 could not be provided his peritoneal dialysis that evening as there were no supplies available to perform the procedure. During an interview on 8/27/26, at approximately 10:53 a.m., the Director of Nursing (DON) confirmed that the facility failed to ensure that its residents who require dialysis receive such services consistent with professional standards of practice for one of three residents reviewed for dialysis services (Resident R1). The DON stated that the facility had used the supplies left from a previous resident and the supplies from [NAME] Dialysis clinic had not been delivered. 28 Pa. Code: 211.5(f) Clinical records28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on a review of the facility policy, clinical records review, observations, and staff interviews, it was determined that the facility failed to practice infection control prevention and management for one of two residents reviewed (Resident 1).Findings include: Review of the facility policy Infection Control Program dated 7/1/26, indicated that the facility will maintain a structured program focused on the prevention and management of infections. The plan is comprehensive and addresses detection, prevention and control of infections. The facility is committed to preventing adverse outcomes, providing a safe and sanitary environment and facilitating compliance with state and federal regulations relating to infection control. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal disease requiring peritoneal dialysis daily, heart flutter, diabetes and a fracture of his left talus (serious break of the bone that connects lower leg to the foot) due to a fall. A Minimum Data Set- a periodic assessment of resident care needs dated 7/20/26, indicated the diagnoses remained current. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included Status post-surgical wound to right below knee amputation (BKA) due to infection, antibiotic long term due to strep bacteremia of right BKA also history of clostridium Difficile (bacteria that causes diarrhea usually caused from long term use of antibiotics, spread when people touch foods, surfaces, etc. Most people who get it have it again). Resident R2, upon review of the clinical record developed C-Diff symptoms again while in the facility. Upon admission, Resident R2 was ordered to use a bedside commode as he was non weight bearing to his right BKA. During an interview on 8/27/26, at approximately 10:53 a.m., with the Director of Nursing, Nursing Home administrator and Corporate Administrator the facility confirmed that Resident R1 and R2 should not have been roomed together and further review identified that Resident R1 left because he was afraid to get an infection in his peritoneal catheter because of the roommate having an infection. The facility failed to ensure infection control prevention and management were implemented for one of two residents. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of two nursing units (North and South units).Findings include: Review of the facility policy Resident Environment dated 1/7/26, indicated the facility will provide an environment that is safe, clean, comfortable and homelike allowing the resident to utilize his or her personal belongings to the extent possible. During an observation of two of three residents' restrooms on the south nursing unit, identified one restroom has no sink and the call bell does not illuminate above door to alert staff, and the second restroom call light does not illuminate, to alert staff. A handrail near these bathrooms had two ends missing leaving sharp edges and it was loose. During an interview, on 7/28/26, at approximately 7:55 a.m., Nurse Aide Employee E1 confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment on the south nursing unit. During an observation of resident room [ROOM NUMBER] a broken floor heating unit was uncovered and left the potential for injury with sharp edges exposed. During an observation of resident room [ROOM NUMBER] a broken floor heating unit was uncovered and left the potential for injury with sharp edges exposed. During an interview on 7/28/26, at approximately 8:14 a.m., Maintenance Director Employee E2 confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment on the north and south nursing unit. 28 Pa. Code 201.18(b)(3)(e)(2) Management.28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store medications properly, for two of three two medication carts (North Hall and Middle Hall medication carts).Findings include: Review of the facility policy Storage of Medications dated 1/7/26, indicated that medications are stored in a safe secure and orderly manner in accordance with federal and state regulations and facility policies. During an observation on 7/28/26, at approximately 7:35 a.m., the North Hall medication cart was left unsecured with two bottles of medications on the top of the cart and the computer screen open and able to be observed by any passerby. During an interview on 7/28/26, at approximately 7:35 a.m., Registered Nurse Employee E3 confirmed that the facility failed to store medications properly. During an observation on 7/28/26, at approximately 7:55 a.m., the Middle Hall medication cart was left unsecured with the computer screen open and able to be observed by any passerby. During an interview on 7/28/26, at approximately 7:55 a.m., Licensed Practical Nurse Employee E4 confirmed that the facility failed to store medications properly. During an interview on 7/28/26, at approximately 8:24 a.m., the Director of Nursing was made aware of the observations and confirmed that the facility failed to store medications properly, for two of three two medication carts (North Hall and Middle Hall medication carts). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k) Pharmacy Services.

Based on facility policy, manufacturers recommendations, observation, clinical record review and staff interview, it was determined that the facility failed to reorder medications timely for one of three residents (Resident R1).Findings included:Review of facility policy Ordering and Receiving Medications from the Dispensing Pharmacy dated 1/7/26, indicated Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. If medications are not automatically refilled by the pharmacy, reorder medication refills three to five days in advance of need to assure an adequate supply is on hand, or seven days for Schedule II controlled substances, Department of Veterans Affairs prescriptions, and mail order prescriptions.Review of facility policy Medication Administration dated 1/7/26, indicated if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the eMAR (electronic Medication Administration Record) for that dose is noted as refuse. A reason is documented in a progress note provided in the EMAR.Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included epilepsy (recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), high blood pressure, and anxiety.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 2/1/26, revealed the diagnoses remain current.Review of a physician order on 7/22/25, indicated to give Briviact (medication used to treat seizures) 100 mg two times a day related to epilepsy. Review of the progress notes revealed the following:-On 5/1/26, at 10:03 a.m. an eMAR note indicated Briviact Oral Tablet 100 mg awaiting medication from pharmacy. -On 5/1/26, at 6:38 p.m. an eMAR note indicated Briviact Oral Tablet 100 mg awaiting medication from pharmacy.