Every finding on record at Lutheran Home at Kane, The

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of 18 residents reviewed (Residents R1, R3, and R77). Findings include: Review of facility policy entitled Transfer or Discharge, Emergency dated 11/3/25, indicated Should it become necessary to make emergency transfer or discharge to a hospital or other related institution, our facility will prepare a transfer packet to send with the resident that includes; face sheet, administration record, order summary, bed hold policy, immunization report, recent weight and vitals, copy of advance directives, and complete e-interact form. Resident R1's clinical record revealed an admission date of 8/27/25, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), atrial fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R1's progress notes revealed a note dated 8/29/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R3's clinical record revealed an admission date of 12/30/24, with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and heart failure (a condition where the heart cannot supply the body with enough blood). Resident R3's progress notes revealed notes dated 5/18/25, 8/11/25, and 8/14/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R77's clinical record revealed an admission date of 8/25/25, with diagnoses that included weakness, dysphagia (difficulty swallowing), and chronic respiratory failure. Resident R77's progress notes revealed a note dated 9/5/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 11/19/25, at 9:09 a.m. the Director of Nursing confirmed that Residents R1, R3, and R77s clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policies, observations, and staff interview it was determined that the facility failed to appropriately discard outdated medications for one of two medication carts reviewed (300 hall medication cart).Findings include: Review of facility policy entitled Storage of Medications dated 11/3/25, indicated Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of manufacturer's guidelines revealed that an open pen of Lispro Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on 11/17/25, at 12:55 p.m. of the 300-hall medication cart revealed an open Lispro Insulin pen with an open date of 10/3/25, and an expiration date of 10/31/25. During an interview on 11/17/25, at the time of observation Licensed Practical Nurse Employee E2 confirmed that the open Lispro insulin pen was beyond the expiration date and also confirmed that the insulin pen should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of four residents reviewed for respiratory care (Residents R4 and R49).Findings include: Review of facility policy entitled Oxygen Administration dated 11/3/25, indicated Concentrator filters cleaned weekly on night shift. Review of resident R4's clinical record revealed an admission date of 8/8/25, with diagnoses that included chronic obstructive pulmonary disease (COPD) (a disease that obstructs air flow from the lungs), heart failure (a condition where the heart cannot supply the body with enough blood), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R4's physician's orders revealed an order dated 8/8/25, for oxygen between two and four liters via nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) continuously. Review of Resident R4's care plan for COPD revealed an intervention of oxygen between two and four liters continuously. Review of Resident R4's tasks (an area in the clinical record where nursing assistant document) revealed a task for oxygen tubing/cannula change/concentrator filter cleaned. Observations on 11/17/25, at 1:55 p.m. and again at 2:25 p.m. revealed Resident R4 lying in his/her bed with oxygen being administered. Further observations revealed a filter on the back of his/her oxygen concentrator that had a large amount of a fluffy white substance covering the filter. Review of Resident R49's clinical record revealed an admission date of 12/5/25, with diagnoses that included COPD, congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and chronic respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R49's physician's orders revealed an order dated 4/15/19, for oxygen at two liters via nasal cannula every evening and night shift. Review of Resident R49's care plan for congestive heart failure revealed an intervention of oxygen at two liters per minute at hour of sleep. Review of Resident R49's tasks revealed a task for oxygen tubing/cannula change/concentrator filter cleaned. Observations on 11/17/25, at 1:08 p.m. and again at 2:25 p.m. revealed Resident R4's oxygen concentrator sitting in his/her room with the nasal cannula lying over the concentrator and the nasal cannula touching the floor. Further observations revealed a filter on the back of his/her oxygen concentrator that had a large amount of a fluffy white substance covering the filter. During an interview on 11/17/25, at 2:32 p.m. Registered Nurse (RN) Employee E1 confirmed that Resident's R4 and R49's oxygen concentrator filters were covered in a large amount of a white fluffy substance and that Resident R49's nasal cannula was touching the floor. RN Employee E1 also confirmed that the oxygen concentrator filters should be clean, and the nasal cannula should not be on the floor. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner in one of two medication rooms reviewed (200-Hall medication storage room). Findings include: Review of a facility policy entitled Labeling of Medication Containers dated 12/05/24, revealed Labels for stock medications include all necessary information, such as: d. The expiration date when applicable. Manufacturer's recommendations for Aplisol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials in use for more than 30 days should be discarded due to possible oxidation and degeneration which may affect potency. Observations of drug storage on 12/17/24, at approximately 3:46 p.m. in the 200-Hall medication storage room refrigerator revealed one open vial of Aplisol without an opened date, therefore the staff were unable to determine the discard date. During an interview at that time, Licensed Practical Nurse Employee E1 confirmed that the open Aplisol vial lacked an opened date and staff were unable to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, resident and staff interviews, it was determined the facility failed to ensure the provision of a substantial evening snack when up to 14 hours and 45 minutes elapsed from the supper meal to breakfast the