Every finding on record at Luther Acres Manor

Based on review of facility policies, clinical record, facility documentation and interviews with staff, it was determined the facility failed to ensure a resident remained free from neglect, which resulted in actual harm to Resident R5 who sustained a left leg periprosthetic femur fracture for one of five residents reviewed (Resident R5). Findings include:Review of facility policy Resident Abuse Prevention and Reporting dated July 22, 2009, with a last revision date of November 28, 2016, and November 29, 2016, defines Neglect as 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 Resident R5's MDS (Minimum Data Set - mandatory periodic assessment) dated May 8, 2026, revealed Resident R5 was readmitted to the facility on [DATE], with the diagnoses of unspecified fall, repeated falls, other abnormalities of gait and mobility, cognitive communication deficit, and need for assistance with personal care. Additional review revealed Resident R5's toilet transfer status is Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Continued review revealed the resident was severely cognitively impaired with a Brief Interview of Mental Status of a 7 out of 15. Review of Resident R5's care plan, date-initiated April 20, 2026, revealed the resident ambulation status is non-ambulatory.Further review of Resident R5's care plan revealed the resident was designated by the facility to be at risk for falls. Interventions included anticipate and meet the resident's needs.Review of documentation submitted on June 17, 2026, to the State Survey Agency revealed on June 14, 2026, Resident R5 experienced a witnessed fall while Certified Nursing Assistant, Employee E3 was assisting Resident R5 from the bathroom ambulating without a walker or gait belt when resident's left knee buckled, causing her to lower herself to the floor. Nursing staff assessed Resident R5 following the fall, documented left knee discomfort and inability to straighten her leg, notified the physician and Power of Attorney (POA), obtained an X-ray, and implemented pain management interventions (ice pack). The X-ray results documented a knee prosthesis in place without loosening, with an effusion and no fracture identified at that time. On June 16, 2026, Resident R5 was transferred to a nearby hospital and admitted with a diagnosis of a left periprosthetic femur fracture (fracture occurring around or near a hip replacement implant).Review of the facility-submitted PB-22 (Report of Investigation of Alleged Abuse, Neglect, or Misappropriation of Property), initiated June 16, 2026, revealed Resident R5's ambulation status was noted to be non-ambulatory and Resident R5, should not have been ambulated by Certified Nurse Aide, Employee E3.Further review of the PB-22 revealed the facility substantiated the allegation of neglect and concluded Resident R5 experienced neglect as a result of Certified Employee E3's actions.Review of facilities fall investigation revealed the following transcript between the Nursing Home Administrator (NHA) and Certified Employee E3, dated June 17, 2026, at approximately 2:35 p.m. Certified Employee E3: We (E3 and Resident R5) went into the bathroom and when we were walking back we right by resident's bed. I turned my head to turn the light off and he/she went down on his/her behind. He/she went down so fast I didn't have time to grab him/her. I was trying to make sure he/she didn't hit his/her head on the footboard.NHA: Do you know what his/her ambulation status is on his/her Kardex?Certified Employee E3: One assist with walker.NHA: Do you remember the last time you looked at resident's Kardex?Certified Employee E3: No I don't - I'm not sure, I just know I was told he/she is a 1 assist with walker.NHA: Who told you he/she is a 1 assist with a walker?Certified Employee E3: I don't know - someone when he/she was admitted .NHA: Do you know her transfer status on her Kardex?Certified Employee E3: A one assist - I'm always there with him/her.NHA: Does a one assist require hands on assistance?Certified Employee E3: Is she needs assistance - I am there to assist. But I am always standing right there.NHA: Were you using a gait belt?Certified Employee E3: NO - I was not using a gait belt.Certified Employee E3: So, we are supposed to check the Kardex every shift!?NHA: Yes, that was the expectation- actually, the Kardex should be checked multiple times a shift as things can change.Certified Employee E3: We don't have time for that.Further review of the investigation transcript revealed Certified Nurse Aide, Employee E3 was suspended pending the outcome of the facility's investigation. Documentation further revealed Employee E3 subsequently resigned effective immediately.Interview conducted with Resident R5 on June 29, 2026, at approximately 12:50 p.m. revealed Resident R5 recalled walking back from the bathroom when his/her knee gave out, causing him/her to fall to the floor. Resident R5 stated Certified Nurse Aide, Employee E3 did not prevent the fall.The above findings were discussed with the Nursing Home Administrator and Director of Nursing on June 29, 2026, at approximately 2:23 p.m.The facility failed to ensure Resident R5 was free from neglect. As a result, Resident R5 sustained a fall resulting in actual harm, including transfer to the hospital via emergency medical services and a diagnosis of a left periprosthetic femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 201.18(b)(3) Management28 Pa. Code 201.29(c) Resident rights28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.11(d) Resident care plan28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clincal record review, faciltiy policy review, observations and staff and resident interviews, it was determined that the facility failed to ensure that call bells were answered in a timely manner for one resident observed (Resident 1).Findings include: During interview conducted with Resident 1 on April 14, 2026, at 11:12 a.m., the resident stated he/she had concerns with the length of time it takes for staff to respond to his/her call bell. Resident 1 stated that he/she required assistance with incontinence care and had initiated his/her call bell at approximately 11:00 a.m. A staff member, who Resident 1 later identified as dietary staff, knocked on the resident's door at 11:17 a.m. to inquire if Resident 1 needed assistance because his/her call bell was on. Resident 1 stated he/she needed assistance with incontinence care, the staff member stated he/she would inform the nurse aide. At 11:35 a.m. when this Surveyor left the resident's room no staff had come to assist the resident. Observations made from the unit's nurses station until 12:03 p.m. revealed no staff responding to Resident 1's call bell.Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 14, 2026, at 12:05 p.m., when the above information was presented, the DON was asked what was considered a long wait time for call bell responses, the DON responded 15 minutes was to long. This Surveyor then informed the DON that Resident 1 had been waiting for over an hour. The NHA called the unit to have staff assist the resident immediately. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review, faciltiy policy review, observations and staff and resident interviews, it was determined that the facility failed to ensure that activities of daily living were performed in a timely manner for one resident observed (Resident 1)Findings include: Facility policy titled Activities of Daily Living (ADL), Supporting, last revised April 2025, documents residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (adls). Residents who are unable to carry out adls independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 1's Quarterly Minimum Data Set (MDS) dated [DATE], under the section for Activities of Daily Living (ADLs), revealed the resident requires a Hoyer lift and is dependent on staff assistance with showering/bathing, and toileting.During interview conducted with Resident 1 on April 14, 2026, at 11:12 a.m., Resident 1 stated that he/she required assistance with incontinence care and had initiated his/her call bell at approximately 11:00 a.m. Observations were made at 11:17 a.m., of a staff member, asking Resident 1 if he/she needed assistance because his/her call bell was on. Resident 1 stated he/she needed assistance with incontinence care, the staff member stated he/she would inform the nurse aide. At 11:35 a.m. when the interview concluded, no staff had come to assist the resident. Observations made from the unit's nurses station from 11:35 a.m. until 12:03 p.m. revealed no staff responded to Resident 1's call for assistance with incontinence care.Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 14, 2026, at 12:05 p.m., when the above information was presented, the DON was asked what was considered a long wait time for call bell responses, the DON stated 15 minutes was to long. The NHA and DON was informed that Resident 1 had been waiting for over an hour for incontinence care. The NHA called the unit to have staff assist the resident immediately. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, observation and staff interview, the facility failed to maintain enhanced barrier precautions for three out of 18 residents reviewed (Residents 10, 11, and 21).Based on review of clinical records, observation and staff interview, the facility failed to maintain enhanced barrier precautions for three out of 18 residents reviewed (Residents 10, 11, and 21).Findings include:A review of facility policy entitled Enhanced Barrier Precautions, revised May 29. 2024 revealed: EBP (Enhanced Barrier Precautions - an infection control intervention to reduce transmission of multi-drug-resistant organisms (MDRO) that requires gown and glove use during high contact resident activities) are indicated for residents with any of the following:Infection or colonization (the presence of organisms without causing harm) with a CDC-targeted MDRO (organisms that are of significant concern to the Centers for Disease Control due to their resistance to multiple antibiotics and potential for spread)Wounds generally include wounds that are chronic and require prolonged healing time.Indwelling medical devices such as .central lines (a flexible tube placed into a large vein that provides access to the central circulation near the heart), midlines (a flexible tube placed into the vein of the upper arm), urinary catheters (a tube placed in the bladder to drain urine).To maintain a homelike environment, residents requiring EBP will have a magnet outside of their door and appropriate signage inside the room indicating what PPE (Personal Protective Equipment such as gowns, gloves, face shields) is required. PPE and alcohol-based hand rub will be readily available for staff use when caring for residents requiring EBP.Review of Resident 10's care plan revealed a care plan for EBP to reduce the spread of MDRO's related to chronic heel wounds and permacath (a type of central line) to right chest. Observation of Resident 10's room at approximately 1:45PM revealed an EBP magnet on the frame of the door, and signage in the bathroom, but no gowns in the room.Review of resident 11's care plan revealed a care plan for EBP to reduce the spread of MDRO's related to urinary .catheter. Observation of Resident 11's room at approximately 1:30PM revealed an EBP magnet on the frame of the door, no signage in the room and no gowns in the room.The DON confirmed this observation on February 26, 2026, at approximately 1:35PM.Review of Resident 21's care plan revealed a care plan for EBP to reduce the spread of MDRO's related to chronic wound on scalp.Observation of Resident 21's room on February 25, 2026 at approximately 1:50PM revealed an EBP magnet on the door frame, no signage inside the room, and no gowns inside the room.Interview with Infection Preventionist on February 25, 2026, at approximately 1:30PM revealed that for residents on EBP, magnets are placed on the door frame facing the hallway, signage indicating the type of PPE required is inside the room, either on the back of the hall door or the back of the bathroom door, and PPE is in the bathroom.Interview with the Director of Nursing on February 27, 2026, at approximately 2:45PM confirmed that for residents with EBP, PPE and signage should be in the resident's room.28 Pa. Code 211.12(d)(1)(3)(5)Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for two of 18 residents reviewed. (Resident 35 and Resident 76). Findings include: Review of Resident 35's physician orders revealed an order dated November 17, 2025, to notify provider immediately by phone call (in-house or on-call provider if after hours) of SBP (Systolic Blood Pressure – the top number in a blood pressure reading indicating the maximum pressure on arteries when the heart contracts) greater than 160 or DBP (Diastolic Blood Pressure- the bottom number in a blood pressure reading indicating the minimum pressure on arteries when the heart contracts) greater than 100, every shift for elevated blood pressure. The order was discontinued on February 6, 2026. Review of Resident 35's December 2025 Medication Administration Report (MAR) revealed six days, December 1, 2025, December 14, 2025, December 20, 2025, December 22, 2025, December 26, 2025, and December 30, 2025, when the resident's SBP was noted to be over 160. Review of Resident 35's January 2026 MAR revealed six days, January 9, 2026, January 15, 2026, January 16, 2026, January 24, 2026, January 26, 2026, and January 29, 2026, when the resident's SBP was noted to be over 160. Review of Resident 35's February 2026 MAR revealed one day, February 5, 2026, when the resident's SBP was noted to be over160. Review of Resident 35's progress notes and clinical records failed to reveal documentation of the physician being notified of the findings on the above dates. Interview conducted with the Director of Nursing (DON) on February 26, 2026, at 1:30 p.m., when the above information was presented, the DON was asked to present documentation of the physician being notified, the DON stated the notifications may be in the resident's paper chart and that she would investigate the matter. The DON could not provide documentation for physician notifications. Review of Resident 76's clinical record revealed diagnoses including acute congestive heart failure (is a sudden and life-threatening condition where the heart is unable to pump enough blood to meet the body's need) and pulmonary hypertension unspecified (condition where there is high blood pressure in the arteries that supply blood to the lungs). Review of Resident 76's clinical record revealed a physician's order dated December 17, 2025, stated CHF Pathway: Weight daily: notify (name of physician) for weight gain > (greater than) 2 pounds in 24hours or > 5 pounds in 7days. Review of Resident 76's clinical record revealed weights on December 25, 2025 -137pounds; December 26, 2025-140.6pounds (weight gain of 3.6pounds) and February 18, 2026-133.8 pounds; February 19, 2026- 137 pounds (weight gain of 3.2). Further review of Resident 76's clinical record revealed the facility failed to notify the physician of weight gain on two occasions. Interview with Employee 3 on February 27, 2025, at 10:30am confirmed the above findings. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that pressure ulcer was assessed and monitored for one of three residents reviewed (Resident 3). Findings Include:Review of the facility's policy titled General Wound Management last reviewed February 10, 2020, stated that 'Ongoing Wound Assessment . the wound nurse us responsible for coordinating, preparing and maintaining the functioning of the wound round team.3. Comprehensive wound assessment should include at least the following parameters: Location of wound which may provide information related to the etiology of the wound; b. Length , width and depth measurements recorded in centimeters; c. Direction and length of tunneling and undermining; d. Appearance of the wound base; e. Type and percentage of tissue in wound; f. Drainage amount and characteristics including color, consistency and odor.'Review of Resident 3 physician orders revealed an order started on January 28, 2026 Wash wound with soap and water scrubbing gently. Rinse well and pat dry. Irrigate well with NSS (Normal Saline Solution- sterile salt water). Pack tunnel at 12o'clock (top) and undermining (occurs when tissue destruction extends beneath the skin edges, creating a hidden pocket or shelf around the margin) from 9 o'clock to 3o'clock (left to right) with white granufoam (black foam placed inside the wound). Place black foam to fill the rest of wound and assist in bridging to side of patient. Set Wound vac (a therapeutic device using controlled suction to promote healing in chronic or severe wounds) at 150mmhg (millimeters of mercury) continuous negative pressure with granufoam to wound. Place drape around edges to protect May use stoma paste (adhesive safe on skin)or alginateperi wound for seal or skin irritation (adhesive safe on skin) one time a day every Mon, Wed, Fri for Wound care AND as needed for Wound care.Review of Resident 3's Treatment Administration Records for December 2025, January 2026 and February 2026 revealed that treatment was provided as per order.Review of Resident 3's clinical record did not include facility documentation of the wound weekly assessments, measurements or monitoring in December 2025, January 2026 and February 2026.Interview with the Director of Nursing on February 27,2026 at 2:30 pm confirmed the above findings.28 Pa. Code: 211.5 (f) Clinical records28 Pa. Code: 211.12 (d) (1) (5) Nursing Services

Based on observations, clinical records review and interview with staff, it was determined that the facility failed to ensure fluid restriction orders for dialysis residents were followed for one of one dialysis resident reviewed. (Resident 10).Findings include:A review of the facility's policy titled Fluid Monitoring, dated 11/05/2019, revealed the following guidelines for restricting fluids: f. Dietician/ Designee is responsible for ensuring the total I/Os for the day, which are recorded in the EMAR. g. Breakdown of fluids for med pass is determined by dietician/designee and placed on EMARReview of Resident 10's diagnosis list includes End Stage Renal Failure (ESRD- failure of kidney function to remove toxins from blood), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally).Review of Resident physician's orders revealed orders for Fluid restriction: 1500ml Fluid Restriction: 7-3 provide 840ml (360ml at breakfast, 240ml at lunch, 240ml at medpass); 1500ml Fluid Restriction: 3-11 provide 540ml (300ml at dinner, 240ml at med pass) every evening shift dated November 10 2025 and 1500ml Fluid Restriction: 11-7 provide 120ml every night shift dated November 9 2025.Review of Resident 10's Medical Administration Record (MAR) failed to reveal evidence of the amount of fluid Resident 10 was receiving each shift.Interview with Director of Nursing on February 27, 2026, at approximately 11:30am confirmed the above findings.28 Pa. Code: 211.5(f) Clinical records28 Pa. Code 211.12(d)(1)(5) Nursing Service

Based upon clinical record review and staff interviews, it was determined that the facility failed to ensure that medication irregularities were acted upon for one of five residents reviewed (Resident 9).Findings include:Review of Resident 9's Pharmacy Regime Review performed between November 1, 2025, and November 30, 2025, revealed a recommendation for PRN (as needed) pain medication Naproxen (a non-steroidal anti-inflammatory medication used to treat pain) to be specifically staged for use according to pain severity, for example, Naproxen 250 mg (milligrams) for prn mild pain, Naproxen 500 mg prn for moderate to severe pain. The physician agreed with and signed the recommendation.Review of Resident 9's physician orders revealed an order for Naproxen Oral Tablet 500 mg, give 2 tablets by mouth every 6 hours as needed for pain with a start date of August 11, 2025.Review of Resident 9's December 2025, January 2026 and February 2026, Medication Administration Reports (MAR) revealed an order for Naproxen Oral Tablet 500 mg, give 2 tablets by mouth every 6 hours as needed for pain with a start date of August 11, 2025.Review of Resident 9's physician orders failed to reveal that the resident's orders were updated to reflect the above pharmacy recommendation.Interview conducted with the Director of Nursing (DON) on February 26, 2026, at 1:30 p.m., when the above information was presented, the DON confirmed the resident's physician orders had not been updated to reflect the pharmacist's recommendations. 483.45 Drug Regimen Review, Report Irregular, Act on28 Pa. Code 211.5(f) Clinical records

Based upon clinical record review and interview, it was determined the facility failed to ensure non-pharmaceutical interventions were completed prior to the administration of pain medication for one resident and failed to ensure side effects were monitored during the use of anti-psychotic medication for three out of 18 Residents. (Resident 39 and Resident 66 and Resident 75).Findings include: Review of facility policy titled Psychotropic Medication Use (psychotropic medications affect mood and behavior and are used to treat mental health conditions) revised April 20. 2021, revealed Resident behaviors will be documented in the medical record as observed by staff, to include documentation in nurse's notes or other designated forms of non-pharmacological interventions (strategies to manage health conditions without medications) used. Review of Resident 39's physician orders revealed orders for oxycodone 5mg tab; 1 tab by mouth at bedtime as needed for pain; an order for oxycodone 5mg tab 1/2 tablet (2.5mg) by mouth every 4 hours as needed for mod-severe pain discontinued February 12, 2026. Review of Resident 39's January 2026 and February 2026 Medication Administration Record revealed Resident 39 received Oxycodone 5mg on the following dates: January 3 2026, January 4 2026, January 5 2026 January 7 2026, January 8 2026, January 9 2026, January 10 2026, January 11 2026, January 12 2026, January 13 2026, January14 2026, January 15 2026, January16 2026 , January17 2026, January 18 2026, January19 2026, January 21 2026, January 23 2026 and January 24 2026; received Oxycodone 10 mg on February 20,2026. Further review of Resident 39's clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of Oxycodone 10 mg. Interview with the Director of Nursing on February 27, 2026, at 1:30 p.m. confirmed that non-pharmaceutical interventions were not attempted prior to the administration of Resident 39's pain medication. Review of Resident 66's January 2026 and February 2026 Medication Administration Record revealed an order for Quetiapine (an antipsychotic medication used to regulate mood or behavior) 25MG once daily at bedtime for unspecified dementia, unspecified severity with other behavioral disturbance, dated January 22, 2026, with no order for side-effect monitoring. Review of Resident 75's January 2026 and February 2026 Medication Administration Record revealed an order for Quetiapine 25MG twice a day for major depressive disorder, recurrent, unspecified dated January 21, 2026, with no order for side-effect monitoring. Review of Resident 66 and 75's clinical record revealed there was no evidence the facility was monitoring the residents for side effects of psychotropic medication or monitoring the residents' behaviors for the effectiveness of the medications. Interview with the Director of Nursing on February 27, 2026, at approximately 1:20PM confirmed that residents 66 and 75 did not have orders to monitor and document the side effects in the resident's chart. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of observations and resident and staff interviews it was determined that the facility failed to provide activity of daily living (ADL) assistance for ten of eighteen residents (Residents R1, R3, R4, R5, R6, R7, R8, R9, R10, and R11).Findings include: During an observation on 8/7/25, at 10:38 a.m. when asked if she needed to wait an extended amount of time when she requests assistance with care, Resident R3 stated, Frequently on third shift. During an observation on 8/7/25, at 10:42 a.m. when asked if she needed to wait an extended amount to time when she requests assistance with care, Resident R4 stated, Depends on the aide. If we have agency people, then we wait. During an observation on 8/7/25, at 10:57 a.m. when asked if she felt the facility maintained an adequate number of staff, Resident R1 stated, Yes and no. I don't think there are enough of them in the evening. During an observation on 8/7/25, at 12:08 p.m. when asked if he needed to wait an extended amount to time when she requests assistance with care, Resident R4 stated, It takes a long time to get back into bed if you get out. Review of facility grievances filed in May 2025, through July 2025, revealed the following: -On 5/9/25, Resident R6 had voiced a concern that he had rung his call light on 5/8/25, at 6:00 a.m. and staff did not respond. Resident R6 stated that he had to use the bathroom unassisted. -On 5/19/25, Resident R7's family member had voiced a concern on third shift (overnight) and weekends the call bell response time was too slow, and that staff are verbally short when responding (on 3rd shift). She stated that he was offered a urinal to use despite not being able to use it without spilling. -On 5/23/25, Resident R8 had voiced a concern that on 5/22/25, his call bell was answered in excess of 1.5 hours. He stated that he activated his call bell at 6:50 a.m. and that he did not receive care until 8:30 a.m. -On 6/16/25, Resident R9's family member had voiced a concern that when she arrived on 6/14/25, she found her mother in the bathroom with bowel movement all over the floor, and no trashcan liner in the trash. She was here with her mother who was in the bathroom ringing to get off the toilet for 15 minutes. During that time, she stated there were many call bells on in the hallway in which she observed staff walking by the call bells and other staff sitting a the nurses stations. She stated she observed many staff sitting at the nurses' station all weekend not answering call bells. She also stated she addressed the call bell issue with (an employee) and he told her that her mother is not the only resident then chuckled. -On 7/7/25, Resident R10's family member had voiced a concern stating, that today her mom was ringing to go to the bathroom, and no one answered her call bell. Resident too herself to the bathroom and rang the bathroom bell as well to get out again and no one came. Daughter approached a woman in blue scrubs regarding the call bell and was told not to expect help when passing trays during mealtime. -On 7/14/25, Resident R11's family member had voiced a concern regarding the length of time it takes to get her call bell answered. This seems to be more of a problem on evening or nights. -On 7/14/25, Resident R9's family member had voiced a concern She was here visiting over the weekend on Saturday on 2nd shift, her mom was ringing her call bell to go to the bathroom. 30 minutes passed and no one came to assist her mother, so she ended up taking her mother to the bathroom herself. She was incontinent and completely soaked, through her clothes and the recliner chair. She stated she was here for 3 hours on Sunday and no one stopped in to even check on her mom in the 3 hours she was visiting. She has stated she is disappointed in the care her mother is currently getting versus the last stay here with us. Visiting family members have mentioned concern over the care she is currently getting. [Family member] stated that the nursing staff have time to sit and play on their phones or sit and mingle with each other but don't have time to care for her mother whom she has found completely saturated more than once now. During an interview on 8/7/25, at approximately 1:15 p.m. the Nursing Home Administrator confirmed the facility failed to provide activity of daily living assistance for ten of eighteen residents. 28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.29(a) Resident's Rights.

Based on review of facility policy, clinical records, observations, and resident and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the wounds for two of six residents (Resident R1 and R2). Findings Include: Review of the facility policy General Wound Management dated 7/22/25, indicated, Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/24/25, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician's order dated 7/25/25, indicated, Cleanse RLE (right lower extremity) skin tear with NSS (normal saline solution), apply calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers derived from brown seaweed or kelp) to wound bed and cover with foam dressing daily & PRN (as needed) every day shift. During an observation on 8/7/25, at 10:52 a.m. the dressing on Resident R1's right lower extremity was dated 8/5/25. Review of Resident R1's TAR (treatment administration record) revealed documentation that Resident R1's RLE dressing change was completed by Licensed Practical Nurse (LPN) Employee E1 on 8/6/25. Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and history of a stroke. During an observation on 8/7/25, at 11:01 a.m. an undated dressing was noted on Resident R2's left lower leg. Review of a progress note dated 7/28/25, at 9:57 a.m. indicated, CNA (nurse aide) reported to this LPN that patient had open area on his L shin. Area measured 3 x 2.5 x 0.1 cm (centimeters). LPN applied xeroform (fine mesh gauze) and bordered foam dressing after cleansing. Further review of Resident R2's progress notes failed to reveal that the open area on his left shin was assessed by a provider. Review of Resident R2's physician orders failed to reveal a treatment order for Resident R2's left lower leg. During an interview on 8/7/25, at approximately 1:15 p.m. the Nursing Home Administrator confirmed that facility failed to provide prescribed treatment and services related to the wounds for two of six residents. 