Every finding on record at Lutheran Home at Hollidaysburg

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for one of four residents reviewed (Resident 1). This deficiency is being cited as past non-compliance.Findings include: A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 1, dated May 5, 2026, revealed that the resident was cognitively impaired, was understood and understood others. A nursing note for Resident 1 dated June 14, 2026, at 11:40 a.m. revealed that the resident was seen propelling herself in her wheelchair down the hallway and that she had white chalky substance on her lips. A medicine cup of what was believed to be Calmoseptine paste was found on her bedside table with a spoon. An investigation into the resident found with white chalky substance for Resident 1, dated June 14, 2026, revealed that the resident was found with white chalky substance on her lips and it was believed to be Calmoseptine paste (an over-the-counter multi-purpose moisture barrier and medicated skin protectant). It was determined that staff had left the Calmoseptine Paste on the resident's bedside table. Interview with the Nursing Home Administrator on June 18, 2026, revealed that through their investigation it was determined that staff had left the calmoseptine paste on the resident's bedsite table, and that she had ingested it, and that the paste should not have been left on the resident's bedside table. Following the incident on June 14, 2026, the facility's corrective actions included: 1. On June 14, 2026, at 11:40 a.m. the resident was assessed, the Medical Director and the Resident Representative was notified. Poison control was called and it was determined that Calmoseptine Ointment was non-toxic and the resident's water intake was increased. Resident 1 continued to be observed for nausea, vomiting, and diarrhea. LPN 1 was educated on site for medication and treatment administration. 2. Education records, dated June 15, and 16, 2026, revealed that all of the facility's nursing staff received education regarding the resident's need for adaptive equipment. 3. The Director of Nursing or designee will audit treatments to ensure that treatments are completed per policy and protocol for five days a week for one week, and then three days a week for one week and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on June 18, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding infection control.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding infection control.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding infection control. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to conduct the minimum 12 hours of nurse aide (NA) training per year for one of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have the required 12 hours of Nurse Aide training per year.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 failed to complete the necessary 12 hours of training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 26 residents reviewed (Residents 32).Findings include:An admission note for Resident 32 dated October 14, 2025, at 6:31 p.m. revealed that the resident arrived at the facility at 5:25 p.m., was alert and oriented and had a midline surgical incision (vertical cut made down the center of the abdomen) that was closed with a VAC dressing (Vacuum-Assisted Closure dressing- a medical device that uses a vacuum pump to apply suction to a wound, promoting healing). Physician's orders for Resident 32 dated October 14, 2025, included for the resident to have his wound VAC settings and all connections checked every four hours, be administered two 500 milligram (mg) capsules of Amoxicillin (an antibiotic medication) twice a day, and be administered 500 mg of Clarithromycin (an antibiotic medication) twice a day for surgical aftercare following surgery on the digestive system. There was no documented evidence that a baseline care plan was developed for Resident 32's care and treatment needs related to having a wound VAC dressing and for antibiotic use. Interview with the Director of Nursing on October 22, 2025, at 2:51 p.m. confirmed that the resident's baseline care plan did not include care and treatment needs required for the resident's wound VAC and for antibiotic use. 28 Pa. Code 211.12(d)(1) Nursing Services Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 26 residents reviewed (Residents 32).Findings include:An admission note for Resident 32 dated October 14, 2025, at 6:31 p.m. revealed that the resident arrived at the facility at 5:25 p.m., was alert and oriented and had a midline surgical incision (vertical cut made down the center of the abdomen) that was closed with a VAC dressing (Vacuum-Assisted Closure dressing- a medical device that uses a vacuum pump to apply suction to a wound, promoting healing). Physician's orders for Resident 32 dated October 14, 2025, included for the resident to have his wound VAC settings and all connections checked every four hours, be administered two 500 milligram (mg) capsules of Amoxicillin (an antibiotic medication) twice a day, and be administered 500 mg of Clarithromycin (an antibiotic medication) twice a day for surgical aftercare following surgery on the digestive system. There was no documented evidence that a baseline care plan was developed for Resident 32's care and treatment needs related to having a wound VAC dressing and for antibiotic use. Interview with the Director of Nursing on October 22, 2025, at 2:51 p.m. confirmed that the resident's baseline care plan did not include care and treatment needs required for the resident's wound VAC and for antibiotic use. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 4's personnel file revealed that she was hired on October 23, 2014. Review of her continuing education transcript revealed that she did not have any education regarding behavioral health.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding behavioral health.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding behavioral health.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 4, Nurse Aide 1, and Licensed Practical Nurse 5 failed to complete the necessary education regarding behavioral health.28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of clinical records as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 26 residents reviewed (Resident 13) who had pressure ulcers.Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated September 29, 2025, indicated that the resident was cognitively intact and had a pressure ulcers (skin breakdown caused by pressure). A wound clinic note, dated September 25, 2025, revealed that Resident 13 had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle.) to the left lateral maleolus (outer ankle), the bone was palpable, and a treatment of collagen powder (a type of medical dressing used to promote wound healing using purified collagen, a protein that is essential for skin and tissue repair) mixed with bacitracin (topical antibiotic) was to be applied every other day and as needed. A wound clinic note, dated October 9, 2025, revealed that Resident 13's pressure ulcer on the the left lateral maleolus was larger upon her hospital return and had undermining (break down under the skin) from 4 o'clock to 7 o'clock. It was recommended to change the treatment to the left lateral maleolus and apply a collagen sheet to the base of the wound to include undermining and apply Hydrogel (moist wound care products that provide hydration, pain relief and infection prevention) to the base of the wound every other day and as needed. A wound clinic note, dated October 16, 2025, revealed that Resident 13's pressure ulcer on the left lateral malleolus was improving and it was recommended to continue the collagen sheet to the base of the wound to include undermining and apply Hydrogel to the base of the wound every other day and as needed. A review of Resident 13's Treatment Administration Record (TAR) for October 2025 revealed that the resident continued to receive collagen powder mixed with Bacitracin and did not receive the Hydrogel as recommended from the wound clinic.Interview with the Director of Nursing on October 21, 2025, at 10:38 a.m. confirmed that the wound recommendations on October 9 and 16, 2025 were not followed.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.Based on review of clinical records as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 26 residents reviewed (Resident 13) who had pressure ulcers.Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated September 29, 2025, indicated that the resident was cognitively intact and had a pressure ulcers (skin breakdown caused by pressure). A wound clinic note, dated September 25, 2025, revealed that Resident 13 had a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle.) to the left lateral maleolus (outer ankle), the bone was palpable, and a treatment of collagen powder (a type of medical dressing used to promote wound healing using purified collagen, a protein that is essential for skin and tissue repair) mixed with bacitracin (topical antibiotic) was to be applied every other day and as needed. A wound clinic note, dated October 9, 2025, revealed that Resident 13's pressure ulcer on the the left lateral maleolus was larger upon her hospital return and had undermining (break down under the skin) from 4 o'clock to 7 o'clock. It was recommended to change the treatment to the left lateral maleolus and apply a collagen sheet to the base of the wound to include undermining and apply Hydrogel (moist wound care products that provide hydration, pain relief and infection prevention) to the base of the wound every other day and as needed. A wound clinic note, dated October 16, 2025, revealed that Resident 13's pressure ulcer on the left lateral malleolus was improving and it was recommended to continue the collagen sheet to the base of the wound to include undermining and apply Hydrogel to the base of the wound every other day and as needed. A review of Resident 13's Treatment Administration Record (TAR) for October 2025 revealed that the resident continued to receive collagen powder mixed with Bacitracin and did not receive the Hydrogel as recommended from the wound clinic.Interview with the Director of Nursing on October 21, 2025, at 10:38 a.m. confirmed that the wound recommendations on October 9 and 16, 2025 were not followed.