Every finding on record at Lebanon Valley Home the

Based on review of facility policy, clinical record, facility documentation, and staff interviews, it was determined the facility failed to implement interventions to prevent an accident during a transfer for one of four sampled residents (Resident 1), which resulted in actual harm (fractures of the leg). The incident has been identified as past non-compliance. Findings include: Review of the facility policy titled, Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriation of Resident Property last reviewed January 22, 2026, revealed a resident had the right to be free from neglect. Staff were to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. In addition, staff were to provide comfort, safety, and help. Review of the facility policy entitled, Accident Prevention - Resident last reviewed January 22, 2026, revealed the facility would implement interventions consistent with a resident's needs, goals, plan of care, and current standards of practice to reduce the risk of an accident. Review of Resident 1's clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (brain disorder that slowly affects memory and the ability to perform everyday tasks), dementia (loss of thinking, remembering, and reasoning skills that is severe enough to interfere with daily life), muscle weakness, difficulty walking, heart failure, and atrial fibrillation (irregular heart rhythm). Review of Resident 1's Minimum Data Set (MDS) assessment (periodic evaluation of resident care needs) dated May 25, 2026, revealed that Resident 1 had memory impairment, loss of mobility on both sides of lower extremities, and was dependent on staff for bed mobility, transferring, dressing, personal hygiene, bathing, and toileting. Review of Resident 1's care plan revealed the facility identified Resident 1 had functional impairment (decline in a person's ability to carry out activities of daily living due to a physical, cognitive, or mental health condition) and required assistance from two staff members to transfer Resident 1 using a gait belt (safety device used in transferring and walking residents to prevent falls) for all transfers. Review of investigative documents revealed on June 22, 2026, during the evening shift, Resident 1 was in her room sitting in a wheelchair. Nurse Aide (NA) 2 transferred the resident to her bed by bear hugging the resident and placing her into bed without assistance from a second staff member. The transfer method was not consistent with the resident's transfer status requiring two staff to assist and using a gait belt. Further review of investigative documentation revealed when asked about the transfer and any signs of pain from Resident 1, NA 2 responded, She's always yelling. Review of Resident 1's clinical record indicated on June 23, 2026, at 6:54 a.m., a nurse aide (NA 1) reported Resident 1 complained of pain in her right ankle. A nurse noted the resident had some swelling in the right ankle compared to the left ankle. Nursing documentation dated June 23, 2026, at 8:18 a.m., revealed Resident 1's right leg was noticeably internally rotated, and her right lower leg was warm with increased swelling and redness. The nurse noted Resident 1 yelled in pain with movement of the right leg or when the leg was touched. An immediate (stat) X-ray was performed on June 23, 2026, at 8:53 a.m., with the results being inconclusive. On June 23, 2026, at 12:20 p.m., the physician requested the resident be transferred to the hospital for further evaluation. The results of the X-rays obtained at the hospital dated June 23, 2026, revealed the resident had a broken shin bone, located between the knee and the ankle and a broken bone located at the ankle joint. Review of an investigative statement dated June 23, 2026, revealed NA 2 was asked what the resident's transfer status was. NA 2 replied, Two-assist with a stand aid or Hoyer. I really don't know. I just always put her into bed the same way I did last night with a bear hug. Interview on July 21, 2026, at 12:30 p.m., with the Director of Nursing (DON) revealed Resident 1's care plan indicated two staff members were required to transfer the resident from the wheelchair to the bed with a gait belt. The DON revealed Nurse Aide (NA) 2 transferred the resident in a bear hug out of the wheelchair and placed her into bed. NA 2 did not call for assistance and did not use the appropriate transfer method. In an interview on July 21, 2026, at 2:30 p.m., the Director of Nursing confirmed NA 2 transferred Resident 1 inappropriately and was negligent with care provided to the resident that resulted in injuries. NA 2 failed to follow the resident's care plan and transfer requirements, which resulted in actual harm to Resident 1. The facility identified NA 2 was negligent in the care provided to Resident 1 at the time of the incident, and on June 23, 2026, through June 24, 2026, implemented the following corrective action plan: 1. On June 23, 2026, all residents who received care from NA 2 during the evening shift on June 22, 2026, were assessed for injuries, pain, or any concerns related to care provided. No injuries, pain, or complaints were identified. 