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from physical restraints (Resident 1). Findings include: Review of facility policy, Restraint Policy, undated, revealed: restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions: 1) as a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2) with a physician order; 3) with the consent of the resident or legal representative; 4) when the benefits of the restraint outweigh the identified risks. Review of facility orientation packet given to outside nursing staff and nursing students revealed: This is a restraint free facility. Review of nurse aide Employee E5's orientation packet revealed the employee signed acknowledgement of receipt and understanding of the orientation materials on October 7, 2023. Review of Resident 1's clinical record revealed the resident was admitted to the facility April 23, 2024, with diagnoses including Parkinson's (chronic and progressive movement disorder that causes tremors, stiffness or slowing of movement), severe dementia (general decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control) with psychotic disturbance, psychotic disorder with delusions, hallucinations, disorientation, unsteadiness on feet, unspecified abnormalities of gait and mobility, and cognitive communication deficit. Review of Resident 1's admission MDS (minimum data set - periodic assessment of resident care needs) dated April 28, 2024, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01, indicating severe cognitive impairment. Review of Resident 1's clinical record failed to reveal orders for any type of restraint. Interview with the recreation manager, Employee E3, on May 29, 2024, at approximately 9:50 a.m. revealed that the employee was made aware by the activity aide, Employee E4, on May 13, 2024, at 4:15 p.m., that Resident 1 had a gait belt (a device put on someone who has mobility issues to aid caregivers in moving them) wrapped around their waist and the wheelchair in the dining room. Employee E3 stated she then went to the dining room and saw the gait belt tied around Resident 1 and secured in the back of the wheelchair. Resident 1 was asleep at this time. Employee E3 informed nurse aide Employee E5 that the gait belt needed to be removed. Employee E3 stated that Employee E5 expressed understanding and stated they put the gait belt on Resident 1 because the resident had fallen a couple times that day. Employee E5 then removed the gait belt from around Resident 1 at approximately 4:30 p.m. Review of facility investigation revealed witness statements from staff Employees E5, E6, and E7, all stating that Resident 1 had a witnessed fall on May 13, 2024, at 4:00 p.m. when the resident tried to stand from the wheelchair. Interview with the Director of Nursing on May 29, 2024, at approximately 11:00 a.m. revealed because of the witnessed fall at 4:00 p.m., Resident 1 was estimated to have been restrained by the gait belt for approximately a half hour. Interview with the Nursing Home Administrator and Director of Nursing on May 29, 2024, at approximately 12:00 p.m. confirmed the facility does not use restraints and Employee E5 should not have wrapped the gait belt around Resident 1 and the wheelchair as a restraint. 28 Pa. Code: 211.8(d)(e)(f) Restraints 28 Pa. Code:211.10(d) Resident care policies 28 Pa. Code:211.12(d)(1)(5)Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to investigate an allegation of being rough during care for one of the 18 residents reviewed (Resident 8). Findings include: Review of Resident 8's diagnosis list includes Traumatic Brain Injury (TBI), and Anxiety (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 8's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated September 14, 2023, revealed resident had moderate impairment with cognition and required extensive assistance with personal hygiene and dressing. Review of Resident 28's nursing progress notes dated October 16, 2023, at 2:56 p.m., revealed Resident 8 told the aide assisting her/him that she/he was being too rough. Another aide came to assist the resident then pulled the second aide's hair and said, Was that soft and gentle? Interview was conducted with the Director of Nursing (DON) on December 14, 2023, at 10:00 a.m. The DON reported a second aide came to assist the first aide after the allegation of being rough was made by the resident. The incident was reported to the nurse who then documented the incident to the EMR (Electronic Medical Record). The DON confirmed that Resident 8's allegation of the first aide being rough during care was not investigated. The facility failed to investigate Resident 8's allegation of staff being rough during care was conducted. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services 28 Pa. Code 201.29(j) Resident rights.

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to follow physician orders for the administration of insulin for one of two residents reviewed (Resident 64). Findings include: Review of facility policy and procedure titled Insulin Administration, revised February 2015 revealed Check blood glucose per physician order or nursing protocol. Review of Resident 64's diagnosis list revealed diagnoses including Type 2 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment). Review of Resident 64's physician orders revealed an order to check glucose with Libre 2 system three times per day before meals. Further review of Resident 64's physician orders revealed an order for Novolog Insulin, Inject 10 units twice daily morning and afternoon with meals. Hold for blood sugar less than 150 and to inject 5 units every evening with meals. Hold for blood sugar less than 150. Review of Resident 64's November 2023 Medication Administration Record (MAR) revealed on November 3, 2023, at 11:00 a.m. Resident 64 received Novolog Insulin for a blood sugar of 148; November 9, 2023 at 4:00 p.m. Resident 64 received Novolog Insulin for a blood sugar of 148; November 11, 2023 at 7:30 a.m. and 4:00 p.m. Resident 64 received Novolog Insulin for blood sugars of 111 and 115; November 14, 2023 at 4:00 p.m. Resident 64 received Novolog Insulin for a blood sugar of 124; November 16, 2023 at 11:00 a.m. Resident 64 received Novolog Insulin for a blood sugar of 134; November 17, 2023 at 7:30 a.m. and 11:00 a.m. Resident 64 received Novolog Insulin for blood sugars of 141 and 136; November 18, 2023 at 7:30 a.m., 11:00 a.m. and 4:00 p.m. Resident 64 received Novolog Insulin for blood sugars of 145, 138 and 145; and on November 23, 2023 at 11:00 a.m. Resident 64 received Novolog Insulin for a blood sugar of 90. Interview with the Director of Nursing on December 14, 2023, at 10:00 a.m. confirmed that Resident 64 received Novolog Insulin with blood sugars outside the parameters of Resident 64's physician orders. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services

Based on clinical record review and staff interviews it was determined that the facility failed to ensure a resident's code status for one out of 24 residents reviewed (Resident 71). Findings include: Review of the clinical record revealed Resident 71 was admitted to the facility on [DATE]. Review of Resident 71's clinical record revealed a POLST (Pennsylvania -Orders for Life Sustaining Treatment), signed on February 7, 2023, indicating the resident wanted life sustaining code status to be considered, Do Not Resuscitate (DNR). Review of the physician orders revealed the DNR was not current. Interview with the Social Service Director, Employee E3 December 7, 2023 at 10:30 a.m., confirmed the DNR order was not listed on the residents physician orders as Resident 71 intended as stated on the POLST form. The facility failed to ensure the resident's right to formulate an advance directive for Resident 71. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 201.29(j) Resident rights.