next day. Findings include: A review of facility's policy entitled Meal times and frequency with a policy review date of 1/2/2024, revealed meals and evening snack will be served at the following times: Breakfast 7:30 a.m., Lunch 11:00 a.m., Dinner 4:45 p.m., Evening snack 7:00 p.m. In nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day. All residents will be offered a bedtime snack. If a nourishing snack is served at bedtime, then up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the next day. Interviews conducted with residents during Resident Council meeting on 1/29/2024, revealed that three of three residents in the meeting indicated that a nourishing evening snack is not consistently served. During an interview on 1/29/2024, at 1:00 p.m. the Dietary Manager and Registered Dietitian confirmed that there was no evidence that dietary staff or nursing staff provided residents with a nourishing evening snack. The Dietary Manager and Registered Dietitian also confirmed that there was more than 14 hours from the evening meal until breakfast the next day. 28 Pa. Code 211.6(a)(b) Dietary services

Based on review of facility policy and Resident Council minutes, and resident and staff interviews, it was determined that the facility failed to ensure that residents were updated in a timely manner regarding Resident Council concerns, and the facility failed to correct Resident Council concerns for a period of three months (November 2023 through January 2024). Findings include: Review of facility policy entitled, Resident Council, dated 1/2/24, revealed Resident Council is a social forum where residents are encouraged to discuss and make decisions about the environment in which they live. Residents are free to make grievances and recommendations to benefit all residents living in the nursing home. Procedure of Resident Council meeting indicated, Activity Director or designated staff will conduct the meeting (as per Resident vote). It is the department's director's responsibility to fully investigate and answer concerns. If any department fails to address/investigate concerns, necessary actions will be taken. Review of the Resident Council minutes and Grievances over the past three months, for November 2023 through January 2024, revealed a pattern/trend with issues regarding lengthy waiting times to go to the bathroom. During a Resident Council meeting on 1/29/24, at 10:00 a.m. interviews with Resident R22, Resident R44, and Resident R58, who all attend Resident Council meetings regularly, indicated that concerns of wait times for toileting have been voiced in several past monthly meetings with no resident update or resolution. An interview with the Activity Director on 1/30/24, at approximately 10:00 a.m. confirmed that he/she attends Resident Council meetings and reviews past monthly concerns in new business and old business with residents; and the concerns of lengthy wait times have been voiced by residents during the meetings in November 2023, December 2023, and January 2024 with no resolution. An interview with the Director of Nursing on 1/30/24, at 12:25 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding lengthy waiting times to go to the bathroom from the November 2023, December 2023, and January 2024 Resident Council meetings. No evidence was provided to ensure the residents' concerns verbalized and further stated in the Resident Council minutes for the past three months reviewed was noted of timely corrective actions, in addition to no evidence of the residents being updated in a timely manner of those actions. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of the Resident Assessment Instrument (RAI-manual that guides facilities with completing resident Minimum Data Set [MDS-periodic assessment of resident care needs] assessments), clinical records, facility documentation, and staff interviews, it was determined that the facility failed to complete the MDS to accurately reflect the resident's status at the time of the assessment for two of 18 residents reviewed (Residents R57 and R67). Findings include: Review of the October 2019 RAI Manual revealed the instructions for completion of M1040 included: review the medical record, including skin care flow sheets or other skin tracking forms; speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review; examine the resident and determine whether any ulcers, wounds, or skin problems are present; check all that apply in the last seven days; and if there is no evidence of such problems in the last seven days, check none of the above. Review of the October 2019 RAI Manual revealed that restraints (a device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) used in the seven-day assessment look-back period were to be documented in Section P (Restraints and Alarms) of the MDS, coding 0 for not used, 1 for used less than daily, and 2 for used daily. Review of Resident R57's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), pressure ulcer of the lower back, high blood pressure, and kidney disease. A Quarterly MDS dated [DATE], under Section M1040A, indicated that Resident R57 was treated for a foot infection in the look back period. Resident R57's clinical record lacked any evidence of he/she being treated for a foot infection. Review of Resident R67's clinical record revealed an admitted [DATE], with diagnoses that included dementia, stroke, high blood pressure, and weakness. A Quarterly MDS dated [DATE], under Section P0100F, revealed that Resident R67 utilized a limb restraint less than daily. Resident R67's clinical record lacked any evidence of a limb restraint being ordered or used. Observations between 2/06/23, and 2/07/23, revealed Resident R67 self propelling in their wheelchair throughout the facility with no limb restraints observed During an interview on 2/07/23, at 2:00 p.m. the Director of Nursing confirmed that Resident R67 did not have a limb restraint and the MDS Section P0100F as listed above was coded incorrectly. During an interview on 2/08/23, at 11:27 a.m. Registered Nurse MDS Coordinator confirmed that Resident R57 was not treated for a foot infection and the Quarterly MDS dated [DATE], Section M1040A was coded incorrectly. 28 Pa. Code 211.5(f) Clinical records