2. All staff were re-educated June 24 through July 13, 2026, on transferring residents and abuse prevention. Education included the importance of following each resident's transfer status and care plan, potential for resident harm, staff consequences when transfer requirements are not followed, staff acknowledgment of completion through a read and sign process, and a post-education quiz to assess understanding of the material. 3. A transfer audit process was implemented on June 24, 2026. RN (registered nurse) supervisors were required to complete five transfer audits to monitor compliance with resident transfer requirements. Each audit included verification of the resident's transfer lift form, observation of the resident's transfer method, compliance with the transfer lift form during the transfer, presence of the required number of staff members for the transfer, the appropriate transfer equipment, and maintenance of resident safety throughout the transfer. 4. Audit results and trends were reviewed through the facility's Quality Assurance and Performance Improvement program. Findings were used to identify opportunities for improvement, provide additional education as needed, and ensure ongoing compliance with safe resident transfer practices. 5. The Director of Nursing or designee initiated weekly audits. The first audit was done on June 24, 2026. 6. The Director of Nursing or designee will review completed transfer audits weekly to identify trends, ensure corrective actions are completed, and provide additional education as needed. In addition, unannounced spot checks on nurse aides while completing transfers will be completed. On July 21, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. All staff interviewed confirmed they received the training described in the facility's action plan. All nursing staff were aware of the requirements for resident transfers and the abuse policy. Staff were observed transferring sampled residents according to their care plan. All training was completed by July 13, 2026. 28 Pa. Code 201.18(b)(1)(3) Management 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 notify the Office of the State Long-Term Care Ombudsman in writing of a transfer from the facility for three of three sampled residents who were transferred to the hospital. (Residents 2, 3, 6)Findings include: Clinical record review revealed that Resident 2 was transferred to the hospital on March 29 and April 20, 2025, after changes in condition. There was no documented evidence that the Ombudsman's office was informed of the transfers to the hospital. Clinical record review revealed that Resident 3 was transferred to the hospital on March 14 and April 20, 2025, after changes in condition. There was no documented evidence that the Ombudsman's office was informed of the transfers to the hospital. Clinical record review revealed that Resident 6 was transferred to the hospital on April 22 and June 6, 2025, after a change in condition. There was no documented evidence that the Ombudsman's office was informed of the transfers to the hospital. In an interview on September 4, 2025, at 11:24 a.m., the Director of Social Services confirmed that the facility had not informed the Office of the State Long-Term Care Ombudsman of transfers out of the facility.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one of 13 residents in one of two dining rooms (Main Dining Room). (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included vascular dementia, anemia, and chronic fatigue. Review of the Minimum Data Set (MDS) assessment, dated July 2, 2024, revealed that the resident had cognitive impairment. Review of Resident 8's care plan revealed that staff was to encourage oral intake and assist with dining. On October 1, 2024, from 11:55 a.m. until 12:18 p.m., Nurse Aide (NA) 1 was observed standing to assist Resident 8 eat lunch while the resident was seated in the wheelchair. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and review of facility documentation, it was determined that the facility failed to notify a resident's physician in a timely manner of an accident for one of 14 sampled residents. (Resident 49) Findings include: Review of the facility's Physician Notification Guidelines, revealed that when a resident experienced any head injury with a change in mental status the physician was to be notified immediately. Immediate notification usually meant the physician would be informed within one hour or as soon as practicable due to resident safety, but no later than the end of the business day. Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On September 2, 2021, at 11:45 p.m., Resident 49 had an unwitnessed fall from his chair. The resident was noted to have a six centimeter (cm) long by six cm wide hematoma (a swollen collection of blood in the tissue) to his right forehead and was unresponsive for three minutes. A nursing note date September 3, 2021, revealed that the physician was notified via fax. There was no documented evidence that Resident 49's physician was aware of the resident's head injury until September 7, 2021, when the physician responded to the fax. 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interviews it was determined that the facility failed to ensure that a call bell was accessible for one of 14 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, dated August 16, 2021, revealed that the resident had no functional limitation with her range of motion and required extensive assistance from staff with activities of daily living, including bed mobility, dressing, and hygiene. Review of Resident 5's current care profile revealed interventions for a soft touch call bell and to have her call bell within reach. On November 8, 2021, at 10:44 a.m. and 12:02 p.m., Resident 5 was observed out of bed in her wheelchair on the window side of her bed, her call bell was draped across her mattress that had no sheets on to the door side of her room. In an interview with Resident 5 on November 8, 2021, at 10:44 a.m., she stated she could not reach her call bell. On November 8, 2021, at 1:14 p.m. and 1:30 p.m., Resident 5 was observed out of bed in her wheelchair on the window side of her bed, her bed was now made with sheets and a blanket, with her call bell draped over the call bell box on the wall to the door side of her bed out of her reach. In an interview on November 9, 2021 at 11:23 a.m., Nurse Aide 1 stated Resident 5 was able to use her call bell. 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 that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN medication to be extended beyond 14 days for one of 14 sampled residents. (Resident 43) Findings include: Clinical record review revealed that Resident 43 had a diagnoses that included hypertension (high blood pressure) and anxiety, and had a physician's order for staff to administer a psychoactive medication (lorazepam) 0.5 milligrams (mg) every eight hours as needed for anxiety dated September 21, 2021. The current order of lorazepam failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on November 10, 2021, at 10:30 a.m., the Director of Nursing confirmed that the physician's order for the use of the psychoactive medication failed to have a time limit for use and that there was no rationale documented by the physician for the continued use of the medication beyond the 14 days. 28 Pa. Code 211.12(d)(5)Nursing services.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility for one of 14 sampled residents. (Resident 26) Findings include: Clinical record review revealed that Resident 26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident required staff assistance for transfers and walking. Review of Resident 26's current plan of care revealed that she needed staff assistance with transfers and walking. A physical therapy discharge summary dated July 27, 2021, revealed that the resident was to transition to a functional mobility program for ambulation. Staff was to assist Resident 26 with walking up to 300 feet with a walker and a second staff member was to follow with a wheelchair for safety due to fatigue. Staff was to provide verbal cues for upright posture and foot clearance. In an interview on November 8, 2021, at 12:30 p.m., Resident 26 stated that staff does not offer to walk her consistently and that she desired to walk. There was no documented evidence that Resident 26's functional mobility program was implemented. In an interview on November 10, 2021, at 11:25 a.m., the Director of Nursing stated that Resident 26's functional mobility program was not implemented as recommended by physical therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations, and manufacture instructions it was determined that the facility failed to maintain medication storage according to manufactures instructions in two of two areas (E Wing medication storage room and F Wing medication storage room). Findings include: Review of the facility policy entitled Storage of Medications, and Labeling of Medication last review date of January 26, 2020, revealed all drugs and medications maintained in the facility were to be properly labeled in accordance with current state and federal regulations. No discontinued, outdated, or deteriorated drugs or biologicals were to be available for use in the facility and all drugs were to be administered and stored in compliance with state and federal regulations. Observation of the E Wing Medication Cart and Medication Storage room on October 27, 2020, at 