-One 5/1/26, at 11:59 p.m. an On-Call note indicated an electronic prescription for Brivact 100 mg was entered on 5/1/26, at 9:46 a.m.Review of the care plan, initiated date 11/29/21, indicated to give medications as ordered. Monitor/document for side effects and effectiveness. Maintain a safe environment. Observe for signs and symptoms of impending seizure.During an interview on 5/8/26, at 10:05 a.m. RN Employee E1 stated Resident R1's medications did not arrive on 5/1/26, before the medications ran out. During an interview on 5/8/26, at 2:00 p.m. the Director of Nursing confirmed the facility failed to refill Resident R1's medication timely to prevent harm of an adverse reaction causing additional seizures and the resident being sent to the hospital for evaluation and treatment (Resident R1).28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on review of facility documents, observations and resident and staff interviews, it was determined that the facility failed to follow physician's orders for five of seven residents (Resident R1, R2, R3, R4, and R5).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 2/26/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), history of deep vein thrombosis (DVT, is a blood clot that forms in a deep vein, usually in the leg or pelvis), and lymphedema (the build-up of fluid in soft body tissues). Review of the plan of care for high blood pressure and CHF (congestive heart failure) dated 2/26/26, indicated to observe for signs and symptoms of CHF: SOB (shortness of breath), chest pain, edema (swelling caused by too much fluid trapped in the body's tissues), or elevated B/P (blood pressure). Review of the plan of care actual/potential risk for skin integrity impairment indicated the care plan was updated on 3/6/26, stating, Lymphedema. Review of a wound nurse practitioner's note dated 3/6/26, indicated Patient needs AeroWrap (air-inflatable compression system designed to treat lower limb edema and chronic venous insufficiency) inelastic compression for all day wear with 30-50 mmHg (millimeters of mercury, scale used to measure pressure) gradient for lymphedema management. Review of a wound nurse practitioner's note dated 3/13/26, indicated Patient needs AeroWrap inelastic compression for all day wear with 30-50 mmHg gradient for lymphedema management. Review of a wound nurse practitioner's note dated 3/20/26, indicated Patient needs AeroWrap inelastic compression for all day wear with 30-50 mmHg gradient for lymphedema management. Review of a wound nurse practitioner's note dated 3/27/26, indicated Patient needs AeroWrap inelastic compression for all day wear with 30-50 mmHg gradient for lymphedema management. Review of Resident R1's physician's orders failed to include an order for AeroWraps, or any other type of compression device to alleviate lower leg edema. During an interview on 3/27/26, at 12:49 p.m. Resident R1 confirmed she does not have any compression stockings, and stated, I need them. Observation at this time revealed Resident R1's lower legs to be edematous, with indentations present at the top of her socks. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of high blood pressure, heart failure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the plan of care dated 8/28/24, indicated Resident R2 has fluid volume excess related to cardiac disease and included in the interventions was, Apply B/L (bilateral) knee high TED hose (Thrombo-Embolic Deterrent are specialized compression stockings to prevent blood clots). Review of physician's order dated 7/16/25, indicated, Apply ace wraps (elastic bandages) to b/l lower exts (extremities). Review of Resident R2's TAR (treatment administration record) for March 2026, indicated that Licensed Practical Nurse (LPN) Employee E2 had applied Resident R2's ace wraps on 3/27/26. During an observation on 3/27/26, at 2:14 p.m. Resident R2 was noted not to have his ace wraps applied. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure, atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and lymphedema. Review of the plan of care dated 3/3/26, indicated Resident R3 has fluid volume excess related to lymphedema and included in the interventions was, Place ace wraps to bilateral lower extremities from base of toes to one inch below knee qam (every morning). Review of physician's order dated 3/2/26, indicated, Place ace wraps to bilateral lower extremities from base of toes to one inch below knee every AM. Review of Resident R3's TAR for March 2026, failed to include documentation that Resident R3's ace wraps were applied on 3/3/26, 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/11/26, 3/13/26, 3/15/26, and 3/20/26. Further review of the TAR revealed that the order was ordered to be completed in the morning but incorrectly scheduled to be completed at night. During an observation on 3/27/26, at 2:16 p.m. Resident R3 was noted to have his ace wraps applied, with a large amount of blood present on the wraps. During an interview at this time, Resident R3 stated that staff don't always apply the ace wraps and confirmed that he cannot do so himself. Additionally, Resident R3 stated that when he does have them on, staff do not assist him to take them off, that he rings his light, but no one comes. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and the need for assistance with personal care. Review of the plan of care dated 2/13/26, indicated Resident R4 required assistance with personal care and included in the interventions was, Bilateral below the knee TED hose daily. On in AM, off in PM. Review of physician's order dated 3/10/26, indicated, Bilateral below the knee TED hose daily, on in AM, off at hs (hour of sleep). Review of Resident R4's TAR for March 2026, indicated that LPN Employee E3 had applied Resident R4's ace wraps on 3/27/26. During an observation on 3/27/26, at approximately 2:20 p.m. Resident R4 was noted not to have her compression stockings applied. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), diabetes, and the need for assistance with personal care. Review of the plan of care dated 4/8/25, indicated Resident R5 has fluid volume excess and included in the interventions was, [NAME] hose BLE (bilateral lower extremities) on every am/off every HS. Review of physician's order dated 7/29/25, indicated, Apply ted hose every day shift for edema. Review of Resident R5's TAR for March 2026, failed to include documentation that Resident R3's ace wraps were applied on 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/10/26, and 3/11/26. Further review indicated that RN Employee E4 had applied Resident R5's ace wraps on 3/27/26. During an observation on 3/27/26, at approximately 2:24 p.m. Resident R5 was noted not to have her compression stockings applied. When Resident R5 asked Registered Nurse (RN) Employee E1 how they looked, RN Employee E1 stated, Swollen, as usual. During an interview on 3/27/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to follow physician's orders for five of seven residents . 