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to ensure a thorough investigation was completed for injuries of unknown origin for 2 of 18 residents reviewed (Resident 15 and Resident 28). Findings include: Review of facility policy and procedure titled Accident, Incident and Death Reporting/Investigation, revised 2019, revealed Any injury should be classified as an 'injury of unknown origin' when the following conditions are met: a) the origin of the injury was not observed by any person or the origin of the injury could not be explained by the resident; b) the injury is suspicious because of the extent of the injury, or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma such as, but not limited to breast or groin area), or the number of injuries observed at one particular point in time (such as multiple bruises in a pattern resembling finger marks), or the incidence of the injuries over time and c) there is no reasonable determination as to how the injury occurred (e.g. a confused resident that self-propels a wheelchair and is known to occasionally bump into doorways, etc., and gets a large bruise on the back of the hand). Further review of this policy and procedure revealed In order to determine probable cause for injuries of unknown origin - statements shall be obtained from team members who were assigned to the resident within 24 hours (3 shifts) prior to becoming aware of the injury. Review of Resident 15's clinical progress notes dated February 14, 2023, revealed While CNA was providing am [morning] care, CNA noted multiple green/yellow bruises on left upper arm. No c/o [complaints of] pain was noted this shift. Resident was unable to explain how areas happened. POA was notified on bruises. Fax was prepared to update MD on bruises. Review of facility documentation revealed only one staff member's statement was obtained regarding Resident 15's bruises. Review of Resident 28's clinical progress notes dated February 16, 2023, revealed that the nurse aides, alerted the nurse that when they took the residents sock off they noticed a bruise at the residents right ankle. Slight swelling noted. The bruise is 10 cm [centimeter] in length and wraps around to the front of the lower rt leg. POA notified of bruise, MD [Medical Doctor] order for an x-ray. Review of facility documentation revealed one staff members statement was obtained regarding Resident 28's bruise. One staff member was interviewed regarding the resident's daily behaviors. Interview with Nursing Home Administrator and Director of Nursing on February 24, 2023, at 11:00 a.m. failed to provide evidence of further investigation or further staff statements regarding Resident 15's bruises and Resident 28's bruise on the ankle. This interview further revealed that a thorough and complete investigation was not conducted by the facility. The facility failed to ensure a complete and thorough investigation was conducted to determine the origin of Resident 15's upper arm bruises and Resident 28's ankle bruise. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 2/22/2022

Based on a review of the facility ' s policy, clinical records review, pharmacy record review, and staff interview, it was determined that the facility failed to timely acquire and administer an emergency-controlled medication for one of 17 residents reviewed (Resident 269). Findings include: Review of the facility policy titled, Dispensing Pharmacy Services, with a revision date of June 1, 1999, revealed that [Pharmacy] Services Pharmacy is responsible for rendering the required services in accordance with local, state, federal laws and regulations, facility policies and procedures, and community standards of practice. The pharmaceutical services include accurate dispensing of prescriptions based on authorized prescriber order; and providing, maintaining, and replenishing in a timely manner an emergency medication supply in a sealed and properly labeled container. Review of Resident 269's diagnosis list revealed Dementia with Lewy Body (A type of progressive dementia that leads to a decline in thinking, reasoning, and independent function due to abnormal microscopic deposits that damage brain cells over time). Review of Resident 269's nursing progress notes dated May 13, 2021, at 5:58 a.m., revealed that at 3:43 a.m., the resident was observed shaking, breathing heavy, non-responsive, the face was turned on the side with saliva coming out from the mouth. Vitals were taken, oxygen was administered, the physician was notified. The physician gave a verbal order at 3: 59 a.m., to administer [MEDICATION(S)] (A medication used for Anxiety, muscle spasm, and [CONDITION(S)]) 5mg via IM (intramuscular), may repeat after fifteen minutes if signs and symptoms of the [CONDITION(S)] (A sudden, uncontrolled electrical disturbances in the brain) do not resolve. A review of the same note revealed that the first dose of the [MEDICATION(S)] was administered to the right arm at 5:00 a.m., one hour after the verbal order was received from the physician. A second dose was administered at 5:26 a.m. the physician and the family was updated with the resident ' s condition. Review of the nursing progress notes dated May 13, 2021, at 7:05 a.m., revealed that the resident was reassessed, vitals monitored, kept on oxygen, resident was stable and not in distress. Further review of the same note revealed per the physician if residents' vitals are stable and jaw is no longer clenched, no other action needs to be taken. The family was notified of the physician's order. Review of the nursing progress notes dated May 13, 2021, at 8:06 a.m., revealed that the resident ' s family requested for the resident to be transferred to the hospital. Resident 269 was admitted to the hospital with a diagnosis of [CONDITION(S)]. Interview conducted on February 22, 2022, at 1:00 p.m. with licensed nurse Employee E3 indicated upon receiving a verbal order for a controlled medication from the physician, the order is to be faxed to the pharmacy, the physician will contact the pharmacy for prescriptions, the pharmacy will enter the order into the system and a profile will be created in the CUBEX (automated medication dispensing system). Employee E3 reported that the delay in the acquisition and administration of the medication [MEDICATION(S)] was due to an error made by the pharmacy. The pharmacy apparently entered into the CUBEX system; the medication under another resident's name. This error had prevented the nursing staff to acquire and administer the medication timely. Review of the facility documents dated May 13, 2021, revealed that the medication [MEDICATION(S)] was entered under another resident with the same last name as Resident 269. The error was corrected at 5:00 a.m. The above information was conveyed to the Nursing Home Administrator on February 22, 2022, at 1:15 p.m. The facility failed to timely acquire and administer an emergency-controlled medication for Resident 269. 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 2/26/21 28 Pa. Code 211.12(c) Nursing services Previously cited 2/26/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/26/21 28 Pa. Code 211.10 (c)(d) Resident care policies

Based on a review of the facility's policy, clinical records, and interviews with staff, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for three of 17 residents reviewed (Resident 2, Resident 29, and Resident 66). Findings include: Review of the facility's policy and procedure titled Accident, Incident and Death Reporting/Investigation, with a most recent revision date of August 7, 2019; revealed that an injury should be classified as an injury of unknown origin when the origin of the injury was not observed by any person, or the origin of the injury could not be explained by the resident. The same policy revealed that the licensed nurse completing the Resident Incident Report is responsible for initiating the investigative process that includes interviewing the resident and team members and preparing written statements. Further review of the policy revealed that to determine probable cause for injuries of unknown origin-statements shall be obtained from team members who were assigned to the resident within 24 hours (three shifts) prior to becoming aware of the injury. Review of Resident 2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 11, 2021, revealed the resident had moderate cognitive impairment. Review of nursing progress notes dated April 4, 2021, revealed that while providing care, the nursing assistant (NA) observed a bruise on [Resident 2's] left shin with a measurement of 15 x 7 cm (centimeter) and a bruise to the left knee with a measurement of 4 x 3 cm. Family notified. Review of the facility's incident report, revealed a witness statement dated April 