11:15 a.m., revealed two open [MEDICATION NAME] Injectable solutions (insulin) with no identified open dates. The manufacturer's guidelines recommended that once the medication was open for 42 days the medications should be discarded. An open bottle of [MEDICATION NAME] solution (insulin) with no identified open date was observed in the medication refrigerator. The manufacturer's guidelines recommended that once the medication was open for 28 days the medications should be discarded. An open bottle [MEDICATION NAME] solution (eye drops) in the medication cart with no identified open date. Observation of the F Wing Medication Cart and Medication Storage on October 27, 2020, at 12:00 p.m., revealed one [MEDICATION NAME] Injectable solutions (insulin) with no identified open date. The manufacturer's guidelines recommended that once the medication was open for 42 days the medications should be discarded. An open bottle of Humalog solution (insulin) with no identified open date. The manufacturer's guidelines recommended that once the medication was open for 28 days the medications should be discarded. An open bottle of [MEDICATION NAME] solution (insulin) with no identified open date. The manufacturer's guidelines recommended that once the medication was open for 28 days the medications should be discarded. 28.Pa.code 211.9(h)(i) Pharmacy Services. 28 Pa.code 211.12(d)(1)(2)(3)(5) Nursing Services

Based on clinical record review, review of incident/accident reports and staff interview, it was determined that the facility failed to ensure that hot liquids were served to residents at a safe temperature for one of 13 residents. (Resident 27) Findings include: Clinical record review revealed that Resident 27 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), identified that the resident had no memory impairment and needed only staff setup assistance to eat meals. A nurse documented on (MONTH) 10, (YEAR), at 11:50 a.m. that Resident 27 went to place a mug of broth onto the dining room table, hit the edge of the table with the mug and hot broth spilled onto the resident's lap. Follow-up documentation revealed that the resident's skin was assessed after the incident and resulted in the resident receiving a partial thickness burn to the lower extremity. Review of the facility's investigation into the incident revealed that a dietary staff member had prepared the chicken broth at the resident's request and failed to take the temperature of the broth prior to serving the resident the hot liquid to ensure a safe temperature. In an interview on (MONTH) 12, (YEAR), at 12:56 p.m. the Dietary Manager stated that the dietary employee who served Resident 27 the broth on (MONTH) 10, (YEAR), failed to follow the facility's hot beverage/liquids policy. According to the policy, staff was to take temperatures of hot beverages/liquids prior to service to ensure temperatures were below 135 degrees Fahrenheit to protect residents [MEDICAL CONDITION] spilled liquids. 28 Pa. Code:201:18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of seven residents sampled that had falls. (Resident R29) Findings include: Clinical record review revealed that Resident R29 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE], indicated that the resident had some cognitive impairment, required staff assistance for transfers and walking, and had a history of [REDACTED]. On November 19, 2015, at 7:45 p.m., the day of admission, Resident R29 was found on the floor at the foot of the bed. Review of the investigative report and care plan related to the fall revealed that to prevent further falls the resident was not to be left alone in her room. On November 22, 2015, at 6:30 a.m., the resident again fell in her room. According to the corresponding incident report, the fall was reported to staff by the resident's roommate thus the resident was in her room without staff present. The care plan intervention documented following this fall, continued to direct staff to not leave the resident alone in her room. On November 24, 2015, at 8:30 p.m., the resident stood up from her wheelchair and fell . Although this fall was observed, staff documented on the care plan a new intervention that resident requires constant monitoring to prevent fall. From November 28, 2015 through April 10, 2016, the resident had 12 additional falls. Eight of those 12 falls were not observed or witnessed by staff. There was a lack of evidence to support that adequate supervision was provided to Resident R29 to prevent falls. Additionally, on December 2, 2015, the resident fell from her wheelchair in the dining room. At that time, therapy recommended that anti-lock brakes were to be applied to the wheelchair and maintenance was notified. On December 5, 2015, the resident had two falls from her wheelchair at 12:30 p.m., and 6:45 p.m. Review of the investigative report revealed that the anti-lock brakes had not been applied. In an interview on April 13, 2016, at 11:20 a.m., the Administrator stated that the anti-locks brakes were not available until December 7, 2015. There was a lack of evidence to support that the facility identified a plan to prevent the wheelchair from moving back when the resident stood until the anti-lock brakes were available. 201.18(b)(1) Management 211.12(d)(5) Nursing service