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to prevent significant medication errors for one of three residents receiving insulin (Resident R34). Findings include: Review of a facility policy entitled, Administering Medication dated 1/03/22, indicated Medications are administered in a safe and timely manner, and as prescribed. It also indicated that medications are administered as prescribed. Review of Resident R34's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Hold if blood sugar less than 150*. During a medication pass observation on 4/25/22, at 4:10 p.m. Licensed Practical Nurse Employee E1 checked Resident R34's blood glucose with a result of 138, then proceeded to administer [MEDICATION(S)] 15 units SQ. Review of Resident R34's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 4/11/22, blood glucose result of 127 4/12/22, blood glucose result of 139 4/20/22, blood glucose result of 135 4/25/22, blood glucose result of 138 During an interview on 4/26/22, at 10:15 a.m. the Director of Nursing confirmed that Resident R34's insulin was administered in error and not according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of the daily menus and facility policy, and interviews with residents and staff, it was determined that the facility failed to offer alternate meals that provide residents with alternate preferences meeting their nutritional requirements for five of 11 residents interviewed (Residents R17, R23, R36, and R47). Findings include: Facility policy titled Meals Available to Residents dated 11/05/2020, stated that dislikes of meal components will be replaced by other food items to round out meal nutrient requirements. Alternate meals of complete nutritional value will be provided upon request. Alternate meal will be posted on menus located throughout the building. During an interview on 4/27/21, at 1:00 p.m. Resident R17 revealed that he/she would like to be offered another choice of a hot meal for lunch and dinner instead of only soup and sandwiches. In addition, he/she stated that many times he/she doesn't like what is offered for lunch and dinner so often doesn't eat a lot. During an interview on 4/27/21, at 1:00 p.m. Resident R47 indicated that the residents are not offered comparable substitute food options, residents can only get soup and/or a sandwich if they don't want the meal provided, residents don't get to choose their meals and are all given the same meal, and that the food is bland without spices. During an interview on 4/28/21, at 1:47 p.m. Residents R47, R36 and R23 expressed that the only substitute that the residents receive if they do not choose the main meal is a soup and sandwich. Resident R23 stated that you get tired of soup and sandwiches after awhile. Observation of the kitchen food prep area revealed that the food prepared for lunch on 4/28/21, had all of the foods that were on the menu that day. The alternate menu revealed a soup of the day and a sandwich of the day. Further review of the menu revealed that every day there is a soup and sandwich of the day as an alternate for lunch and dinner. An interview conducted with the Certified Dietary Manager (CDM), and Assistant Dietary Manager on 4/29/21, at 1:20 p.m. revealed that every day is the same alternate meal of soup and sandwich if the resident does not like the main meal. An interview with the Registered Dietitian (RD) on 4/29/21, at 3:10 p.m. revealed that there were no other options on the menu for residents for alternates other than a soup of the day and sandwich of the day. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to address a significant weight change for one of five residents reviewed (Resident R60). Findings include: The Obtaining Weights policy, dated 11/05/2020, revealed that New residents will be weighed weekly for 4 weeks upon admission. Certified Nursing Assistants (CNA), will be responsible for obtaining daily, weekly and any re-weighs. Weights will be reviewed by Certified Dietary Manager (CDM)/Assistant Dietary Manager to determine if a re-weigh needs to be performed. Resident R60's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R60's weights revealed a weight of 182.4 pounds on 3/20/21 upon admission, a re-weigh of 183 pounds on 3/22/21, and then 161 pounds on 4/05/21, reflecting a significant weight loss of 12 percent over a 14 day period. The clinical record lacked evidence that this weight loss was addressed until 4/29/21, a period of 24 days after the significant weight loss was identified for Resident R60. The clinical record lacked evidence that weights were obtained weekly for four weeks from Resident R60's admission of 3/20/21. During an interview on 4/29/21, at 1:20 p.m. the Dietary Manager and the Assistant Dietary Manager acknowledged that the significant weight loss occurred and was not acted upon in a timely manner and weights were not recorded on a weekly basis per policy. During an interview on 4/29/21, at 3:10 p.m. the Registered Dietitian acknowledged that weights were not recorded and reported weekly for a new admission as they are ordered and the significant weight loss was not acted upon in a timely manner for Resident R60. 483.25 Previously cited state deficiency 9/13/19 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records and facility policies and staff interviews, it was determined that the facility failed to ensure advance directive choices were coordinated with all sources of information for one of 19 residents (Resident R50) Findings include: The Identifying Residents with CPR (cardiopulmonary resuscitation) Code Status policy, dated [DATE], revealed that residents identified as wanting CPR would have a red heart placed on the outside sleeve of the chart and above the resident's bed. Resident R50's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent signed Advanced Directive form dated [DATE], indicated that Resident R50 was a Do Not Resuscitate (DNR). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], at 12:31 p.m. Ward Clerk Employee E1 confirmed that the outside of the chart and the electronic medical record information identified that Resident R50 wanted CPR however, the most recent signed Advance Directive identified the resident as a DNR. During an inteview on [DATE], at 9:19 a.m. the Director of Nursing confirmed that the clinical record did not reflect the correct Advance Directive choice for Resident R50. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to ensure proper handwashing occurred during a wound dressing change for one of two residents (Resident R33). Findings include: The Changing Dry and Clean Dressing policy, dated 11/5/20, revealed that during a dressing change, hands should be cleansed after removing the soiled dressing and cleaning of the soiled wound area. During a dressing change for Resident R33, on 4/29/21, at 1:00 p.m. Licensed Practical Nurse (LPN) Employee E1 did not sanitize or wash hands after removing his/her soiled dressing and cleaning of the soiled wound area. LPN Employee E2 confirmed the above information on 4/29/21 at 1:05 p.m. During an interview on 4/29/21, at 1:10 p.m. the Director of Nursing confirmed that hands are to be washed or sanitized after removing the soiled dressing and cleaning of the soiled wound area. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to maintain sanitary dish machine area operations in the main kitchen. Findings include: Observation of the kitchen area on 9/10/19, between 2:05 p.m. and 2:25 p.m. revealed two fans in the dish machine area covered in dust turned on and blowing toward the clean dish area. During an interview on 9/10/19, at 2:16 p.m. the Certified Dietary Manager confirmed that the fans were dusty and needed cleaned. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/17/18

Based on review of the facility's staff education records and staff interview, it was determined that the facility failed to monitor Nurse Aides (NA) attendance at in-services to ensure a total of 12 hours of yearly in-service education was achieved for two of five employees from (MONTH) 18, (YEAR) to (MONTH) 9, 201 (Employees E1 and E3). Findings include: The staff education records revealed that NA Employee E1 had a total of 10 out of 12 hours and NA Employee E3 had a total of 9.75 out of 12 hours of required yearly in-service education. During an interview on 9/13/19, at 12:25 p.m. the Human Resources Director Employee E4 confirmed the above information. 28 Pa. Code 201.20(a)(c) Staff development

Based on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to address a significant weight change for one of eight residents (Resident R79). Findings include: The Admission Record revealed that Resident R79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Tracking Weight Changes policy, dated 12/04/18, revealed that the Dietary Manager or assistant will review resident weights daily and weight gains and losses will be tracked and determined if significant (five percent increase or decrease in a month ., Resident R79's weight's revealed a weight of 161.6 pounds on 6/04/19 and 147.7 pounds on 6/18/19, reflecting a significant weight loss of 8.6 percent. The clinical record lacked evidence that this weight loss was addressed until 7/26/19, a period of 38 days after the significant weight loss was identified. During an interview on 9/13/19, at 10:50 a.m. the Registered Dietitian and the Dietary Manager acknowledged that the significant weight loss occurred and was not acted upon in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/17/18

Based on review of clinical records and staff interview, it was determined that the facility failed to demonstrate the use of non-pharmacological interventions to assure the clinical necessity for the administration of an anti-anxiety medication for one resident (Resident R42) and failed to document the rationale for the continued use of an as-needed psychoactive medication (affecting the mind) for two (Residents R17 and R76) of 21 residents. Findings include: Resident R42's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R42's admission orders [REDACTED]. Resident R42's Medication Administration Record [REDACTED]. Ten of the twelve documented doses of [MEDICATION NAME] administered on an as-needed basis, lacked evidence that non-pharmacological interventions were attempted prior to the use of the medication. Resident R17's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R17's current physician orders [REDACTED]. Resident R17's clinical record revealed that Resident R17 received seven doses of the as-needed [MEDICATION NAME] since the original order. The clinical record lacked evidence of the order being evaluated by the physician for continued use past 14 days. Resident R76's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Resident R76's clinical record revealed that Resident R76 received three doses of the as-needed [MEDICATION NAME] since the original order. The clinical record lacked evidence of the order being evaluated by the physician for continued use past 14 days. During an interview on 9/13/19, at 12:25 p.m. the Director of Nursing confirmed that non-pharmacological interventions should have been attempted before administering Resident R42's [MEDICATION NAME] and that Residents R17 and R76's as needed [MEDICATION NAME] and [MEDICATION NAME] should have been limited to a 14 day ordering period, then reviewed by the physician to determine the need for continued usage. 28 Pa. Code 211.5 Clinical records 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records and staff and resident interviews, it was determined that the facility failed to accommodate resident needs relating to call bells and water accessibility for two of 21 residents (Residents R68 and R24). Findings include: Resident R68's Minimum Data Set, (periodic review of resident care needs), dated 7/02/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. During an interview on 9/10/19 at 2:40 p.m. Resident R68 ws observed searching/feeling around his/her bed. When questioned about the movement, Resident R68 stated that he/she could only see shadows and was looking for the call bell. Resident R68 revealed that many times the staff would leave the call bell attached to the sheet of the bed and when the bed was made, the call bell would be left under the blanket and not easily accessible. During an observation and interview on 9/10/19, at 2:47 p.m. Medical Records Employee E8 came into the room and found the call bell under Resident R68's blanket. Resident R24's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] disorder of the central nervous system) and [MEDICAL CONDITION](severe mental disorder) with hallucinations (see, hear or smell something that dos not exist) and anxiety. Observations on 9/10/19 at 3:12 p.m. and 9/12/19 10:30 a.m. revealed Resident R24 sitting in a geri chair (special positioning chair) with their cup of water sitting on a nightstand behind his/her chair not within their sight or reach. and the resident's lips appeared dry with a dried piece of skin hanging from their lip. During an interview at the time of the observation, Resident R24 indicated he/she was thirsty. Nurse Aide (NA) Employee E9 entered the room and offered Resident R24 a beverage. Resident R24 proceeded to drink from the cup offered to him/her. NA Employee E9 then stated you were thirsty . 