Every finding on record at Longwood at Oakmont

Based on facility policy, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a medication administration for one of three residents (Resident R2).Findings include: Review of the facility Infection Prevention and Control policy dated 11/5/25, indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/1/26, indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. Resident R2's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R2's BIMS score was a 12 indicating Resident R2 is moderately impaired. During an observation on 4/28/26, at 11:45 a.m. Resident R2 was in the bathroom combing his hair. A medication cup of pills was sitting on the bedside table by the bed. No nurse was in the room. The medication cup contained the following: (2) oval peach/tan pills(3) white oblong pills(2) white round pills(1) pink oblong pill(1) lavender round pill During an interview on 4/28/26, at 11:58 a.m. Registered Nurse (RN) Employee E1 stated, I should have watched him take his medication, and confirmed the medications were at bedside. During an observation on 4/28/26, at 12:00 p.m. RN Employee E1 lifted the cup of medications off the bedside table, put the medication cup with medication into her shirt pocket, and then put them into the medication cart, to give at a later time. RN Employee E1 confirmed that she failed to prevent cross contamination during a medication administration for one of three residents (Resident R2). During an observation on 4/28/26, at 12:15 p.m. RN Employee E1 took the medication cup of medications out of the medication cart and administered them to Resident R2. 28 Pa. Code: 211.10(d) Resident Care Policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications for one of five residents (Resident R2).Findings: Review of facility Medication Storage policy dated 11/5/25, indicated that the facility will ensure all medications are stored according to recommendations. All drugs and biologicals will be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medication. Review of facility Self-Administration of Medication policy dated 11/5/25, indicated residents in our facility who wish to self-administer their medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/1/26, indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. Resident R2's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R2's BIMS score was a 12 indicating Resident R2 is moderately impaired. During an observation on 4/28/26, at 11:45 a.m. Resident R2 was in the bathroom combing his hair. A medication cup of pills were sitting on the bedside table by the bed. No nurse was in the room. The medication cup contained the following: (2) oval peach/tan pills(3) white oblong pills(2) white round pills(1) pink oblong pill(1) lavender round pill During an interview on 4/28/26, at 11:58 a.m. Registered Nurse (RN) Employee E1 stated, I should have watched him take his medication, and confirmed the medications were at bedside. Review of Resident R2's physician orders failed to include self-administration of medications. Review of Resident R2's care plan failed to include self-administration of medications. During an interview on 4/28/26, at 2:15 p.m. the Director of Nursing stated, I don't think any residents at this time can self-administer medications. There is a process to be able to do, and I know that Resident R2 is not able to self-administer his medications and confirmed that the facility failed to properly store medications for one of five residents (Resident R2). 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services.

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of six residents (Residents R7, R11, R13, and R26).Findings include:Review of facility policy Cleaning, Changing Nasal Cannulas and Masks dated 11/5/25, indicated all residents who are receiving oxygen therapy shall have masks and nasal cannula tubing changed weekly and/or as needed.Review of facility policy CPAP and BiPAP (Continuous Positive Airway Pressure keeps airways open when you sleep and Bilevel Positive Airway Pressure -normalizes breathing by delivering pressurized air) dated 11/5/25, indicated use clean, distilled water only in the humidifier chamber.Review of the admission record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/24/26, indicated the diagnoses of hypertension (a condition impacting blood circulation through the heart related to poor pressure), depression, and heart failure (heart doesn't pump blood as well as it should).Review of Resident R7's current physician orders indicated CPAP apply every night at bedtime. Remove every morning. Use 6-12cm H2O (centimeters of water) pressure setting as was preset from personal care, one time a day.Review of Resident R7's current care plan indicated resident utilizes CPAP at bedtime related to obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked).Observation on 2/17/26, at 10:05 a.m. Resident R7 was observed in bed with eyes closed. The bedside stand had a CPAP machine. On the floor directly below the CPAP was a gallon jug of distilled water opened and without a date.Review of the admission record indicated Resident R11 was admitted to the facility on [DATE].Review of Resident R11's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/27/26, indicated the diagnoses of hypertension, heart failure, and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids).Review of Resident R11's current physician orders indicated empty (BIPAP/CPAP) reservoir and clean with mild soap and distilled water every evening prior to applying at bedtime. Ipratropium-Albuterol Solution (inhaled medication for breathing) inhale orally three times a day for chronic obstructive pulmonary disease.Review of Resident R11's current care plan on indicated resident utilizes CPAP at bedtime related to obstructive sleep apnea. Observation on 2/17/26, at 10:15 a.m. Resident R11 was observed in bed actively inhaling a breathing treatment via hand pipe nebulizer. The tubing of the nebulizer was not dated or labeled. The CPAP device was dangling off the side of the bedside stand not stored in a bag. The distilled water gallon was on the floor opened and without a date.Review of the admission record indicated Resident R13 was admitted to the facility on [DATE].Review of Resident R13's MDS dated [DATE], indicated the diagnoses of hypertension, heart failure, and muscle weakness.Review of Resident R13's current physician orders indicated oxygen 2 lpm (liters per minute) via nasal cannula continuously.Review of Resident R13's current care plan failed to include management and monitoring of oxygen use.Observation on 2/17/26, at 10:20 a.m. Resident R13's room the oxygen concentrator humidifier bottle had a date of 2/5/26, connector tubing lying on the bed not covered in a bag and without a date.Observation on 2/17/26, at 10:22 a.m. Resident R13 was observed out of bed in the wheelchair wearing oxygen via nasal cannula. The nasal cannula failed to have a date as required.Review of the admission record indicated Resident R26 was admitted to the facility on [DATE].Review of Resident R26's MDS dated [DATE], indicated the diagnoses of hypertension, heart failure, and renal insufficiency.Review of Resident R26's current physician orders indicated (CPAP/BIPAP) at bedtime one time a day.Review of Resident R26's current care plan failed to indicate management and monitoring of the CPAP device.Observation on 2/17/26, at 10:25 a.m. Resident R26's CPAP mask was not stored in a bag, distilled gallon of water on the floor, opened and without a date as required.Tour and interview on 2/17/26, at 10:38 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the observations above for Resident R7, R11, R13, and R26.Interview on 2/17/26, at 2:30 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of six residents (Residents R7, R11, R13, and R26).28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three of twelve months (October 2025, November 2025, and December 2025). Findings include: Review of the admission record indicated Resident R44 was originally admitted on [DATE], with diagnoses that included diabetes, benign prostatic hyperplasia (BPH - a common enlargement of the prostate gland in aging men that squeezes the urethra), and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids) Review of Resident R44's clinical record revealed that the resident was transferred to the hospital on [DATE]. Review of facility provided documentation failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for Resident R44's hospitalization on 11/22/25. Review of the admission record indicated Resident R46 was originally admitted on [DATE], with diagnoses that included Covid 19, atrial fibrillation (irregular heart rhythm), and BPH. Review of Resident R46's clinical record revealed that the resident was discharged home on [DATE]. Review of facility provided documentation failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for Resident R46's discharge on [DATE]. Interview with the Nursing Home Administrator on 2/18/26, at 1:00 p.m. indicated that the facility had missed a few months of written transportation notifications to the Office of the Long-Term Care Ombudsman and could not produce written evidence for three of twelve months (October 2025, November 2025, and December 2025). 28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations and influenza vaccinations were offered upon admission for two of five residents (Residents R11, and R13). Findings include: Review of the facility policy Nursing- Influenza Policy dated 11/5/25, indicated Residents or representatives will be provided a vaccine information statement. After completion of consent, the influenza vaccinations may be administered in accordance with physician-approved orders.Review of the facility policy Nursing- Pneumococcal Vaccine dated 11/5/25, indicated each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician orders.Review of the admission record indicated Resident R11 was admitted to the facility on [DATE].Review of Resident R11's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/27/26, indicated the diagnoses of hypertension, heart failure, and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids).Review of Resident R11's clinical record on 2/18/26, failed to provide evidence that the influenza or the pneumococcal vaccines were offered or administered as required for the influenza season of 2025.Review of the admission record indicated Resident R13 was admitted to the facility on [DATE].Review of Resident R13's MDS dated [DATE], indicated the diagnoses of hypertension, heart failure, and muscle weakness.Review of Resident R13's clinical record on 2/18/26, failed to provide evidence that the influenza vaccines were offered or administered as required for influenza season 2025.Interview on 2/18/26, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that pneumococcal vaccinations and influenza vaccinations were offered upon admission for two of five residents (Residents R11, and R13). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings with all the required committee members for one of four quarters(Quarter One on 1/28/25). Findings Include: The facility policy Quality Assurance and Performance Improvement (QAPI) Plan dated 11/5/25 indicated the QA&A Committee consisted of the following members: Medical Director/Designee, Director of Nursing, Administrator, the Infection Preventionist and additional members at a minimum of two staff. Review of Quality Assurance and Performance Improvement sign in sheets and attendance records for Quarter One of 2025, dated 1/28/25, failed to indicate the Infection Preventionist was in attendance. During an interview on 2/18/26, at 11:00 a.m. the Nursing Home Administrator confirmed the facility could not provide documented evidence that the facility conducted Quality Assessment and Assurance (QAA) meetings with all the required committee members for one of four quarters (Quarter One on 1/28/25).28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.

Based on review of facility policy, clinical record, and staff interview it was determined that the facility failed to provide sufficient and timely social services for one of three residents reviewed (Resident R42).Findings include: Review of facility documentation social services job description indicated: Summary Develops, implements, operates and supervises specialized counseling, education and psychosocial programs to meet the needs of residents and their family members. Identifies and suggest innovative approaches and participates in implementing performance improvement opportunities. Maintains compliance with Longwood at Oakmont policy and procedures in accordance with governing laws, regulations, regulatory agencies, accreditation bodies and facility standards. Demonstrates on a consistent basis individual and team behavior that supports culture change. Provides primary social work to assigned including direct resident and family contact, medical chart documentation, discharge planning and related social work duties. Develop a plan of care of each resident; puts into practice a person-centered philosophy. Review of admission record indicated Resident R42 was admitted on [DATE]. Review of Resident R42 admission record indicated diagnosis of COPD (ongoing lung condition caused by damage of the lungs), Parkinson (movement disorder of the nervous system that worsens overtime), and unspecified arterial fibrillation (an irregular and often very rapid heart rhythm). Review of Resident R42 progress notes dated 9/3/25, indicated: Staff providing personal care today c/o resident making sexual inappropriate comments stated to her I bet you taste good let me eat you while attempting to grab at her breast and vaginal area. When re-directed states why are you being mean to me that's not allowed All you women are so uptight. Review of Resident R42 progress notes dated 9/4/25, indicated: During morning medication administration resident became sexually inappropriate, stating turn around I want to see your butt. Initial visit with patient. The patient is having inappropriate sexual behaviors with staff. Continue with non-pharmacological interventions. Continue to monitor for mood/behavioral changes. Review of Resident R42 clinical record dated 10/15/25, visit type mind care psychiatric evaluation, indicated: initial evaluation per staff: pt has increased sexual behaviors. He is inappropriately grabbing staff and making sexual comments. Pt has baseline symptoms of depression and anxiety. Follow up recommendations - follow up in 90 days. Review of Resident R42 care plans failed to include a care plan regarding sexually inappropriate behaviors. Review of Resident R42 clinical record failed to include documentation of interventions, and mood/behavioral changes. During an interview on 2/18/26, at 1:08 p.m. Social Service indicated that she does not do care plans or follow up from psychiatric evaluation. During an interview on 2/18/26, at 2:37 p.m. Nursing Home Administrator and Director of Nursing were informed that the facility failed to provide sufficient and timely social services for one of three residents reviewed (Resident R42). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.29( a) Resident rights. 28 Pa. Code 211.16( a)(1) Social services

