Every finding on record at Little Sisters of the Poor

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance while preparing for a transfer from the wheelchair to the bed, which resulted in actual harm of a skin tear (a traumatic wound where the outer layers of skin are partially or completely separated from underlying tissue, usually caused by mechanical forces such as friction, shearing, or adhesive removal) for one of four residents (Resident R1).Findings include: Review of facility policy Accident/Incident Reports, Residents dated 11/10/25, indicated an accident is defined as an event that results in bodily injury or potential injury and/or causes a change in resident status. Review of facility policy Mechanical Lift, Use Of dated 11/10/25, indicated nursing staff members will assess each resident prior to transferring them to determine the safest way to accomplish the transfer. A mechanical lift can be used to transfer a resident who cannot transfer independently. All mechanical lifts are to be performed by a two-person assist. It is imperative that all transfers involving the mechanical lift are to be handled with two (2) nursing staff members present for the entire process. Training for the use of the mechanical lift will be provided by Rehab Staff and Nursing Personal for all members of the nursing staff as well as nursing personnel assigned to home from outside nursing agencies. The staff will complete and document training upon hire and as required to correct improper use/understanding of safe resident handling a movement. Review of facility policy Transferring Residents Using a Mechanical Lift dated 11/10/25, indicated there are always two trained staff members present when a mechanical lift is being used. All Certified Nursing Assistants will receive training prior to using the mechanical lift to move a resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 4/17/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and generalized muscle weakness. Section GG - Functional Abilities, Question GG0170E: Chair/bed-to-chair transfer indicated Resident R1 was coded 1 dependent for the ability to transfer to and from a bed to a chair (or wheelchair). Review of a physician order dated 4/9/26, indicated Resident R1 transfers with assist 2 and may use Hoyer lift (a full-body mechanical lift) with 2 assists when tired or drowsy. Review of Resident R1's comprehensive plan of care dated 4/9/26, indicated the resident is at risk for falls r/t (related to) confusion, gait/balance problems/muscle weakness/muscle wasting and atrophy (wasting or thinning) multiple sites. Resident has diagnosis of dementia/cognitive impairment. Interventions included anticipate and meet resident's needs, follow facility protocol, and transfer with Hoyer lift and two clinical staff members. Review of Resident R1's Kardex (a snapshot of resident care needs) dated 7/9/26, indicated resident transfers with Hoyer lift and two clinical staff members. Review of facility submitted documentation dated 7/9/26, indicated the following: Resident R1 was preparing for transfer from wheelchair to bed. While adjusting the sling, the resident slid forward off the edge of the wheelchair and descended to the floor. The resident's head struck the metal frame of the wheelchair before coming to rest on the floor. Resident denied pain but verbalized discomfort upon palpation (touching) of the occipital region (back of the head). Neuro status intact, [NAME] (moves all extremities), and VSS (vital signs stable). RN (Registered Nurse) placed call to DON (Director of Nursing) and MD (physician) notified. Per facility policy, resident sent to hospital for further evaluation. Review of a nursing progress note dated 7/9/26, completed by RN Employee E9 stated, At 7:35PM this nurse was notified of a fall that took place at approximately 7:30PM in room [ROOM NUMBER]. Per report from Nurse Aide (NA) Employee E1 and witness Unit Supervisor Employee E2, the resident was being transferred from the wheelchair to the bed utilizing a mechanical lift. While the sling was being positioned behind the resident in preparation for the transfer, the resident remained seated on the edge of the wheelchair. According to the witness, difficulty was encountered while applying the sling. During manipulation of the sling, the resident slid forward off the edge of the wheelchair and descended to the floor. Following the fall, it was noted that the left wheelchair brake was engaged, however, the right brake was not locked. During the descent, the resident's head struck the metal frame of the wheelchair adjacent to the front caster before coming to rest on the floor. Unit Supervisor Employee E2 had placed a pillow under the resident's head before this RN arrived at the scene. Resident has a known history of dementia, is alert and oriented 1-2. Resident denied having pain, however, she verbalized discomfort upon gentle palpation of the occipital region. Cervical spine precautions were maintained during the entire assessment. Pupils were noted to be pinpoint and sluggish bilaterally (both sides). Baseline pupillary responsiveness is unknown to this nurse. A skin tear was sustained to the right anterior (front) forearm measuring 4cm (centimeters) x 4.5cmx 0.1cm. The wound was cleansed with NSS (normal sterile saline), patted dry, OpSite (a transparent dressing that provides a waterproof, breathable barrier to protect wounds while promoting healing) applied. Resident was able to move all extremities, no obvious deformities, asymmetry, or additional acute injuries were identified during the examination. DON was informed of the circumstances via phone. Resident's daughter was contacted, informed of the above, she requested to transfer her mother to the emergency department for further evaluation as a precaution. 911 was activated and the resident was transported by EMS (emergency medical services) to the emergency department. Review of a staff witness statement dated 7/9/26, completed by Unit Supervisor Employee E2 stated, Around 7:30 p.m. I entered Resident R1's room to check to see how she was doing. I observed her in her wheelchair with the footrests off and her feet flat on the floor. NA Employee E1 was attempting to put her Hoyer lift sling under her but could not find the left side that goes under her leg. I offered to help and NA Employee E1 pulled Resident R1 forward so I could untangle the sling and at that moment Resident R1 began to slide. She slid down and hit her head of the left corner of the metal part of the seat and her backside slid to the ground. She did not hit her head on the ground. It happened so quickly but I was able to stop her from going all the way down. I then supported her upper body in my lap and called for the nurse. She had a skin tear on her arm which they treated and preceded to call the on-call phone, her daughter, and 911. Review of an undated staff witness statement, completed by NA Employee E1 stated, On Thursday July 9, about 7:30, went to get Resident R1 into bed, I got the sling as I was putting under her she slide out of chair. Review of a staff witness statement dated 7/9/26, completed by the Nursing Home Administrator (NHA) stated, On Thursday evening at approximately 6:45 p.m. I went to the resident unit to visit a resident. I noticed Resident R1 was in the dining room in her wheelchair at the table but appeared to be lethargic and leaning slightly to the left. It appeared to me that she did not feel well. After observing her for a few minutes I noticed that the nurse on duty was taking her vital signs. I approached the nurse and Resident R1 and remarked I noticed that Resident R1 seems lethargic and that she did not eat any supper from what I observed. I spoke briefly to the nurse and thought that Resident R1 should go to bed. The staff was planning on assisting her to bed as soon as possible. Unit Supervisor Employee E3 was also in the dining room when I arrived but left because Resident R1 was unable to eat. I spoke to Unit Supervisor Employee E3 and she explained that: She noticed how sleepy Resident R1 seemed to be, lethargic, barely acknowledging any attempts to get her attention. Unit Supervisor Employee E3 thought that Resident R1 may have taken a little soup, and a couple of tiny bites of her sandwich that she put to her lips. She tried to give her a few strawberries which were among her favorite foods. She would not take any. Unit Supervisor Employee E2 was sitting diagonally from Unit Supervisor Employee E3, helping another resident and alerted her that about Resident R1's condition. Unit Supervisor Employee E2 acknowledged that she had noticed it as well. Before Unit Supervisor Employee E3 left the dining room, she told the nurse, RN Employee E9, that she did not have any success in getting Resident R1 to eat or drink and that something was wrong. RN Employee E9 told Unit Supervisor Employee E3 that she and Unit Supervisor Employee E2 had discussed the situation. Unit Supervisor Employee E3 left the unit after that. Review of an undated staff witness statement, completed by Unit Supervisor Employee E3 stated, On said day, at the time of the evening meal, I noted how sleepy Resident R1 seemed to be, lethargic, barely acknowledging any attempts to get her attention. She may have taken a little soup, I am not sure, and a couple of tiny bites of her sandwich that I actually put to her lips. I got her a few strawberries which were among her favorite foods. She would not take any. Unit Supervisor Employee E2 was sitting diagonally from me, helping another resident. I said something to her referencing Resident R1's condition. She let me know she also noticed it. Before I left the dining room, I told the nurse, RN Employee E9, that I did not have any success in getting Resident R1 to eat or drink, that something was wrong. RN Employee E9 told me she and Unit Supervisor Employee E2 had discussed the situation. I left the unit after that. On 8/26/26, at 10:33 a.m. the State Agency (SA) attempted to call NA Employee E1 to obtain a telephonic statement. A voicemail was left requesting a return call. NA Employee E1 never returned a call to the SA. During an interview on 8/26/26, at 10:36 a.m. the DON stated, The nurse on duty during the incident was RN Employee E9, she no longer works at the facility. She was contracted through a staffing agency. RN Employee E9 was not in Resident R1's room during the incident. Review of a signed Mechanical Lift Training policy indicated NA Employee E1 was trained and signed off as competent on mechanical lift operation on 2/17/26. During an interview on 8/26/26, at 11:56 a.m. NA Employee E4 stated, I received training on the mechanical lifts during orientation. You always have to have two people in the room from the time of putting the sling on through putting the resident on the lift, to the time the sling comes off. That has always been the procedure. I would not attempt to put a sling on a resident by myself if the resident was lethargic. During an interview on 8/26/26, at 12:02 p.m. NA Employee E5 stated, I have been trained by the facility on how to operate a mechanical lift. It's one person to put the sling on, two with transfers using the lift. I would get a second person to help put the sling on if a resident was more stiff or contracted. I would get a second person to help put the sling on if the resident was lethargic. During an interview on 8/26/26, at 12:48 p.m. NA Employee E6 