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 26 residents reviewed (Resident 22).Findings include:A quarterly MDS assessment for Resident 22 dated July 13, 2025, indicated that the resident was cognitively impaired, had clear speech, was usually understood, could rarely understand, required assistance with daily care needs, was always incontinent of bowel, and had diagnoses that included dementia. Current physician's orders for Resident 22, included an order for the resident to receive 5 ounces (oz) of Fiberjuice (laxative- used to produce a bowel movement) as needed for constipation if no bowel movement by the second day. Resident 22's bowel movement records dated September and October, 2025 indicated that the resident did not have a bowel movement on September 4, 2025, through September 7, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement. The resident did not have a bowel movement on October 6, 2025, through October 10, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement.Interview with the Director of Nursing on October 23, 2025, at 10:17 confirmed that the staff did not follow the facility's bowel policy and physicians orders for Resident 22 on the above-mentioned dates.28 Pa. Code 211.12(d)(5) Nursing Services. Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 26 residents reviewed (Resident 22).Findings include:A quarterly MDS assessment for Resident 22 dated July 13, 2025, indicated that the resident was cognitively impaired, had clear speech, was usually understood, could rarely understand, required assistance with daily care needs, was always incontinent of bowel, and had diagnoses that included dementia. Current physician's orders for Resident 22, included an order for the resident to receive 5 ounces (oz) of Fiberjuice (laxative- used to produce a bowel movement) as needed for constipation if no bowel movement by the second day. Resident 22's bowel movement records dated September and October, 2025 indicated that the resident did not have a bowel movement on September 4, 2025, through September 7, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement. The resident did not have a bowel movement on October 6, 2025, through October 10, 2025. There was no documented evidence that 5 ounces (oz) of Fiberjuice was offered to or refused by the resident after the second day of no bowel movement.Interview with the Director of Nursing on October 23, 2025, at 10:17 confirmed that the staff did not follow the facility's bowel policy and physicians orders for Resident 22 on the above-mentioned dates.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of nurses aides dates of hire and their most recent performance review dates, it was determined that the facility failed to complete annual nurse aide performance evaluations for two of three nurse aides reviewed (Nurse Aides 1 and 2).Findings include:A list of nurse aides provided by the facility revealed that Nurse Aide 1 was hired on May 23, 2000. Based on her date of hire, an annual performance evaluation was due in May, 2025. However, there was no documented evidence that the annual performance evaluation was completed as required.Nurse Aide 2 was hired on June 21, 2022. Based on her date of hire, an annual performance evaluation was due in June, 2025. However, there was no documented evidence that the annual performance evaluation was completed as required.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aides 1 and 2 did not have an annual performance evaluations. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of 26 residents reviewed (Resident 34).Findings include:A facility policy for medication and treatment administration dated September 5, 2025, indicated that medications are administered in accordance with prescriber orders, including any required time frame.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34 dated October 8, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnoses that included atrial fibrillation (a heart rhythm disorder characterized by a rapid and irregular heartbeat) and aneurysm of an artery in the lower extremity (an enlargement or weakened area in a blood vessel in the leg). Hospital discharge records for Resident 34 dated September 4, 2025, included physician's orders to administer 50 mg of enoxaparin (a blood thinner medication) once daily until the resident's international normalized ratio (INR-a test that measures the amount of time taken for your blood to clot-used to monitor the effectiveness of blood-thinning medications).Review of laboratory results for Resident 34 dated September 17, 2025, revealed that the resident's INR was 2.8 and the INR therapeutic range for high intensity therapy was 2.5-3.5. A review of the Medication Administration Record (MAR) for Resident 34 dated September 2025, revealed that 50 mg of enoxaparin was administered on September 17, 18, and 19. Interview with the Director of Nursing on October 21, 2025, at 4:17 p.m. confirmed that Resident 34's INR was in therapeutic range on September 17, 2025, and enoxaparin should have been discontinued on September 17, however, it was not, and the enoxaparin was administered on September 18 and 19, 2025 when it should not have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety.Findings include:The facility's dietary policy regarding food storage, dated September 5, 2025, revealed that to prevent cross contamination, food should be properly stored. Raw meat, raw eggs, and poultry should be separate from ready to eat and prepared foods. Observations in the kitchen on October 20, 2025, at 9:12 a.m. revealed that in the walk in cooler there was a roll of frozen raw ground [NAME] thawing on a tray. Below the tray of raw [NAME] was a container labeled cooked ground beef for chili.Interview with Dietary Aide 3 on October 20, 2025, at 9:26 a.m., revealed that he should have moved the raw thawing [NAME] to the bottom shelf below the cooked prepared [NAME].Interview with the Dietary Director on October 20, 2025, at 9:25 a.m. confirmed that the cooked [NAME] should not have been placed below the raw hamburger.28 Pa. Code 211.6(f) Dietary services.

Based on review of job descriptions, facility documents and staff interviews, it was determined that the facility failed to provide Communication training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 4's personnel file revealed that she was hired on October 23, 2014. Review of her continuing education transcript revealed that she did not have any education regarding effective communication.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding effective communication.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding effective communication.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 4, Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding effective communication. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding resident rights Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding resident rights.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding resident rights for the current year. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide abuse, neglect, and exploitation training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding abuse, neglect, and exploitation.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding abuse, neglect, and exploitation.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1, and Licensed Practical Nurse 5 failed to complete the necessary education regarding abuse, neglect, and exploitation. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to three of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 4's personnel file revealed that she was hired on October 23, 2014. Review of her continuing education transcript revealed that she did not have any education regarding Quality Assurance and Performance Improvement (QAPI) training.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding Quality Assurance and Performance Improvement (QAPI) training.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding Quality Assurance and Performance Improvement (QAPI) training.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aides 4 and 1, and Licensed Practical Nurse 5 failed to complete the necessary education regarding Quality Assurance and Performance Improvement (QAPI) training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of job description, facility documents and staff interviews, it was determined that the facility failed to provide compliance and ethics training to two of five direct care facility staff reviewed.Findings include:Review of the facility Nursing Assistant Job Description indicated the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort. Complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Review of the Licensed Practical Nurse Job Description indicated that the primary purpose of your job role is to provide a safe environment, give emotional and social support and attend to the residents physical needs and comfort, and to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulations.Interview with the Human Resources Director on October 22, 2025 at 1:48 p.m. revealed that staff are required to complete their annual training each year.Review of Nurse Aide 1's personnel file revealed that she was hired on May 23, 2000. Review of her continuing education transcript revealed that she did not have any education regarding compliance and ethics.Review of Licensed Practical Nurse 5's personnel file revealed that she was hired on May 28, 2020. Review of her continuing education transcript revealed that she did not have any education regarding compliance and ethics.Interview with the Nursing Home Administrator on October 22, 2025 at 2:26 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 5 failed to complete the necessary education regarding compliance and ethics. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of corrections for an annual survey ending October 12, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 13, 2024, identified repeated deficiencies related to a failure to develop and implement comprehensive care plans, failure to revise care plans, failure to protect residents from accidents/hazards, failure to store medications securely,; and failure to ensure that resident's medical records were complete and accurate. The facility's plan of correction for a deficiency regarding developing and implementing care plans, cited during the survey ending October 12, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure care plans were developed and implemented timely. The facility's plan of correction for a deficiency regarding revision of care plans, cited during the survey ending October 12, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were revised timely. The facility's plan of correction for a deficiency regarding safety and accident hazards, cited during the survey ending October 12, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure residents were free from accidents and hazards. The facility's plan of correction for a deficiency regarding labeling and storing medications, cited during the survey ending October 12, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that medications were stored securely. The facility's plan of correction for a deficiency regarding complete and accurate medical records, cited during the survey ending October 12, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's medical records were complete and accurate. Refer to F656, F657, F689, F761, F842. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of polices and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 25 residents reviewed (Residents 42, 45). Findings include: A facility policy for medication administration, dated January 11, 2024, indicated that medications were to be poured, administered, and documented by the licensed team member with accountability for the specific medication cart. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated August 28, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included diabetes, and received insulin. Physician's orders for Resident 42, dated August 22, 2024, included an order for the resident to receive Humalog insulin (medication used to lower blood sugar) subcutaneously (beneath the skin) with meals based on a sliding scale (amount of insulin based on blood sugar results). Review of the Medication Administration Record (MAR) for Resident 42, dated August and September 2024, revealed that the amount of insulin administered with meals (7:30 a.m., 11:30 a.m., 4:30 p.m.) according to the sliding scale were not documented on the MAR. Interview with the Director of Nursing on September 11, 2024, at 1:26 p.m. confirmed that there was no documentation of the amount of insulin provided according to the sliding scale and that the amount of insulin administered should be charted on the MAR. Review of the clinical record for Resident 45 revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes. Physician's orders for Resident 45, dated September 8, 2024, included an order for the resident to have her blood sugar checked before meals and at bedtime and for staff to administer sliding scale (dose is based on a person's blood sugar) insulin (medication used to lower blood sugar). Review of the MAR for Resident 8, dated September 2024, revealed that the results of Resident 45's blood sugar testing were not documented before supper on September 8, 2024, or before breakfast, lunch and supper on September 9, 10 and 11, 2024. Interview with the Director of Nursing on September 12, 2024, at 3:05 p.m. confirmed that there was no documented evidence that Resident 8's blood sugar results were documented in her clinical record, and they should have been. 28 Pa Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined the facility failed to provide clearly documented reasons for facility-initiated transfers to the hospital to the resident and resident's representative in language and manner that could be easily understood for five of 25 residents reviewed (Residents 8, 18, 35, 42, 47). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 4, 2024, revealed that the resident was cognitively intact, was independent with personal hygiene care needs, and had diagnosis that included dementia. A nurse's note for Resident 8, dated January 17, 2024, revealed that the resident had a fall in her bathroom and complained of right hip pain. The physician was notified, and the resident was transferred to the emergency room for evaluation. There was no documented evidence that a written notice of Resident 8's transfer to the hospital was provided to the resident or her responsible party regarding the reason for the transfer. A review of the clinical record revealed that Resident 18 was transferred to the hospital on September 2, 2024. There was no documented evidence that a Notice of Transfer letter was issued to Resident 18 or his responsible party. A quarterly MDS assessment for Resident 35, dated August 22, 2024, revealed that the resident was cognitively impaired, was rarely/never understood and was rarely/never able to understand others, was dependent for care needs, and had a diagnosis that included dementia. A nurse's note for Resident 35, dated July 9, 2024, at 11:55 a.m. revealed that the facility received a call from the physician's assistant at Elite Orthopedics indicating that the resident's fracture to her right upper extremity was open and they were sending her to the hospital for intravenous antibiotics. There was no documented evidence that a written notice of Resident 35's transfers to the hospital was provided to the resident's representative regarding the reason for transfer. An admission MDS assessment for Resident 42, dated August 28, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included diabetes. A nurse's note for Resident 42, dated August 26, 2024, at 9:19 a.m. revealed that the resident had complaints of dizziness and nausea, and was diaphoretic (sweating). The physician was notified, and the resident was transferred to the emergency room for evaluation. There was no documented evidence that a written notice of Resident 42's transfers to the hospital were provided to the resident or the resident's representative regarding the reason for transfer. A nursing note for Resident 47, dated September 4, 2024, at 10:27 a.m. revealed that the resident was admitted to the facility with diagnoses that included dementia. A nursing note, dated September 6, 2024, at 12:00 a.m. revealed the resident had a fall and received a 1.5 centimeter laceration to her forehead. The physician was notified, and the resident was transferred to the emergency room for evaluation. There was no documented evidence that a written notice of Resident 42's transfers to the hospital were provided to the resident or the resident's representative regarding the reason for transfer. Interview with the Director of Nursing on September 12, 2024, at 12:15 p.m. revealed that she was not aware that a written notice must be sent to the resident or their responsible party upon transfer out of the facility and therefore, no such letter was done. 28 Pa. Code 201.29(f)(k)(l)(2) Resident Rights. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for two of 25 residents reviewed (Residents 15, 29). Findings include: The facility's policy regarding care plans, dated January 11, 2024, indicated that the care plan is to ensure care and treatment is planned and individualized to the person's served problems/needs, conditions, impairment, disability, and or disease. If a significant change occurs, the care plan is to be reviewed for accuracy and completeness and revised if necessary. If any team member identifies an interim change that does not meet the definition of a significant change, the care plan may be adjusted accordingly. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated July 10, 2024, indicated that the resident was understood and able to understand others, was dependent on staff for personal hygiene care, and had diagnoses that included hemiplegia (paralysis that affects only one side of your body) after having a stroke. Review of the care plan for Resident 15, dated July 29, 2019, revealed that the resident had right-sided hemiparesis (weakness on one side of the body) and hemiplegia and that staff were to encourage the resident to wear an AFO (Ankle Foot Orthosis - a support device intended to control the position and motion of the ankle) brace on his right foot when he was out of bed and wear a resting hand splint (device that supports the hand and wrist in the best position while resting) on his right hand at night and removed in the morning. There was no documented evidence that the resident was wearing an AFO brace or a resting hand splint. Interview with Resident 15 on August 12, 2024, at 9:11 a.m. revealed that the resident had not been wearing an AFO brace or a resting hand splint, and he did not recall if he ever had. Interview with the Director of Rehabilitation on August 12, 2024, at 9:29 a.m. revealed that the resident previously had an order to use a resting hand splint on his right hand; however, the resident refused to wear it, and the order was discontinued. Interview with Physical Therapist 1 on August 12, 2024, at 9:29 a.m. revealed that he was not aware of the resident needing or using an AFO brace in the two years he has been a physical therapist in the facility. The resident does not currently have an issue that would indicate the need for an AFO brace. Interview with the Director of Nursing on August 12, 2024, at 10:02 a.m. revealed that the resident did not use an AFO brace or a resting hand splint and that his care plan should have been revised to reflect that but was not. An annual MDS assessment for Resident 29, dated June 14, 2024, revealed that the resident was cognitively impaired, was sometimes understood and sometimes able to understand others, required assistance with some care needs, and had a diagnosis of diabetes. A care plan for Resident 29, dated June 23, 2023, indicated that she was to have fingerstick blood sugars obtained per physician's orders. There was no documented evidence in the resident's clinical record that she was ordered to have fingerstick blood sugars obtained. An interview with the Director of Nursing on September 12, 2024, at 1:46 p.m. confirmed that Resident 29's care plan was not revised to reflect that the fingerstick blood sugars were discontinued. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide adequate supervision and failed to ensure that the environment remained as free of accident hazards as possible for three of 25 residents reviewed (Residents 4, 29, 40). Findings include: A facility policy for elopement, dated January 11, 2024, indicated that an elopement is defined as when a resident leaves the facility, or enters an unsafe area, without any team member being aware that the resident has done so. An analysis of each elopement is to be completed by the health care center management team, identifying all possible reasons why safety and security measures were breached. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated August 9, 2024, indicated that the resident was moderately cognitively impaired, had a history of wandering, was independent with personal hygiene needs and ambulation, and had diagnoses that included dementia. A care plan for Resident 40, dated August 1, 2023, indicated that the resident was at risk for wandering out of the facility. Staff were to discuss and investigate causes of wandering and exit-seeking behaviors, attempt to intervene, and provide interventions, support, and reassurance for her needs and wants. An intervention, dated April 1, 2024, indicated that staff were to complete checks on her whereabouts for safety every 15 minutes when warranted. A nurse's note for Resident 40, dated November 24, 2023, at 9:00 p.m. revealed that the resident went to the first floor using the front elevator. She reported to staff at the time that she knew she was not supposed to use the elevator but did anyway. A nurse's note, dated January 10, 2024, at 3:24 p.m. revealed that the resident was found roaming the front hall on the first floor by housekeeping staff. The resident was given a snack and returned to the second floor. A nurse's note, dated January 15, 2024, at 8:43 p.m., revealed that the resident was found wandering on the first floor near the back hall nurse's station, reporting that she was going to dinner with her family. She was escorted to her room on the second floor. A nurse's note, dated February 11, 2024, at 11:26 a.m., revealed that the resident appeared on the first floor from the front elevator. The nurse aide was not aware that the resident was not on the second floor. A nurse's note, dated April 1, 2024, at 6:24 p.m., revealed that the resident was not on the second floor when staff completed a 15-minute check on the resident. The resident was found on the first floor sitting on the sofa in the lounge and she was assisted upstairs. A nurse's note, dated June 14, 2024, at 2:45 p.m., revealed that the resident was off the unit and returned by staff at 2:40 p.m. A nurse's note, dated July 5, 2024, at 1:30 p.m., revealed that the resident was in her room at 1:15 p.m. and was found on the first floor at 1:22 p.m. The resident reported that she was looking for the bathroom and was redirected to the bathroom on the second floor. A nurse's note, dated July 29, 2024, at 9:13 p.m., revealed that the resident was unable to be located during her 15-minute check and was found on the first floor. She was returned to the second floor without difficulty. A nurse's note, dated August 31, 2024, at 1:21 p.m., revealed that at approximately 11:50 a.m. the resident was observed by staff on the first floor at the rear elevator. She was last seen at 11:45 a.m. in the activity room and returned to the second floor without difficulty. An interview with the Director of Nursing on September 10, 2024, at 11:54 a.m. revealed that resident rooms on the first floor have been empty since March 6, 2024. There was no documented evidence that the facility conducted an investigation or an analysis of Resident 40's repeated elopements from the second floor. An interview with the Director of Nursing on September 10, 2024, at 2:34 p.m. confirmed that Resident 40 left the second floor on the identified dates and times without supervision. An analysis was not completed because the facility did not view the incidents as elopements. Resident 40 was not supposed to leave the floor without supervision, but the facility believed she remained safe because the outside doors were locked preventing her from leaving the facility. The Director of Nursing confirmed that there was potential for the resident to be unsafe when leaving the unit unsupervised. An interview with the Director of Nursing on September 11, 2024, at 10:44 a.m. confirmed that there was a risk for Resident 40 when she eloped from the second floor and administration was not in the facility, but believed the resident remained safe because of the 15-minute checks being completed. The resident and her elopements were discussed at morning meetings, but there was no documentation of it and no formal investigations or analysis were completed. A facility policy for assessments of falls, dated January 11, 2024, indicated that when a resident falls, the following information should be recorded in the resident's medical record: the immediate interventions and appropriate interventions taken to prevent future falls. A facility policy for managing falls and fall risk, dated January 11, 2024, indicated that if a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The attending physician will help the staff reconsider possible causes that may not previously been identified. A significant change MDS assessment for Resident 4, dated June 29, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, was dependent for transfers, had a fall without injury since his prior assessment, and had diagnoses that included Parkinson's and dementia. A nurse's note for Resident 4, dated August 25, 2024, at 2:42 p.m., indicated that the resident had a fall at 1:30 p.m. when he attempted to transfer himself to the bathroom. The resident was assessed with no apparent visible injuries. Review of the fall investigation revealed that Resident 4 was stated on hourly safety checks beginning August 26, 2024, through August 28, 2024. Review of the hourly safety checks for Resident 4, initiated on August 26, 2024, revealed that there was no documented evidence that the hourly safety checks were completed on August 27, 2024, at 11:00 a.m., 12:00 p.m., and 1:00 p.m. Interview with the Director of Nursing on September 12, 2024, at 1:25 p.m. confirmed that hourly safety checks were not completed for Resident 4 on August 27, 2024, on the above-mentioned times. An annual MDS assessment for Resident 29, dated June 14, 2024, revealed that the resident was cognitively impaired, was sometimes understood and sometimes able to understand others, required assistance with some care needs, and had two or more falls without injury since the prior assessment. A physician's note, dated March 7, 2024, indicated that the resident had a diagnosis of dementia. A nurse's note for Resident 29, dated December 24, 2023, at 11:57 a.m., indicated that at 8:15 a.m. a staff nurse aide notified the nurse that the resident had indicated she had fallen on the floor and hit her head and left shoulder. Upon investigation, the nurse observed a discolored, reddened, raised area to the back of the resident's head with a small circular area in middle that was purple/blue in color and a dark red and purple abrasion to the resident's left upper ear. A nursing assessment to the resident's left shoulder area revealed no changes in skin color and no bruising or open areas. The resident indicated that she was going to go to the bathroom when she slipped on her socks and fell to the floor beside the bed. She indicated that she got herself up and crawled back to bed. The nurse indicated that nonskid slipper socks were applied, and the resident was educated to wear nonskid slipper socks with ambulation. X-ray results to the resident's left shoulder were pending. A nurse's note for Resident 29, dated December 24, 2023, at 1:22 p.m., indicated that Resident 29 complained of pain with range of motion to her left shoulder. The nurse indicated there was no swelling or bruising to the resident's left upper extremity/shoulder. A nurse's note for Resident 29, dated December 24, 2023, at 2:52 p.m., indicated that Resident 29's x-ray results were suspicious for a nondisplaced fracture of the distal fourth shaft aspect of the left clavicle. A nurse's note for Resident 29, dated December 24, 2023, at 3:45 p.m., indicated that Resident 29's neurological checks and safety checks were ongoing. Review of the hourly safety checks for Resident 29, initiated on December 24, 2023, revealed no documented evidence that the hourly safety checks were completed on December 24, 2023, at 4:00 p.m., 5:00 p.m., 6:00 p.m., 7:00 p.m., 8:00 p.m. and 9:00 p.m. and on December 25, 2023, at 3:00 p.m., 4:00 p.m., 5:00 p.m., 6:00 p.m., 7:00 p.m., 8:00 p.m. and 9:00 p.m. Interview with the Director of Nursing on September 12, 2024, at 12:35 p.m. confirmed that hourly safety checks were not completed for Resident 29 on December 24, 2023, and December 25, 2023, on the above-mentioned times. A nurse's note for Resident 29, dated April 26, 2024, at 7:04 a.m., revealed that the resident said she rolled out of bed during the night because she was too close to the edge. She denied hitting her head and indicated that she hit her knees but did not have pain and was able to get back into bed on her own. There were no documented injuries to her head or bilateral knees. Neurological checks and safety checks were initiated. A nurse's note for Resident 29, dated May 16, 2024, at 7:33 p.m., indicated that the resident lost her balance with her walker and fell across her bed with no injuries documented. Interview with the Director of Nursing on September 12, 2024, at 12:35 p.m. revealed that new interventions were not developed after Resident 29's fall on the above-mentioned dates because the facility felt that all of the appropriate interventions were already in place. A nurse's note for Resident 29, dated June 14, 2024, at 10:15 p.m., indicated that the resident reported that she fell in her room and hit the left side of her head. There were no documented injuries. Neurological checks and hourly safety checks were initiated. Review of the hourly safety checks for Resident 29, initiated on June 14, 2024, revealed that there was no documented evidence that the hourly safety checks were completed on June 17, 2024, at 3:00 p.m., 4:00 p.m., 5:00 p.m., 6:00 p.m., 7:00 p.m., 8:00 p.m. and 9:00 p.m. Interview with the Director of Nursing on September 12, 2024, at 12:35 p.m. confirmed that hourly safety checks were not completed for Resident 29 on June 17, 2024, on the above-mentioned times and revealed that new interventions were not developed after Resident 29's fall on the above-mentioned date. A nurse's note for Resident 29, dated August 8, 2024, at 6:28 p.m., indicated that the resident had a fall and was observed lying on her right side with her walker on top of her and head toward the door. The resident denied hitting her head and reported that she was putting her blanket on her bed and got her walker tangled in it. There were no documented injuries. Neurological checks and safety checks were initiated. Review of the hourly safety checks for Resident 29, initiated on August 8, 2024, revealed that there was no documented evidence that the hourly safety checks were completed on August 8, 2024, at 6:00 p.m., 7:00 p.m., 8:00 p.m. and 9:00 p.m. Interview with the Director of Nursing on September 12, 2024, at 12:35 p.m. confirmed that hourly safety checks were not completed for Resident 29 on August 8, 2024, on the above-mentioned times. A nurse's note for Resident 40, dated January 28, 2024, revealed that the resident had an unwitnessed fall in her room. The resident reported that her foot slipped causing her to fall. A nurse's note, dated April 19, 2024, at 4:13 p.m., revealed that the resident had a witnessed fall in her room. The resident lost her balance and fell hitting her head on the footboard and sustained a hematoma to her head and a bruise to her left shoulder. A nurse's note, dated April 20, 2024, at 1:54 p.m., revealed that the resident was observed on the floor in her room. The resident reported sliding off the bed. A nurse's note, dated June 3, 2024, at 8:35 p.m., revealed that the resident was observed on the floor in her room. The resident reported sliding off the bed. A nurse's note, dated June 11, 2024, revealed that the resident was observed on the floor in her room beside her bed. A nurse's note, dated July 15, 2024, at 11:51 p.m., revealed that the resident was observed on the floor in front of the chair in her room. The resident reported sliding off the chair. Interview with the Director of Nursing on August 12, 2024, at 1:40 p.m. revealed that new interventions were not developed after Resident 40's fall on the above-mentioned dates because the facility felt all the appropriate interventions were already in place. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by the failure to transfer a resident properly, resulting in a fractured arm for one of three residents (Resident 2) reviewed. This deficiency was cited as past noncompliance. Findings include: The facility's policy on freedom from abuse, neglect, misappropriation of property, exploitation and other suspicious crimes or events, dated January 11, 2024, indicated that each resident had the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; misappropriation of property; and involuntary seclusion. Every resident in the facility was to be treated with consideration, respect, and full recognition of his/her dignity and individuality, and management and staff were jointly and individually responsible to ensure each resident was free from abuse, neglect, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident abilities and care needs) for Resident 2, dated May 3, 2024, revealed that the resident was sometimes understood and could sometimes understand, was cognitively impaired, required assistance for all care, and had diagnoses that included dementia. A care plan for Resident 2, dated August 17, 2021, indicated that the resident required assistance for all care. A nursing note for Resident 2, dated June 12, 2024, at 5:04 p.m. revealed that staff reported the resident had a bruise on her right arm. A registered nurse assessment was difficult because the resident was guarding her arm. The family and physician were notified and an order was received for an x-ray. A statement by Nurse Aide 4, dated June 12, 2024, at 5:00 p.m. revealed that her and Nurse Aide 5 transferred Resident 2 onto the toilet. Upon attempting to stand the resident to clean her behind, the resident was unable. They used the sit-to-stand lift (a mechanical device designed to assist individuals in moving from a sitting to standing position and vice versa) on the resident. She complained of pain in her arm and could not use it for the sit-to-stand transfer to stand back up. Nurse Aide 4 went and got Licensed Practical Nurse 6 and the three of them assisted the resident and sat her back down on the chair. A statement by Nurse Aide 5, dated June 12, 2024, at 5:00 p.m. revealed that he and Nurse Aide 4 did a two-arm assist on Resident 2 to help her hold the bar to sit on the toilet. Resident 2 was unable to stand so they sat her on the toilet. Afterwards, they attempted to use the sit-to-stand lift to help her off the toilet, but she complained of pain in her right arm. Nursing was notified. A statement by Licensed Practical Nurse 6, dated June 12, 2024, at 5:00 p.m. revealed that she was called to Resident 2's room and the resident was on the toilet. Nurse Aides 4 and 5 were unable to get her off the toilet. A sit-to-stand lift was used. The resident was noted to have a hematoma of her right upper arm and complained of pain. A statement by Registered Nurse 7, dated June 12, 2024, at 5:10 p.m. revealed that Licensed Practical Nurse 6 brought Resident 2 to her to look at the her arm. The resident was complaining of pain, and there was a bruise on her right upper arm. The resident was holding her arm and did not want Registered Nurse 7 to move it. Registered Nurse 7 assessed the area and found bruising and some swelling. The physician was notified and an x-ray was ordered and scheduled for morning. A nursing note for Resident 2, dated June 12, 2024, at 9:15 p.m., revealed that nursing staff reported the resident's right arm was more swollen and more bruised. When Registered Nurse 7 attempted to assess range of motion, she felt bone grind against bone and immediately stopped and started the notification process. An order was received to transport the resident to the emergency room for evaluation and treatment. Resident 2 left the facility at 9:45 p.m. A nursing note for Resident 2, dated June 13, 2024, at 2:57 a.m., revealed that a call was received from the hospital to inform them that the resident was being admitted with a displaced fracture of the midshaft of the right humerus. The Director of Nursing was notified and arrived at the facility at 4:45 a.m. Investigation documents for Resident 2, dated June 13, 2024, at 10:15 a.m. revealed that the Director of Nursing made contact with Nurse Aide 4 for further questioning of what happened. Nurse Aide 4 refused to speak over the phone and wanted to come to the building. Nurse Aide 4 came to the building and provided new verbal and written statements revealing that she did not use a gait belt when transferring Resident 2 to the toilet with Nurse Aide 5. She stated that he transferred her by bear hugging her (when someone wraps their arms all the way around a person and squeezes tightly). The second written statement by Nurse Aide 4, dated June 13, 2024, revealed that on June 12, 2024, she brought Resident 2 into the bathroom to be toileted. She and Nurse Aide 5 planned on cleaning the resident because she could smell a bowel movement. Nurse Aide 5 bear hugged the resident so that Nurse Aide 4 could pull down her pants and her incontinent brief prior to sitting on the resident on the toilet. They cleaned and changed the resident's clothing as much as they could while she was on the toilet. Upon standing her up they noticed she was not able to do it. Nurse Aide 4 decided to get the sit-to-stand lift. After hooking her up and trying to put her arm up on the bar to lift her up, she complained of pain and could not move it. Nurse Aide 4 went and found Licensed Practical Nurse 6, and she came back and assisted them with a three-person transfer. Nurse Aide 5 supported her left side, Nurse Aide 4 supported her waist and lower back to help her stand better, and Licensed Practical Nurse 6 assisted with perineal, bowel and urine cleaning. They sat the resident down on her wheelchair. A couple hours later a coworker noticed more bruising and brought it to the attention of the Registered Nurse Supervisor, who assessed her arm and stated the resident needed to be sent out. Investigative documents for Resident 2, dated June 13, 2024, at 11:10 a.m. revealed that the Director of Nursing made contact with Nurse Aide 5. His statement remained consistent with statement given the night of injury. He confirmed that he did not use a gait belt. The facility's investigation concluded on June 13, 2024, at 6:00 p.m. and determined the cause of Resident 2's injury to be from neglect. Review of Nurse Aide 5's personnel file revealed that he had completed training regarding preventing, recognizing, and reporting abuse on March 18, 2024. Following the investigation on June 13, 2024, the facility's corrective actions included: Nurse Aide 5 was terminated from employment at the facility. Staff education on abuse was completed. Audits to identify any issues with abuse were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on June 24, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 24 residents reviewed (Resident 3), resulting in the resident suffering mental anguish. Findings include: The facility's abuse policy, dated January 11, 2023, indicated that each resident had the right to be free from verbal, sexual, physical, and mental abuse; corporate punishment; misappropriation of property; and involuntary seclusion. Every resident in the facility was to be treated with consideration, respect, and full recognition of his/her dignity and individuality, and management and staff were jointly and individually responsible to ensure each resident was free from abuse, neglect, and misappropriation of property. A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 13, 2023, indicated that the resident was alert and oriented, and required the extensive assistance of staff for daily care needs, including transfers and ambulation. Facility investigation documents, dated August 9, 2023, revealed that on August 8, 2023, at approximately 5:00 p.m. Licensed Practical Nurse 1 responded to Resident 3's call bell. Resident 3 asked Licensed Practical Nurse 1 to help her get her walker and get out of her recliner chair and into her wheelchair for dinner. At that time Licensed Practical Nurse 1 threw the resident's walker in front of her and told her to walk herself. Resident 3 then pushed herself out to the nurse's station where she talked to Licensed Practical Nurse 2 and told her what happened. Licensed Practical Nurse 2 immediately told the Director of Nursing what Resident 3 stated had happened. The Director of Nursing stated that she was too tired to stay and deal with it. Licensed Practical Nurse 2 notified the Nursing Home Administrator several hours later when she realized the Director of Nursing still had done nothing about the incident. The Nursing Home Administrator immediately came in to investigate. A witness statement, dated August 9, 2023, at 3:15 p.m., by Nurse Aide 3 indicated that he responded to Resident 3 waving at him from within her room. When he entered her room, she was upset. He noted that her wheelchair was approximately ten feet away from her and her walker was in front of her. Resident 3 told Nurse Aide 3 that Licensed Practical Nurse 1 moved her wheelchair, threw her walker in front of her, and told her to walk by herself. Nurse Aide 3 stated that he assisted the resident into her wheelchair, and Resident 3 proceeded to the nurse's station and she was still upset. A witness statement, dated August 9, 2023, by Staff Member 4 revealed that Resident 3 was emotionally upset by the incident involving Licensed Practical Nurse 1 and that after the Director of Nursing was made aware of the incident, Licensed Practical Nurse 1 went to Resident 3 and stated, You may have just cost me my job. Resident 3 was emotionally distressed by this and verbalized she never intended for anyone to get fired. She stated that later in the evening, after the incident, Licensed Practical Nurse 1 came to give Resident 3 her bedtime medications but did not make any further comments to her at that time. Interview with the Nursing Home Administrator on October 12, 2023, at 11:23 a.m confirmed that Resident 3 was visibly upset regarding Licensed Practical Nurse 1's actions and words and that she remained upset the next day. He stated that the Director of Nursing should have immediately escorted Licensed Practical Nurse 1 out of the building and started an investigation, but she did not, and this allowed Licensed Practical Nurse 1 to have further contact with Resident 3 after the initial incident. He stated that Resident 3 was afraid to go back to her room and was tearful after this occurred. The Director of Nursing and Licensed Practical Nurse 1 were terminated. 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)(5) Nursing services.

Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to develop fall/injury prevention interventions for residents who were at risk for falls for one of eight residents reviewed (Resident 8), resulting in a fall with fracture. Findings include: The facility's policy regarding falls, dated May 19, 2022, indicated that the facility was to provide an immediate, appropriate assessment and treatment of a resident following a fall. Immediately after the fall, a team consisting of the nurse aide, licensed practical nurse, and registered nurse was to meet to attempt to determine how the fall occurred. The team was to discuss the need for interventions to prevent additional falls. These interventions would be documented immediately on the resident's care plan by the licensed practical nurse or registered nurse. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated April 18, 2022, indicated that the resident was cognitively impaired, required extensive assistance from staff for her daily care, including mobility and transfers, had limited range of motion of her lower extremities, was not steady when transferring from surface to surface and moving from a seated position to a standing position and only able to stabilize with staff assistance, had a history of falls, and had medical diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Resident 8's care plan, dated April 11 and 19, 2022, indicated that the resident was at risk for falls due to impaired cognition with poor safety awareness, frequent bowel and bladder incontinence, potential side effects of medications, frequent falls, and she requires staff assistance for transfers with a wheeled walker and gait belt. Staff were to encourage the use of assistive devices (wheeled walker, wheelchair), provide a pressure-sensitive call bell, keep frequently used personal items within reach, wear footwear that was well fitting with non-slip soles, provide verbal reminders to call for assistance, and have reminder signs placed in her room to ring the call bell for assisstance. A nursing note and incident report, dated April 21, 2022, at 7:31 p.m. revealed that Resident 8 attempted to get out of her wheelchair and walk unassisted to her recliner, approximately two feet away. She did not ring for assistance, despite being repeatedly instructed to do so, and was found on her left side propped up with her left arm in front of her recliner. An Interdisciplinary Team (IDT) note, dated April 22, 2022, revealed that the fall that occurred on April 21, 2022, was reviewed and the resident attempted to get out of her wheelchair on her own and get into her recliner. The resident is non-compliant with using the call bell, and there were no new orders at that time. However, following the fall on April 21, 2022, there was no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury. A nursing note and incident report dated May 17, 2022, at 11:12 a.m. revealed that the resident was observed sitting on floor with her legs outstretched in front of her and her back to the recliner. She was wearing non-skid shoes and the call bell had not been activated. The resident's wheelchair was located about two feet in front of her where she sat on the floor in front of the recliner. Staff stated the last time she was seen she was in her wheelchair. It was also observed that the resident's recliner seat was tilted forward and dycem (material that prevents sliding) was added to the recliner. An IDT note, dated May 19, 2022, revealed that the fall that occurred on May 17, 2022, revealed that Resident 8 attempted to self transfer from her wheelchair to her recliner and fell on the floor. The resident did not activate her call bell even though she has a reminder sign in her room to ring for assistance and is non-compliant with ringing the call bell. However, following the fall on May 17, 2022, there was no documented evidence that interventions were put into place to address the resident not ringing her call bell and getting up unassisted and not following the reminder sign, or that a safety assessment of the recliner chair was completed. A nursing note and incident report, dated May 23, 2022, at 5:28 p.m. revealed that at 5:00 p.m. Resident 8 was found lying on the floor in front of her wheelchair. The resident was attempting to stand and ambulate from her wheelchair to her chair without assistance, despite being instructed to call for assistance first. However, following the fall on May 23, 2022, there was no documented evidence that interventions were put into place to address the resident not ringing her call bell and getting up unassisted. A nursing note and incident report, dated June 7, 2022, at 9:59 a.m. revealed that Resident 8 was found on the floor and her head was towards the bathroom door and her feet were pointing towards her wheelchair. Her call bell was in reach but was not on. She had a hematoma (collection of blood) to her right eyebrow. The fall was discussed by the IDT team on June 7, 2022, and indicated that the resident was unable to state how she fell or what she was attempting to do. The resident's call bell was in reach but not activated at time of the fall. The resident has a reminder sign in her room to ring for assistance and dycem on her chair. The resident is non-compliant with ringing her call bell. However, following the fall on June 7, 2022, there was no documented evidence that interventions were put into place to address the resident not ringing her call bell and getting up unassisted and not following the reminder signs. A nursing note and incident report, dated June 11, 2022, at 6:41 p.m. revealed that Resident 8 was found on the floor propped up against the side of her bed. Apparently she had stood up from her recliner chair without assistance and had attempted to walk three feet to her bed, despite frequent reminders not to walk without assistance. Her right leg was bent at a forty-five degree angle and bent beneath her left leg. She reported severe pain to her right leg from her hip to her knee. She reported that she was having terrible pain with even the slightest touch to her right thigh and hip area and was transferred to the hospital. A nursing note, dated June 13, 2022, at 8:56 p.m. revealed that Resident 8 remained in the hospital and was having surgical repair of her right femur (large leg bone) fracture. Interview with the Nursing Home Administrator on June 6, 2022, at 3:50 p.m. confirmed that there were no new interventions added following the falls noted on the above dates and times to address the resident not using her call bell and getting up unassisted. She confirmed that the resident did not use her call bell or follow the reminder sign and reminding the resident to use the call bell and follow the reminder sign were ineffective in preventing falls and new interventions should have been put into place. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the Pennsylvania Nurse Practice Act, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident was assessed after a change in condition for one of 4 residents reviewed (Resident 1), resulting in a delay in sending the resident to the hospital for a serious medical condition. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's policy regarding changes in a resident's condition, dated April 27, 2020, indicated that the registered nurse assesses human responses and plans, and implements and evaluates nursing care for the person served. In carrying out this responsibility, the nurse was to perform all the functions as defined by the Nurse Practice Act. If a variance from baseline was noted, the Registered Nurse (RN) Supervisor was to notify the physician, document the findings and communications in the interdisciplinary notes in the electronic health record, and document any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 8, 2021, revealed that the resident was cognitively impaired, required extensive assistance for daily care tasks, had occasional mild pair, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note for Resident 1, dated March 28, 2021, at 5:00 p.m. and written by Registered Nurse Supervisor 1, revealed that the resident had a small emesis (vomiting) and complained of nausea and mild mid-sternal chest pain. Resident Family Member 1 had brought in a three-meat pizza to share with the resident that afternoon and the emesis consisted of the undigested meal. All vital signs were within normal limits. Registered Nurse Supervisor 1 informed Physician 5 and new orders were received for four milligrams (mg) of [MEDICATION(S)] (a medication to reduce nausea) every six hours, and to continue to monitor the resident. The resident's nausea subsided some one hour after the administration of [MEDICATION(S)]. The resident stated that her chest hurts,just a little now. All vitals signs were still within normal limits, respirations were even/unlabored, her lungs were clear to auscultation (listening to sounds with a stethoscope), and the abdomen was soft/nontender with positive bowel sounds in all four quadrants. In extended discussion with Resident Family Member 1, he stated, I think it would be premature at this point to send her out to the emergency room . The nurse and Resident Family Member 1 agreed the pizza most likely upset her stomach. Registered Nurse 1 noted that at this time, the licensed practical nurse would check on the resident frequently, every 20 minutes, and report any significant changes to Resident Family Member 1, and the resident would be monitored in accordance with the facility's protocol following emesis. A nursing note for Resident 1, dated March 29, 2021, at 2:38 a.m. (entered as a late entry for March 28, 2021, at 9:00 p.m.), and written by Registered Nurse Supervisor 2, revealed that the resident was noted to have an emesis on the prior shift. Upon assessment, her skin was pale, warm, and dry to touch, her respirations were equal and non-labored, the lung fields were clear bilaterally, and the resident stated that she was hungry. Toast and jelly were provided, and the resident ate a few bites at this time. A nursing note for Resident 1, dated March 29, 2021, at 6:07 a.m. and written by Licensed Practical Nurse 3, revealed that the resident did not have any further emesis that shift. She complained of nausea and requested a ginger ale. The head of the bed was elevated, her vital signs were within normal limits, and around 11:00 p.m., she