Every finding on record at Lebanon Skilled Nursing and Rehabilitation Center

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for one of four sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included traumatic brain injury and depression. Review of the Minimum Data Set assessment dated [DATE], revealed Resident 1 had no cognitive impairment. Review of facility documentation dated August 19, 2026, revealed Resident 1 alleged staff pushed him out of bed and that he had a history of false allegations and manipulative behavior.In an interview on August 26, 2026, at 3:35 p.m., the Administrator stated that Resident 1 often gets agitated depending on his care giver's ethnicity. There was no documented evidence that the facility developed a care plan or interventions related to Resident 1's false allegations, manipulative behavior, or aggression triggers related to ethnicity.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department.Findings include: Review of the facility's policy entitled, Personal Hygiene, dated February 2, 2026, revealed that all staff must wear hair restraints to effectively keep hair from contacting exposed food. Observation during the lunch meal service tray line on April 15, 2026, from 11:30 a.m., to 12:03 p.m., revealed Dietary Employee (DE) 1 and DE 2 were observed working the meal tray line directly over uncovered food with mustaches that were not covered. The window frame above the shelf where a large mixer with an uncovered bowl, the Robot-coupe mixer, and a blender were stored had paint peeling off of it. The Robot-coupe mixer and blender were being used to prepare resident food at that time. The blind in this window frame had dried food debris along the length of it. There was another window frame above a storage rack of trays used for resident meals with paint peeling off of it. CFR 483.60(i) Food Safety RequirementPreviously cited 3/26/25 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined the facility failed to notify the resident and/or resident's representative(s) of transfer(s), and failed to notify a representative of the Office of the Long-Term Care Ombudsman, including the reasons for the moves, in writing upon transfer for six of six residents who were transferred out of the facility. (Residents 2, 7, 14, 42, 149, and 151) Findings include: Clinical record review revealed that Resident 2 was transferred to the hospital on December 26, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 7 was transferred to the hospital on January 9, 2026, after a change in condition. There was no documented evidence that notification of the transfer was provided to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 14 was transferred to the hospital on March 30, 2026, after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital or that notification of the transfer was provided to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 42 was transferred to the hospital on March 12, 2026, after a change in condition. There was no documented evidence that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital or that notification of the transfer was provided to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 151 left the facility against medical advice on February 3, 2026. There was no documented evidence that notification of the transfer was provided to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on April 17, 2026, at 10:22 a.m., the Administrator confirmed that the notifications of transfers were not sent to the residents and/or resident representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed the individual resident's needs as identified in the comprehensive assessment for one of 31 sampled residents. (Resident 13) Findings include:Clinical record review revealed that Resident 13 had diagnoses that included chronic kidney disease and diabetes mellitus. The Minimum Data Set completed on February 20, 2026, indicated that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated February 20, 2026, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 13's urinary incontinence were included in the current care plan.In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that the identified care area was addressed in the care plan.CFR 483.21(b)(1) Comprehensive Care PlansPreviously cited 3/26/25 and 2/4/2628 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for one of 31 sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility March 12, 2026, with diagnoses that included chronic kidney disease, polyneuropathies (nerve damage), and muscle weakness. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment, required substantial assistance from staff for showers, and was totally dependent on staff for transfers. Review of facility documentation revealed that the resident was to receive a shower on Wednesdays and Saturdays on the evening shift. In an interview on April 14, 2026, at 11:47 a.m., Resident 1 stated, I haven't had a shower since I got here. Review of the clinical record revealed no documented evidence that Resident 1 received, was offered, or refused a shower during the previous 30 days. In an interview on April 16, 2026, at 10:22 a.m., the Director of Nursing confirmed that there was no documented evidence that showers were offered or provided to Resident 1. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for three of 31 sampled residents. (Residents 4, 8, and 139) Findings include: Clinical record review revealed that Resident 4 had a diagnosis of diabetes mellitus. A physician's order dated November 25, 2025, ordered staff to inject eight units subcutaneously of a diabetic medication, Novolog Injection Solution 100 unit/milliliter (insulin) in the morning prior to breakfast. Staff were to hold the insulin if the resident's blood sugar was less than 80 milligrams per deciliter (mg/dL). Review of Resident 4's April 2026 medication administration records (MAR) revealed that staff administered the medication three times in April when the resident's blood sugar was less than 80mg/dL. Clinical record review revealed that Resident 8 had diagnoses that included cerebral palsy, diabetes mellitus, and heart failure. A physician's ordered dated January 27, 2026, directed staff to weigh the resident every night shift and notify the physician if the resident gained more than two pounds (lbs.) in 24 hours or five pounds in one week. Review of clinical records revealed no evidence that the physician was notified when the resident gained 4.7 lbs. between December 31, 2025, and January 1, 2026, 3.4 lbs. between January 5 and 6, 2026, 6 lbs. between January 6 and 7, 2026, 2.3 lbs. between March 9 and 10, 2026, 5.8 lbs. between March 19 and 20, 2026, 4 lbs. between March 31, 2026 and April 1, 2026, 2.4 lbs. between April 5 and 6, 2026, and 3.3 lbs. between April 13 and 14, 2026. Clinical record review revealed that Resident 139 had diagnoses that included anemia and chronic kidney disease. A physician's order dated February 13, 2026, directed staff to obtain two blood tests (a Complete Blood Count and a Comprehensive Metabolic Panel). A review of Resident 139's clinical record revealed there was no documented evidence to support that the blood tests were obtained as ordered. In an interview on April 17, 2026, at 10:25 a.m., Director of Nursing confirmed there was no documented evidence that the facility had provided care or services in accordance with the aforementioned physicians' orders. CFR 483.25 Quality of CarePreviously cited 3/26/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review and clinical record review it was determined that the facility failed to attempt and document non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for two of 31 sampled residents. (Resident 6, 96)Findings include:Review of the facility policy entitled, Pain Management, last reviewed February 24, 2026, revealed that staff would document non-pharmacological interventions (NPI's) and their effectiveness for patients receiving interventions for pain.Clinical record review revealed that Resident 6 had diagnoses that included left knee osteoarthritis, pain in the right hip, and diabetes. On March 17, 2026, the physician ordered for staff to document NPI's every shift. On April 6, 2026, the physician ordered staff to administer the narcotic pain medication, oxycodone, every four hours as needed for moderate to severe pain. Review of Medication Administration Records (MAR) revealed that the resident received the as needed narcotic (oxycodone) without documented evidence that NPI's were attempted prior to administration 23 times in April 2026. Clinical record review revealed that Resident 96 had diagnoses that included cerebral infarction (stroke), diabetes, and hemiplegia and hemiparesis (paralysis). On February 7, 2026, the physician ordered for staff to document the NPI's used before administering the as needed pain medication. On April 3, 2026, the physician ordered for staff to administer the narcotic pain medication, oxycodone, every four hours as needed for moderate to severe pain. Review of the MAR revealed that the resident received the as needed narcotic (oxycodone) without documented evidence that NPI's were attempted prior to administration nine times in April 2026.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical record review, observations, and staff interviews, it was determined the facility failed to provide appropriate dialysis treatment for one of 31 sampled residents (Resident 10).Findings include:A review of the policy, Dialysis: Hemodialysis External Catheter Evaluation and Maintenance, last reviewed February 24, 2026, revealed that facility staff were to avoid taking blood pressure from an arm with a dialysis access device. Clinical record review revealed that Resident 10 had diagnoses that included diabetes mellitus with chronic kidney disease. A review of Resident 10's Minimum Data Set assessment (MDS), dated [DATE], revealed that Resident 10 was mildly cognitively impaired. Review of the care plan initiated November 11, 2021, and last reviewed December 17, 2025, revealed that Resident 10 required ongoing hemodialysis. The care plan directed staff to monitor the fistula (a surgically created connection between an artery and a vein that provides reliable vascular access for dialysis treatments) site located in the left upper extremity (upper arm) for bleeding and to avoid using the upper extremity for any treatment to avoid complications related to dialysis access. A review of the clinical record revealed that the facility had documented use of Resident 10's left arm to measure blood pressure 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, at 10:22 a.m., the Director of Nursing confirmed that the documentation revealed that Resident 10's blood pressure had been measured on her left arm.