Based on a review of facility provided documentation, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides reviewed (Nurse Aide (NA) Employee E3). Findings include:Review of facility provided documentation dated [DATE], indicated NA Employee E3's Pennsylvania Nurse Aide Registration expired on [DATE]. The facility was unaware that NA Employee E3's registration was expired until it was discovered on [DATE].Despite the expired registration, NA Employee E3 continued to work at the facility during the months of [DATE], [DATE], [DATE], [DATE], and February 2026.Interview with the Nursing Home Administrator on [DATE], at 3:00 PM confirmed the facility was unaware of the expired registration and the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides reviewed (Nurse Aide NA Employee E3). 28 Pa. Code 201.29 Personnel Policies and Procedures.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to adequately monitor and assess nutritional status for one of five resident's reviewed for nutritional concerns (Resident R3). Findings include: The facility policy Dietary-Weights last reviewed 11/5/25, revealed if a resident has experienced a 5-pound weight change a re-weigh will take place within 24 hours. If the weight change is evident through re-weigh, nursing will notify the dietitian, and interventions may be initiated if appropriate. Review of clinical record indicated Resident R3 was admitted to the facility 12/4/25. Review of Resident R3's Minimum Data Set (MDS-a periodic assessment of care needs) dated 12/26/25, indicated diagnoses diabetes mellitus (chronic condition characterized by high levels of glucose in the blood due to the body's inability to produce or effectively use insulin), dementia (pattern of mental decline occurring when brain cells die) and hypertension. Review of Resident R3's weight summary indicated on 1/6/26 Resident R3's weight was 113.8. Resident R3 was weighed 2/2/26 at 106.8, which reflected a 7-pound weight loss (7%). There was a lack of evidence to support that the Registered Dietitian (RD) was notified of the significant weight loss. There was no documented evidence that Resident R3 was reweighed within 24 hours according to facility policy. In an interview 2/18/26, at 11:30 a.m., the Registered Dietitian Employee E1 confirmed there was no reweigh or documentation regarding weight loss for Resident R3 as required. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation and staff interview it was determined the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Countryside Medication room). Findings: Review of facility Storage of Medications policy dated 11/5/24, indicated that medications and biologicals are stored safely, securely, and properly, following manufacturer ' s recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Review of facility Disposal of Medications- Discontinued Medications policy dated 11/524, indicated medications not returned to the pharmacy are destroyed in accordance with the Medication Destruction policy. During a medication room review on 1/8/25, at 1:30 p.m. two plastic basins with medications was observed sitting on the counter, unsecured. Medications were dated November 2024 from the pharmacy. The medications observed were: - Atropine (used to decrease saliva) - 1 bottle. - Pantoprazole (used to treat acid reflex) - 40 mg 3 pills. - Pantoprazole - 20 mg 2 pills. - Calcium 600/800 mg 4 pills. - Eliquis (used to prevent or treat blood clots- 5 mg 7 pills - Tums- 1 bottle. - Centrum (a vitamin) - 1 bottle. - Scopolamine patch (used to decrease saliva)- 8 patches. - Nitroglycerin (used to treat chest pain) -1 bottle. - Simethicone (used to treat upset stomach) - 1 bottle. - Albuterol (used to breathing problems)- 12 vials. - Tylenol - 650 mg 27 pills. - Aspirin (a blood thinner) - 81 mg 2 pills. - Lisinopril (used for high blood pressure) -5 mg 2 pills. - Lisinopril- 40 mg 1 pill. - Metoprolol (used for high blood pressure) -25 mg 2 pills. - Zoloft (used for depression) -100 mg 2 pills. - Tylenol Cold and Flu -5 capsules. - Vitamin D -1000 units 2 pills. - Atorvastatin (used for high cholesterol) 40 mg 3 pills. - Montelukast (used to treat allergies) -10 mg 3 pills. - Senna (used for constipation)- 8.6 mg 3 pills. - Melatonin (used to help sleep) -3 mg 1 pill. - Seroquel (used for mental health conditions)- 25 mg 1 pill. - Carvedilol (used for high blood pressure) - 6.25 mg 2 pills. - Depakote (used for seizures) - 125 mg 2 pills. - Fluoxetine (used to treat depression) - 20 mg 1 pill. - Remeron (used to treat depression) - 15 mg 1 pill. - Simvastatin (used to treat high cholesterol) - 20 mg 1 pill. - Ferrous Sulfate (an iron supplement) - 325 mg 1 pill. - Multivitamin -1 pill. During an interview on 1/8/25, at 1:05 p.m. Licensed Practical Nurse (LPN) Employee E8 stated, These are old medications. We don't have any paperwork to complete prior to destroying the medications. They tell us to destroy the medications when we have time using the med buster (a solution that dissolves medication). There is no accountability paperwork that goes in residents medical record that I know of. During an interview on 1/8/25, at 1:30 p.m. the Director of Nursing confirmed that the facility failed to dispose or reconcile discontinued medication in a timely manner for one of two medication rooms reviewed (Countryside Medication room). 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Residents R9, R20, and R205). Findings include: Review of facility policy Oxygen Administration dated 11/5/24, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents ' goal and preferences. Change oxygen tubing and tubing weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty or weekly. Review of facility policy Infection Prevention and Control Program dated 11/5/24, indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/24, indicated diagnoses of hypertension (high blood pressure), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and sleep apnea (a sleeping disorder in which breathing repeatedly stops and starts). Section O0100, C1 Oxygen therapy was marked and section G1 was checked indicating use of Continuous Positive Airway Pressure (CPAP - a treatment that uses a machine to deliver air pressure to help a person breathe while sleeping). Review of a physician's active orders dated 1/3/25, indicated to administer oxygen via nasal cannula (a medical device that provides supplemental oxygen to patients through two prongs inserted into the nostrils) continuously at 4 liters per minute. Change oxygen tubing and humidifier every week. Review of physician's active orders dated 1/4/25, indicated CPAP at bedtime, pressure 12. Apply at bedtime and remove in the morning. During an observation on 1/7/25, at 12:20 p.m. Resident R9 was sitting in her wheelchair receiving 4 liters per minute of oxygen via nasal cannula. No date was present on the oxygen nasal cannula and humidification bottle. CPAP mask was laying on a chair bedside the nightstand and failed to be stored in a bag, when not in use. During an interview on 1/7/25, at 12:35 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed that no date was present on Resident R9's nasal cannula tubing and humidification bottle, and her CPAP mask was not properly stored in a bag, when not in use. Review of Resident R20's clinical record indicated an admitted [DATE]. Review of Resident R20's MDS dated [DATE], indicated the diagnosis of respiratory failure (not enough oxygen in the body), hypertension (high blood pressure), and diabetes (high sugar in the blood). Review of Resident R20's physician order dated 12/13/24, indicated to wear CPAP through nighttime. Review of Resident R20's care plan dated 3/5/24, with revision on 11/29/24, indicated Resident R20 has CPAP machine to wear at night. During an observation on 1/7/25, at 10:18 a.m. Resident R20's CPAP mask was sitting on dresser not properly stored in a bag. During an interview completed on 1/7/25 at 10:23 a.m. LPN Employee E1 confirmed the CPAP mask was not properly stored in a bag. Review of the clinical record indicated Resident R205 was admitted to the facility on [DATE]. Review of Resident R205's MDS dated [DATE], indicated diagnoses of pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), anemia (a condition in which the blood doesn't have enough red blood cells to carry oxygen all through the body), and asthma (airway becomes inflamed, narrow, and swell and makes breathing difficult). Review of a physician's active orders dated 1/3/25, indicated to administer Ipratropium-Albuterol (medication causing your airway to relax and make breathing easier) every two hours as needed for shortness of breath. During an observation on 1/7/25, at 1:02 p.m. Resident R205 was sitting in his chair with nebulizer (a machine used to administer medication) on his nightstand. Nebulizer tubing was not dated and was not stored in a bag, when not in use. During an interview on 1/7/25, at 1:14 p.m. Registered Nurse (RN) Employee E2 confirmed that no date was present on R205's nebulizer tubing, and his mask was not properly stored in a bag, when not in use. During an interview on 1/7/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for three of four residents (Residents R9, R20, and R205). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of resident clinical records and staff interviews, it was determined the facility failed to obtain a physican order for hospice services and to ensure the coordination of hospice services (supportive services for end stage terminal illness) with facility services to meet the needs of each resident for end-of-life care for three of four residents ( Resident R3, R8, and R39). Findings include: Review of the facility policy Hospice Program dated 11/5/24, indicated that when a resident has been diagnosed as terminally ill, the facility will contact hospice agency. When a resident participates in a hospice program, a coordinated plan of care between the facility, hospice agency and resident or family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's status. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 11/7/24, indicated diagnoses of high blood pressure, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section O-Special Treatments, Procedures, and Programs indicated hospice care while a resident. Review of Resident R3's clinical record revealed a physician order dated 11/11/24, that resident is under hospice services, but did not include a diagnosis related to the need of hospice services. The facility failed to provide documentation completed by the hospice service, including admission into hospice, plan of care, communication between hospice service and facility, and contact information. Review of Resident R3's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. Review of the clinical record revealed that Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia, and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Section O-Special Treatments, Procedures, and Programs indicated hospice care while a resident. Review of Resident R8's clinical record revealed a physician order dated 2/20/24, that resident admitted to hospice services, but did not include a diagnosis related to the need of hospice services. Review of Resident R8's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's MDS, dated [DATE], indicated the diagnosis of dementia (decline in mental abilities that affects thinking, memory, and reasoning), diabetes mellitus and hyperlipidemia. Review of Resident R39's current physician orders indicated consult hospice care for evaluation and admit if appropriate on 12/13/2024. The order failed to include what vendor, and the diagnosis qualifying the resident for Hospice Services. Review of Resident R39's progress notes indicated resident's wife would like Bridges Hospice as the vendor. During an interview on 1/9/25, at 10:30 a.m. the Director of Nursing (DON) confirmed the facility failed to obtain a physican order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for three of four residents ( Resident R3, R8, and R39). 28 Pa. Code: 201.14(a) Responsibilities of licensee 28 Pa. Code: 201.18(a)(b)(1)(3) Management 28 Pa. Code: 201.20(a)(b)(c)(d) Staff development 28 Pa. Code: 211.10(c)(d) Resident care policies

Based on review of facility policy, clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for one of four residents observed during dining (Resident R4). Findings include: Review of physician orders for Resident R4 confirmed a diet order dated 11/18/24, for Low Lactose diet, Mechanical Soft Ground Meat texture, Nectar/Mildly Thick liquids. During observations during dining, on 1/7/24, at 12:15 p.m. revealed Resident R4 was served turkey vegetable soup and had her liquids in a sippy cup. Resident R4 revealed no orders for adaptive equipment. Interview with Dietary Director Employee E9 confirmed the above-mentioned findings. Interview with Director of Nursing (DON) on 11/8/24, at 2:00 p.m. confirmed Resident R4 should have not been served the soup or the sippy cup. 28 Pa. Code 211.6(a) Dietary Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly and securely in one of three medications carts (Riverside medication cart). Findings include: Review of the facility policy Storage of Medications dated 11/5/24, indicates medications and biologicals are stored safely, securely, and properly. Orally administered medications are kept separate from externally used medications and treatments such as including but not inclusive to ointments, creams, and vaginal products. During an interview and observation on 1/7/25, at 10:26 a.m. it was revealed that the Riverside medication carts fourth drawer contained dividers that were labeled with room numbers and contained various creams, ointments, and gels. Licensed Practical Nurse (LPN) Employee E1 stated we don't have a separate treatment cart; all the treatments are kept in the medication cart. LPN Employee E1 referred to this drawer as the treatment drawer. The fifth drawer contained: . An open box of paper tape. . A container of antifungal powder. . A box of vaginal cream commingling with seven oral Tussin liquid medication bottles. . One Ventolin inhaler and three Nasal sprays commingling with dry dressing supplies that included but not inclusive to abdominal pads, 4x4 gauze sponges, and multiple different cover dressings. The bottom drawer contained the following items commingling with respiratory treatment agents: . A tube of antifungal cream. . A tube of Voltaren gel. . A tube of hydrocortisone cream. . Two containers of Silvadene ointment. During an interview completed on 1/7/25, at 10:38 a.m. LPN Employee E1 confirmed the above observations and confirmed that the facility failed to store medications and biologicals properly and securely in one of three medications carts (Riverside medication cart). 28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services. 28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one out of three residents sampled with facility-initiated transfer (Residents R52). Findings include: Review of Resident R52's admission record indicated she was originally admitted on [DATE], with diagnoses that included surgical aftercare, muscle weakness and venous insufficiency. Review of Resident R52's clinical record revealed that the resident was transferred to the hospital on 10/13/24, and did not return to the facility. Review of Resident R52's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents specific needs at the receiving facility. During an interview on 1/9/25, at 10:30 a.m. the Director of Nursing (DON) confirmed that the facility failed to provide the necessary information for Resident R52. 28 Pa. Code 201.29(a)(c)(3)(2) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two out of three residents (Residents R39, R52). Findings include: Review of Resident R39's admission record indicated he was originally admitted on [DATE], with diagnoses that included dementia(decline in mental abilities that affects thinking, memory, and reasoning), diabetes mellitus and hyperlipidemia. Review of Resident R39's clinical record revealed that the resident was transferred to the hospital on 9/9/24, and returned to the facility on [DATE]. Review of Resident R39's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of Resident R52's admission record indicated she was originally admitted on [DATE], with diagnoses that included surgical aftercare, muscle weakness and venous insufficiency. Review of the clinical record indicated Resident R52 was transferred to hospital on 10/13/24, and did not return to the facility. Review of Resident R52's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on [DATE]. During an interview on 1/9/25, at 10:30 a.m. the Director of Nursing (DON) confirmed the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two out of three residents (Residents R39, R52). 