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 201.29(d) Resident rights.28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of eight residents (Resident R1, R3, R6, R7, and R8).Findings Include: Review of the facility policy Nursing Department Staff dated 1/7/26, indicated the facility will provide services by sufficient numbers of personnel on a 24-hour basis to provide nursing care to all resident sin accordance with resident care plans. Review of the facility policy Call Light Response dated 1/7/26, indicated, Staff will respond to the call light and the resident's requests and needs in a timely manner. During an interview on 3/27/26, at approximately 11:25 a.m., when asked if the facility maintained sufficient staff, Resident R6 stated, No, and they need better staff. Half don't do their job; they sit there and screw around. When asked if they receive showers, Resident R6 stated that it depends on which aides are on shift. Resident R6 further confirmed that they have urinated on themselves while waiting for staff to respond to the call light. During an interview on 3/27/26, at approximately 12:49 p.m. Resident R1 stated that she felt there was not sufficient staff, and they sometimes only have four aides (nurse aides) for the entire building. Observation at this time revealed Resident R1 had facial hair on her chin. During an interview on 3/27/26, at approximately 1:15 p.m. when asked if the facility maintained sufficient staff, Resident R7 stated, No. When asked what was lacking due to care, she stated that she has to wait a long time for call light response, particularly at night. During an interview on 3/27/26, at approximately 1:25 p.m. when asked if the facility maintained sufficient staff, Resident R8 stated, It could be more. During an observation on 3/27/26, at 2:16 p.m. Resident R3 was noted to have his ace wraps applied, with a large amount of blood present on the wraps. During an interview at this time, Resident R3 stated that staff don't always apply the ace wraps and confirmed that he cannot do so himself. Additionally, Resident R3 stated that when he does have them on, staff do not assist him to take them off, that he rings his light, but no one comes. Review of Resident Council minutes dated 2/5/26, indicated concerns regarding ice water not being provided and that nursing staff are not very nice. Review of Resident Council minutes dated 3/5/26, indicated concerns regarding ice water not being provided, call light response times, struggling to know who their aide is. During an interview on 3/27/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of eight residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of facility documents, clinical records and staff interviews, it was determined that the facility failed to schedule a follow-up appointment for one of four residents (Resident R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 2/26/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), history of deep vein thrombosis (DVT, is a blood clot that forms in a deep vein, usually in the leg or pelvis), and lymphedema (the build-up of fluid in soft body tissues). Review of the plan of care for high blood pressure and CHF (congestive heart failure) dated 2/26/26, indicated to observe for signs and symptoms of CHF: SOB (shortness of breath), chest pain, edema (swelling caused by too much fluid trapped in the body's tissues), or elevated B/P (blood pressure). Review of the plan of care actual/potential risk for skin integrity impairment indicated the care plan was updated on 3/6/26, stating, Lymphedema. Review of a nurse practitioner's note dated 2/24/26, indicated Resident R1 had a diagnosis of lymphedema. Review of the Assessment/Plan section of the note indicated, Lymphedema: on diuretics, needs f/u (follow-up) with lymphedema clinic. Review of a physician's note dated 2/25/26, indicated Resident R1 had a diagnosis of lymphedema. Review of the Assessment/Plan section of the note indicated, Lymphedema: chronic, on diuretics, needs f/u with lymphedema clinic as outpatient. Review of a nurse practitioner's note dated 3/3/26, indicated Resident R1 had a diagnosis of lymphedema. Review of the Assessment/Plan section of the note indicated, Lymphedema: chronic, on diuretics, needs f/u with lymphedema clinic as outpatient. Review of Resident R1's clinical record failed to reveal an order for the appointment or an attempt to schedule the follow-up lymphedema appointment. During an interview on 3/27/26, at approximately 1:00 p.m. Registered Nurse Employee E1 confirmed that Resident R1 was not provided a follow-up appointment with the lymphedema clinic. During an interview on 3/27/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to schedule a follow-up appointment for one of four residents. 28 Pa. Code: 211.16(a) Social services.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for ten of ten staff members (Employee E9, E10, E11, E12, E13, E14, E15, E16, E17 and E18).Findings include:Review of the Facility Assessment most recently reviewed 1/7/26, listed under the training topics Infection Control Training is identified.Review of the facility policy Staff Development Program last reviewed on 1/7/26, with a previous review date of 1/9/25, identified Infection Prevention and Control as a topic for orientation and annual trainings required.Physical Therapy Aide Employee E9 had a hire date of 9/15/16, failed to have Infection Control training in-service between 1/17/25, and 1/30/26.Environmental Services Employee E10 had a hire date of 2/22/06, failed to have Infection Control training in-service between 2/22/24, and 1/30/26. Registered Nurse Employee E11 had a hire date of 11/4/19, failed to have Infection Control training in-service between 11/4/24, and 1/30/26. Activity Director Employee E12 had a hire date of 5/22/23, failed to have Infection Control training in-service between 5/22/24, and 1/30/26.Nurse Aide Employee E13 had a hire date of 10/21/98, failed to have Infection Control training in-service between 10/21/24, and 1/30/26.Central Supply Employee E14 had a hire date of 9/23/24, failed to have Infection Control training in-service between 9/23/24, and 1/30/26.Nurse Aide Employee E15 had a hire date of 7/31/23, failed to have Infection Control training in-service between 1/17/25, and 1/30/26.Nurse Aide Employee E16 had a hire date of 9/11/24, failed to have Infection Control training in-service between 9/11/24, and 1/30/26.Nurse Aide Employee E17 had a hire date of 11/25/24, failed to have Infection Control training in-service between 11/25/24, and 1/30/26.Nurse Aide Employee E18 had a hire date of 11/27/24, failed to have Infection Control training in-service between 11/27/24, and 1/30/26.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that the facility failed to provide training on Infection Control for ten 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 policy, documentation, staff interview and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (January 2025 through January 2026). Findings include:Review of the facility policy Legionella Policy dated 1/7/26, with a previous review date of 1/9/25, indicated specific actions should be taken for prevention of Legionella and for investigation should a case occur. Core Elements of the Water Management Plan are:1. Establish Water Management Plan team.2. Describe Center's water system using text and flow diagram.3. Risk assessment with control methods and corrective actions.4. Monitoring control measures.5. Corrective actions.6. Verification and validation.7. Documentation and communication.Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 7/6/18, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at minimum, ensure each facility:-Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Nontuberculous Mycobacteria, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in the facility water system.-Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit.-Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.-Maintains compliance with other applicable Federal, State, and local requirements.Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine-dioxide, copper-silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50-3.00 ppm (part per million).Review of the Water Management Program Control Measures did not contain a policy for any specific type of water testing. Review of a water test that had been conducted in 2025, identified a document from a company called Tap score. The document did not include any specific water pathogens that were being tested for.During a phone interview on 1/29/26, at 1:10 p.m., Tapscore support staff Employee E3 stated that the test conducted did not include testing for any water pathogens only for forever chemicals, which did not include any chemical that would be toxic to water pathogens. During an interview on 1/29/26 at approximately 1:22 p.m., the Maintenance Director, Employee E2 confirmed the facility had no documentation of water testing as per the Legionella Policy and that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of the facility's facility assessment, staff interview, professional standards, and facility documentation, it was determined the facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure licensed nursing staff possessed the required training and competencies necessary to provide care and services for residents and Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required. Findings include:Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served.The facility assessment dated [DATE], and provided during survey on January 30, 2026, identified that the facility provided specialized services for residents with behaviors, infectious diseases, and have an effective system to identify, collect and use data and information from all departments and monitor performance.The facility could not provide documented evidence that licensed nursing staff received initial or ongoing training or competency evaluations (the ability of staff to demonstrate, through education and skills validation, that they can safely and effectively perform specific clinical procedures) in providing care for residents with behaviors, infectious diseases and have trained staff related to providing feedback of effective systems relate to quality assurance, as required by the facility's own assessment.During an interview o 1/30/26, at 11:40 a.m., the Nursing Home Administrator and the Director of Nursing (DON) confirmed that the facility failed to ensure its facility assessment was operationalized through staff training, competency evaluation, and implementation of policies and procedures related to conduct and document a comprehensive, evidence-based facility assessment to ensure licensed nursing staff possessed the required training and competencies necessary to provide care and services for residents and Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.19 (6)(7) Personnel records.28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on observations and a staff interview, it was determined the facility failed to post contact information, Adult Protective Services (APS), State Agency, and a statement the resident may file a complaint with the State Agency as required, in the building in one of one location where postings are (first floor nursing unit). Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. During observations completed on 1/29/26, at approximately 11:30 a.m., in the lobby, hallways in and around the nursing units, revealed the facility did not have the required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), State Agency statement that the residents may file a complaint with the State Agency posted or accessible to residents or resident representatives. During rounds and an interview with the Nursing Home Administrator (NHA) on 1/30/26, at 9:00 a.m., the NHA confirmed the facility failed to post required information for Adult Protective Services (APS), State Agency statement the residents may file a complaint with the State Agency as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on observations, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (North and South Nursing Units). Findings include:During an observation on 01/28/2026, from 10:12 a.m., through 11:25 a.m., the following was identified:Residents R44 and R41(room [ROOM NUMBER]) window air conditioner unit not covered to prevent cold air from entering, Resident R112 stated that she had told them cold air was coming in but was not fixed. Resident R112's personal fan had a white dusty substance covering the filtering area.Residents R77 and R2 (room [ROOM NUMBER]) air conditioner window unit was left with gaps in covered area allowing cold air to enter.Resident R61(room [ROOM NUMBER]) unit was loose from window and uncovered allowing cold air to enter room.Residents R35 and R25 (Room141) air conditioner window unit is observed with a flannel shirt to prevent cold air from entering and window blind is broken.Resident R30 and R71(Room137) air conditioning window unit has gaps in plastic allowing cold air to enter.Residents R76 and R39 (room [ROOM NUMBER]) has a towel under air conditioner unit and has gaps in plastic allowing cold air to enter.Additional resident rooms with broken blinds include:Residents R20, R51 and R43 room [ROOM NUMBER])Residents R36 and R8(Room132)Residents R53 and R38(Room133)Residents R31 and R32 (Room134)Residents R33 and R23 (Room136)Residents R42 and R4(Room140)Residents R5 and R63 (Room117) has a plastered unfinished wall under the window Residents R71 and R59 (Room138) has loose floor strip at entrance, causing a potential tripping hazardResidents R54 and R10 (Room116) has area around electrical plug that has unfinished plasterResidents R3, R1 and R14 (Room143) has unfinished plaster area around the heater, and their bathroom wall has broken wall areasResident R71 and R59 (Room138) bathroom walls are chipped During an interview on 1/28/26, at 11:25 a.m., Maintenance Director Employee E2 confirmed the above findings and that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (North and South Nursing Units).28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on resident and staff interviews, and review of facility documents (grievances, resident council, and staffing) review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for ten of sixteen residents (Residents R200, R500, R501, R502, R503, R504, R505, R506, R507, and 508).Findings include: During a group interview, on 1/28/26 at approximately 1:30 p.m., when asked if he felt the facility maintained enough staff to care for resident needs and answer call lights, consensus from the group was no. Residents verbalized frustration relating to care when staff is lower epically with the lack of aides and sometimes nurses in the building. Residents stated it is on all the shifts; the residents stated often the wait time is thirty minutes, though it can go to an hour or longer. Residents stated some of the staff responses when you use your call light are you just rang your light, you ring too much, what do you want now, and staff will come in and turn the light off without taking care of what you need. The residents stated they don't report these events or concerns as they are fearful of retaliation. During the interviews the residents asked and requested