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) for four of six residents transferred out of the facility to the hospital (Residents R1, R76, R14 and R68). Findings include: The facility policy related to bed holds, dated 12/04/18, indicated that residents and/or their legal guardians would be notified of the bed hold policy upon admission and at the time of every transfer to the hospital or when going on leave. Resident R1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record revealed that Resident R1 was transferred from the facility to the hospital on [DATE], and returned on 7/24/19. There was no evidence that Resident R1 and/or their representative, was provided a written notice of the facility bed-hold policy. Resident R76's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record revealed that Resident R76 was transferred to the hospital on [DATE], and returned on 4/25/19, and transferred to the hospital again on 6/13/19, and returned on 7/02/19. There was no evidence that Resident R76 and/or their representative was provided a written notice of the facility bed-hold policy. Resident R14's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record revealed that Resident R14 was transferred to the hospital on [DATE], and returned to the facility on [DATE]. There was no evidence that Resident R14 and/or their representative was provided a written notice of the bed hold policy. Resident R68's Minimum Data Set, (periodic review of resident care needs), dated 7/02/19, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record revealed that Resident R68 was transferred to the hospital on [DATE], and returned to the facility on [DATE], and again went out on 7/11/19, to the hospital and returned on 7/13/19. There was no evidence that Resident R68 and/or their representative was provided a written notice of the bed hold policy for either transfer. During an interview on 9/12/19, at 12:21 p.m. the the Social Services Director Employee E7 confirmed that Residents R1, R76, R14, and R68 and/or their representatives did not receive a written notice of the facility bed hold policy. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(f) Residents Rights

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that in preparation for a room change, the resident's responsible party received written notice, including the reason for the change, before the resident's room was changed for one of one residents with a room change (Resident R9). Findings include: Resident R9's face sheet documented an admission date of [DATE], with [DIAGNOSES REDACTED]. A progress note dated 6/14/18, revealed that Resident R9 was moved to a different room in the facility. There was no documentation to indicate that Resident R9's responsible party was provided written notification prior to the room change. During an interview on 8/16/18, at 11:57 a.m. Social Worker Employee E1 confirmed that written notification regarding Resident R9's room change was not provided prior to the room change. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(j) Resident rights

Based on observations and staff interviews, it was determined that the facility failed to maintain sanitary and orderly rooms for two of four wings (200 wing and 400 wing). Findings include: Observations of the 200 wing and 400 wing on 10/16/17, from 6:00 p.m. through 6:45 p.m. revealed the following: Room 201 had a white pillowcase under the head of the bed Room 208 had a bed wedge (device used to help support a resident in positioning) on the floor Room 417 had wheelchair footrests on the floor Observations on 10/19/17, from 9:00 a.m. through 9:15 a.m., revealed the following: Room 415 wheelchair footrests were on the floor Room 208 had a towel lying on the floor next to the wastebasket During an interview on 10/19/17, at 9:16 a.m. Medical Records Employee E1 confirmed that the wheelchair footrests and the towel should not have been on the floor. During an interview on 10/19/17, at 10:00 a.m., the Nursing Home Administrator confirmed that the items identified should not be on the floor. 483.15(h)(2) Previously cited state deficiency 3/30/17 28 Pa. Code 207.2 (a) Administrator's responsibility Previously cited 3/30/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 3/30/17, 4/25/17, 5/30/17, 8/14/17

Based on review of facility policies, clinical records, facility documentation and staff interviews, it was determined that the facility failed to provide a safe environment free from accidents by transferring a resident improperly, resulting in actual harm of a fractured lower end of the left tibia (lower leg) for one of five residents (Resident R2). Findings include: The facility policy, Recognizing Signs and Symptoms of Abuse/Neglect, dated 4/26/17, indicated that the facility will not condone any form of resident abuse or neglect. The following were signs of actual physical neglect: Inadequate provision of care, signs of actual physical abuse; fractures ( broken bones). Resident R2's Admission Record Report revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R2's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated 5/29/17, revealed that Resident R2 had severe cognitive impairment and the transfer status was total dependence with a two person physical assist. Resident R2's plan of care, updated 12/30/16, indicated that transfers for Resident R2 should be with the assistance of two staff and Mechanical Lift (Hoyer-a lift designed to assist caregivers in raising non - weight-bearing patients). An incident report involving Resident R2 dated 7/25/17, revealed that at 11:00 p.m. Resident R2 was noted to have bruising and swelling to his/her left ankle area. Witness statements revealed that the Certified Nurse Assistant Employee E1 statement stated I changed her in her chair so when Employee E2 brought me the Hoyer I told her I didn't need it. I put a pillow in the gap under her legs so she could lay comfortably and her feet wouldn't go in the gap while I rolled her. We 2 person lifted her into bed Employee E3 was on the left I was on the right we lifted her by her underarm and her pants. The investigation revealed that staff used incorrect method of transfer, placing resident at risk for injury of unknown origin. All staff in-serviced on following resident transfer status following incident. A nurses' note dated 7/25/17, at 11:03 p.m. for Resident R2 indicated that Registered Nurse (RN), Employee E4, documented that: Resident R2 was noted to have a six centimeter by six centimeter bruise on left lateral malleolus (ankle) with slight swelling; upon assessment resident noted to have facial grimacing; wing nurse to medicate for pain; will continue to monitor. Nurses' notes dated 7/26/17, at 7:47 a.m. indicated that resident crying out when attempting to put socks on. physician's orders [REDACTED]. On 7/26/17, an X-ray report revealed that Resident R2 had a left distal tibia fracture (broken bone just above the ankle). During an interview on 8/11/17, at 1:45 p.m. the Nursing Home Administrator confirmed that an improper transfer method was utilized during the transfer of Resident R2, and resulted in actual harm to the resident. The facility did not use the proper equipment for a safe transfer which placed a resident at risk for injury from an improper transfer method. As a result, there was actual harm to the resident who suffered a fractured tibia. 