complained of pain that started in her epigastric region (upon or over the stomach) and radiated into the left chest and shoulder. Registered Nurse Supervisor 2 was made aware. There was no documented evidence in Resident 1's clinical record that Registered Nurse Supervisor 2 assessed the resident at 11:00 p.m. on March 28, 2021, when she was made aware of the resident's complaints of epigastric pain that radiated into her left chest and shoulder. A nursing note for Resident 1, dated March 29, 2021, at 9:12 a.m. and written by Registered Nurse Supervisor 4, revealed that the nurse was called into the resident's room to assess. Resident 1's bilateral legs were blue with mottling (blotchy color) to her upper thighs, she was conversing with staff and was pale in color. The resident attempted to eat breakfast and was unable to do so. She kept sweeping her mouth with her tongue but was unable to swallow her food. Resident Family Member 1 was updated on her condition and wanted her sent to the hospital, and an ambulance was called. A nursing note for Resident 1, dated March 29, 2021, at 10:02 a.m. revealed that Physician 5 was notified about the resident's condition at this time. Orders were received to transfer the resident to the emergency room for evaluation and treatment. The ambulance arrived at 9:20 a.m. and they worked on Resident 1 in her room, attempting to gain intravenous access, which was unsuccessful. The resident's color remained poor, her lower extremities were cold and mottled, she continued to converse with staff while being worked on, her pulse was 62 beats per minute and her blood pressure was 96/54 millimeter of mercury (mmHg) (normal is about 120/80 mmHg) at the time of departure. A nursing note for Resident 1, dated March 29, 2021, at 3:23 p.m. revealed that the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A social services note dated March 30, 2021, at 11:57 a.m. revealed that the resident ceased to breathe at the hospital on March 29, 2021. During a telephone interview with Registered Nurse Supervisor 2 on April 1, 2021, at 11:15 a.m. she confirmed that on March 28, 2021, at 11:00 p.m., Licensed Practical Nurse 3 reported to her that Resident 1 was having epigastric pain with [CONDITION(S)] to the left chest and shoulder. She asked the LPN if the resident was diaphoretic (excessive sweating) or had any nausea or vomiting and was told no. When asked why she did not assess Resident 1 at the time of the LPN's report, she stated, I did assess her about an hour or so later and she was sleeping. There was no documented evidence of Registered Nurse Supervisor 2's assessment of Resident 1. Interview with Physician 5 on April 1, 2021, at 12:00 p.m. confirmed that he expected Resident 1 to be monitored after receiving the [MEDICATION(S)] on March 28, 2021. He stated that his expectation was if the [MEDICATION(S)] was ineffective and the resident continued to have pain, that he would have been called back and would have sent her to the hospital. Interviews with the Director of Nursing and Nursing Home Administrator on April 1, 2021, at 1:00 p.m. confirmed that Registered Nurse Supervisor 2 should have assessed Resident 1 on March 28, 2021, at 11:00 p.m. when the resident complained of the epigastric pain with [CONDITION(S)] to her chest and shoulder. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide care in a safe manner for one of four residents reviewed (Resident 1), resulting in harm for the resident who suffered second degree [CONDITION(S)]. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 16, 2020, revealed that the resident was understood and could understand, required extensive assistance with daily care tasks, and had diagnoses that included [CONDITION(S)] (a degeneration of joint cartilage and the underlying bone that causes pain and stiffness), [CONDITION(S)] (CHF - a progressive heart disease that affects the pumping action of the heart muscle), and difficulty walking. The resident's care plan regarding pain, dated March 6, 2020, indicated that she had a potential for pain due to [CONDITION(S)], a history of right hip replacement, restless leg syndrome, and chronic back pain. An addendum to a nursing note for Resident 1, dated May 10, 2020, at 1:21 p.m. (the original note was May 10, 2020, at 7:05 am.) indicated that the nurse was asked by a nurse aide to take a look at the resident's back due to increased redness and reported discomfort. Upon entering room, the resident was noted to be sitting on the toilet and when asked what was wrong, the resident stated, My back hurts. The nurse assessed the resident's back and noted two large irregularly shaped reddened areas on the right flank that were warm to touch, painful with palpation and blanchable, and there were 4-5 pinpoint blisters starting. One of the areas measured 10.0 x 10.0 centimeters (cm) and the other area measured 10.0 x 9.0 cm. The resident reported that a warm compress was applied to her back last evening and the past several nights to relieve spasms/cramping in her right flank area. The resident stated, I told her several times it was too hot and she moved it different times, but it was still too hot. I even tried to place my hand between it and my back and it was still too hot. The resident stated that the warm compress was applied to her back sometime around 2:30 a.m. this morning. It was noted in report (communication between staff member working different shifts) that the resident was given a warm compress due to increased spasms and cramping. The note indicated that the Registered Nurse (RN) Supervisor was called, informed about the finding, and was asked to come and assess the areas as well. A nursing note for Resident 1, dated May 10, 2020, at 9:30 a.m. revealed that the RN Supervisor, along with the Registered Nurse Assessment Coordinator (RNAC), assessed the right flank area and indicated it was decreased in redness, that smaller areas were noted, and it was no longer two large areas. A cool compress was applied to the area. The resident denied current pain related to the area. The physician was informed and the nurse was awaiting new orders. A nursing note dated May 10, 2020, at 11:00 a.m. revealed that the resident had eight small blistered areas to the right flank, a new order for [MEDICATION(S)] (a topical antibiotic used to prevent infection for [CONDITION(S)]) was obtained, and the nurse was awaiting the medication from the pharmacy. A nursing note for Resident 1, dated May 10, 2020, at 4:00 p.m. revealed that the nurse noted two large, intact fluid-filled blisters on the right side of the mid to lower back. The resident complained of pain and burning at the site. [MEDICATION(S)] cream was to be applied to the area upon arrival from the pharmacy. A nursing note for Resident 1, dated May 10, 2020, at 8:05 p.m. revealed that there were three irregular shaped, fluid-filled areas to the mid lower back extending to the right of midline and closer to the right flank. The areas were fluid-filled vesicles with surrounding [CONDITION(S)] (redness). The resident voiced some discomfort to the midline back with clothing adjustments and her clothing was changed to a gown to avoid irritating the area with the waistband on her pants. A nursing note for Resident 1, dated May 11, 2020, at 3:43 a.m. revealed that the blisters to the resident's right lower back were assessed and two large, fluid-filled blisters and one smaller fluid-filled blister were noted. All blisters remained intact with a red area surrounding the blisters. The resident denied pain and discomfort, but stated that it feels as though the area is burning when she is lying down on her back. The doctor was notified and a new order was received to apply a 15.4 x 15.4 cm Allevyn dressing (a foam dressing that can be left in place for several days) to the area for comfort, but to ensure that the dressing does not adhere to the blisters or the red area, as more trauma could be caused to the skin. An interview with the Nursing Home Administrator on May 13, 2020, at 10:15 a.m. revealed that the facility does not have a policy for nursing staff to apply moist heat for residents, and that this is only permitted to be done in the therapy department by licensed therapy personnel due to the risk of [CONDITION(S)]. An interview with Licensed Practical Nurse (LPN) 1 on May 13, 2020, at 11:53 a.m. revealed that on May 10, 2020, Resident 1 rang her bell at approximately 5:30 a.m. LPN 1 and Nurse Aide 2 responded and assisted the resident into the bathroom. The resident complained of severe muscle spasms and requested heat on her back. LPN 1 stated that she dampened a wash cloth, placed it in a plastic zip bag and put it in the microwave for one minute. LPN 1 took the moist heat into Resident 1's room and placed it under her bed pad because the resident was still in the bathroom with Nurse Aide 2. LPN 1 stated that she thought moist heat was a nursing measure and that a physician's order was not needed. She had no idea how hot it was against the resident's skin because she placed it under her bed pad. An interview with Nurse Aide 2 on May 13, 2020, at 1:11 p.m. revealed that she had no idea who put the moist heat on Resident 1. She indicated that when she came out of the bathroom with the resident, Nurse Aide 3 took over with her care. Nurse Aide 2 stated, I know the resident complained that it was too hot. I didn't see it under a bed pad, it was wrapped in a pillow case or something. A written statement from Nurse Aide 3, dated May 11, 2020, revealed that around 5:30 a.m. Resident 1 rang to go to the restroom. Nurse Aide 2 said that she would get the bell, and when Nurse Aide 3 was done documenting, she went to Resident 1's room and found that the resident was in the restroom. Nurse Aide 2 put the resident into bed. Licensed Practical Nurse 1 had put the warm compress on the resident's bed and the resident did not like where it was placed, so Nurse Aide 3 took it out and put it back in on the center of her back. The resident rang her bell again and Nurse Aide 2 answered it. Nurse Aide 3 did not see any red mark or areas at that time. Interviews with the Nursing Home Administrator and Director of Nursing on May 28, 2020, at 4:40 p.m. confirmed that Resident 1 was burned as a result of moist heat being used on her back without ensuring that the temperature was safe to place on her skin, and without obtaining a physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, investigative reports and clinical records, as well as staff interviews, it was determined that the facility failed to take precautions to prevent accidents and injuries by not having foot rests in place on wheelchairs during transport for one of seven residents reviewed (Resident 2), resulting in a fall with a nasal fracture for the resident, and the facility failed to assess if not removing wheelchair foot rests after transport created accident hazards for residents who self-propelled their wheelchairs for three of seven residents reviewed (Residents 1, 4, 7). Findings include: The facility's policy regarding the use of wheelchairs, dated (MONTH) (YEAR), indicated that foot rests were to be used when transporting residents in a wheelchair. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated (MONTH) 3, (YEAR), revealed that the resident was confused, required extensive assistance from staff for all of her care, and had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 11, (YEAR), revealed that she was at risk for falls, had impaired mobility, weakness and fatigue, and was to use leg rests on her wheelchair at all times. A nursing note for Resident 2, dated (MONTH) 18, (YEAR), at approximately 4:05 p.m. revealed that staff notified the registered nurse that the resident was on the floor in the hallway and the nurse visualized the resident lying prone on the floor, near the doorway to her room, with a large amount of blood coming from her nose. Resident 2's wheelchair was on and over her legs at the ankles, and it was noted that there were no foot rests in place. Investigative documents for Resident 2, dated (MONTH) 18, (YEAR), revealed that at approximately 4:00 p.m. Nurse Aide 1 transported the resident in a wheelchair to go to the bathroom near the front hall. The resident suddenly put her foot down onto the floor and fell face first onto the floor. Licensed Practical Nurse 3 was called to the scene and found Resident 2 face down and bleeding from the nose, with a large hematoma (a collection of blood outside the blood vessels, due to either disease or trauma including injury) to her forehead, two small abrasions/lacerations on the bridge of her nose, which was bruised, and swelling to her mid-forehead measuring approximately 2.5 centimeters (cm). When questioned if she had any pain, the resident stated that her head hurt. The physician was notified and the resident was sent to the emergency room . A written statement by Nurse Aide 1, dated (MONTH) 19, (YEAR), indicated that she was pushing Resident 2 and did not notice that the leg rests were not on the wheelchair. A written statement by Registered Nurse 4, dated (MONTH) 18, (YEAR), indicated that Nurse Aide 1 told her that she did not have the leg rests on the resident's wheelchair. The facility's investigation determined that Nurse Aide 1 violated the facility's policy when she transported Resident 2 in a wheelchair without using foot rests. Information submitted by the facility, dated (MONTH) 18, (YEAR), revealed that while at the hospital, the resident received a computed tomography scan (CT scan - a computerized scan) which revealed a nasal bone fracture and soft tissue swelling in the frontal scalp with a hematoma. Interview with the Nursing Home Administrator on (MONTH) 26, (YEAR), at 7:00 p.m. confirmed that Nurse Aide 1 did not use foot rests while transporting Resident 2 in her wheelchair. He indicated that the facility had educated all staff regarding foot rest use on (MONTH) 15, (YEAR), and foot rests were to be used to maintain safety when transporting residents from place to place. The facility's policy regarding the use of wheelchairs, dated (MONTH) (YEAR), indicated that if a resident preferred to self-propel, but sometimes requested to be pushed in the wheelchair, leg rests were to be kept in a bag on the back of wheelchair when not in use. A quarterly MDS assessment for Resident 1, dated (MONTH) 29, (YEAR), revealed that the resident was confused, was independently mobile in a wheelchair, and had [DIAGNOSES REDACTED]. Observations on (MONTH) 26, (YEAR), at 5:30 p.m. revealed that Nurse Aide 5 transported Resident 1 from the dining room in a wheelchair with leg rests in place. At 5:55 p.m. and 6:10 p.m. the resident self-propelled in and out of the dining room using her feet, and the leg rests were still in place. She then self-propelled down the hall to her room and then back up the hall to the dining room. Observations on (MONTH) 26, (YEAR), at 7:30 p.m. revealed that Resident 1 was in her room sitting in her wheelchair with leg rests in place. The resident had undressed, there were clothes lying on the floor, and she was struggling to put her pajama bottoms on while in the wheelchair. A quarterly MDS assessment for Resident 7, dated (MONTH) 29, (YEAR), revealed that the resident was alert and oriented with some confusion and was independently mobile once in her wheelchair. A physical therapy note, dated (MONTH) 19, (YEAR), indicated the resident was being seen for bilateral lower extremity weakness and transfer and balance deficits, and the resident's care plan, dated (MONTH) 20, (YEAR), revealed that she was at risk for falls. Observations on (MONTH) 26, (YEAR) at 5:45 p.m. revealed that Resident 7 was self-propelling her wheelchair out of the dining room using her feet, and there were leg rests in place on the wheelchair. A quarterly MDS assessment for Resident 4, dated (MONTH) 29, (YEAR), revealed that the resident was alert and oriented and was independently mobile once in her wheelchair. The resident's care plan, dated (MONTH) 19, (YEAR), revealed that she was at risk for falls. Observations on (MONTH) 26, (YEAR), at 5:55 p.m. revealed that Resident 4 was using her feet to self-propel her wheelchair out of the dining room, and there were leg rests in place on the wheelchair. Interview with Nurse Aide 5 on (MONTH) 26, (YEAR), at 7:32 p.m. revealed that Resident 4 self-propelled her wheelchair with her feet, but that the leg rests were kept on the wheelchair just in case staff have to push her somewhere. There was no documented evidence that an assessments were completed regarding the safety of leaving wheelchair foot rests in place after transporting Residents 1, 4 and 7 in a wheelchair. Interview with the Director of Nursing on (MONTH) 26, (YEAR), at 8:15 p.m. confirmed that there were no assessments completed regarding the safety of leaving wheelchair foot rests in place after transporting Residents 1, 4 and 7 in a wheelchair. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 3/30/18, 1/31/18. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/30/18, 1/31/18. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 1/6/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/30/18, 1/31/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/30/18, 1/31/18, 9/10/17.

Based on review of policies, investigative reports and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and the facility's policy for one of seven residents reviewed (Resident 2), resulting in a fall with a nasal fracture for the resident. Findings include: The facility's policy regarding the use of wheelchairs, dated (MONTH) (YEAR), indicated that foot rests were to be used when transporting residents in a wheelchair. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated (MONTH) 3, (YEAR), revealed that the resident was confused, required extensive assistance from staff for her care, and had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 11, (YEAR), revealed that she was at risk for falls, had impaired mobility, weakness and fatigue, and was to use leg rests on her wheelchair at all times. A nursing note for Resident 2, dated (MONTH) 18, (YEAR), at approximately 4:05 p.m. revealed that staff notified the registered nurse that the resident was on the floor in the hallway and the nurse visualized the resident lying prone on the floor, near the doorway to her room, with a large amount of blood coming from her nose. Resident 2's wheelchair was on and over her legs at the ankles, and it was noted that there were no foot rests in place. Investigative documents for Resident 2, dated (MONTH) 18, (YEAR), revealed that at approximately 4:00 p.m. Nurse Aide 1 transported the resident in a wheelchair to go to the bathroom near the front hall. The resident suddenly put her foot down onto the floor and fell face first onto the floor. Licensed Practical Nurse 3 was called to the scene and found Resident 2 face down and bleeding from the nose with a large hematoma (a collection of blood outside the blood vessels, due to either disease or trauma including injury) to her forehead, two small abrasions/lacerations on the bridge of her nose, which was bruised, and swelling to her mid-forehead measuring approximately 2.5 centimeters (cm). When questioned if she had any pain, the resident stated that her head hurt. The physician was notified and the resident was sent to the emergency room . A written statement by Nurse Aide 1, dated (MONTH) 19, (YEAR), indicated that she was pushing Resident 2 and did not notice that the leg rests were not on the wheelchair. A written statement by Registered Nurse 4, dated (MONTH) 18, (YEAR), indicated that Nurse Aide 1 told her that she did not have the leg rests on the resident's wheelchair. The facility's investigation determined that Nurse Aide 1 violated the facility's policy when she transported Resident 2 in a wheelchair without using foot rests. Information submitted by the facility, dated (MONTH) 18, (YEAR), revealed that while at the hospital, the resident received a computed tomography scan (CT scan - a computerized scan) which revealed a nasal bone fracture and soft tissue swelling in the frontal scalp with a hematoma. Interview with the Nursing Home Administrator on (MONTH) 26, (YEAR), at 7:00 p.m. confirmed that Nurse Aide 1 did not use foot rests while transporting Resident 2 in her wheelchair. He indicated that the facility had educated all staff regarding foot rest use on (MONTH) 15, (YEAR), and foot rests were to be used to maintain safety when transporting residents from place to place. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/30/18, 1/31/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/30/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/30/18, 1/31/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/30/18, 1/31/18, 9/10/17.