multiple that the surveyor promise them to keep their identity confidential. -Resident R505 stated when staffing is not how it should be, there is tension between staff and residents, and she just will get out of the staff's way. I zoom the other way from them. - Resident 507 stated I have to wait for my pain meds, I use my call light and tell them I need my pain medication, I then wait thirty minutes up to two hours to get them. - Resident 502 stated I can't walk, and I can't get to the bathroom by myself, I often have to wait thirty minutes or more to get help. My bigger concern is when my oxygen supply gets low and I get very anxious about running out of oxygen. I just start to yell for help when they don't respond to the call light, but this makes me more anxious and shorter of breath. I asked my family to bring me in a whistle, so I get a response. During a confidential staff interview, when asked if the staff members felt there was sufficient staff to care for resident needs. The staff member stated no, we have gaps in our schedule, we just don't have the number of aides that we should, I think it's mostly because of call offs and times when we are just short staffed. We do take care of every resident but sometimes they have to wait until we can get to them. During a confidential staff interview, when asked if the staff members felt there was sufficient staff to care for resident needs, the staff member stated there are days we are short staffed, we do all work together to take care of everyone, it might take us a little longer on these days. During a confidential staff interview, when asked if the staff members felt there was sufficient staff to care for residents' needs, the staff member stated, you know how it is, there are times when we are short, this is how it is everywhere, it just takes longer to get to everybody on these days. Review of a grievance filed by Resident R200, dated 9/1/25, revealed concerns documented for the aide coming into residents' room when the resident used the call light. Aide stated she would be back to address the residents' needs and never returned. Review of a grievance filed on behalf of Resident R200, dated 9/2/25, revealed concerns documented for wait times. Resident requested her bed linen be changed, after an hour the resident went and got the linens and changed the bed. The aide returned later that day as reportedly told the resident You need to be more patient I have a lot of residents to take care of. Resident stated the aide doesn't need to chastise me and that the aide was unprofessional and as a resident she does not deserve to be spoken to and treated this way. Aide was not to be assigned to resident in the future. Review of resident council minutes, dated 9/6/25, revealed concerns documented for ice pitchers and ice water not being passed. Review of resident council minutes, dated 9/6/25, reveled concerns when staff say they don't have enough workers, showers do not happen. During an interview on 1/30/26, at 10:45 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA Employee E13, E15, E16, E17 and E18). Findings include:Review of personnel files revealed that Nurse Aide Employee E13 hire date was 10/21/98, there was no performance evaluation completed.Review of personnel files revealed that Nurse Aide Employee E15 hire date was 7/31/23, there was no performance evaluation completed.Review of personnel files revealed that Nurse Aide Employee E16 hire date was 9/11/24, there was no performance evaluations completed.Review of personnel files revealed that Nurse Aide Employee E17 hire date was 11/25/24, there was no performance evaluations completed.Review of personnel files revealed that Nurse Aide Employee E18 hire date was 11/27/24, there was no performance evaluations completed.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that the facility failed to complete annual performance evaluations for five of five nurse aides (NA Employee E13, E15, E16, E17 and E18).28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination (Main Kitchen). Findings include:Review of facility policy Food Storage dated 1/9/26, indicated foods shall be received and stored in a manner that all foods in the freezer and refrigerators will be stored above the floor on shelves to facilitate thorough cleaning.During an observation of the main kitchen on 1/27/26, from 9:00 a.m., through 9:42 a.m., the following was observed:Walk in cooler and freezer had food stored to the ceiling and under the fan encasement allowing potential cross contamination. During an interview on 1/27/26, at 9:42 a.m., Dietary Manager Employee E21 confirmed that the facility failed to properly store food products which created the potential for food borne illness and cross contamination in the Main Kitchen.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(3) Management.

Based on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for four of four quarterly meetings (2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25).Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25, failed to reveal the Lab Representative and Community Member, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems.During an interview on 1/30/26, at 10:20 a.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for four of four quarterly meeting (2/12/25, 3/19/25, 4/23/25, 5/28/25, 6/25/25 ,7/30/25, 8/27/25, 9/24/25,10/28/25, 11/18/25, and 12/16/25), as required.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for three of ten staff members (Employees E9, E10 and E15).Findings include:Review of the Facility Assessment most recently reviewed 1/7/26, listed under the training topics Residents rights is identified.Review of the facility policy Staff Development Program last reviewed on 1/7/26, with a previous review date of 1/9/25, identified resident rights as a topic for orientation and annual trainings required.Physical Therapy Aide Employee E9 had a hire date of 9/15/16, failed to have Resident Rights in-service between 1/17/25, and 1/30/26.Environmental Services Employee E10 had a hire date of 2/22/06, failed to have Resident Rights in-service education between 2/22/25 and 1/30/26.Nurse Aide Employee E15 had a hire date of 7/31/23, failed to have Resident Rights in-service education between 1/17/25, and 1/30/26.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that the facility failed to provide training on Resident Rights for three 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 personnel records, and staff interview it was determined that the facility failed to ensure that five of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E13, E15, E16, E17 and E18). Findings include:Review of facility nurse aide training records revealed that NA Employee E13 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E13 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E15 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E15 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E16 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E16 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E16 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E16 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E17 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E17 had received a minimum of 12 hours of in-service training yearly.Review of facility nurse aide training records revealed that NA Employee E18 did not receive 12 hours of in-service training in the last year.The facility was unable to provide documented evidence that NA Employee E18 had received a minimum of 12 hours of in-service training yearly.During an interview on 1/30/26, at 10:15 a.m., the Director of Nursing confirmed that the facility failed to provide 12 hours of in-service trainings yearly for five of five nurse aides.28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.20(c) Staff Development.

Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions, for two of six residents reviewed (Resident R8, and R36).Findings Include: A review of the facility policy Advance Directives last reviewed 17/26 with a prior review date of 1/9/25, indicated procedures for periodic review of DNROrders will occur at least annually. This facility will allow revocations or amending DNR orders by the resident, the attorney in fact, the representative or treating physician. Such changes will be documented in the medical record. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R8 was originally admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/12/25 and admission records, indicated diagnoses of hypothyroidism (thyroid gland creates less than the normal amount of thyroid hormone. The result is the slowing down of many bodily functions), anxiety, and depression. A BIMS score of 14. A review of the clinical record revealed that Resident R8 provided power of attorney (POA) (residents sister) for health care documents to the facility, that included an advance directive dated 1/3/02. On 2/23/22 facility documentation of Healthcare Determinations page reveals the resident does not have an advanced directive and no copy of the advanced directive has been provided to the facility. There is no evidence that periodic advanced directive review occurred with Resident R8 or the power of attorney. During an interview on 1/30/26 at approximately 10 a.m. the Social Service Director Employee E1 confirmed that Resident R8 and the POA have been invited to the care conferences. The POA has not responded to the mailed invitations to attend and has not been visiting the resident for some time. The facility was unable to provide documentation to show if the resident or the POA attended the care conferences in the past twelve months, the documentation reveals code status had been reviewed at the conference by the staff in attendance. Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/18/25 and admission records, indicated diagnoses of diabetes mellitus (high blood sugar), hypertension (high blood pressure), and depression. A BIMS score of 13. A review of the clinical record failed to reveal an advance directive, evidence that a periodic advanced directive review occurred or documentation that Resident R36 was given the opportunity to formulate an Advanced Directive. During an interview on 1/30/26 at approximately 10 a.m. the Social Service Director Employee E1 confirmed that Resident R36 and family had been invited to the care conferences. The facility was unable to provide documentation to show if the resident or the family attended the care conferences in the past twelve months, the documentation reveals code status had been reviewed at the conference by the staff in attendance. During an interview on 1/30/26 at 10:30 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of instructions. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for the bed mobility needs for one of six residents (Resident R1), which resulted in actual harm of facial abrasions and a subarachnoid hemorrhage for Resident R1. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of 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 Flow of Care dated 1/26/23, indicated care will be provided to residents, as needed 24-hours a day to attain the highest level of functioning. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 4/21/23, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), muscle weakness, and the need for assistance in personal care. Review of Resident R1's MDS assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, dated, 5/6/21, 6/11/21, 9/2/21, 10/1/21, 12/29/21, 1/26/22, 2/3/22, 5/3/22, 6/15/22, 9/15/22, 12/12/22, 3/7/23, and 4/21/23, all indicated that Resident R1 required extensive assistance of two or more staff members. Review of Resident R1's physician's orders since admission did not reveal an order that specified bed mobility assistance until 7/17/23. Review of Resident R1's plan of care for assistance with dressing, personal hygiene, walking, transferring, toileting, changing position in bed initiated 7/2/20, revealed no documented assistance level for bed mobility for Resident R1 until 7/13/23. Review of Resident R1's plan of care for potential for falls initiated 7/2/20, revealed no documented assistance level for bed mobility for Resident R1 until 7/13/23. Review of Nurse Aide (NA) Point of Care documentation screen on 8/18/23, utilizing an effective date of 7/12/23, indicated that when nurse aides document the level of assistance that was provided, it notes that Resident R1 required assistance of two or more staff members for bed mobility. Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated with an effective date of 7/12/23, revealed that the assistance level for bed mobility was not provided on the Kardex. Review of Resident R1's Documentation Survey Report from 6/13/23, through 7/12/23, revealed Resident R1 had bed mobility documented on 53 times for day and evening shifts, 40 of which (approximately 75%) were documented as having utilized two people for assistance. Review of a progress note written by Registered Nurse (RN) Employee E1 dated 7/13/23, at 12:12 p.m. indicated Resident was receiving A.M. care by CNA (NA), rolled off the bed and landed on the floor in prone position. Assessment as follows: AROM and PROM x 4 extremities with no discomfort. Speech clear. Eyes PERRLA. Answering simple one answer question appropriately. VS obtained and are stable. Neuro checks initiated per policy and are at baseline. Skin asses for abrasions, lacerations, bruises, and skin tears. Three superficial abrasions found as follows: one between eye brows measuring 2.5 x 0.3 x 0.2 cm (centimeters), one above right eye brow measuring 2.3 x 0.3 x 0.2 cm, and one below right eye brow measuring 2.2 x 0.2 x 0.2 cm. Hematoma found left frontal scalp measuring 2.8 x 2.8 x 1.0 cm with three pin prick abrasions on top of it. Resident removed from floor with Hoyer lift and three assist. Nurse Practitioner Employee E2 on site and assessed resident. Review of a progress note written by CRNP Employee E2 dated 7/13/23, at 2:12 p.m. indicated Seen acutely, patient rolled out of bed while staff was performing care, sustained hematoma to top of left side of head and superficial abrasions to forehead, no loss of consciousness. Able to perform passive range of motion to bilateral legs without any complaint of pain, no noted deformity. Other extremities are moving at his baseline. This progress note further indicated that the plan for this visit included monitoring neuro checks and vital signs, cleanse abrasions with soap and water daily, and for staff to perform care with two care givers. Review of a progress note written by Registered Nurse (RN) Employee E1 dated 7/13/23, at 3:45 p.m. indicated that Resident R1 had a change in condition, and was ordered to be transferred to the hospital. Review of a progress note dated 7/13/23, at 3:45 p.m. indicated that Resident R1 exited the facility with emergency services