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for one of 31 sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] , 2026, with diagnoses that included PTSD, depression, polyneuropathy (nerve damage), and insomnia. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment, required substantial assistance from staff for activities of daily living, and had a diagnosis of PTSD. There was no documentation to support that the resident was assessed for symptoms or triggers related to the diagnosis of PTSD. The care plan for Resident 1 did not include any measures to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on April 16, 2026, at 10:22 a.m., the Director of Nursing confirmed that Resident 1 had not been assessed or care planned for PTSD. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 31 sampled residents. (Residents 6 and 12)Findings include: Clinical record review revealed that on March 20, 2026, the consultant pharmacist made recommendations regarding Resident 6's medication regimen. There was no documented evidence regarding the recommendation or that the attending physician had acknowledged or acted upon this recommendation. Clinical record review revealed that on October 20, 2025, and February 26, 2026, the consultant pharmacist made recommendations regarding Resident 12's medication regimen. There was no documented evidence regarding the recommendations or that the attending physician had acknowledged or acted upon these recommendations. In an interview on April 17, 2026, at 10:22 a.m., the Director of Nursing confirmed that there was no documented evidence that the medication review recommendations for Residents 6 and 12 were addressed by the physician. 28 Pa. Code 201.18(e)(1)(3)(4) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually, including training for dementia management, resident abuse prevention, and identified performance weaknesses for two of two nurse aides reviewed (NA 1 and NA 2).Findings include:Review of NA 1's personnel record revealed that the facility hired them on August 28, 2023.Review of facility training records dated April 17, 2025, to April 17, 2026, revealed that NA 1 completed only 31 minutes of in-service education in infection control and respirator use. Review of Employee NA 2's personnel record revealed that the facility hired them on December 19, 2023.Review of facility training records dated April 17, 2025, to April 17, 2026, revealed that NA 2 completed only 3 hours and 48 minutes of in-service education in safe resident handling, mechanical lift use, elopement prevention, and ethics. In an interview on April 17, 2026, at 12:59 p.m., the Director of Nursing and the Nursing Home Administrator confirmed that employees NA 1 and NA 2 had not completed the required annual in-service training. 28 Pa. Code 201.19(7) Personnel policies and procedures28 Pa. Code 201.20(a)(6)(d) Staff development

Based on facility policy review, resident group interview, a review of facility resident council meeting minutes and grievances, and staff interview, it was determined that the facility failed to address grievances voiced by residents.Findings include:Review of the facility policy entitled, Grievance Policy, last reviewed February 24, 2026, revealed that grievances may include a formal, written grievance process or a resident's verbalized complaint to facility staff. The facility was to acknowledge complaints/grievances and actively work toward resolution of the complaint/grievance.During a confidential group interview conducted on April 14, 2026, at 10:00 a.m., four of four residents reported that resident call bells were answered slowly, often taking more than 30 minutes. A review of resident council minutes dated from September 8, 2025, through December 11, 2025 revealed complaints of slow call bell responses on September 8, 2025, October 9, 2025, November 13, 2025, and December 11, 2025. No evidence was provided that resident council minutes were recorded in 2026.A review of resident grievances dated from October 31, 2025, through March 23, 2026, revealed several complaints of slow call bell responses on October 30 and 31, 2025, November 18 and 28, 2025, December 2, 2025, and January 19 and 22, 2026. In an interview on April 17, 2026, at 10:22 a.m., the Director of Nursing and Nursing Home Administrator confirmed that the facility had a pattern of complaints about slow call bell responses and had failed to respond to those grievances. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of five nursing units. ([NAME] and [NAME] units)Findings include:Observations on April 13, 2026, from 10:01 a.m. through 1:10 p.m. and on April 16, 2026 from 9:40 a.m. through 12:00 p.m. revealed the following: The clear, plastic fire extinguisher cover in the hallway between rooms 135 & 137 was shattered. There were holes on left and right walls of the bathroom in room [ROOM NUMBER].The doorframe of the entrance to room [ROOM NUMBER] was dented and misshaped near the floor.There was a hole in the wall between the beds in room [ROOM NUMBER]. The wallboard at the bottom of the wall on the right of the entrance to the bathroom in room [ROOM NUMBER] was dented and crumbling. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 31 sampled residents. (Resident 139)Findings include: Clinical record review revealed that Resident 139 had diagnoses that included diabetes mellitus and a history of falling and required glasses to correct her vision. Resident 139's care plan revealed a problem with impaired vision and that the resident required glasses starting on March 8, 2022. The MDS assessment dated [DATE], incorrectly indicated in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lens during the previous seven days. Observation on April 14, 2026, at 11:00 a.m., revealed that Resident 139 was wearing her glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that Resident 139's MDS assessment was inaccurate.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of six sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic respiratory failure with hypoxia, heart failure, and venous insufficiency (leg veins become damaged or weak preventing efficient blood return to the heart). The Minimum Data Set assessment dated [DATE], indicated that the resident was able to communicate her needs clearly and was dependent for activities of daily living (ADL), including bed mobility, transfers, and toileting. A review of the care plan revealed that the resident had an ADL self-care deficit and was dependent for ADL care in bed mobility, transfers, locomotion, and toileting related to limited mobility and interventions included assistance of two to three staff and a bed pad for bed mobility. Review of facility documentation dated January 28, 2026, revealed that while providing care, Nurse Aide (NA) 1 observed a bruise on the resident's left forearm. Further investigation revealed that while providing care, NA 2 used the resident's left forearm to roll the resident towards him. There was a small bruise noted on the resident's left forearm. There was no evidence that a second staff member was present or bed pad was used to perform bed mobility, per the resident's care plan. In an interview on February 4, 2026, at 10:45 a.m., Resident 1 stated that she was able to reposition in bed with the assistance of one staff member and a bed pad. In an interview on February 4, 2026, at 3:30 p.m., the Director of Nursing confirmed that the bed pad was not used when NA 2 was providing care and that the care plan did not reflect the resident's current bed mobility status requiring the assistance of one staff with a bed pad. CFR 483.21(b)(1) Comprehensive Care PlansPreviously cited 3/26/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to report an alleged violation of potential neglect for one of six sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Abuse Prohibitions, last reviewed February 24, 2025, revealed that the facility prohibited abuse, mistreatment, neglect, and exploitation, for all residents. The facility was to implement abuse prohibition through the following, to include reporting of incidents, investigations, and the facility's response to the results of their investigations immediately upon receiving information concerning a report of suspected neglect or abuse. The designee was to report the allegations involving neglect to the appropriate state and local authorities. Clinical record review revealed that Resident 1 had diagnoses that included chronic respiratory failure with hypoxia, heart failure, and venous insufficiency (leg veins become damaged or weak preventing efficient blood return to the heart). The Minimum Data Set assessment dated [DATE], indicated that the resident had no cognitive impairment and was dependent for activities of daily living (ADL), including bed mobility, transfers, and toileting. A review of the care plan revealed that the resident had an ADL self-care deficit and was dependent for ADL care in bed mobility, transfers, locomotion, and toileting related to limited mobility and interventions included assistance of two to three staff and a bed pad for bed mobility. Review of facility documentation dated January 28, 2026, revealed that while providing care, Nurse Aide (NA) 1 observed a bruise on the resident's left forearm. Further investigation revealed that while providing care, NA 2 used the resident's left forearm to roll the resident towards him. There was a small bruise noted on the resident's left forearm. There was no evidence that a second staff member was present or bed pad was used to perform bed mobility, per the resident's care plan. There was no documented evidence that the facility reported the incident of alleged neglect to the appropriate state and local agencies as per facility policy. In an interview on February 4, 2025, at 3:30 p.m., the Director of Nursing stated that the facility failed to report the incident of alleged neglect to the appropriate state and local agencies. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on resident interview, review of facility documentation, and results of a test tray audit, it was determined that the facility failed to provide food and beverages that were at an appetizing temperature on one of five nursing units. ([NAME] unit) Findings include: In an interview on May 27, 2028, at 10:43 a.m., Resident 1 stated that he had a hard time getting coffee that was not cold. Review of facility documentation entitled, Food and Nutrition Services Test Tray Evaluation, revealed that the coffee should be greater than 140 degrees Fahrenheit (F) at point of service to the resident. Results of a test tray audit conducted on May 27, 2025, at 12:27 p.m., after the last resident meal tray was served from the dining cart, revealed the coffee at a temperature of 128 degrees F. The previously mentioned beverage was noted to be below 140 degrees F. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on a review of facility policy, review of facility documentation, and staff interview, it was determined that the facility failed to perform infection surveillance in accordance with facility policy. Findings include: Review of the facility policy entitled, Infection Control Outcome and Process Surveillance and Reporting, last reviewed February 24, 2025, revealed that the Infection Preventionist would conduct regular surveillance related to infections. During the review of the facility infection control program on March 26, 2025, there was no documented evidence of any infection surveillance since January 2025. In an interview on March 26, 2025, at 10:54 a.m., the Director of Nursing confirmed that infection surveillance should be done monthly and was not done per facility policy since January 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department. Findings include: Review of the facility policy entitled, Food Handling, dated February 24, 2025, revealed that staff were to label food items with the date prepared or opened and then discard after seven days after opening an item or three days after a food was prepared. Observations during the kitchen tour on [DATE], at 9:30 a.m., revealed the following: In the walk-in cooler, there was an opened bag of shredded mozzarella that was dated [DATE], and a pan of ham salad that was dated [DATE]. There was a pan of egg salad, a bag of lettuce, and a pan of raw pork cubes that were not dated. In the freezer, there was an opened bag of 20 sausage patties that was not dated. In an interview on [DATE], at 11:00 a.m., the Dietary Manager confirmed that the previously mentioned items should have been dated and were not and the expired items should have been removed. CFR 483.60(i) Food Safety Requirement Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on March 23, 2025, at 10:30 a.m., the Dietary Manager stated the facility did not employ a certified dietary manager. In an interview conducted on March 25, 2025, at 12:05 p.m., the Administrator confirmed that there was not a full-time dietitian employed onsite at the facility and that the facility did not employ a qualified certified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, review of current facility procedure guidelines, staff interviews, and review of facility documentation submitted to the Department, it was determined that the facility failed to ensure that staff provided sufficient safety and supervision to prevent a fall that resulted in serious injuries for one of five sampled residents. (Resident R72) Finding include: Clinical record review revealed that Resident R72 had [DIAGNOSES REDACTED]. Review of documentation submitted by the facility to the Department on June 22, 2016, revealed that on June 19, 2016, at 7:45 AM the nurse aide was providing incontinence care to Resident R72, who was in bed. The nurse aide was alone. The nurse aide rolled the resident away from her and the resident fell out of bed onto the floor. Nurses' notes reflected that the next day the resident began exhibiting signs of pain. Staff notified the physician who ordered X-rays, which revealed a fractured left femur (the long bone of the thigh). On June 22, 2016, the resident was evaluated by the orthopedic physician who documented that the resident had sustained a fracture of not just the left femur, but the right femur as well. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed that the resident had impaired memory and decision making ability. The assessment also noted that the resident could not walk and was totally dependent on the assistance of two staff for bed mobility. (That the resident needed two staff for bed mobility was documented elsewhere in the clinical record. For example, a nurse's note dated May 11, 2016, at 10:13 AM reflected that staff report that (Resident R72) is a total assist of two for bed mobility, transfer and toileting.) However, clinical record review revealed a lack of evidence that the facility ensured that this information was communicated to staff, to ensure that Resident R72 received sufficient staff assistance. In an interview on June 30, 2016, at 10:50 AM the adminstrator reported that the facility used an electronic document called a KARDEX to communicate resident care needs to staff. This was corroborated in interviews on July 5, 2016, at 11:40 AM by three nurse aides who provided care to Resident R72. Review of Resident R72's KARDEX revealed that at the time of the fall on June 19, 2016, the KARDEX reflected that Resident R72 usually required the assistance of two staff for activities of daily living (which include bed mobility). There was no documentation on the KARDEX to clarify how staff were to determine when the resident required two assist and when she did not. In the June 30, 2016, interview, the Administrator confirmed that the word usually should not have been included on the KARDEX, because it made the resident's care needs unclear. In addition to failing to provide care with sufficient number of staff, the nurse aide also used unsafe technique when turning Resident R72 in bed. Review of the current facility procedure guidelines for performing incontinence care, last revised in August 2014, revealed that staff was to turn the resident toward the caregiver and then ensure that the resident was positioned in the center of the bed before moving to the opposite side of the bed to provide care. Documentation by the adminstrator dated June 22, 2016, reflected that the nurse aide knew facility procedure was to turn the resident toward her but that she had turned the resident away from her because it was easier to clean the resident. In an interview on June 30, 2016, at 10:50 AM the Adminstrator confirmed that facility guidelines directed staff to turn a resident in bed toward the caregiver, not away. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 1/15/2016 28 Pa. Code 211.12 (d)(5) Nursing Services. Previously cited 1/15/2016

Based on clinical record review and incident report review, it was determined that the facility failed to provide adequate supervision to prevent a fall that resulted in serious injury to one of four sampled residents who had a history of [REDACTED]. Findings include: Clinical record review revealed that Resident R146 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial Minimal Data Set assessment dated [DATE], identified that the resident had memory impairment, severely impaired daily decision making ability and did not ambulate and had a fall with injury since admission to the facility. Review of an incident report revealed that the resident had fallen at 6:30 p.m., in the facility on the day of his admission. Facility staff found the resident scooting on his behind out of his room into the hallway. Staff documented on the incident report that to prevent additional falls staff would provide increased supervision on an as needed basis. On November 27, 2014, at 3:34 a.m., a nurse documented that the resident had fallen again at 1:00 a.m. According to the nurse's note, the resident "hopped out of the recliner chair" quickly falling on the floor at the nurses station. The nurse documented that the resident was then placed at the nurses station with the nurse sitting next to the resident as the resident "appears to be sleeping and can quickly jump up, and has fallen twice since his admission." The corresponding incident report to the November 27, 2014, fall revealed that the resident had appeared to be sleeping prior to the fall and when staff turned away the resident fell from a reclining chair. Staff documented that they had discovered that even though the resident appears to be sleeping, he can not be left alone. The final conclusion of the investigation was for staff to provide increased supervision to the resident when restless to prevent additional falls. There was no evidence to support that the facility determined what level of supervision staff was to provide to prevent additional falls. The care plan from November 26, 2014, identified that the resident was at risk to fall due to confusion, history of falls and poor safety awareness, however, the care plan failed to identify when and how staff was to supervise the resident to prevent falls. On December 13, 2014, at 10:51 p.m., a nurse documented that the resident was restless at times and was provided one to one supervision. On the morning of December 14, 2014, at 9:37 a.m., a nurse again documented that the resident required close one to one staff supervision due to trying to get up by himself. Staff placed him immediately next to the nurses' desk. Later that afternoon at 6:56 p.m., a nurse documented that the resident had fallen out of a Broda chair at 2:45 p.m., while seated at the nurses' station. There was no evidence to support that staff was supervising the resident at the time of the fall. According to the nurse notes and incident report the resident's fall was unwitnessed by staff. On December 15, 2014, at 4:42 a.m., a nurse documented that Resident R146 was admitted to hospital with a fractured hip from the fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/16/14