4, 2021, indicating per NA, she/he was informed by Resident 2 that she/he tripped from another resident's feet but did not fall. The statement failed to reveal that the incident was witnessed by the NA. The facility documentation failed to reveal further statements from other staff and residents. Additional review of the same documents revealed the probable cause of Resident 2's 15 x 7 cm bruise to the left shin was from banging against a bed frame. Review of Resident 29's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 29's Minimum Data Set, dated dated dated [DATE], revealed that the resident had severe cognitive impairment. Review of the nursing progress notes dated December 17, 2021, at 8:30 p.m., revealed that after transferring the resident to the bed, a bruise was observed on Resident 29's left calf with a measurement of 6.0 x 6.0 cm. and right calf with a measurement of 5.0 x 5.0 cm. Review of the facility's documentation, incident report dated December 17, 2021, revealed that there was no witnesses to the incident. Documentations review failed to revealed statements from any staff. Review of Resident 29's nursing progress notes dated January 6, 2022, at 8:30 a.m., revealed that a 14 x 6.0 grey discoloration bruise was observed on the resident's right posterior calf while NA was providing morning care. Review of the facility's documentation, incident report dated January 6, 2022, revealed one statement from the NA who identified the bruise in the morning. Further review of documentation failed to reveal any additional staff witness statements. Review of Resident 66's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 66's Minimum Data Set, dated dated dated [DATE], revealed that the resident had severe cognitive impairment. Review of Resident 66's nursing progress notes dated September 27, 2021, at 11:12 a.m., revealed a large bruise was observed on the resident's right anterior bicep during morning care. The bruise had a measurement of 4.0 x 6.0 cm. Review of the facility's documentation, incident report dated September 27, 2021, revealed that the resident was unable to identify possible cause of the bruise. The report revealed one statement from the staff who identified the bruise, no statements from other shifts were noted The above information was conveyed to the Nursing Home Administrator and Director of Nursing on February 22, 2022, at 1:30 p.m. The facility failed to conduct a thorough investigation for the bruise of unknown origin for Residents 2, 29, and 66. 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 2/26/21 28 Pa. Code 211.12(c) Nursing services Previously cited 2/26/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/26/21 28 Pa. Code 211.5(f) Clinical records

Based on staff interview, clinical records and facility documentation review, it was determined that the facility failed to provide meal supervision for one of eighteen residents reviewed (Resident R47). Findings include: A review of the Resident R47 [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated June 19, 2020, revealed that Resident R47 required supervision and set up during mealtime. A review of Resident R47's care plan for ADL (Activities of Daily Living)/Self-Care Deficit, initiated on March 15, 2019, revealed an intervention written on June 26, 2019, Eating: The resident requires staff assistance for eating. A review of the physician's orders [REDACTED]. A review of the progress note dated June 27, 2020, at 10:27 p.m., revealed that staff found Resident R47 with a red face and it looked like the resident was choking. The resident was able to clear the airway on her/his own and chunks of hot dog came out. The resident was assessed, the Nurse Practitioner (NP) was notified and the resident was monitored. The family was aware of the incident. A review of the facility documentation dated June 27, 2020, at 6:15 p.m., revealed that a Nursing Assistant (NA) went into Resident R47's room to pick up a dinner tray and found resident with a red face and appeared to be choking. The resident was able to clear her/his airway. Food came out while the resident was coughing, and it was a piece of a hot dog. Further review of the same documentation revealed that it was seen that a regular hot dog was on the tray. It was unclear as to why the resident received a regular hot dog on the tray. An interview with the Dining Director, Employee E3 on February 26, 2021, at 1:30 p.m., revealed that the facility's mechanical soft texture for a hot dog is almost a consistency of a puree (foods that are easy to swallow, and do not need to be chewed). A review of the progress note dated June 29, 2020, at 8:46 a.m., revealed that the Interdisciplinary Team met and reviewed the incident. An order was received from the speech therapy; education was provided to nursing and dietary staff regarding ensuring appropriate diet. Further review of the same note revealed that the resident did not have adverse signs and symptoms from the event. The facility failed to provide supervision to Resident R47 during mealtime to ensure an appropriate diet was provided. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 18 residents reviewed. (Residents R1, R9, and R59). Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's physician's orders [REDACTED].> 92%. Review of the May 2020 and June 2020 Medication Administration Records and progress noted revealed that Resident R1 received oxygen per the physician orders. Review of Resident R1's quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) dated June 9, 2020, Section O - Special Treatments, Procedures, and Programs, indicated that the resident was not receiving oxygen in the facility. Interview with licensed nurse Employee E4 on February 26, 2021, at 11:45 a.m., confirmed that Resident R assessment regarding oxygen was not accurately identified in the MDS. A review of Resident R9's [DIAGNOSES REDACTED].), and [MEDICAL CONDITION] (CKD- a condition in which the kidney function gradually declines over time). A review of the social worker's progress notes dated December 3, 2020, at 4: 25 p.m. revealed that after talking to Resident R9's daughter, it was decided that the daughter would like hospice (a type of healthcare that focuses on the palliation of a terminal patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) service for the resident. The referral was made to the Hospice. A review of the progress note dated December 5, 2020, at 8:46 p.m. revealed: Hospice services in place. A review of the Significant Change MDS dated [DATE], revealed that on Section O which indicates a resident's Special Treatments, Procedures, and Programs, revealed that Resident R9 was not on hospice. An interview with licensed nurse Employee E4 on February 26, 2021, at 11:50 a.m., confirmed that Resident R9's assessment regarding hospice was not accurately identified in the MDS. Review of Resident R59's physician orders [REDACTED]. Review of Resident R59's Quarterly MDS dated [DATE], revealed that on Section O which indicates the resident's Special Treatments, Procedures, and Programs, revealed that Resident R59 was coded as not on hospice. Review of Resident R59's Quarterly MDS dated [DATE], revealed that on Section O which indicates the resident's Special Treatments, Procedures, and Programs, revealed that Resident 59 was coded as not on hospice. An interview with the Director of Nursing and the Nursing Home Administrator at 10:00 a.m. on February 26, 2021 confirmed that Resident R59 was on hospice services and the quarterly MDSs of November 5, 2020, and February 4, 2020 did not accurately reflect the residents status. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records Previously Cited 11/10/20