28 Pa. Code 201.29(a)(c)(3)(2) Resident rights.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) for two of three resident hospital transfers (Residents R39 and R52). Review of Resident R39's admission record indicated he was originally admitted [DATE], with diagnoses that included dementia(decline in mental abilities that affects thinking, memory, and reasoning), diabetes mellitus and hyperlipidemia Review of Resident R39's clinical record revealed that the resident was transferred to the hospital on 9/9/24, and returned to the facility on [DATE]. Review of Resident R39's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 9/9/24. Review of Resident R52's admission record indicated she was originally admitted on [DATE], with diagnoses that included surgical aftercare, muscle weakness and venous insufficiency. Review of the clinical record indicated Resident R52 was transferred to hospital on 10/13/24, and did not return to the facility. Review of Resident R52's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 10/13/24. During an interview on 1/9/25, at 10:30 a.m. Director of Nursing (DON) confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for two of three resident hospital transfers as required (Resident R39, R52). 28 Pa. Code 201.29 (a)(c)(2) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for two of three residents reviewed (Residents R3 and R8). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2023, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section O-Special Treatments, Procedures, and Programs indicated hospice care while a resident. Review of physician order dated 11/11/24, indicated Resident R3 was admitted under hospice services. Review of Resident R3's MDS assessments revealed a MDS significant change was not completed to include hospice services. Review of the clinical record revealed that Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia, and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Section O-Special Treatments, Procedures, and Programs indicated hospice care while a resident. Review of physician order dated 2/20/24, indicated Resident R8 was admitted to hospice on 2/20/24. Review of Resident R8's MDS assessments revealed a MDS significant change was not completed to include hospice services. During an interview on 1/8/25, at 3:07 p.m. Licensed Practical Nurse Assessment Coordinator Employee E5 confirmed that a significant change MDS was not completed for Resident R3 and R8. During an interview on 1/8/25, at approximately 3:10 p.m. the Director of Nursing confirmed the facility failed to complete a significant change MDS assessment for two of three residents reviewed (Residents R3 and R8). 28 Pa. Code: 211.5(f) Clinical records.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for one of three residents (Resident R156). Findings include: Review of facility policy Baseline Care Plans dated 11/5/24, indicated a baseline plan of care to meet the residents immediate needs and provide instruction needed to provide effective and person-centered care shall be developed for each resident within forty-eight hours of admission. Review of the clinical record revealed Resident R156 was admitted to the facility on [DATE], with diagnoses of dementia (loss of intellectual functioning), benign prostatic hyperplasia (BPH- enlargement of the prostate gland), and depression. During an observation on 1/8/25, at 10:31 a.m. Resident R156 was in his room sitting in his wheelchair, a foley catheter bag was noted attached to chair. Review of Resident R156's physician orders dated 1/4/25, indicated Resident R156 has a 16 french (size) 10cc bulb (holds catheter in place in the bladder). Review on 1/8/25, at 1:00 p.m. Resident 156's baseline care plan failed to include interventions for the care of the foley catheter. During an interview completed on 1/8/25, at 1:23 p.m. Licensed Practical Nurse (LPN) Employee E5 confirmed Resident R156's baseline care plan did not include interventions for the foley catheter, and that the facility failed to develop a baseline care plan for one of three residents (Resident R156). 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement appropriate transmission-based precautions for 11 of 16 residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11). Findings include: Review of facility policy Infection Control-Infection Prevention and Control Program dated 11/5/24, indicated a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Centers for Disease Control and Prevention) guidelines. Review of facility policy Norovirus Prevention and Control dated 11/5/24, indicated this facility will implement strict infection control measures to prevent the transmission of norovirus infection. During outbreaks, residents with norovirus gastroenteritis will be placed on Contact Precautions for a minimum of 48 hours after the resolution of symptoms. Review of the CDC Guidelines indicated Contact Precautions are measures that are intended to prevention transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. During an interview on 12/26/24, the Director of Nursing (DON) stated that the facility had several residents with gastrointestinal illness symptoms such as nausea, vomiting, and diarrhea, but at the time, no resident stool sample had come back positive for Norovirus. Review of the facility's Outbreak Line List on 12/26/24, indicated 16 residents had reported gastrointestinal illness symptoms and were being treated as positive for Norovirus. Review of the facility's Outbreak Line List revealed the following: Resident R1 had symptoms of diarrhea starting on 12/22/24. Review of a physician order dated 12/22/24, indicated Resident R1 was placed on Contact Precautions for Norovirus until no further N/V/D (nausea/vomiting/diarrhea) for 48 hours. During an observation on 12/26/24, at 12:10 p.m. no sign was present outside of Resident R1's room indicating that the resident was ordered Contact Precautions. Resident R2 had symptoms of diarrhea starting on 12/20/24. Review of Resident R2's physician orders failed to include an order for Contact Precautions. Resident R3 had symptoms of diarrhea starting on 12/21/24. Review of Resident R3's physician orders failed to include an order for Contact Precautions. Resident R4 had symptoms of diarrhea and vomiting starting on 12/23/24. Review of Resident R4's physician orders failed to include an order for Contact Precautions. Resident R5 had symptoms of diarrhea and vomiting starting on 12/23/24. Review of a physician order dated 12/23/24, indicated Resident R5 was on Contact isolation precautions for Norovirus. During an observation on 12/26/24, at 11:51 a.m. no signage was present outside of Resident R5's room indicating that the resident was ordered Contact Precautions. Resident R6 had symptoms of diarrhea and vomiting starting on 12/23/24. Review of Resident R6's physician orders failed to include an order for Contact Precautions. Resident R7 had symptoms of diarrhea and vomiting starting on 12/23/24. Review of Resident R7's physician orders failed to include an order for Contact Precautions. Resident R8 had symptoms of diarrhea and vomiting starting on 12/22/24. Review of a physician order dated 12/22/24, indicated Resident R8 was on Contact precautions for Norovirus until no further N/V/D for 48 hours. During an observation on 12/26/24, at 12:08 p.m. no signage was present outside of Resident R8's room indicating that the resident was ordered Contact Precautions. Resident R9 