Based on review of facility policy and personal files, it was determined that the facility failed to ensure that staff had verified employment eligibility timely with the Pennsylvania Nurse Aide Registry for one of three sampled personal files. (Employee 1) Findings include: Review of the facility's " Resident Abuse and Neglect" policy dated January 22, 2015, revealed that the facility was required to obtain status verification from the Pennsylvania Nurse Aide Registry for all nurse aides. Review of personal files revealed that Employee 1, a nurse aide, was hired on January 19, 2015. Facility orientation was completed on January 19, 2015. The facility did not verify with the Pennsylvania Nurse Aide Registry the nurse aide's enrollment and history of abuse, neglect or misappropriation of property until March 9, 2015. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on clinical record review, it was determined that the facility failed to ensure that a pharmacist's recommendation was acted upon timely for one of 15 sampled residents. (Resident R14) Findings include: Clinical record review revealed that Resident R14 had [DIAGNOSES REDACTED]. The resident had received both Ativan and Klonopin twice a day since at least June 2014. On April 9, 2015, the pharmacist recommended that the physician evaluate the risk and benefits of the resident receiving both of these psychoactive medications. The physician was faxed the pharmacist's recommendation on April 10, 2015. As of May 12, 2015, there was no documentation in the clinical record that the physician acknowledged the pharmacist's recommendation to evaluate the risk and benefits of continued duplicate medication therapy. 28 Pa. Code 211.2(a) Physician services.

Based on observation and clinical record review, it was determined that the facility failed to implement a care plan intervention for one of 14 sampled residents. (Resident R53) Findings include: Clinical record review revealed that Resident R53 had [DIAGNOSES REDACTED]. This skin disorder is a connective tissue disease that results in friction and skin fragility. This disease causes skin blisters. The care plan reviewed May 8, 2014, identified that the resident was to wear elbow protectors to decrease skin shearing when seated in the wheelchair. Observations on June 10, 2014, at 10:10 a.m., 12:10 p.m., and 2:00 p.m., and again on June 11, 2014, at 9:45 a.m., and 10:50 a.m., revealed that the resident was in the wheelchair without the elbow protectors in place. The resident had a short sleeved shirt on and there was redness observed on the right elbow. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/17/13.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide assistance at meals to ensure optimal food intake for one of eight residents observed during meals. (Resident R5) Findings include: Clinical record review revealed that Resident R5 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment dated [DATE], noted that the resident had a poor appetite, required staff assistance with eating and was inattentive. Review of the resident's nutritional needs revealed that the physician ordered a pureed diet with thickened liquids and gastrostomy tube feeding nutrition during the night. Review of the most recent nutritional assessment dated [DATE], noted that the resident required a lot of encouragement to eat. The care plan dated March 14, 2013, noted that staff was to assist with dining as needed. During observation of lunch on May 15, 2013, at 12:20 p.m., Resident R5 was seated at a table with other residents and she received her lunch. From 12:20 p.m., until 1:15 p.m., the resident was observed taking her filled spoon from the plate to her mouth, but did not actually get the food into her mouth. The resident did this action over and over while looking around the dining room and not being attentive to the task of eating. At no time during this observation did staff offer assistance to the resident. The following day on May 16, 2013, at 10:45 a.m., staff provided the resident breakfast which consisted of a bowl of hot cereal and two thickened beverages. The resident was observed taking several spoonfuls of the hot cereal until 11:10 a.m., when staff removed the food. There was at least half of the cereal in the bowl yet and both beverages were still full. In an interview at that time NA 1 stated that she had not offered assistance to Resident R5 prior to removing the unfinished meal. 28 Pa. Code 211.12(d)(5) Nursing services.