stated, Staff are educated on the mechanical lifts when they get hired, they get one in-service from the Physical Therapy department, they actually put the staff in the slings and lift them with the lifts so they can experience it. They provide education on the different slings. To get the sling on, it depends on the situation and safety concerns for how many people you need. I would get a second person to put the sling on if the resident was more lethargic. During an interview on 8/26/26, at 12:50 p.m. Restorative Aide Employee E7 stated, Staff are educated twice on the mechanical lifts when they are hired, Physical Therapy trains them and they receive a second in-service education with NA Employee E8. The number of people needed to put the sling on depends on the safety concerns of the resident and if there is a tendency to slide down, two people would be needed. You need to assess the situation, if a resident was more lethargic, you might even need three people in the room. During an interview on 8/26/26, at 12:56 p.m. Unit Supervisor Employee E2 stated, I was making my final rounds on the household before I went to bed. Resident R1 wasn't feeling good earlier, NA Employee E1 was putting the sling on her. It was a toileting sling because Resident R1 is able to move her arms. I could see NA Employee E1 was struggling, so I asked if I could help, the sling was twisted behind Resident R1. I had Resident R1 on the edge of the chair trying to get the sling off of her, Resident R1 slid down, she didn't hit the floor. I caught her, she hit the back of her head where the footrests go on the wheelchair. She slid down the chair. We sent her to the hospital to make sure she was ok. NA Employee E1 was putting the toileting sling on Resident R1 when I came in the room, Resident R1 only uses the toileting sling because she is able to follow directions. Resident R1 was more lethargic than normal at that time. We received education on the mechanical lifts, new staff receive the education during orientation and NA Employee E8 gives a second orientation to the new staff. There should be two people in the room, the whole process should always be two people. I would not put a sling on a resident by myself if the resident was more lethargic, I wouldn't feel comfortable. During an interview on 8/26/26, at 1:30 p.m. NA Employee E8 stated, The whole process for using a mechanical lift is, go in the resident room with both people, explain to the resident the process, put the sling under the resident, make sure it is the correct sling. Once the sling is under the resident, bring the lift over, make sure it's within a safe distance, hook the sling to the lift, both staff members should make sure it's connected correctly, make sure there is nothing in the way, then you turn the lift on, the resident goes up, you transfer them to the chair or wherever you are putting them, lower the lift. The whole process should be a two person process. You should have two people when putting the sling under a resident in a wheelchair. I would expect there to be two people to apply the sling if a resident is more lethargic, especially in that case. Staff get mechanical lift education when they are hired during orientation, and I do a second in-service prior to their first shift on the floor. I always tell them over and over again, you need two people. During an interview on 8/26/26, at 1:59 p.m. the DON confirmed that the facility failed to make certain each resident received adequate supervision and assistance while preparing for a transfer from the wheelchair to the bed, which resulted in actual harm of a skin tear for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, facility documents, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate an accident to rule out the potential for neglect for one of four residents reviewed (Resident R1).Findings include: Review of facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 11/10/25, indicated neglect is the failure of the Home, 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. It is the policy of this Home that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Review of facility policy Accident/Incident Reports, Residents dated 11/10/25, indicated an accident is defined as an event that results in bodily injury or potential injury and/or causes a change in resident status. Review of facility policy Mechanical Lift, Use Of dated 11/10/25, indicated nursing staff members will assess each resident prior to transferring them to determine the safest way to accomplish the transfer. A mechanical lift can be used to transfer a resident who cannot transfer independently. All mechanical lifts are to be performed by a two-person assist. It is imperative that all transfers involving the mechanical lift are to be handled with two (2) nursing staff members present for the entire process. Training for the use of the mechanical lift will be provided by Rehab Staff and Nursing Personal for all members of the nursing staff as well as nursing personnel assigned to home from outside nursing agencies. The staff will complete and document training upon hire and as required to correcting improper use/understanding of safe resident handling a movement. Review of facility policy Transferring Residents Using a Mechanical Lift dated 11/10/25, indicated there are always two trained staff members present when a mechanical lift is being used. All Certified Nursing Assistants will receive training prior to using the mechanical lift to move a resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 4/17/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and generalized muscle weakness. Section GG - Functional Abilities, Question GG0170E: Chair/bed-to-chair transfer indicated Resident R1 was coded 1 dependent for the ability to transfer to and from a bed to a chair (or wheelchair). Review of a physician order dated 4/9/26, indicated Resident R1 transfers with assist 2 and may use Hoyer lift (a full-body mechanical lift) with 2 assists when tired or drowsy. Review of Resident R1's comprehensive plan of care dated 4/9/26, indicated the resident is at risk for falls r/t (related to) confusion, gait/balance problems/muscle weakness/muscle wasting and atrophy (wasting or thinning) multiple sites. Resident has diagnosis of dementia/cognitive impairment. Interventions included anticipate and meet resident's needs, follow facility protocol, and transfer with Hoyer lift and two clinical staff members. Review of Resident R1's Kardex (a snapshot of resident care needs) dated 7/9/26, indicated resident transfers with Hoyer lift and two clinical staff members. Review of facility submitted documentation dated 7/9/26, indicated the following: Resident R1 was preparing for transfer from wheelchair to bed. While adjusting the sling, the resident slid forward off the edge of the wheelchair and descended to the floor. The resident's head struck the metal frame of the wheelchair before coming to rest on the floor. Resident denied pain but verbalized discomfort upon palpation (touching) of the occipital region (back of the head). Neuro status intact, [NAME] (moves all extremities), and VSS (vital signs stable). RN (Registered Nurse) placed call to DON (Director of Nursing) and MD (physician) notified. Per facility policy, resident sent to hospital for further evaluation. Review of a nursing progress note dated 7/9/26, completed by RN Employee E9 stated, At 7:35PM this nurse was notified of a fall that took place at approximately 7:30PM in room [ROOM NUMBER]. Per report from Nurse Aide (NA) Employee E1 and witness Unit Supervisor Employee E2, the resident was being transferred from the wheelchair to the bed utilizing a mechanical lift. While the sling was being positioned behind the resident in preparation for the transfer, the resident remained seated on the edge of the wheelchair. According to the witness, difficulty was encountered while applying the sling. During manipulation of the sling, the resident slid forward off the edge of the wheelchair and descended to the floor. Following the fall, it was noted that the left wheelchair brake was engaged, however, the right brake was not locked. During the descent, the resident's head struck the metal frame of the wheelchair adjacent to the front caster before coming to rest on the floor. Unit Supervisor Employee E2 had placed a pillow under the resident's head before this RN arrived at the scene. Resident has a known history of dementia, is alert and oriented 1-2. Resident denied having pain, however, she verbalized discomfort upon gentle palpation of the occipital region. Cervical spine precautions were maintained during the entire assessment. Pupils were noted to be pinpoint and sluggish bilaterally (both sides). Baseline pupillary responsiveness is unknown to this nurse. A skin tear was sustained to the right anterior (front) forearm measuring 4cm (centimeters) x 4.5cmx 0.1cm. The wound was cleansed with NSS (normal sterile saline), patted dry, OpSite (a transparent dressing that provides a waterproof, breathable barrier to protect wounds while promoting healing) applied. Resident was able to move all extremities, no obvious deformities, asymmetry, or additional acute injuries were identified during the examination. DON was informed of the circumstances via phone. Resident's daughter was contacted, informed of the above, she requested to transfer her mother to the emergency department for further evaluation as a precaution. 911 was activated and the resident was transported by EMS (emergency medical services) to the emergency department. Review of a staff witness statement dated 7/9/26, completed by Unit Supervisor Employee E2 stated, Around 7:30 p.m. I entered Resident R1's room to check to see how she was doing. I observed her in her wheelchair with the footrests off and her feet flat on the floor. NA Employee E1 was attempting to put her Hoyer lift sling under her but could not find the left side that goes under her leg. I offered to help and NA Employee E1 pulled Resident R1 forward so I could untangle the sling and at that moment Resident R1 began to slide. She slid down and hit her head of the left corner of the metal part of the seat and her backside slid to the ground. She did not hit her head on the ground. It happened so quickly but I was able to stop her from going all the way down. I then supported her upper body in my lap and called for the nurse. She had a skin tear on her arm which they treated and preceded to call the on-call phone, her daughter, and 911. Review of an undated staff witness statement, completed by NA Employee E1 stated, On Thursday July 9, about 7:30, went to get Resident R1 into bed, I got the sling as I was putting under her she slide out of chair. Review of a staff witness statement dated 7/9/26, completed by the Nursing Home Administrator (NHA) stated, On Thursday evening at approximately 6:45 p.m. I went to the resident unit to visit a resident. I noticed Resident R1 was in the dining room in her wheelchair at the table but appeared to be lethargic and leaning slightly to the left. It appeared to me that she did not feel well. After observing her for a few minutes I noticed that the nurse on duty was taking her vital signs. I approached the nurse and Resident R1 and remarked I noticed that Resident R1 seems lethargic and that she did not eat any supper from what I observed. I spoke briefly to the nurse and thought that Resident R1 