had symptoms of diarrhea and vomiting starting on 12/22/24. Review of Resident R9's physician orders failed to include an order for Contact Precautions. Resident R10 had symptoms of diarrhea and vomiting starting on 12/22/24. Review of a physician order dated 12/22/24, indicated Resident R10 was on Contact Precautions for Norovirus until no N/V/D for 48 hours. During an observation on 12/26/24, at 12:09 p.m. no signage was present outside of Resident R10's room indicating that the resident was ordered Contact Precautions. Resident R11 had symptoms of diarrhea starting on 12/22/24. Review of a physician order dated 12/22/24, indicated Resident R11 was on Isolation Precautions for Norovirus until no N/V/D for 48 hours. During an observation on 12/26/24, at 12:10 p.m. no signage was present outside of Resident R11's room indicating that the resident was ordered Contact Precautions. During an interview on 12/26/24, at 11:51 a.m. Registered Nurse Employee E2 stated, We get in report which residents are in isolation precautions and why. The residents on this unit seem to have symptoms for only a few hours and then they are done. The rooms should have a sign up indicating that they are on isolation precautions. The Nurse Practitioner will write an order and then that order gets entered into the electronic medical record and the corresponding isolation sign gets put on the door of the resident room. During an interview on 12/26/24, at 12:21 p.m. the DON stated, Residents in isolation precautions should have signs on their doors and an order in the computer. I think the isolation only lasts for 48 hours, some of the residents on the line list are already out of isolation. During an interview on 12/26/24, at 12:0 p.m. the DON stated, Residents who don't have isolation orders are having them entered into the computer now and residents who don't have isolation signs on their doors are having them placed right now. During an interview on 12/26/24, at 12:50 p.m. the DON confirmed that the facility failed to implement appropriate transmission-based precautions for 11 of 16 residents as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, facility documents, employee file, employee statements, and staff interviews, it was determined that the facility failed to ensure that a resident received adequate supervision and was provided a safe transfer, which resulted in actual physical harm (fracture of right fibula-lower leg) for one of three residents reviewed (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of facility policy Skilled Nursing Adverse Events last reviewed 3/4/22, indicated that adverse events are unexpected occurrences that result in serious injury, or loss of customer satisfaction, the most common events are safety fall events. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a progressive narrowing of the blood vessels impacting blood flow to the limbs), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and depression. Review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 12/14/22, indicated that the diagnoses remained current. Review of Resident R1's physician orders dated 7/12/22, indicated that resident R1 was to be transferred with extensive assistance of two people. A review of Resident R1's care plan dated 7/13/22, indicated that Resident R1 had impaired ability to perform transfers and that the facility should provide two people to assist with safe transfers. A review of facility documents dated 12/27/22, indicated NA (nursing assistant) Employee E1 transferred Resident R1 from the wheelchair to the bed without a second person. NA Employee E2 then heard Resident R1 screaming, and found Resident R1 in bed. Resident R1 indicated that her leg hurt and that it had been caught under the bed during the transfer from the wheelchair to the bed. NA Employee E2 stated that Resident R1's leg did not look right. Resident R 1 was then transferred to the hospital. Review of hospital Discharge Clinical Summary, Resident R1 was admitted on [DATE] and discharged on [DATE], with a diagnosis of right fibular fracture. Review of NA Employee E1's signed witness statement, dated 12/27/22, stated that NA Employee E1 picked up Resident R1 and placed Resident R1 into bed, which resulted in Resident R1 hollering out in pain. NA Employee E1 stated that he was aware that Resident R1 was a two person assist and that no other employee was in the room at the time of the transfer. A review of NA Employee E1's employee file indicated that NA Employee E1 received education on Fall Prevention, Safe Care Giving Techniques and Abuse training on 9/24/22, as well Safe Transfer training on 11/3/22. During an interview on 1/20/23, at 1:04 p.m., NA Employee E3 stated that a resident's transfer status is marked on the assignment sheets that they receive each day at the beginning of the shift. It was also stated that there is an additional form at the nurses station entitled Two Person Transfer Audit, where all residents who required a two person transfer are listed. NA Employee E3 then explained that when one of these residents is transferred that both nursing assistants who provided the transfer must sign the form along with a nurse as a witness. NA employee E3 was able to provide both pieces of documentation. During an interview on 1/20/23, at 1:15 p.m., NA employee E4 also confirmed the above process and was also able to produce both forms of documentation. NA Employee E4 also stated that she has never had any issues finding this documentation and that it is updated daily. During an interview on 1/20/23, at 1:30 p.m., NA Employee E2 also confirmed the above process and added that there are orange stickers on the outside of residents' rooms that indicated that a resident required assistance of two people for safe transfers. It was also stated that Resident R1 was on NA Employee E2's assignment on the day of the incident. NA Employee E2 had requested assistance from NA Employee E1 with transferring Resident R1 from wheelchair back to bed, however NA employee E1 was on a break. NA Employee E2 proceeded to complete tasks for other residents while waiting for assistance from NA Employee E1. NA Employee E2 stated that she came back to Resident R1's room a a few minutes later and found Resident R1 to be back in bed and calling out for help as she was in pain. During an interview on 1/20/23, at 3:30 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA)confirmed that the facility failed to ensure that Resident R1 was free from a preventable accident, resulting in actual harm when Resident R1 was not provided adequate supervision of two persons for a transfer, which caused resident to sustained a fibular fracture. This was identified as harm for past non-compliance for Resident R1 The facility implemented a plan of correction that included the following: Immediate suspension of NA Employee E1 during the investigation which resulted in termination. Facility initiated education on 1/6/23, for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that transfers were performed as ordered. Audits of transfer status completed to ensure that they were up to date and accurate and that this information was reflected on the nursing assistant assignment sheets. Monthly audits by DON or designee to determine if there are any issues or trends related to care. Results from audits are submitted in the quarterly Quality Assurance Performance Improvement (QAPI) process for two quarters. The facility has demonstrated compliance with the above since 1/6/23. Information was verified via review of Plan of Correction binder. During an interview on 1/20/23, at 1:45 p.m. with the Director of Nursing (DON) and NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety interventions during transfers. 28. Pa Code 201.14(a) Responsibility of licensee. 28. Pa. Code 211.12(d)(1) Nursing services. 28. Pa. Code 211.12(d)(5) Nursing services. 28. Pa Code 201.18(b)(1)(e)(1) Management.