482.12 Previously cited state deficiency 8/22/14 28 Pa. Code 201.18(b)(1) Management Previously cited 4/25/17, 9/29/16 28 Pa. Code 201.18(b)(2)(3) Management Previously cited 4/25/17, 9/29/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/25/17, 3/30/17, 9/29/16

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to accurately assess, timely identify, consistently monitor, and provide all the necessary care and treatment to prevent the development and treatment of [REDACTED]. Findings include: The facility policy entitled, Pressure Ulcers, dated 4/27/16, indicated that resident skin assessments would be completed within two hours of admission, utilizing the, Admission Nursing Assessment form, and on readmission to the facility, utilizing a, Skin Assessment Sticker. The policy further indicated that pressure ulcers are to be assessed weekly by a Registered Nurse (RN) on the, Daily Ulcer Documentation Form to include description; measurements of length, width and depth; and staging (determination of depth of tissue damage) to be completed in accordance with National Pressure Ulcer Advisory Panel. The policy indicated that any changes identified by nurses reviewing the wound on a daily basis, such as changes in the wound bed, pain, signs of infection or amount of drainage are to be reported to the RN. Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS-a periodic review of resident care needs), dated 8/04/16, revealed that Resident R6 had pressure ulcers. The Daily Ulcer Documentation Form revealed that Resident R6 had a pressure ulcer to the heel of the right foot. Assessments were documented on 8/30/16, 9/06/16, and then not again until 9/20/16, (14 days later). There was no evidence that the right heel ulcer had been assessed between 9/06/16 and 9/20/16. During an interview on 9/29/16, at 9:10 a.m. the Director of Nursing confirmed that the right heel assessment was not completed weekly for Resident R6. Resident R10's quarterly MDS dated [DATE], revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The resident required the extensive assistance of two staff for bed mobility, transferring, hygiene and dressing. The resident was frequently incontinent of urine and was assessed as high risk for pressure ulcers. The MDS indicated that Resident R10 had a Stage II pressure ulcer (a partial thickness loss of tissue) that was acquired at the facility. Resident R10's Daily Ulcer Documentation forms revealed a Left Ischium (the lower and back part of the hip bone) wound with an onset date of 7/20/16, assessed as a Stage II pressure ulcer, measuring 0.9 centimeters (cm) in length by 0.9 cm in width. The documentation revealed that a collagen and bordered foam (an enclosed dressing product to promote the growth of new tissue) dressing was utilized daily for the treatment of [REDACTED]. The next assessment was not completed until 8/04/16, (14 days later) and lacked staging of the two wounds of the left ischium. On 8/07/16, documentation revealed that the two left ischium wounds had combined and was assessed as a Stage III pressure ulcer (a full thickness skin loss), measuring 3.5 cm in length by 2.4 cm in width. The pressure ulcer was described as having a red /yellow wound bed and a small amount of purulent drainage (containing pus). The tissue type was assessed as slough (a layer of dead tissue separated from the wound base). Documentation also revealed that Resident R10 had pain present with this assessment. The clinical record lacked evidence that the physcian was notified of the worsening wound until 8/14/16, (seven days later). The Daily Ulcer Documentation dated 9/15/16, revealed the left ischium wound as unstageable with red wound edges, yellow slough and scant sanguineous drainage (fresh blood), the assessment also indicated that pain was present. The next full wound assessment was not done until 9/29/16, (14 days later). During an interview on 9/29/16, at 9:45 a.m. the Nursing Home Administrator confirmed that Resident R10 was not monitored following the identified skin changes on 8/07/16, and that the assessment, treatment and interventions were not updated in a timely manner to prevent the development and worsening of a pressure ulcer, resulting in harm to the resident. Resident R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], revealed that Resident R11 had pressure ulcers. The Daily Ulcer Documentation form revealed that Resident R11 had a pressure ulcer to the left great toe. Assessments were documented on 8/09/16, 8/11/16, and then not again until 9/15/16, (35 days later). There was no evidence that the left great toe had been assessed between 8/11/16 and 9/15/16. During an interview on 9/28/16, at 2:20 p.m. the Director of Nursing confirmed that the left great toe assessment was not completed weekly for Resident R11. Resident R16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Daily Ulcer Documentation form revealed that Resident R16 was assessed to have a Stage II pressure ulcer to the right inner bunion area identified on 8/20/16. There was no evidence that the pressure ulcer area was assessed again until 9/01/16, (11 days later). During an interview on 9/28/16, at 4:00 p.m. the Nursing Home Administrator confirmed that Resident R16's wound was not assessed weekly. Resident R7's quarterly MDS dated [DATE], revealed an admission date of [DATE], a readmission date of [DATE], and current [DIAGNOSES REDACTED]. The MDS further indicated that Resident R7 was assessed to be at risk for the development of pressure ulcers and had a Stage III pressure ulcer (full thickness loss of