should go to bed. The staff was planning on assisting her to bed as soon as possible. Unit Supervisor Employee E3 was also in the dining room when I arrived but left because Resident R1 was unable to eat. I spoke to Unit Supervisor Employee E3 and she explained that: She noticed how sleepy Resident R1 seemed to be, lethargic, barely acknowledging any attempts to get her attention. Unit Supervisor Employee E3 thought that Resident R1 may have taken a little soup, and a couple of tiny bites of her sandwich that she put to her lips. She tried to give her a few strawberries which were among her favorite foods. She would not take any. Unit Supervisor Employee E2 was sitting diagonally from Unit Supervisor Employee E3, helping another resident and alerted her that about Resident R1's condition. Unit Supervisor Employee E2 acknowledged that she had noticed it as well. Before Unit Supervisor Employee E3 left the dining room, she told the nurse, RN Employee E9, that she did not have any success in getting Resident R1 to eat or drink and that something was wrong. RN Employee E9 told Unit Supervisor Employee E3 that she and Unit Supervisor Employee E2 had discussed the situation. Unit Supervisor Employee E3 left the unit after that. Review of an undated staff witness statement, completed by Unit Supervisor Employee E3 stated, On said day, at the time of the evening meal, I noted how sleepy Resident R1 seemed to be, lethargic, barely acknowledging any attempts to get her attention. She may have taken a little soup, I am not sure, and a couple of tiny bites of her sandwich that I actually put to her lips. I got her a few strawberries which were among her favorite foods. She would not take any. Unit Supervisor Employee E2 was sitting diagonally from me, helping another resident. I said something to her referencing Resident R1's condition. She let me know she also noticed it. Before I left the dining room, I told the nurse, RN Employee E9, that I did not have any success in getting Resident R1 to eat or drink, that something was wrong. RN Employee E9 told me she and Unit Supervisor Employee E2 had discussed the situation. I left the unit after that. No additional staff witness statements were provided by the facility. On 8/26/26, at 10:33 a.m. the State Agency (SA) attempted to call NA Employee E1 to obtain a telephonic statement. A voicemail was left requesting a return call. NA Employee E1 never returned a call to the SA. Review of the facility-provided investigation documents failed to include a witness statement obtained from RN Employee E9. During an interview on 8/26/26, at 10:36 a.m. the DON stated, The nurse on duty during the incident was RN Employee E9, she no longer works at the facility. She was contracted through a staffing agency. RN Employee E9 was not in Resident R1's room during the incident. Review of a signed Mechanical Lift Training policy indicated NA Employee E1 was trained and signed off as competent on mechanical lift operation on 2/17/26. During an interview on 8/26/26, at 12:56 p.m. Unit Supervisor Employee E2 stated, I was making my final rounds on the household before I went to bed. Resident R1 wasn't feeling good earlier, NA Employee E1 was putting the sling on her. It was a toileting sling because Resident R1 is able to move her arms. I could see NA Employee E1 was struggling, so I asked if I could help, the sling was twisted behind Resident R1. I had Resident R1 on the edge of the chair trying to get the sling off of her, Resident R1 slid down, she didn't hit the floor. I caught her, she hit the back of her head where the footrests go on the wheelchair. She slid down the chair. We sent her to the hospital to make sure she was ok. NA Employee E1 was putting the toileting sling on Resident R1 when I came in the room, Resident R1 only uses the toileting sling because she is able to follow directions. Resident R1 was more lethargic than normal at that time. We received education on the mechanical lifts, new staff receive the education during orientation and NA Employee E9 gives a second orientation to the new staff. There should be two people in the room, the whole process should always be two people. I would not put a sling on a resident by myself if the resident was more lethargic, I wouldn't feel comfortable. During an interview on 8/26/26, at 1:52 p.m. the DON stated, We investigated to rule out neglect, we talked with NA Employee E1 and Unit Supervisor Employee E2. RN Employee E9 called me, said we had to send Resident R1 out, she fell and smacked her head off of the floor, I said ok, let me contact the doctor, called her back. Unit Supervisor Employee E2 said Resident R1 didn't smack her head off of the floor. We ruled out neglect because of the conflicting staff witness statements and two staff members were in the room at the time of the incident, they were following policy. During an interview on 8/26/26, at 1:59 p.m. the DON confirmed that the facility failed to thoroughly investigate an accident to rule out the potential for neglect for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1)(2) Management.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, clinical records, and staff interviews, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm resulting in a scalp laceration, requiring three staples for one of three residents reviewed (Resident R35). Findings include: Review of the facility Abuse, Neglect, mistreatment, and Misappropriation of Resident Property policy dated 11/10/25, revealed neglect is the failure of the facility, it's 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 the facility Mechanical Lift, Use Of policy dated 11/10/25, revealed the facility wants to ensure that the residents are cared for safely while maintaining a safe work environment for employees. Nursing staff members will assess each resident prior to transferring them to determine the safest way to accomplish the transfers. It is imperative that all transfers involving the mechanical lift are to be handled with two nursing staff members present. Review of Resident R35's admission record indicated resident was admitted to the facility on [DATE], with diagnoses of Non-Alzheimer's Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), depression, and muscle weakness. Review of Resident R35's care plan dated 12/19/22, revealed the resident required a full body lift assist of two persons for transfers. Review of the Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated 6/6/25, revealed the diagnoses were current. Section GG: Functional Abilities, Section GG0170 indicated Resident R35 was dependent on staff for bed to chair transfers. Review of Resident R35's progress note dated 8/20/25, revealed Resident R35 slipped out of lift pad and onto floor. The resident was laying on their back on the floor; bleeding was observed from the back of head. The physician was notified and the resident was transferred to the hospital for evaluation. Review of Resident R35's hospital records dated 8/20/25, revealed Resident R35 sustained scalp laceration following a fall. Resident R35 required three staples. Review of Nurse Aide (NA) Employee E3's witness statement dated 8/20/25, revealed NA Employee E3 walked into Resident R35's room looking for help with a transfer for another resident. NA Employee E1 had Resident R35 in the Hoyer lift and out of her wheelchair. Resident R35 was not hooked up properly in the lift. The straps were not all hooked to the lift, and Resident R35 was leaning forward with the upper straps around her neck and shoulders. While NA Employee E3 was trying to get Resident R35 to the bed, NA Employee E1 was watching me and not helping me and Resident R35 fell out of the sling and onto the floor. Review of Registered Nurse (RN) Employee E4's witness statement dated 8/20/25, revealed the resident was observed on the floor, lying on back. It was revealed resident slid out of lift pad during lift and landed on floor. Bleeding noted on floor from back of resident's head. Physician was notified and the resident was sent to hospital for further evaluation. Review of report submitted on 8/21/25, revealed Resident R35 was transferred to the hospital following an injury during a transfer. NA Employee E1 initially hooked the resident up to a whole-body lift, she lifted the resident up from chair with lift and started to move from wheelchair to bed. NA Employee E3 entered the room to help move her, but sling was not on right and they both tried to help move her to the bed fast, but she slid through the lift to floor. The resident returned back to the facility with three staples to back of head. Review of NA Employee E2's witness statement dated 8/21/25, revealed on Monday, 8/18/25, NA Employee E1 was observed coming out of Resident R35's room around 8:30 p.m. by herself pushing the full body lift. NA Employee E2 asked NA Employee E1 if she put Resident R35 in bed by herself and she said no. NA Employee E2 said Ok good because you must always be two people for the lift. Review of NA Employee E1's witness statement dated 8/22/25, indicated while in the process of putting Resident R35 to bed, it was noticed the resident was going to fall on the side. Resident R35 fell out of the side of the sling onto the floor Review of the facility incident report dated 8/31/25, revealed on 8/20/25, at 9:15 p.m., NA Employee E1 transferred Resident R35 from high back wheelchair to bed, and the resident slid out of lift pad and fell onto floor. NA Employee E1 should have double checked lift was on properly. The resident returned back to the facility with three staples to the back of head. During an interview on 1/20/26, at 1:20 p.m. NA Employee E2 stated a few days before Resident R35 was injured on 8/20/25, NA Employee E1 was observed coming out of the room with the lift and asked her if she transferred the resident by herself. NA Employee E2 informed NA Employee E1 to ensure two people assist with the lift at all times. NA Employee E2 stated then on 8/20/25, NA Employee E3 walked into Resident R35's room, and the resident was in the air, and the sling only had two rings attached instead of three. During an interview on 1/20/26, at 1:22 p.m. the Director of Nursing revealed NA Employee E1 was terminated after the incident involving Resident R35. During an interview on 1/20/26, at 1:41 p.m. RN Employee E4 stated she recalls Resident R35, and in order to transfer her from out of bed to wheelchair, a lift must be used, and two people must be used. Someone can hook up, but we always double check, never transfer without lifting. It was revealed on that particular day, NA Employee E1 hooked Resident R35 to the Hoyer lift to transfer her from her wheelchair to bed and was transferring her by herself. The resident fell out of lift pad onto floor. It was revealed the resident required three staples to her scalp. During an interview on 1/20/26, at 2:20 p.m. NA Employee E3 stated I needed assistance from another aide, and when I entered into Resident R35's room, I found the resident was already out of the chair, in the air. NA Employee E3 indicated the resident's lift pad wasn't properly hooked up by NA Employee E1. There was not a middle hook attached. Resident R35 was bent forward, and there was no safe way to put her back in the chair. When NA, Employee E3 attempted to transfer the resident in the bed, the resident fell out and fell on their head. It was indicated NA Employee E1 was near the head of the resident. Review of NA Employee E1's personnel file on 1/22/26, revealed a hire date of 7/7/25, and NA, Employee E1 received NA training and competencies for activity of daily living training, mechanical lift and safety, and transferring residents using a mechanical lift on 7/7/25. During an interview on 1/22/26, at 10:04 a.m. the Director of Nursing confirmed the facility failed to protect a resident from neglect that resulted in actual harm resulting in a scalp laceration, requiring three staples for one of three residents reviewed (Resident R35). 