Based on review of facility policies, clinical records, incident reports, facility documents, employee file, employee statements, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (fracture of right fibula-lower leg) for one of three residents reviewed (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of the facility policy Skilled Nursing-Abuse dated 5/11/22 indicated that neglect is the failure of the community, 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 stress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a progressive narrowing of the blood vessels impacting blood flow to the limbs), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and depression. Review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 12/14/22, indicated that the diagnoses remained current. Review of Resident R1's physician orders dated 7/12/22, indicated that Resident R1 was to be transferred with extensive assistance of two people. A review of Resident R1's care plan dated 7/13/22, indicated that Resident R1 had impaired ability to perform transfers and that the facility should provide two people to assist with safe transfers. A review of facility documents dated 12/27/22, indicated NA (nursing assistant) Employee E1 transferred Resident R1 from the wheelchair to the bed without a second person. NA Employee E2 then heard Resident R1 screaming, and found Resident R1 in bed. Resident R1 indicated that her leg hurt and that it had been caught under the bed during the transfer from the wheelchair to the bed. NA Employee E2 stated that Resident R1's leg did not look right, Resident R1 was then transferred to the hospital. Review of hospital Discharge Clinical Summary, Resident R1 was admitted on [DATE] and discharged on [DATE], with a diagnosis of right fibular fracture. Review of NA Employee E1's signed witness statement, dated 12/27/22, stated that NA Employee E1 picked up Resident R1 and placed Resident R1 into bed, which resulted in Resident R1 hollering out in pain. NA Employee E1 stated that he was aware that Resident R1 was a two person assist and that no other employee was in the room at the time of the transfer. A review of NA Employee E1's employee file indicated that NA Employee E1 received education on Fall Prevention, Safe Care Giving Techniques and Abuse training on 9/24/22, as well Safe Transfer training on 11/3/22. During an interview on 1/20/23, at 1:04 p.m., NA Employee E3 stated that a resident's transfer status is marked on the assignment sheets that they receive each day at the beginning of the shift. It was also stated that there is an additional form at the nurses station entitled Two Person Transfer Audit, where all residents who required a two person transfer are listed. NA Employee E3 then explained that when one of these residents is transferred that both nursing assistants who provided the transfer must sign the form along with a nurse as a witness. NA employee E3 was able to provide both pieces of documentation. During an interview on 1/20/23, at 1:15 p.m., NA employee E4 also confirmed the above process and was also able to produce both forms of documentation. NA Employee E4 also stated that she has never had any issues finding this documentation and that it is updated daily. During an interview on 1/20/23, at 1:30 p.m., NA Employee E2 also confirmed the above process and added that there are orange stickers on the outside of residents' rooms that indicated that a resident required assistance of two people for safe transfers. It was also stated that Resident R1 was on NA Employee E2's assignment on the day of the incident. NA Employee E2 had requested assistance from NA Employee E1 with transferring Resident R1 from wheelchair back to bed, however NA Employee E1 was on a break. NA Employee E2 proceeded to complete tasks for other residents while waiting for assistance from NA Employee E1. NA Employee E2 stated that she came back to Resident R1's room a few minutes later and found Resident R1 to be back in bed and calling out for help as she was in pain. During an interview on 1/20/23, at 3:32 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (fracture of right fibula-lower leg) for Resident R1. This was identified as harm for past non-compliance for Resident R1. The facility implemented a plan of correction that included the following: Immediate suspension of NA Employee E1 during the investigation which resulted in termination. Facility initiated education on 1/6/23, for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that transfers were performed as ordered. Audits of transfer status completed to ensure that they were up to date and accurate and that this information was reflected on the nursing assistant assignment sheets. Monthly audits by DON or designee to determine if there are any issues or trends related to care. Results from audits are submitted in the quarterly Quality Assurance Performance Improvement (QAPI) process for two quarters. The facility has demonstrated compliance with the above since 1/6/23. Information was verified via review of Plan of Correction binder. During an interview on 1/20/23, at 1:45 p.m. with the Director of Nursing (DON) and NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety interventions during transfers. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical records and hospital documents, staff interviews and written statements it was determined that the facility failed to make certain that a resident received adequate supervision and was provided a safe transfer resulting in actual harm when a resident fell during a transfer causing the resident to sustain a right femur bone (longest bone in the body) fracture at the distal end of the bone that was comminuted, displaced and angulated (fracture of the upper leg bone where the break is closer to the knee than the hip, the leg bone is broken in two and pointing at an odd angle) for one of four residents (Resident R1). Finding include: Review of facility policy Skilled Nursing Adverse Events last reviewed 11/9/21, indicated that adverse events are unexpected occurrences that result in serious injury, or loss of customer satisfaction, the most common events are safety fall events. Review of Resident R1's Minimum Data Set (periodic review of care needs) dated 9/17/22, indicated she was admitted on [DATE], and her current diagnosis included high blood pressure, difficulty walking and muscle weakness. The Functional Status Section G0110b, activities of daily living assistance for transfer status, indicated she required an extensive assistance of two or more staff members when transferring from one surface to another. Review of Resident R1's physician order dated 9/12/22, instructed that two staff are to stand and pivot the resident for transfers. Review of Resident R1's facility investigation dated 9/22/22, indicated that resident is an assist of two staff for transfers and was transferred by one staff, and the root cause of the fall was ordered transfer status was not followed. Review of Nurse Aide (NA) Employee E1's witness statement dated 9/22/22, at 7:10 a.m. indicated she was transferring Resident R1 to the shower chair. Resident R1 stood up with a walker then started to go down I caught resident with my knee and tried to get her onto the bed or chair. Then I lowered resident to the ground and went to get nurses. Review of Registered Nurse (RN) Employee E2's witness statement dated 9/22/22, at 8:00 a.m. indicated that NA Employee E1 notified me that Resident R1 was on the floor. Then RN Employee E2 and RN Employee E3 went to the room and found Resident R1 on the floor with right leg extending out. Resident R1 was saying leg was really painful. Review RN Employee E3's interdisciplinary note dated 9/22/22, at 8:46 a.m. indicated she was called to the room regarding a fall. That Resident R1 was on the floor in front of the bed with her right leg turned inward. That Resident R1 complained of right hip and knee pain. Resident R1 was assessed and the assessment was unable to be completed fully due to pain, and resident was sent to the hospital. During a phone interview on 10/5/22, at 12:42 p.m. RN Employee E3 stated that she and RN Employee E2 were doing shift report when NA Employee E1 summoned them to Resident R1's room. That during the assessment Resident R1 had some pain and did not want to turn, so they hoyered (mechanical lift that bears all the weight of resident) lifted her back into bed. RN Employee E3 indicated she did part of the investigation report and that NA Employee E1 attempted to do a stand and pivot transfer by herself without a second staff members assistance when the resident fell . During an interview on 10/5/22, at 1:37 p.m. RN Employee E4 stated that he heard a commotion and went into Resident R1's room to see what happened and did not like the way resident's leg looked. That NA employee E1 was the only NA in the room when he arrived. During a phone interview on 10/5/22, at 2:00 p.m. RN Employee E2 stated that it was her first or second day at the facility and she was doing shift report with RN Employee E3 when NA Employee E1 summoned them to the room. That she assessed the resident along with the other RN's and her right leg was pointing out, and resident stated hip was really painful, and was sent to the hospital. Review of Resident R1's hospital document Emergency Department Note dated 9/22/22, indicated that resident was sent to the hospital for follow up from a fall, was complaining of right hip femur pain, and complained of right hip pain with any movement of the leg. Review of Resident R1's hospital document Right Femur X-Ray dated 9/22/22, indicated right femur bone (longest bone in the body) was fractured at the distal end of the bone and the fracture was comminuted, displaced and angulated (fracture of the upper leg bone where the break is closer to the knee than the hip, the leg bone is broken in two and pointing at an odd angle). Review of Resident R1's hospital document Discharge Clinical Summary dated 9/26/22, indicated her discharge diagnosis was right femur fracture. During an observation of Resident R1 on 10/5/22, at 12:30 p.m. resident was seated in wheelchair eating lunch, appeared comfortable and was alert and able to make needs known. During an interview on 10/6/22, at 10:26 a.m. the Director of Nursing confirmed that the facility failed to ensure that Resident R1 was free from a preventable accident, resulting in actual harm when Resident R1 was not provide adequate supervision of two persons for a transfer, which resulted in a fall causing resident to sustained a femur fracture. 28. Pa Code 201.14(a) Responsibility of licensee. 28. Pa. Code 211.12(d)(1) Nursing services. 28. Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/17/22. 28. Pa Code 201.18(b)(1)(e)(1) Management.