tissue) that was acquired prior to re-admission to the facility and experienced almost constant pain that interfered with sleep and daily activities. Resident R7's clinical record revealed readmission to the facility on [DATE], at 12:19 p.m. following a two-day stay at a local hospital. A, Skin Assessment Sticker, dated 7/25/16, at 12:20 p.m. reflected that Resident R7 had an area on the left buttocks described as a, scab with surrounding area red. The assessment lacked measurements, identification of a wound stage and a correlating entry on a, Daily Ulcer Documentation form. Resident R7's, Daily Ulcer Documentation forms for the left buttock wound revealed that a full wound assessment, containing all required data, was not completed until 8/01/16 (seven days after re-admission). The 8/01/16 wound assessment, assessed the left buttock pressure area as a Stage III pressure ulcer, measuring 3.8 cm in length by 3.2 cm in width, and 0.2 cm in depth with pain present. The documentation revealed that a skin protectant paste was utilized daily for the treatment of [REDACTED]. Resident R7's physician's orders [REDACTED]. Pain Flow Sheets from 7/25/16, to 8/08/16, the period following readmission to the time a treatment order was obtained, revealed that Resident R7 complained of buttock pain on the following dates: 7/26/16, 7/30/16; 7/31/16; 8/01/16; 8/02/16; 8/03/16/; 8/04/16; and 8/05/16. Resident R7 rated the pain as a ten (most severe on a scale of one to ten) on four (7/31/16, two times; 8/03/16; 8/04/16) of the six occasions when pain medication was administered. During an interview on 9/27/16, at 10:30 a.m. Registered Nurse, Employee E4 confirmed that Resident R7 was not assessed in a timely manner for pressure ulcers upon readmission to the facility, or were orders obtained in a timely manner for the treatment of [REDACTED]. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal Pressure sores Previously cited 08/22/14 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/22/14 28 Pa. Code 201.18(b)(1) Management Previously cited 08/22/14, 07/10/15 28 Pa. Code 201.18(e)(1) Management Previously cited 08/22/14 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 08/22/14, 07/10/15, 03/31/16

Based on review of clinical records, facility policy and an incident report and staff interviews, it was determined that the facility failed to effectively implement the abuse policy and failed to assure that care was provided in a timely manner for one of three residents reviewed (Resident R44). The findings include: Resident R44's admission sheet showed an admission date of [DATE], and [DIAGNOSES REDACTED]. Resident R44's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated 10/17/13, revealed Resident R44 had severe cognitive impairment and the transfer status was total dependence with a two person physical assist. Resident R44's Plan of Care, updated 10/24/13, indicated that transfers for Resident R44 were to be with the assistance of two staff. An event report with a Provider Bulletin-22 (a report form for investigation of alleged abuse, neglect, misappropriation of property) submitted to the State Department of Health, dated 1/12/14, disclosed an event that had occurred on 1/11/14, at 7:00 p.m. The report revealed that Nurse Aide (NA), Employee E7, transferred Resident R44 alone, causing serious physical injury. The Safe Transfer of a Resident sheet for Resident R44 revealed that therapy instructed the staff to use two assist, maximum assist, and a two person lift since January of 2013. Investigation documentation revealed that Employee E7 reported to Licensed Practical Nurse (LPN), Employee E4, at 7:00 p.m., that he/she heard a cracking noise while transferring Resident R44. At 9:00 p.m. Employee E7 approached Employee E4 again regarding Resident R44 and at this time, Employee E4 assessed Resident R44,which was a period of two hours after the time the initial incident occurred. Resident R44 was noted to have swelling and limited range of motion to the right shoulder. Resident R44 was transferred to the hospital for evaluation. The hospital diagnosed Resident R44 as having a fractured right humerus (broken right upper arm). Review on 7/24/14, of the facility policy titled, "Preventing Resident Abuse", indicated that facility management shall promptly and thoroughly investigate all reports of resident abuse, neglect and injuries. The facility will protect residents from harm during investigations of abuse allegations. Review of Resident R44's nurses' notes dated 1/11/14, at 9:30 p.m., indicated that Registered Nurse (RN), Employee E10, was called to Resident R44's room and it was noted that Resident R44 had swelling to the right shoulder and had increased facial grimace and sounds, with touch or gentle movement to the right arm. A physician's orders [REDACTED]. Review of the hospital records dated 1/11/14, disclosed that Resident R44 had a CT (computed tomography-a computer generated x-ray to produce images) scan which diagnosed the resident as having a comminuted (broken into several pieces) right humeral neck fracture with impaction (bone fragments driven into other bone fragments). During an interview on 8/22/14, at 1:15 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that an investigation was not conducted related to Employee E4's failure to promptly evaluate Resident R44 injuries that were sustained from the improper transfer by Employee E7 on 1/11/14. The facility failed to thoroughly investigate care and supervision to a resident at risk for injury from an improper transfer method, resulting in actual harm to the resident. 483.13(c) Previously cited state deficiency 7/18/13. 28 Pa. Code 201.18(b)(1)(2)(3)(e)(1) Management. Previously cited 7/18/13. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. Previously cited 7/18/13.