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) Resident care policies 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to ensure that residents received adequate assistance to prevent accidents, which resulted in actual harm, requiring three staples for one of three residents reviewed (Resident R35). Findings include: Review of the facility Accident/Incident Reports, Residents policy dated 11/10/25, revealed the purpose of the policy is to ensure quality resident care and to prevent or treat complications. An accident is an event that results in bodily injury or potential injury and/or causes a change in a resident's status. Review of the facility Mechanical Lift, Use Of policy dated 11/10/25, revealed the facility wants to ensure that the residents are cared for safely while maintaining a safe work environment for employees. Nursing staff members will assess each resident prior to transferring them to determine the safest wat to accomplish the transfers. It is imperative that all transfers involving the mechanical lift are to be handled with two nursing staff members present. Review of Resident R35's admission record indicated resident was admitted to the facility on [DATE], with diagnoses of Non-Alzheimer's Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), depression, and muscle weakness. Review of Resident R35's care plan dated 12/19/22, revealed the resident required a full body lift assist of two persons for transfers. Review of the Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated 6/6/25, revealed the diagnoses were current. Section GG: Functional Abilities, Section GG0170 indicated Resident R35 was dependent on staff for bed to chair transfers. Review of Resident R35's progress note dated 8/20/25, revealed Resident R35 slipped out of lift pad and onto floor. The resident was laying on their back on the floor, bleeding was observed from the back of head. The physician was notified and the resident was transferred to the hospital for evaluation. Review of Resident R35's hospital dated 8/20/25, revealed Resident R35 sustained scalp laceration following a fall. Resident R35 required three staples. Review of Nurse Aide (NA) Employee E3's witness statement dated 8/20/25, revealed NA Employee E3 walked into Resident R35's room looking for help with a transfer for another resident. NA Employee E1 had Resident R35 in the Hoyer lift and out of her wheelchair. Resident R35 was not hooked up properly in the lift. The straps were not all hooked to the lift, and Resident R35 was leaning forward with the upper straps around her neck and shoulders. While NA Employee E3 was trying to get Resident R35 to the bed, NA, Employee E1 was watching me and not helping me and Resident R35 fell out of the sling and onto the floor. Review of Registered Nurse (RN) Employee E4's witness statement dated 8/20/25, revealed the resident was observed on the floor, lying on back. It was revealed resident slid out of lift pad during lift, and landed on floor. Bleeding noted on floor from back of resident's head. Physician was notified and the resident was sent to hospital for further evaluation. Review of report submitted on 8/21/25, revealed Resident R35 was transferred to the hospital following an injury during a transfer. NA Employee E1 initially hooked the resident up to a whole-body lift, she lifted the resident up from chair with lift and started to move from wheelchair to bed. NA Employee E3 entered the room to help move her, but sling was not on right and they both tried to help move her to the bed fast, but she slid through the lift to floor. The resident returned back to the facility with three staples to back of head. Review of NA Employee E2's witness statement dated 8/21/25, revealed on Monday, 8/18/25, NA Employee E1 was observed coming out of Resident R35's room around 8:30 p.m. by herself pushing the full body lift. NA, Employee E2 asked NA, Employee E1 if she put Resident R35 in bed by herself and she said no. NA Employee E2 said Ok good because you must always be two people for the lift. Review of NA Employee E1's witness statement dated 8/22/25, indicated while in the process of putting Resident R35 to bed, it was noticed the resident was going to fall on the side. Resident R35 fell out of the side of the sling onto the floor Review of the facility incident report dated 8/31/25, revealed on 8/20/25, at 9:15 p.m., NA Employee E1 transferred Resident R35 from high back wheelchair to bed, and the resident slid out of lift pad and fell onto floor. NA Employee E1 should have double checked lift was on properly. The resident returned back to the facility with three staples to the back of head. During an interview on 1/20/26, at 1:20 p.m. NA Employee E2 stated a few days before Resident R35 was injured on 8/20/25, NA Employee E1 was observed coming out of the room with the lift and asked her if she transferred the resident by herself. NA Employee E2 informed NA Employee E1 to ensure two people assist with the lift at all times. NA Employee E2 stated then on 8/20/25, NA Employee E3 walked into Resident R35's room, and the resident was in the air, and the sling only had two rings attached instead of three. During an interview on 1/20/26, at 1:22 p.m. the Director of Nursing revealed NA Employee E1 was terminated after the incident involving Resident R35. During an interview on 1/20/26, at 1:41 p.m. RN Employee E4 stated she recalls Resident R35, and in order to transfer her from out of bed to wheelchair, a lift must be used, and two people must be used. Someone can hook up, but we always double check, never transfer without lifting. It was revealed on that particular day, NA Employee E1 hooked Resident R35 to the Hoyer lift to transfer her from her wheelchair to bed and was transferring her by herself. The resident fell out of lift pad onto floor. It was revealed the resident required three staples to her scalp. During an interview on 1/20/26, at 2:20 p.m. NA Employee E3 stated I needed assistance from another aide, and when I entered into Resident R35's room, I found the resident was already out of the chair, in the air. NA Employee E3 indicated the resident's lift pad wasn't properly hooked up by NA Employee E1. There was not a middle hook attached. Resident R35 was bent forward, and there was no safe way to put her back in the chair. When NA Employee E3 attempted to transfer the resident in the bed, the resident fell out and fell on their head. It was indicated NA Employee E1 was near the head of the resident. During an interview on 1/21/26, at 2:10 p.m. RN Employee E6 stated when nurse aides use a Hoyer lift, they must get help, even before lifting the resident. During an interview on 1/21/26, at 2:16 p.m. NA Employee E7 stated two people must be present prior to lifting a resident in a Hoyer lift. Resident must be properly placed in lift pad; one person should be in front and one person in back to guide Hoyer lift. During an interview on 1/22/26, at 10:04 a.m. the Director of Nursing confirmed the facility failed to ensure that residents received adequate assistance to prevent accidents that resulted in actual harm resulting in a scalp laceration, requiring three staples for one of three residents reviewed (Resident R35). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.Findings include: Review of facility policy Food Safety and Sanitation, dated 11/10/25, indicated all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. During an observation and interview with Dietary Supervisor (DS) Employee E5 in the Main Kitchen on 1/20/26, at 10:44 a.m. the cold air condenser unit, (3) fan covers, and the ceiling immediately forward in the produce and production walk-in cooler had a build-up of dust, grime, and dark colored debris. During an observation and interview with Dietary Supervisor (DS) Employee E5 in the Main Kitchen on 1/20/26, at 10:48 a.m., the cold air condenser fan covers in the dairy walk-in cooler had a build-up of dust, grime, and dark colored debris. During an interview on 1/20/26, at 10:48 a.m., DS Employee E5 confirmed that the facility failed to properly maintain (2) walk-in coolers in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on effective communication for nine of ten staff members (Nurse Aides (NA) Employee E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, Licensed Practical Nurse (LPN) Employee E10, and Registered Nurse (RN) Employee E11).Findings include:Review of facility provided documents and training records for NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, LPN Employee E10, and RN Employee E11 failed to include education on effective communication as required.Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training on effective communication for nine of ten staff members (NA E2, NA E3, NA E4, NA E5, NA E6, NA E7, NA E9, LPN Employee E10, and RN Employee E11).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide Compliance and Ethics training for three of ten staff members (Nurse Aides (NA) Employees E2, NA E3, and NA E4).Findings include:Review of facility provided documents and training records for NA Employees E2, NA E3, and NA E4, failed to include education on Compliance and Ethics as required.Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training for Compliance and Ethics for three of ten staff members (NA Employees E2, NA E3, and NA E4).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide Behavioral training for three of ten staff members (Nurse Aides (NA) Employee E6, NA E8, and Licensed Practical Nurse (LPN) Employee E10.Findings include:Review of facility provided documents and training records for NA Employee E6, NA E8, and LPN Employee E10 failed to include Behavioral training as required.Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide Behavioral training for three of ten staff members (Nurse Aides (NA) Employee E6, NA E8, and Licensed Practical Nurse (LPN) Employee E10.28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for three of ten staff members (Nurse Aides (NA) Employees E2, NA E3, and NA E4).Findings include:Review of facility provided documents and training records for NA Employees E2, NA E3,and NA E4, failed to include education on QAPI as required.Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training for QAPI for three of ten staff members (NA Employees E2, NA E3, and NA E4).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on review of facility education documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for one of ten staff members (Nurse Aide (NA) Employee E4).Findings include:Review of facility provided documents and training records for NA Employee E4 failed to include education on Resident Rights as required.Interview on 10/28/25, at 2:30 p.m. the Nursing Educator Employee E12 confirmed that the facility failed to provide training on Resident Rights for one of ten staff members (NA Employee E4).