Based on review of facility policy and procedure, review of clinical record and review of documentation provided by the facility, it was determined that the facility failed to ensure a safe transfer via a mechanical lift for one of 21 residents reviewed which resulted in actual harm to Resident 303 sustaining a left leg tibial fracture (Resident 303). Findings include: Review of facility policy and procedure titled, Resident Safe Handling Program - Community Wide, revised (MONTH) (YEAR), revealed Sit-to-Stand Lift Usage - (c) Two staff members are recommended to utilize the lift. Further review of the above-mentioned policy revealed I. Sit-to-Stand Lift Resident Transfers; a. Resident must be cooperative and able to follow simple directions; able to put both feet on the base of the sit-to-stand lift and bear some weight; able to lean back into the lifting belt at least a little; if resident has history of knees giving way to the side, utilize leg strap per therapy department and manufacturer recommendations. Review of Resident 303's [DIAGNOSES REDACTED]. Review of Resident 303's quarterly Minimum Data Setassessment (MDS - periodic assessment of resident needs) dated (MONTH) 3, (YEAR), revealed Resident 303's Brief Interview for Mental Status Score (BIMS) to be 5 which indicated severe cognitive impairment. Further review of Resident 303's quarterly MDS revealed that Resident 303 required the extensive assistance of two persons for transfer. The resident was assessed as not steady and only able to stabilize with staff assistance for moving from a seated position to a standing position and from surface to surface transfer (transfer between bed and chair or wheelchair). Review of Resident 303's comprehensive care plan dated (MONTH) 12, (YEAR), reviewed on (MONTH) 16, (YEAR), identified the resident with a self care deficit requiring assistance with activities of daily living. Review of interventions on the resident's plan of care revealed that the resident required the use of a sit-to-stand lift for all transfers. Review of Resident 303's interdisciplinary notes dated (MONTH) 10, (YEAR), revealed at about 1845 (6:45 p.m.) the CNA (nurse aide) had me go to the room and should me a skin tear to the left forearm. The nurse then perform first-aid to the wound by cleansing the wound with wound cleanser and applying a border bandage to it. Once getting her to bed, she c/o (complained of) knee pain upon movement. The nurse then called the on-call Dr. which then gave an order for [REDACTED].>Review of Resident 303's Interdisciplinary Notes dated (MONTH) 11, (YEAR), revealed that Staff reported bruising and pain to (L) (left) lower extremity. Assessment of leg found a 9 cm (centimeter) x 6 cm purple area with some redness. Review of X-ray report of left lower extremity dated (MONTH) 11, (YEAR), revealed a proximal tibial metaphysis fracture (break of bone located in the lower leg) with associated impaction. Review of documentation provided by the facility, dated (MONTH) 10, (YEAR), revealed the Resident was transferring from wheelchair to bed with one staff member assist and use of the sit-to-stand lift .Resident complained of pain to the left knee region and the leg began to swell. Review of this documentation further revealed, Prior to incident transfer status was a sit to stand lift. Facility protocol recommends two staff members at all times for transferring with use of sit to stand lift. Review of additional documentation provided by the facility, dated (MONTH) 12, (YEAR), revealed the IDT (interdisciplinary team) met to discuss skin tear to left arm and injury to left leg during transfer from w/c (wheelchair) to bed. Left arm slid thru sling as most likely resident unable to hold onto mechanical bar. Staff note left knee buckled and appeared hyperextended. Swelling and new onset pain noted. Resident with fracture to left tibia. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 26, (YEAR), at approximately 11:30 a.m. confirmed that Resident 303 was transferred with only one staff member present and further confirmed that two staff members should have been present during the transfer. The facility failed to ensure that Resident 303 was properly transfer from the wheelchair to the bed with the use of mechanical lift which resulted in Resident 303's hyperextening and buckling the left knee and sustaining a [MEDICAL CONDITION] tibia. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 06/20/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/16/16, 06/20/16 28 Pa. Code 201.18(b)(1) Management Previously cited 08/16/16, 06/20/16 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 06/20/16 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c) Resident rights Previously cited 05/23/17 28 Pa. Code 211.5(f) Clinical records Previously cited 05/23/17, 06/20/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/20/16 28 Pa. Code 211.12(c) Nursing services Previously cited 08/16/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 05/23/17, 08/16/16, 06/20/16

Based on review of facility policies and procedures, clinical record review and review of documentation provided by the facility, it was determined that the facility failed to ensure that one of 21 residents reviewed was free of neglect during a transfer via a sit-to-stand lift which resulted in actual harm to Resident 303 who sustained a a left leg tibial fracture (Resident 303). Findings include: Review of facility policy and procedure titled, Resident Abuse Prevention and Reporting, revised (MONTH) (YEAR), revealed Neglect - is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy and procedure titled, Resident Safe Handling Program - Community Wide, revised (MONTH) (YEAR), revealed Sit-to-Stand Lift Usage - (c) Two staff members are recommended to utilize the lift. Review of Resident 303's [DIAGNOSES REDACTED]. Review of Resident 303's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 3, (YEAR), revealed Resident 303's Brief Interview for Mental Status Score (BIMS) to be 5 which indicated severe cognitive impairment. Further review of Resident 303's quarterly MDS revealed that Resident 303 required the extensive assistance of two persons for transfer. The resident was assessed as not steady and only able to stabilize with staff assistance for moving from a seated position to a standing position and from surface to surface transfer (transfer between bed and chair or wheelchair). Review of Resident 303's comprehensive care plan dated (MONTH) 12, (YEAR), reviewed on (MONTH) 16, (YEAR), identified the resident with a self-care deficit requiring assistance with activities of daily living. Review of intervention on the resident's plan of care revealed that the resident required the use of a sit-to-stand lift for all transfers. Review of Resident 303's interdisciplinary notes dated (MONTH) 10, (YEAR), revealed a nurse entry stating, at about 1845 (6:45 p.m.) the CNA (nurse aide) had me go to the room and show me a skin tear to the left forearm. The nurse then perform first-aid to the wound by cleansing the wound with wound cleanser and applying a border bandage to it. Once getting her to bed, she c/o (complained of) knee pain upon movement. The nurse then called the on-call Dr. which then gave an order for [REDACTED].>Review of Resident 303's interdisciplinary notes revealed a nurse entry on (MONTH) 11, (YEAR), Staff reported bruising and pain to (L) (left) lower extremity. Assessment of leg found a 9 cm (centimeter) x 6 cm purple area with some redness. Review of X-ray report of left lower extremity dated (MONTH) 11, (YEAR), revealed that Resident 303 was diagnosed with [REDACTED]. Review of documentation provided by the facility, dated (MONTH) 10, (YEAR), revealed the Resident was transferring from wheelchair to bed with one staff member assist and use of the sit-to-stand lift .Inspection by the licensed staff member was conducted and noted a 4.0 cm x 3.0 cm skin tear to the left forearm and a 9 cm x 6 cm bruise to the left lower leg. Resident complained of pain to the left knee region and the leg began to swell. Review of this documentation further revealed that Prior to incident transfer status was a sit-to-stand lift. Facility protocol recommends two staff members at all times for transferring with use of sit-to-stand lift. Review of additional documentation provided by the facility, dated (MONTH) 12, (YEAR), revealed the IDT (interdisciplinary team) met to discuss skin tear to left arm and injury to left leg during transfer from w/c (wheelchair) to bed. Left arm slid thru sling as most likely resident unable to hold onto mechanical bar. Staff note left knee buckled and appeared hyperextended. Swelling and new onset pain noted. Resident with fracture to left tibia. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 26, (YEAR), at approximately 11:30 a.m. confirmed that Resident 303 was transferred with only one staff member present and further confirmed that two staff members should have been present during the transfer. The facility failed to ensure Resident 303 was free from neglect by transferring Resident 303 via a sit-to-stand lift with one person physical assist, which resulted in actual harm to Resident 303 hyperextening and buckling the left knee and sustaining a [MEDICAL CONDITION] tibia. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 08/16/16, 06./20/16 28 Pa. Code 201.18(b)(1) Management Previously cited 08/16/16, 06/20/16 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 06/20/16 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c) Resident rights Previously cited 05/23/17 28 Pa. Code 211.5(f) Clinical records Previously cited 05/23/17, 06/20/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/20/16 28 Pa. Code 211.12(c) Nursing services Previously cited 08/16/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 05/23/17, 08/16/16, 06/20/16