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to accurately assess, monitor and provide timely interventions for the prevention of pressure ulcers, resulting in actual harm for one of two residents with pressure ulcers reviewed (Resident R10). The findings include: The facility policy, "Pressure Ulcers", dated 7/23/14, stated that residents are assessed to identify risk for developing pressure ulcers, appropriate preventative measures are initiated and appropriate treatment provided. The policy further indicated that upon identification of a pressure ulcer, a referral form will be submitted to the facility Care Coordinators (professional nurses managing the care of facility residents); measurements of the wound to include length by width by depth and staging (a determination of the amount of tissue loss) will be completed and documented in the nurses' notes; and appropriate treatment initiated following physician notification. Resident R10's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated 4/15/14, revealed that Resident R10 had moderate cognitive impairment, [DIAGNOSES REDACTED]. The resident required the extensive assistance of two staff for bed mobility, transferring, hygiene, eating and dressing. The resident was frequently incontinent of urine and had no pressure ulcers at the time of the assessment, but was assessed as high risk for their development. A nurses' note, dated 6/15/14, revealed a skin assessment reflecting the presence of, "three scabbed areas" along Resident R10's spine with a surrounding, "pink, reddened area." The clinical record lacked evidence of the physician or the Care Coordinator notification related to the scabbed areas, changes in the plan of care or treatment, or further assessment of the area on 6/16/14, 6/17/14, or 6/18/14. A nurses' note, dated 6/19/14, revealed Resident R10 to have developed an, "open area mid spine, possibly infected". Initial documentation of the wound by a facility Care Coordinator, on 6/19/14 (four days following the skin assessment), revealed Resident R10 to have a, "red area noted on mid spine, slowly blanches, increased warmth to touch, two open areas in reddened area with intact skin between measuring 2.0 by 1.5 centimeters, proximal wound bed with purple discoloration from 9:00 to 11:00 o'clock. Copious amount of thick, rusty colored [MEDICATION NAME] drainage. No odor noted after cleaning area." Documentation by the Care Coordinator lacked complete measurements and staging of the wound. Documentation of the area on 6/27/14, (eight days after the initial assessment by the Care Coordinator) indicated the wound to be 9.0 centimeters in length, 5.0 centimeters wide, and 0.2 centimeters in depth and, "pale, pink wound bed with scattered pale white non-viable tissue. Entire area red and non-blanching with three open areas with intact skin between them. Heavy purulent drainage." The tissue type was assessed as "slough" (a layer of dead tissue separated from the wound base), the exudate (oozing) was assessed as heavy and the wound was classified a Stage III (full thickness skin loss). Resident R10's nursing plan of care entitled, "Potential for impaired skin," revealed a review and update related to the development of the pressure ulcer area, which was completed on 6/26/14, eleven days after the identification of the scabbed areas over the spine and seven days after the identification of a Stage III pressure ulcer. During an interview on 8/22/14, at 1:00 p.m., Registered Nurse, Employee E2, confirmed that Resident R2 was not monitored following the identified skin changes on 6/15/14, and that treatment and interventions were not updated in a timely manner to prevent the development and worsening of a pressure ulcer initially identified as a Stage III, resulting in harm to the resident. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 7/18/13. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 7/18/13. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 7/18/13.

Based on review of clinical records, facility policy and an incident report and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during the transfer, resulting in actual harm for one of three residents reviewed (Resident R44). The findings include: Resident R44's admission sheet showed an admission date of [DATE], and [DIAGNOSES REDACTED]. Resident R44's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated 10/17/13, revealed Resident R44 had severe cognitive impairment and the transfer status was total dependence with a two person physical assist. Resident R44's Plan of Care, updated 10/24/13, indicated that transfers for Resident R44 were to be with the assistance of two staff. An event report with a Provider Bulletin-22 (a report form for investigation of alleged abuse, neglect,misappropriation of property) submitted to the State Department of Health, dated 1/12/14, disclosed an event that had occurred on 1/11/14, at 7:00 p.m. The report revealed that Nurse Aide (NA), Employee E7, transferred Resident R44 alone, causing serious physical injury. The Safe Transfer of a Resident sheet for Resident R44 revealed that therapy instructed the staff to use two assist, maximum assist, and a two person lift since January of 2013. Investigation documentation revealed that Employee E7 reported to Licensed Practical Nurse (LPN), Employee E4, at 7:00 p.m., that he/she heard a cracking noise while transferring Resident R44. At 9:00 p.m., Employee E7 approached Employee E4 regarding Resident R44, and at this time Employee E4 assessed Resident R44. Resident R44 was noted to have swelling and limited range of motion to the right shoulder. Resident R44 was then transferred to the hospital for evaluation. The hospital diagnosed Resident R44 as having a fractured right humerus (broken upper right arm). Review on 7/24/14, of the facility policy titled, "Preventing Resident Abuse," indicated that the facility will monitor staff on all shifts to identify inappropriate behaviors toward residents. Review of Resident R44's nurses' notes dated 1/11/14, at 9:30 p.m., indicated that Registered Nurse (RN), Employee E10, was called to Resident R44's room and it was noted that Resident R44 had swelling to the right shoulder and had increased facial grimace and sounds, with touch or gentle movement to the right arm. A physician's orders [REDACTED]. Review of the hospital records dated 1/11/14, disclosed that Resident R44 had a CT (computed tomography-a computer generated x-ray to produce images) scan which diagnosed the resident as having a comminuted (broken into several pieces) right humeral neck fracture with impaction (bone fragments driven into other bone fragments). During an interview on 8/22/14, at 1:15 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that an improper transfer method was utilized during the transfer of Resident R44, resulting in actual harm to the resident. The facility failed to provide adequate care and supervision to a resident at risk for injury from an improper transfer method resulting in actual harm to the resident. 28 Pa. Code 201.18(b)(1)(2)(3)(e)(1) Management. Previously cited 7/18/13. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. Previously cited 7/18/13.