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision during bathing for one of three residents (Resident R1). This failure was determined to be past non-compliance. Findings include: Review of the facility policy Bath, Mechanical Lift dated November 2024, indicated before helping resident into or out of chair, lock the wheels of the carrier. Lock the carrier onto patient transfer lift. Be sure belts are tight on chair. Before moving resident, fasten seat belt onto resident. Review of the facility's Resident Bathing Safety: Quick Reference Guide dated November 2024, indicated review care plan for bathing assistance level. Stay with resident at all times. If you must step away: call another aide or nurse to stay with the resident. Never rely on just telling them to wait. Use proper lifting/transfer equipment as needed. Use all available safety mechanisms, i.e. bars, seatbelts, etc. Unsupervised bathing is a serious violation of resident rights, facility policy and federal regulations. Review of the admission Record indicated Resident R1 was admitted to the facility on [DATE]. Review of R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/13/25, indicated the diagnoses of high blood pressure, arthritis (inflammation and pain in the joints), and Schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behaviors, and decreased participation in activities of daily living). Section C0500 - Brief Interview for Mental Status (BIMS -is a screening test that aids in detecting cognitive impairment) indicated a score of thirteen - cognitively intact. Review of Resident R1's current care plan, indicated resident needs assistance with activities of daily living (ADL's). Staff will assist her into the tub twice weekly. Review of Resident R1's progress note dated 9/29/25, at 7:50 a.m. indicated staff was informed that Resident R1 was in the bathing room yelling for help. At the time staff heard yelling, they ran into bathing room and found resident sliding down in the bath chair. They immediately pulled resident up in the chair and secured the safety belt. Review of facility provided documentation dated 9/29/25, at 7:35 a.m. indicated the household supervisor arrived on unit and heard screaming coming from the bathing room. Resident R1 was in bath chair sliding down and water was up to the collarbone/neck and resident was yelling, Help me, help me. Bath chair belt was not strapped, handlebar was not in front of resident, and the bath chair wheels were unlocked. When asked who put resident in the tub, resident responded The agency girl. The supervisor and another Nurse Aide (NA) drained some water and used a towel to sit resident up and strapped resident into bath chair. Once secure, the bath was completed and hair washed. Resident denied going under the water. No noted injuries. Assessment of resident: respirations easy and unlabored, lungs clear throughout, vital signs stable, and afebrile. Interview on 10/28/25, at 9:35 a.m. Resident R1 indicated recalling the episode in the bathtub. Resident indicated feeling temporarily terrified at the time of being left alone in the tub. Resident believes it was overall about ten minutes because the agency NA left immediately after placing resident in the tub. Resident stated the NA was asking the resident how the machine works, because the facility had not taught NA how to use it. Resident indicated they were not afraid of bathing and felt safe as long as the regular staff took care of resident. Interview with the Director of Nursing on 10/28/25, at 11:00 a.m. confirmed the facility failed to provide adequate supervision during bathing for one of three residents (Resident R1) and requested past non-compliance status be reviewed for the event and handed over information on immediate interventions and education that had been completed on bathing and supervision by the facility. Review of the facility's corrective actions on 10/28/25, at 2:45 p.m. verified the following had been met by the facility:-Resident R1 was immediately assisted in tub, assessed by nursing and physician with no injuries and only temporarily terrified during the time left alone in the tub.-NA Employee E1 was interviewed and immediately sent home from the facility.-Resident R1's care plan was updated on 9/29/25, indicated resident has had a bad experience while being bathed in the whirlpool. Resident will express satisfaction and comfort with their bathing routine. Resident will only be assisted with bathing by trained staff and will not be left alone during bathing. Social services to visit and monitor mood and behaviors and offer counseling to express any feelings about the incident. Staff will encourage resident to express concerns regarding bathing.-Review of Resident R1's progress notes revealed seventeen daily visits from social services from 9/29/25, through 10/27/25. Resident expressed no ill effects from the incident.-All nursing staff 66 of 66 facility nursing staff and 11 of 15 agency nurse aides were re-educated on resident bathing safety and equipment, and ensuring a resident in a tub is never left unattended.-In person interviews on 10/28/25, indicated six of six NAs on site received training and understood the education.-Any new facility nursing staff or newly assigned agency staff will receive resident bathing safety and equipment, and ensuring a resident in a tub is never left unattended prior to the start of their shift.-Observation on 10/28/25, of all four whirlpool rooms in the facility indicated appropriate equipment available and signage with safety reminders in all areas for staff reference.-As of 10/6/25, over 95% of nursing staff received training and education, and the facility was determined to be past non-compliance as of 10/6/25. Exit interview on 10/28/25, at 2:45 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain each resident received adequate supervision during bathing for one of three residents (Resident R1) and that the facility had successfully met the task of Past Non-Compliance effective 10/6/25, when the corrective actions were achieved by the facility. 28 Pa. Code 201.14 Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29 Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on review of facility policy, clinical record review and resident and staff interview it was determined that the facility failed to provide medically related social services for one of three resident reviewed (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE]. Resident R1 MDS (minimum data set periodic assessment of resident needs) dated 4/14/25, indicated diagnosis of Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance), bipolar disease (mental health condition causes extreme mood swings) and anxiety disorder. Review of facility documentation submitted to the state survey office dated 5/2/25, indicated: Medical driver took 2 residents to AGH hospital for 2 different appointments, took one resident in hospital and went back to get Resident R1 out of the van when Medical Driver noticed he didn't have the lift up and tried to pull her back but she fell to the ground striking the left side. Resident R1 was immediately surrounded by paramedics and hospital staff and she was put into ER to be evaluated and treated. Review of facility documentation indicated a psychiatric progress note completed on 5/12/25, with the following concerns/recommendations: Background information: long standing Bipolar disorder, Hx of past hallucinations History of present psychiatric illness: 5/12/25, psych visit: 1 week ago fell out of a van when lift not in alignment . Resident keeps asking same questions and insist she hit her head though she didn't according to staff. Obsessing about incident. Interview with resident: Resident R1 would like to see a counselor again, especially now that she can't stop thinking about the fall out of van. States she talks about it with everyone and has a hard time not thinking about it. Impressions: Mood ok., but displays preoccupation with thoughts of recent fall, would like to talk with therapist about this so she can stop thinking over it again and again. Recommendations: Please obtain psychology counseling for Resident R1, especially in light of recent trauma in May 2025. During interview on 5/21/25, at 9:50 a.m. Social Service Employee E2 indicated that the facility has not had a counseling service that comes in since last year, they currently do not have a counseling appointment set up for Resident R1 and the facility failed to provided medical social services for Resident R1. 28 Pa. Code 211.10(a) Resident care policies

Based on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for one of three residents (Resident R1). Findings include: Review of facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated November 2024 through November 2025, indicated: Neglect is the failure of the home, 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 Resident R1 was admitted to the facility on [DATE]. Resident R1 MDS (minimum data set periodic assessment of resident needs) dated 4/14/25, indicated diagnosis of Parkinson's disease ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance), bipolar disease (mental health condition causes extreme mood swings) and anxiety disorder. Review of facility documentation submitted to the state survey office dated 5/2/25, indicated Medical driver took 2 residents to AGH hospital for 2 different appointments, took one resident in hospital and went back to get Resident R1 out of the van when Medical Driver noticed he didn't have the lift up and tried to pull her back but she fell to the ground striking the left side. Resident R1 was immediately surrounded by paramedics and hospital staff and she was put into ER to be evaluated and treated. Review of facility documentation witness statement from Employee E1 Medical Driver indicated that the lift was not up and they confirmed that they failed to put the lift into the proper position. During an interview on 5/20/25, at 4:35 p.m. Director of Nursing (DON) confirmed that Employee E1 Medical Driver did fail to put the lift in the appropriate position, and Resident R1 did fall from the van. During an interview on 5/20/25, at 4:40 p.m. DON was informed that the facility failed to protect Resident R1 from neglect with the van lift not being in the appropriate position and Resident R1 failing form the van. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10 (a) (d) Resident care policies