personnel for the hospital. Review of hospital paperwork dated 7/14/23, indicated that Resident R1 received a CT scan (a medical imaging technique used to obtain detailed internal images of the body) of the brain showing in the right frontal lobe area hyperdense intra-axial cortical (intra-axial hemorrhages within the brain tissue) and/or subarachnoid (surrounding the brain) hemorrhage. It was noted that these areas of hemorrhage are new compared to a previous CT scan and are most likely posttraumatic. At the left frontal region, 6.9 x 1.1 cm acute hyperdense extracranial (outside of the cranium) scalp hematoma, also new from the previous CT. Review of a progress note dated 7/17/23, 7:50 p.m. indicated that Resident R1 returned to the facility. Review of a progress note written by CRNP Employee E2 dated 7/18/23, at 1:05 p.m. indicated Resident returned to the facility status post hospitalization after a fall with head injury. CT brain showed scattered subarachnoid hemorrhage in the front sulci and insula, no significant local mass effect. Was monitored and evaluated by neurosurgery, returned on one week course of keppra (anti-seizure medication). Resident R1 presents today alert and interactive, however appears uncomfortable, forehead tender to touch, a few areas of dried blood noted, hematoma to top of head. This progress note further indicated that the plan for this visit included a follow-up visit to neurosurgery in four weeks, and an increase in oxycodone (a narcotic medication used to treat moderate to severe pain) to 10 mg (milligrams) twice daily, and an additional 10 mg every four hours for breakthrough pain. Review of a progress note dated 8/8/23, at 12:09 p.m. indicated the nurse practitioner increased Resident R1's Butrans patch (a patch applied weekly with buprenorphine, opiate pain medication, for severe ongoing pain) from 15 to 20 micrograms per hour. Review of a progress note written by CRNP Employee E3 dated 7/27/23, signed 7/29/23, at 5:55 a.m. indicated an additional increase in oxycodone for pain (10 mg every eight hours, and an additional 10 mg every four hours for breakthrough pain). Review of facility provided fall investigation documents dated 7/13/23, indicated Resident R1's fall was due to non-compliance with care plan. The facility's Point Click Care (PCC) documentation displays the level of assistance each time the nurse aides chart for bed mobility at the top of the screen. Review of an employee statement written by NA Employee E4 dated 7/13/23, stated, I was in the process of changing him (and) getting him dressed. In the event of this he rolled out the bed. NA Employee E4 is no longer employed by the facility and did not answer the phone or return the message left by the State Agency. Review of an employee statement written by Employee E5 dated 7/13/23, stated, Called to room by CNA (NA) Resident was on his back on floor. Small abrasion on R (right) eyebrow and between eyes. RN called in to room. Resident assessed Hoyer lift and pad used to place resident back onto bed x 4 assist. Review of an employee statement written by Employee E6 dated 7/14/23 stated, LPN informed me that resident fell out of bed. Upon entering room resident was laying supine on the right side of his bed on bare floor. The bed was at waist level. His head was at top of bed and legs at foot of bed. During an interview 8/18/23, at 2:30 p.m. NA Employee E7 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E14 stated she would ask the nurse on duty. During an interview and observation on 8/18/23, at 2:36 p.m. NA Employee E8 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E8 demonstrated entering the electronic point of care charting portal and reviewing the documentation screen. During a group interview 8/18/23, at 3:00 p.m. NA Employees E9 and E10 were asked how they know what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E9 stated she would ask the nurse. NA Employee E10 stated she would either ask the nurse or look in the computer. During an interview on 8/18/23, at 3:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision for the bed mobility needs for one of six residents, which resulted in of facial abrasions and a subarachnoid hemorrhage. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for three of six residents (Resident R1, R2 and R3), that resulted in actual harm for Resident R1 of facial abrasions and a subarachnoid hemorrhage. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy Abuse Protection dated 1/26/23, indicated that each resident has the right to be free from abuse and neglect. Review of the facility policy Flow of Care dated 1/26/23, indicated care will be provided to residents, as needed 24-hours a day to attain the highest level of functioning. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 4/21/23, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), muscle weakness, and the need for assistance in personal care. Review of Resident R1's MDS assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, dated, 5/6/21, 6/11/21, 9/2/21, 10/1/21, 12/29/21, 1/26/22, 2/3/22, 5/3/22, 6/15/22, 9/15/22, 12/12/22, 3/7/23, and 4/21/23, all indicated that Resident R1 required extensive assistance of two or more staff members. Review of Resident R1's plan of care for assistance with dressing, personal hygiene, walking, transferring, toileting, changing position in bed initiated 7/2/20, revealed no documented assistance level for bed mobility for Resident R1 until 7/13/23. Review of Resident R1's plan of care for potential for falls initiated 7/2/20, revealed no documented assistance level for bed mobility for Resident R1 until 7/13/23. Review of Nurse Aide (NA) Point of Care documentation screen on 8/18/23, with an effective date of 7/12/23, indicated when nurse aides document the level of assistance that was provided, it is noted that Resident R1 required assistance of two or more staff members for bed mobility. Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated with an effective date of 7/12/23, revealed that the assistance level for bed mobility was not provided on the Kardex. Review of Resident R1's Documentation Survey Report from 6/13/23, through 7/12/23, revealed Resident R1 had bed mobility documented on 53 times for day and evening shifts, 40 of which (approximately 75%) were documented as having utilized two people for assistance. Review of a progress note written by Registered Nurse (RN) Employee E1 dated 7/13/23, at 12:12 p.m. indicated Resident was receiving A.M. care by CNA (NA), rolled off the bed and landed on the floor in prone position. Assessment as follows: AROM (active range of motion) and PROM (passive range of motion) x 4 extremities with no discomfort. Speech clear. Eyes PERRLA. Answering simple one answer question appropriately. VS obtained and are stable. Neuro checks initiated per policy and are at baseline. Skin asses for abrasions, lacerations, bruises, and skin tears. Three superficial abrasions found as follows: one between eye brows measuring 2.5 x 0.3 x 0.2 cm (centimeters), one above right eye brow measuring 2.3 x 0.3 x 0.2 cm, and one below right eye brow measuring 2.2 x 0.2 x 0.2 cm. Hematoma found left frontal scalp measuring 2.8 x 2.8 x 1.0 cm with three pin prick abrasions on top of it. Resident removed from floor with Hoyer lift and three assist. Nurse Practitioner Employee E2 on site and assessed resident. Review of a progress note written by CRNP Employee E2 dated 7/13/23, at 2:12 