Based on clinical record review, select facility policy review, and staff interview, it was determined that the facility failed to prevent a resident accident that resulted in harm (serious injury) for one of one residents reviewed, who sustained a fractured left femur (Resident CR204). The facility also failed to implement planned interventions to prevent falls for two of two residents reviewed (Resident CR204 and R34). Findings include: Review of the facility policy titled, Rehab-Wheelchair Management Training, dated 3/6/17, stated that all physical and occupational therapists and assistants will review and identify contraindications, warnings, and precautions prior to treatment to assure delivery without incident. Review of the facility Quality Assurance and Improvement Plan dated for fiscal year 2017, revealed that, goals will be specific, measurable, actionable, relevant, and time sensitive. The current Network-wide projects include: Reduction of bed rail use, fall reduction and prevention, and reduction of readmissions. Review of the Director of Nursing (DON) job description signed 8/29/17, indicated that the DON develops, implements, evaluates, and updates written policies and procedures for the nursing department, ensuring quality care, and ensures the nursing personnel comply with all established policies and procedures. Closed clinical record review for Resident CR204 revealed an admission record dated 7/13/13, that indicated this resident was a [AGE] year-old female admitted with a [DIAGNOSES REDACTED]. Documentation from a Minimum Data Set assessment (MDS, a comprehensive assessment of care needs) dated 9/11/17, reported that Resident CR204 had a BIMS (Brief Interview for Mental Status, an interview which assesses for cognitive function) score of three, which indicated severe impairment. A physician's order dated 10/24/17, requested an occupational therapy assessment for Resident CR204 related to the resident leaning over to the side of her wheelchair. The occupational therapy evaluation dated 10/26/17, documented that the resident had poor posture in a standard wheelchair, with right cervical and trunk lean. Further documentation revealed that the resident had impaired wheelchair mobility and was a high fall risk. A plan of treatment for [REDACTED]. It was further documented that, therapist trialed various leg rest/footboard with education provided to caregiver on why footboard and leg rest given. Therapist educated that when being pushed in wheelchair that leg was tending to move off leg rest and footboard added for safety. The facility report to the Department of Health field office dated 11/16/17, revealed that on 11/16/17, at 5:30 p.m. staff was escorting Resident CR204 down the hall in a wheelchair and the resident's right foot got caught on the floor causing the resident to fall forward onto the floor. Resident CR204 was immediately assessed by the nursing staff. The facility received a physician's order to send the resident out to the hospital for evaluation. While at the hospital, Resident CR204 was diagnosed with [REDACTED]. Documentation did not indicate that Resident CR204 had footboards in place at the time of the fall. The facility investigation revealed that Resident CR204 had no awareness of safety factors, and was unaware of their inability to walk. During an interview on 1/5/18, at 1:30 p.m. the Director of Nursing and the Nursing Home Administrator confirmed that Resident CR204 did not have footboards in place while staff transported her in her wheelchair, which resulted in a fracture of Resident CR204's left leg. During an interview on 1/8/17, at 2:10 p.m. the Director of Nursing verified that prior to 11/16/17, the date in which Resident CR204 fell out of her wheelchair, there was no fall policy in place to include specific protocols for wheelchair use and safety in residents listed as a high fall risk. The MDS assessment dated [DATE], indicated that Resident R34 had severe cognitive impairment and [DIAGNOSES REDACTED]. The 11/14/17, MDS also indicated that Resident R34 had impaired range of motion in the lower extremities and required extensive assist of one staff member for transfer. Review of an occupational therapy (OT) note dated 11/13/17, indicated that Resident R34, was referred by nursing following family concern over increased difficulty in maneuvering wheelchair and increased risk of tipping. OT evaluated Resident R34 for wheelchair safety. Review of a physician's progress note dated 12/8/17, indicated that Resident R34 complained of right knee pain and had a recent right ankle sprain. During an observation on 1/3/18, at 9:08 a.m. Nurse Aide (NA) Employee E1 was quickly transporting Resident R34 in a wheelchair without leg rests or footboards, down the hallway to the dining room. During an interview on 1/4/18, at 9:40 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed that Resident R34 had a fall on 1/2/18. LPN Employee E3 also confirmed that there was no documentation for nurse aides indicating whether leg rests/footboards were to be used on Resident R34's wheelchair and that the care plan did not contain this information. During an observation on 1/4/18, at 12:10 p.m. Resident R34 was noted to be sitting in a wheelchair in the dining room without leg rests or footboards present on the wheelchair. During an interview on 1/4/18, at 12:20 p.m. NA Employee E2 confirmed that Resident R34's leg rests were in her room and she was never told she had to use them. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 1/21/16 28 Pa. Code 201.18(b)(1) Management Previously cited 2/8/17 28 Pa. Code 201.29(a) Resident rights Previously cited 2/8/17 28 Pa. Code 211.5(f) Clinical records Previously cited 2/8/17 28 Pa. Code 211.10(c) Resident care policies Previously cited 1/21/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 2/8/17, 1/21/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 2/8/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/8/17, 1/21/16