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1). This failure created an immediate jeopardy situation for one of four residents (Resident R1). Findings include: Review of the facility Elopement Risk policy last reviewed 11/1/24, indicated all residents are assessed for elopement risk and those found to be at risk will have a resident care plan that addresses this issue. Policy is to attempt to prevent incidents of elopement and to provide for the safety and well-being of all residents. A resident elopement risk assessment will be performed at the following times: - At time of admission - After an elopement attempt - Verbalizing desire to leave the facility - Anytime a staff member feels a need to reassess a resident In the event an incident of elopement the attending physician is made aware of the incident, the resident's representative or family is notified, an incident report is completed, staff will encourage activities that the resident enjoys in order to provide diversion to the resident. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/5/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of Section C0500-BIMS screening indicated a score of 8, which indicated Resident R1 was moderately impaired. Review of Resident R1's admission Elopement Risk assessment dated [DATE], revealed the assessment score was a four and placed resident as a moderate risk for elopement. Elopement Risk Assessment indicated that resident had no wandering episodes and walked independently. Review of Resident R1's physician order dated 3/5/21, indicated the resident may go on therapeutic leave with family/staff with medications. Review of Resident R1's clinical record indicated that she resided on the Second Floor in a private room. Review of documentation provided by the facility to the Department of Health on 4/6/25, indicated that a staff member (Activity Employee E9), who was leaving for the day, observed Resident R1 outside the building on the loading dock, walking down the steps towards the parking lot. Resident R1's wheelchair was noted to be sitting on the loading dock. Resident R1 was seen 15 minutes prior to the incident in her room where the nurse was administering her medication. Resident R1 had left the unit there after and made her way off the unit, to the ground floor and through the outside doors to exit the building. On the date of incident, resident was noted to be more confused than usual. Review of a progress note dated 4/5/25, at 5:22 p.m. revealed that the resident was brought to unit by activities staff, who stated that she found resident outside when she (staff) was leaving the parking lot. Staff says she found resident at the bottom of the loading zone stairs by the kitchen area on the north side of the building. Resident's wheelchair was at the top of the stairs and resident was at the bottom of the stairs holding on to the railing. Staff brought resident back to the unit in her wheelchair. Resident appeared unharmed but was scared. Resident reminded not to leave the unit, and especially not to go on the elevators. Director of Nursing (DON) and supervisor notified. Supervisor to notify resident's nephew. Incident report completed and faxed to physician office. New order received for a Wander Guard monitor to resident's right ankle. Review of Resident R1's physician orders failed to reveal check placement of wander guard, check function of wander guard, and when to replace the wander guard. No other interventions were implemented to increase resident supervision and increase resident safety. Resident R1's care plans were not updated. During a tour on 4/15/25, at 9:02 a.m. with the DON, revealed that the Second Floor of the facility failed to have wander guard alarms on the doors leading off the unit and that the general elevator that is used by residents and visitors fail to lock if someone is wearing a wander guard bracelet. Review of Resident R1's clinical record on 4/15/25, indicated that facility failed to complete an Elopement Risk Assessment from 3/7/21 through 3/29/25. Resident R1's most recent Elopement Risk Assessment was completed on 3/30/25, and 4/5/25, indicating she was at risk for elopement. During an interview on 4/15/25, at 9:45 a.m. Registered Nurse Assessment Coordinator Employee E8 stated that elopement risk assessments are completed upon admission and if they have a wander guard due to them being identified as a high elopement risk, then they would have an elopement risk assessment quarterly. During a review of the facility's Incident Report for Resident R1's elopement on 4/5/25, at 4:30 p.m., revealed Resident R1 was in her room at 4:15 p.m. receiving her evening medication. Resident left unit. Resident was found on back outside loading dock on steps, was very confused. No noted injuries. Wander guard placed on right lower leg. Family notified. Physician was notified. Resident calmed down afterwards after remaining with staff. Activity Employee E9 stated, I was leaving work at 4:30 p.m. I witnessed Resident R1 at the bottom of the steps on the loading dock standing. Her wheelchair was at the top. No other witness statements were obtained. During an interview on 4/15/25, at 9:30 a.m. DON stated that the facilities video surveillance revealed resident entering the loading dock through the doors and was seen on the loading dock. The cement column blocked the view of resident walking down the steps. DON stated that the resident was more confused on that day and reported that Resident R1 stated she was scared when they found her. During a review of Resident R1's progress notes from 4/27/24 through 4/15/25 indicated the following: On 4/27/24, at 10:56 p.m. a progress note indicated resident was found on ground level near the kitchen by the garbage dumpsters by the kitchen staff. Came back to second floor. [NAME] was found in another room on the unit behind the closed door in her motorized wheelchair. Was redirected back to her room. Resident was very confused. During a review of Resident R1's clinical record indicated the facility failed to identify this incident as an elopement. Failed to complete a head-to-toe assessment. Failed to complete elopement risk assessment. Failed to notify family and physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. Facility failed to notify appropriate agencies of an elopement, as required. On 4/28/24, at 2:10 a.m. a progress note indicated staff reports that resident has been resting quietly in bed. At 2:00 a.m., writer rounded on resident and observed her laying quietly on her left side in bed. Recommend a wander guard device to her wheelchair due to reports of increased episodes of anxiety and confusion. Voice message of the same left for DON. Follow up with MD as warranted, as needed. During a review of Resident R1's clinical record indicated the facility failed to complete an Elopement Risk Assessment and failed to notify the physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. On 5/8/24, at 6:16 p.m. a quarterly occupational therapy (OT) screen completed revealed Resident R1 has been presenting with increased confusion and wandering, especially overnight. She was recently followed by OT for a plan of care due to an increased need for assistance with ADLs and transfers. While she did demonstrate the ability to perform required physical tasks, she remains unsteady and requires supervision for safety, cues, and redirection. She presented to therapy department in her power wheelchair wearing pajamas at 4:30 p.m. today, requesting water for a fell ow resident. Due to cognitive deficits and limited carryover of education, no need for OT intervention identified at this time. Resident will continue to benefit from oversight and supervision of staff for safety and redirection. On 5/18/24, at 1:10 a.m. a progress note indicated at the beginning of the shift writer observed resident in a non-electric wheelchair wheeling self-down the hallway. Writer inquired of evening nurse why the resident not using her electric wheelchair. Informed that two days ago, resident was found downstairs in a closet. Nurse stated, Nursing Home Administrator had instructed her to keep the resident on the unit. Therefore, resident was assisted to a regular wheelchair for monitoring whereabouts. At 11:05 p.m. resident observed in the wheelchair and wandering down the hallway then back to her room. 11:20 p.m., again up in the hallway in her wheelchair. Offered her a snack with tea requested and hot tea given at table but, resident went back to her room. 12:25 a.m. resident returned to the table and drank her tea. At 12:45 a.m. returned to her room. Safety measures maintained. Call pendant around her neck. During a review of Resident R1's clinical record indicated the facility failed to identify an incident from two days ago as an elopement. No documentation completed for the alleged incident. Failed to complete a head-to-toe assessment. Failed to complete elopement risk assessment. Failed to notify family and physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. Facility failed to notify appropriate agencies of an elopement, as required. On 5/26/24, at 11:09 p.m. a progress note indicated the resident was found on the first floor in her wheelchair. Was confused. Was escorted back to her unit. During a review of Resident R1's clinical record indicated the facility failed to identify this incident as an elopement. Failed to complete a head-to-toe assessment. Failed to complete elopement risk assessment. Failed to notify family and physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. Facility failed to notify appropriate agencies of an elopement, as required. On 1/31/25, at 11:44 p.m. a progress note indicated the resident was attempting to elope. She is going to every door she sees to open it and get out. Staff explaining to her its late and everyone is sleeping, and all the doors are locked. So, at present time she is getting into bed. Monitoring. During a review of Resident R1's clinical record indicated the facility failed to complete an Elopement Risk Assessment due to exit seeking behaviors and failed to notify the physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. On 2/14/25, at 5:50 p.m. a Physical Therapy quarterly screen completed revealed, resident independent on unit with mobility in manual wheelchair, participated with ambulation 15 feet with no reports of decline in mobility at this time, no intervention needed at this time. On 2/17/25, at 2:19 p.m. revealed resident had a fall. On 2/28/25, at 12:40 p.m. a progress note indicated that resident was moving herself around unit via wheelchair, speaking to staff. Resident stated, take me to work I have to get paid I have to go back home. Resident held her TV remote and asked staff to call the timekeeper. Unit supervisor aware of resident's behavior. DON made aware, urine sample to be obtained. During a review of Resident R1's clinical record indicated the facility failed to complete an Elopement Risk Assessment due to exit seeking behaviors and failed to notify the physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. On 3/19/25, at 7:07 a.m. a progress note indicated that resident stayed up throughout night, trying many times to go out of the main door (on unit). Continue following behind staff, entering other resident rooms. Number of times noted and when: three to four times. Interventions/redirection attempted: Resident was reminded not to go to the door and was taken away from main door. Was reminded and taken away from other resident's room. Resident also cursed at the staff. When resident was praised. Evaluation of interventions: Resident was quiet down after praises. During a review of Resident R1's clinical record indicated the facility failed to complete an Elopement Risk Assessment due to exit seeking behaviors and failed to notify the physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. On 3/30/25, at 10:41 p.m. a progress note indicated that resident found on first floor at reception desk by front door by staff. Was brought back up and returned to unit. Currently wandering on unit. Staff completed an Elopement Evaluation and Resident R1 scored a 2, indicating resident is at high risk for elopement. During a review of Resident R1's clinical record indicated the facility failed to identify this incident as an elopement. Failed to complete a head-to-toe assessment. Failed to respond to a high-risk elopement risk assessment. Failed to notify family and physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. Facility failed to notify appropriate agencies of an elopement, as required. On 4/8/25, at 10:44 p.m. a progress note indicated that the resident wondered out in hallway by units then went over to another unit. Was returned to her room and given a snack. During a review of Resident R1's clinical record indicated the facility failed to identify this incident as an elopement. Failed to complete a head-to-toe assessment. Failed to complete an elopement risk assessment. Failed to notify family and physician. Care plans were not updated. No other interventions were implemented to increase resident supervision and increase resident safety. Facility failed to notify appropriate agencies of an elopement, as required. On 4/13/25, at 2:25 p.m. a progress note indicated that resident found on the ground floor in the kitchen, by kitchen staff approximately 12:45 pm. Resident's wander guard on and functioning properly. No injuries noted. Unit supervisor aware and Nursing Home Administrator. Room change was completed after this incident to the First floor where two out of four sets of doors have wander guard systems on them due to wandering behaviors. During a review of Resident R1's clinical record indicated the facility failed to identify this incident as an elopement. Failed to complete a head-to-toe assessment. Failed to complete an elopement risk assessment. Failed to notify family and physician. Care plans were not updated. No other interventions, other than room change, were implemented to increase resident supervision and increase resident safety. Facility failed to notify appropriate agencies of an elopement, as required. During a review of Resident R1's clinical record revealed the following: - On 5/15/24, Resident R1 was given a new diagnosis of Dementia. - On 6/20/24, BIMS score was 8, indicating moderately impaired. - On 3/5/25, BIMS score was 8, indicating moderately impaired. - On 4/15/25, An elopement risk assessment completed, indicating a 16, high risk for elopement. On 4/15/25, at 3:30 p.m. the Nursing Home Administer and DON were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 4/5/25. The Nursing Home Administer and DON were provided the Immediate Jeopardy template, and a corrective action plan was requested. On 4/15/25, at 7:42 p.m. an immediate action plan was received and accepted which included the following interventions: An elopement assessment will be done on every resident by 4/16/25, at 8:00 a.m. Resident R1 now has a wander guard and is moved to the first floor where the alarms are located. Resident R1 has been assessed for injury and family was notified of all the events. Elopement care plans, which include resident specific interventions, will be done on every resident by 4/16/25, at 8:00 a.m. Hourly rounds will be added to all night and weekend shifts. Wander guard placement will be checked every shift, and wander guard function will be checked daily. This can be found in the residents chart under doctor orders and treatment administration record. At risk residents must be supervised when out of bed by a staff member to ensure residents are safe. Educate all departments including agency by 12:00 p.m. on 4/16/25 on the following: - Elopement Risk and Assessment - Care plans - Supervision - Wander guards - How to activate wander guards and where they are located - Color light indicators Elopement policy revised 4/15/25, to add the following: - Head to toe assessment (full body) is added - Elopement risk assessments will be done quarterly with care plan review - Elopement binders will be on each nurse's station and front desk, to include picture and room number. Elopement binders on the nurse's station will include residents care plan and will be updated as needed. - All departments will be educated on elopement risk and assessment and will be added to the new hire training as well. Emergency Quality Assurance Performance Improvement (QAPI) meeting will be held 4/16/25 with all supervisors and committee members. All other incidents will be reviewed at regular QAPI meetings. Audits will be completed. On 4/16/25, at 8:35 a.m. all residents with wander guards had completed orders to include, location of wander guard, check placement every shift, check function daily, and wander guard light indicator mean. On 4/16/25 at 8:50 a.m., all resident assessments for elopement risk were reviewed and found to be completed, and care plans were reviewed and updated with resident specific interventions for 41 of 41 residents. On 4/16/25, the facilities audit tool was reviewed. Daily audits will be completed by DON or designee daily for two weeks, then weekly for three weeks, then monthly for three months, and then quarterly. On 4/16/25, the facilities Hourly Round tool was reviewed. Will be conducted at night and on the weekends. On 4/16/25, the facility called and emergency QAPI meeting, and signature sheet was provided and reviewed. During a tour of the facility on 4/16/25, elopement binders were observed on all nursing units and front desk with pictures and care plans that allow staff quick access to resident specific behaviors to aid in redirecting a resident. Staff education was verified with dated sign-in sheets and review of all current staff and agency staff utilized in the facility having signed and/or educated over the phone as indicated. During in-person and phone interviews completed from 4/16/25, at 1:20 p.m. until 4/16/25, at 2:16 p.m. 20/20 staff confirmed they were educated in person and 1/1 staff via phone. Staff were educated on how and when to complete an elopement assessment, and what to do for residents that are displaying exit seeking behaviors. Staff were educated on the updated elopement policy. Staff were educated on new elopement binders found at nurses ' station, and nursing staff was educated on activating and checking function of wander guards. All staff educated signed the education sheet. 105/127 staff members were educated. All other staff will be educated prior to their next shift and sign the education sheet. During an interview on 4/16/25, at 1:20 p.m. Nursing Assistant (NA) Employee E1 stated, I thought the education was educational and learned a lot. During an interview on 4/16/25, at 1:28 p.m. NA Employee E2 stated, I like the Elopement binder. It has all their pictures in and interventions in the care plan. Very informative. During an interview on 4/16/25, at 1:37 p.m. NA Employee E3 stated, I learned how to redirect residents and to report residents who are able to leave the unit and when they come back to the supervisor. During an interview on 4/16/25, at 1:44 p.m. Maintenance Employee E5 stated, I know the definition of elopement now. During an interview on 4/16/25, at 2:01 p.m. Registered Nurse Employee E6 stated, The education was definitely worthwhile. Good to review things, everyone needs reminders. During an interview on 4/16/25, at 2:10 p.m. Social Service Employee E7 stated, I liked learning what to do, which residents are at higher risk and that you can see resident specific interventions in their care plans. Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 4/16/25, at 3:19 p.m. During an interview on 4/15/25, at 3:30 p.m., the Nursing Home Administrator and DON confirmed that the facility failed to provide adequate supervision resulting in Resident R1's elopements. This failure created an immediate jeopardy situation for Resident R1 and potentially put her at risk of harm or injury. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopements of a resident (Resident R1). Findings include: The job description for the Nursing Home Administrator dated 10/3/23, indicated the NHA collaborates with the Little Sisters of the Poor to coordinate, direct develop, and maintain various programs within all departments of the home. He or she will work together to ensure adherence to policies and procedures. NHA will direct and guide the performance of others. Knowledge of all relevant federal and state rules and regulations governing long-term care facilities and the ability to properly interpret these. The job description for the Director of Nursing dated 10/1/24, indicated the DON is responsible for the development and maintenance of nursing service objectives, standards of nursing practice, nursing policy and procedure manual. DON must have thorough knowledge of state and federal regulations that govern a long-term facility. Oversee initiation and implementation of a plan of care for each resident and that it is reviewed and modified as indicated. Based on findings identified in this report, the facility failed to prevent the elopement of a resident (Resident R1), which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 4/15/25, at 3:30 p.m. the NHA and DON were notified that they failed to effectively manage the facility to prevent the elopement of a resident. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of elopements for one of four residents (Resident R1). Findings include: Review of the facility Accident/Incident Reports, Residents policy last reviewed 11/1/24, indicated that residents involved in an accident or incident are assessed by a licensed nurse and receive appropriate care with follow up care as indicated. The purpose is to ensure quality resident care and to prevent or treat complications. Notify physician and responsible party of any accident. The limit time for notification of physician or family will never be greater than twelve hours from the time of accident or incident. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/5/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). During a review of Resident R1's clinical record on 4/15/25, at 9:15 a.m. the following were identified: On 4/27/24, at 10:56 p.m. indicated resident found on ground level near the kitchen by the garbage dumpsters by the kitchen staff. Came back to second floor. Blaster was found in another room on the unit behind the closed door in her motorized wheelchair. Was redirected back to her room. Resident was very confused. The facility failed to notify the physician of this incident. On 5/18/24, at 1:10 a.m. revealed at the beginning of the shift writer observed resident in a non-electric wheelchair wheeling self-down the hallway. Writer inquired of evening nurse why the resident not using her electric wheelchair. Informed that two days ago, resident was found downstairs in a closet. Nurse stated, Mother had instructed her to keep the resident on the unit. Therefore, resident was assisted to a regular wheelchair for monitoring whereabouts. At 11:05 p.m. resident observed in the wheelchair and wandering down the hallway then back to her room. 11:20 p.m., again up in the hallway in her wheelchair. Offered her a snack with tea requested and hot tea given at table but, resident went back to her room. 12:25 a.m. resident returned to the table and drank her tea. At 12:45 a.m. returned to her room. Safety measures maintained. Call pendant around her neck. The facility failed to notify the physician this incident. On 5/26/24, at 11:09 p.m. reveled resident found on the first floor in her wheelchair. Was confused. Was escorted back to her unit. The facility failed to notify the physician of this incident. On 3/30/25, at 10:41 p.m. revealed resident found on first floor at reception desk by front door by staff. Was brought back up and returned to unit. Currently wandering on unit. Staff completed an Elopement Evaluation and Resident R1 scored a 2, indicating resident is at high risk for elopement. The facility failed to notify the physician of this incident. On 4/8/25, at 10:44 p.m. revealed resident wondered out in hallway by units then went over to another unit. Was returned to her room and given a snack. The facility failed to notify the physician of this incident. On 4/13/25, at 2:25 p.m. revealed resident found on the ground floor in the kitchen, by kitchen staff approximately 12:45 pm. Resident's wander guard on and functioning properly. No injuries noted. Unit supervisor aware and Mother. Room change was completed after this incident to the First floor where two out of four sets of doors have wander guard systems on them due to wandering behaviors. The facility failed to notify the physician of this incident. During an interview on 4/15/25, at 3:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to notify the physician of elopements for one of four residents (Resident R1), as required. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision for a visually impaired resident during an activity involving a horse that resulted in the actual harm of the horse biting a resident and causing a fracture for one of six residents reviewed (Resident R17). Findings include: Review of facility policy Accident/Incident Reports, Residents dated 11/6/23, last reviewed 11/4/24, indicated an accident is an event that results in bodily injury or potential injury and/or causes a change in Resident status. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated diagnoses of depression (a constant feeling of sadness and loss of interest), need for assistance with personal care, and legal blindness. Section B - Hearing, Speech, and Vision, Question B1000 Vision, indicated Resident R17 was coded 4 severely impaired, no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Review of a progress note dated 10/14/24, at 2:58 p.m. stated, At approximately 2:30 p.m. resident was returned to unit by Activities. They asked that resident be examined because she was bit by a horse. Examination revealed right pointer fingertip blackened (apparent hematoma [a collection of blood that pools outside of a blood vessel]) with base of fingernail lifting from nail bed. Small laceration (a tear or ragged cut) at underside of fingertip. Finger cleansed with peroxide (a disinfectant), bacitracin (an antibiotic) and band aides applied. Unit manager to notify family. Review of a progress note dated 10/14/24, at 10:45 p.m. stated, Dressing applied to right forefinger. Right hand warm. Finger swollen. Temperature 98.3 degrees Fahrenheit. Received Augmentin (an antibiotic). Will continue to monitor. Review of a progress note dated 10/15/24, at 11:03 a.m. stated, Pleasant. Transferred to emergency room for evaluation at approximately 10:45 a.m., with volunteer. Family and unit manager aware. Review of a progress note dated 10/15/24, at 2:57 p.m. stated, Pleasant. Returned to facility at approximately 2:45 p.m. Splint intact at right pointer finger. New orders received. Review of an After Visit Summary from the emergency room dated 10/15/24, indicated an x-ray was performed of Resident R17's right hand with a result of transversely oriented mildly displaced fracture across the distal tuft of the distal phalanx of the index finger (a break in the bone at the tip of the finger). Review of Resident R17's care plan dated 090/9/19, indicated Resident R17 has a history of depression and anxiety, she is legally blind. Resident R17 prefers to use her iPhone, [NAME], and [NAME] device to communicate. Staff will encourage participation in activities, she enjoys listening to talking books, music, community outings, pet therapy. Review of R17's care plan failed to reveal interventions related to safety precautions and supervision requirements to facilitate safe activity interactions due to the resident's visual impairment. Review of Resident R17's care plan dated 10/15/24, indicated while at an activity, she reached her hand out and a horse bit her hand, open area, nail loose and a hematoma on right pointer finger. Review of a Accident or Incident Report dated 10/15/24, indicated Activity Director Employee E3 was a witness to the accident and the accident was described as, Apparently resident was feeding a horse and her right pointer finger was bitten. During an interview on 11/25/24, at 9:22 a.m. Resident R17 stated, I was sitting in my wheelchair. I'm totally blind and I didn't know a lot of other ladies were feeding carrots to the horse. I was occupied with the regular riding pony. I talk with my hands, they're always moving, and I guess the horse thought my finger was a carrot and he bit it. It did break my finger. I didn't know it had happened because I have no feeling in my fingers because of my nerves. I didn't have any pain when it happened because I had no idea it had happened until someone started yelling that there was blood all over my hand. The nurse wrapped my finger and said he thought I was going to lose my fingernail, which I did. They sent me to the emergency room . During an interview on 11/26/24, at 11:37 a.m. Nurse Aide Employee E3 stated, Resident R17 is blind, I think she is maybe able to see shadows, but she is completely dependent. I don't think she would be able to do an activity on her own. During an interview on 11/26/24, at 1:24 p.m. Activity Director Employee E4 stated, I was there, one of our Occupational Therapists brought two of their horses in. They were giving the residents treats to feed the horses. I didn't witness the actual bite. She [Resident R17] didn't say anything when it happened. One of the volunteers said she is bleeding. During an interview on 11/26/24, at 1:30 p.m. the Nursing Home Administrator (NHA) stated she does not think anyone witnessed the accident and that Resident R17 told a different story to the State Agency than she had told to the facility at the time of the accident. During an interview on 11/27/24, at 8:59 a.m. Activity Director Employee E4 stated, There were about 6 to 7 residents at the horse activity because Bingo was also happening at the same time. I think there were 4 to 5 staff and volunteers present and the therapist who owns the horse, but she was off duty at the time. During an interview on 11/26/24, at 1:30 p.m. the NHA confirmed that the facility failed to provide adequate supervision for a visually impaired resident during an activity involving a horse that resulted in the actual harm of the horse biting a resident and causing a fracture for one of six residents reviewed (Resident R17). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly date food items to ensure proper rotation, and failed to prevent possible cross-contamination while storing food service items, and failed to properly perform handwashing in the Main Kitchen. Findings include: A review of the facility policy Food Safety dated 11/4/24, and previously dated 11/6/23, indicated that the facility will provide safe and sanitary storage, handling, and consumption of all food that includes storage, preparations, distribution, and serving food in accordance with professional standards for food service safety. A review of the facility document Kitchen Porter/Dishwasher/Helper Job Description indicated that the employee must maintain high standards of sanitation, safety, proper storage and handling in accordance with Health Department, State, and Federal Codes. During an observation in the Dry Foods Storage Area of the Main Kitchen on 11/25/24, at 9:25 a.m. it was noted that none of the food items were dated at the time of receiving. During an observation in the Walk- In Refrigerator and Walk-in Freezer on 11/25/24, at 9:30 a.m. it was noted that none of the food items were dated at the time of receiving. During an interview on 11/25/24, at 9:30 a.m. Dietary Supervisor Employee E7 confirmed that the facility failed to date food items when they were received to ensure proper food rotation. During an observation on 11/26/24, at 1:20 p.m. in the Dish Room, six casserole dishes, 12 bowls, eight serving platters, six saucepans, seven frying pans were being stored on shelves in the drying area and were not inverted to prevent cross contamination and proper drying. During an interview on 11/26/24, at 1:22 p.m. Dietary Supervisor Employee E7 confirmed that the facility failed to properly store dishes. During an observation in the Dish Room on 11/26/24, at 1:25 p.m. Kitchen [NAME] (KP) Employee E8 was noted to be wearing gloves and loading dirty dishes into the dish machine. The area of the Dish Room that KP Employee E8 was working is where dirty dishes are loaded into the dish machine. This area has a sink with a water sprayer to remove debris from the dishware prior to being loaded into the dish machine. No hand soap is in this area, but there is a handwashing sink at the opposite end of the Dish Room. When the clean dishes emerged from the other side of the dish machine, KP Employee E8 ran has gloved hands under water for about two seconds before he went to retrieve the clean dishes. During an interview on 11/26/24, at 1:25 p.m. KP Employee E8 was stopped by State Agency and was advised that he did not remove his dirty gloves and wash his hands with soap and water prior to touching clean dishes, to which KP Employee E8 confirmed that he failed to properly wash his hands. During an interview on 11/26/24, at 1:25 p.m. Dietary Supervisor Employee E7 confirmed that the facility failed to properly perform handwashing which created the potential for foodborne illness. 28 Pa. Code: 211.6(c) Dietary services 28 Pa Code 201.14 (a) Responsibility of licensee.

Based on observations and staff interview it was determined that the facility failed to have required postings for the Medicaid Fraud Control Unit for the facility. Findings include: Observations on the nursing care units on the First and Second Floor bulletin boards failed to include information for the Medicaid Fraud Control Unit throughout the survey from 11/25/24, through 11/27/24. During an observation and interview on 11/27/24, at 11:10 a.m. The Director of Nursing confirmed that the facility failed to post information about the Medicaid Fraud Control Unit. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18e Management.

Based on observations, Group interview, and staff interview, it was determined that the facility failed to ensure that the Department of Health Survey Results were readily accessible to residents and visitors, and failed to post notice of the availability of the results on two of two Nursing Floors. (First Floor, and Second Floor) Findings Include: Observations on the nursing care units on the First and Second Floor bulletin boards failed to include information for the Department of Health Survey results throughout the survey from 11/25/24, through 11/27/24. During a group interview on 11/26/24, at 9:59 a.m. ten out of ten residents were unaware of the location where the survey results binder would be located and available to review. During an observation and interview on 11/27/24, at 11:10 a.m. The Director of Nursing was able to locate two Department of Health Survey Results Binders that were out of sight, as they were inside of desks on the First Floor and Second Floor, and confirmed that the facility failed to post notice of availability of these results on two of two Nursing Floors. 28 Pa. Code 201.14 (a) Responsibility of licensee