p.m. indicated Seen acutely, patient rolled out of bed while staff was performing care, sustained hematoma to top of left side of head and superficial abrasions to forehead, no loss of consciousness. Able to perform passive range of motion to bilateral legs without any complaint of pain, no noted deformity. Other extremities are moving at his baseline. This progress note further indicated that the plan for this visit included monitoring neuro checks and vital signs, cleanse abrasions with soap and water daily, and for staff to perform care with two care givers. Review of a progress note written by Registered Nurse (RN) Employee E1 dated 7/13/23, at 3:45 p.m. indicated that Resident R1 had a change in condition, and was ordered to be transferred to the hospital. Review of a progress note dated 7/13/23, at 3:45 p.m. indicated that Resident R1 exited the facility with emergency services personnel for the hospital. Review of hospital paperwork dated 7/14/23, indicated that Resident R1 received a CT scan (a medical imaging technique used to obtain detailed internal images of the body) of the brain showing in the right frontal lobe area hyperdense intra-axial cortical (intra-axial hemorrhages within the brain tissue) and/or subarachnoid (surrounding the brain) hemorrhage. It was noted that these areas of hemorrhage are new compared to a previous CT scan and are most likely posttraumatic. At the left frontal region, 6.9 x 1.1 cm acute hyperdense extracranial (outside of the cranium) scalp hematoma, also new from the previous CT. Review of a progress note dated 7/17/23, 7:50 p.m. indicated that Resident R1 returned to the facility. Review of a progress note written by CRNP Employee E2 dated 7/18/23, at 1:05 p.m. indicated Resident returned to the facility status post hospitalization after a fall with head injury. Review of facility provided fall investigation documents dated 7/13/23, indicated Resident R1's fall was due to non-compliance with care plan. The facility's Point Click Care (PCC) documentation displays the level of assistance each time the nurse aides chart for bed mobility at the top of the screen. Review of an employee statement written by NA Employee E4 dated 7/13/23, stated, I was in the process of changing him (and) getting him dressed. In the event of this he rolled out the bed. NA Employee E4 is no longer employed by the facility and did not answer the phone or return the message left by the State Agency. Review of an employee statement written by Employee E5 dated 7/13/23, stated, Called to room by CNA (NA) Resident was on his back on floor. Small abrasion on R (right) eyebrow and between eyes. RN called in to room. Resident assessed Hoyer lift and pad used to place resident back onto bed x 4 assist. Review of an employee statement written by Employee E6 dated 7/14/23 stated, LPN informed me that resident fell out of bed. Upon entering room resident was laying supine on the right side of his bed on bare floor. The bed was at waist level. His head was at top of bed and legs at foot of bed. During an interview on 8/21/23, at 2:00 p.m. the Director of Nursing confirmed that the required level of assistance was visible to NA Employee E4 in the Point of Care charting system. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R2's MDS assessment dated [DATE], indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior), anxiety, depression, and the need for assistance in personal care. Review of Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility indicated that Resident R2 required extensive assistance of two or more staff members. Review of Resident R2's plan of care for assistance with dressing, personal hygiene, walking, transferring, toileting, changing position in bed, and eating initiated 4/11/23, updated 5/11/23, indicated care is to be given with two staff members at all times and to assist more in the evening and night as needed when resident becomes more fatigued. Review of a progress note written by RN Employee E8 dated 8/3/23, at 5:31 a.m. stated (NA) alert nurse of resident fall. 10-15 minutes prior to fall LPN (Licensed Practical Nurse) did ask NA to get resident up so resident did not climb out of bed. NA stated I am not getting her up right now because she will just yell in the hall. Bed was in low position, fall mats in place, bed alarm in place. Resident was sitting on fall mat on the left side of the bed. Review of facility submitted documentation dated 8/3/23, indicated At approximately 5:30 a.m. this morning, (Resident R2) slid out of bed and onto her fall mats resulting in no injury. Approximately 10 minutes prior to the fall, the LPN assigned to her asked the NA assigned to her to get her up out of bed before she attempted to climb out. The NA said I'm not get her up now, because she will just yell in the hall. Review of an employee statement written by NA Employee E9 dated 8/3/23, stated, The LPN asked me to get someone up earlier than usual and I told her that I wasn't getting her up yet because it was too early and I was doing something else. I waited until 5am to get her washed, dressed, and in her chair to the hallway. Review of the facility provided Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for Resident R2, completed 8/4/23, indicated findings of No mitigating circumstances; neglect substantiated. Review of Resident R3's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R3's MDS assessment dated [DATE], indicated diagnoses of an open wound to the head, visual loss, and age-related physical disability. Review of Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility indicated that Resident R3 required extensive assistance of two or more staff members. Review of Resident R3's plan of care for urinary incontinence initiated 6/1/23, indicated for staff to assist resident to the toilet as needed and provide incontinence care. Review of Resident R3's plan of care for nutritionally at risk initiated 6/13/23, indicated for staff to provide assistance as necessary. Review of facility submitted documentation dated 5/31/23, indicated (Resident R3) stated an aide would not empty his urinal nor give him anything to drink. Review of an employee statement written by RN Employee E10 dated 6/1/23, stated, While I was feeding this resident pudding this morning, he stated that he asked for a drink of water from NA Employee E12. He stated that NA Employee E12 responded, Get it your own damn self. He further stated that NA Employee E12 stated I am too busy to cater to you. I am not gonna be in here every five minutes. Review of an employee statement written by NA Employee E11 dated 6/1/23, stated, I was picking up dinner trays, and Resident R3 rang his call light and I answered it. NA Employee E12 followed me in and when I asked what he needed, he told me that he wanted a drink of water. NA Employee E12 responded with the comment Im not answering your light every time you need a drink. I gave Resident R3 a drink and walked out of the room. Review of the facility provided Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property for Resident R3 completed 8/4/23, indicated findings of Investigation completed - found to be substantiated. During an interview on 8/23/23, at 10:03 a.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from neglect for three of six residents, that resulted in actual harm of facial abrasions and a subarachnoid hemorrhage for one of six residents. 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.