Every finding on record at Masonic Village at Elizabethtown

Based on review of facility policy, review of the clinical record, review of facility documentation, and interviews with staff, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 40 residents reviewed (Resident 203).Findings include:Review of facility policy, Occurrence Prevention, Documentation, and Reporting, reviewed July 21, 2026, revealed that all sections of the incident report will be completed to the best of staff's ability to include details surrounding the incident including statements from staff/individuals involved in resident care/situation prior to or during incident and those involved with incident response.Review of Resident 203's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of September 16, 2025, revealed resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment.Review of Resident 203's progress note of October 6, 2025, revealed a bruise to the right front axilla (armpit), measuring 3.56 centimeters by 4.34 centimeters. Additional progress note of October 6, 2025, revealed LPN (licensed practical nurse) observed a dark bruise to the resident's right upper arm and resident was not sure how bruise happened.Review of facility documentation revealed a statement was obtained from Employee E4 indicating that the nursing assistant from the outgoing shift reported the bruise to Employee E4. Further review of the facility documentation revealed no other statements were obtained from staff prior to the identification of the bruise. The documentation indicated that resident is independent with self-propelling wheelchair and is able to move upper and lower extremities independently. Resident has thin, fragile skin that put resident at increased risk for skin injury.Interview with licensed staff, Employee E3 and the Director of Nursing on January 23, 2025, at 1:03 p.m. confirmed that no other statements were obtained from staff regarding the bruise. Employee E3 indicated that no further investigation was done because the location of the bruise was consistent with the bed enabler (device designed to assist with bed mobility).483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 8/25/2528 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policiesPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing servicesPreviously cited 12/5/24

Based on review of clinical record, facility documentation, and staff interviews it was determined the facility failed to ensure Resident CL1 was free from neglect for one out of four residents reviewed (Resident CL1). Findings Include: Observation conducted on August 25, 2025, at approximately 10:45 am of the [NAME] nursing unit spa room and whirlpool bath chair. Observation was conducted in the company of licensed staff, RN Supervisor, Employee E2 and RN Nurse Manager, Employee E3. The chair has a large width strap that is strung through a loop positioned between resident's legs and then fastened on opposing side. there are two padded metal bars positioned in front and behind resident. the front bar snaps into place, secure, once resident is positioned into place. Interviews conducted August 25, 2025, at approximately 10:50 am with Employee E3 (in presence of Employee E2, RN Supervisor). Employee E3 was the nursing staff called to assess and assist after incident and assessed resident for injuries. Employee E3 described the position she found the resident in the whirlpool tub and nurse aide's statement. Employee E3 found the resident face down on his/her left side. There was no water in the whirlpool tub, but the resident was wet. Further interview revealed that Employee E3 asked Employee E4 (nurse aide) what happened for resident to end up in this position. Nurse aide, Employee E4 stated that it happened too fast, but that resident slipped out of the whirlpool chair. Additional interview with Employee E3 and Employee E4 revealed the whirlpool chair has 2 types of safety apparatus on the chair. The witness statement of the nurse aide was reviewed but lacking details of timeline of events. The administrative staff including Director of Nursing (who was off at time of survey) asked the nurse aide to demonstrate how resident slid out of the whirlpool chair. Employee E2 felt that the nurse aide was confused by questions asked so she and Employee E3 demonstrated by placing themselves as re-enactors of the incident. The re-enactment revealed, if the resident was placed in chair with both seatbelt (secured through legs) and safety bars locked in place, the resident would not have been able to slide from the chair. Employees E2 and E3 indicated that the nurse aide only responded that the incident happened quickly so she is unclear of the details. Interviews conducted on August 25, 2025 at approximately 12:00 p.m. with nurse aides, Employees E5 and E6 revealed, staff are trained during orientation classes on how to properly secure a person in the whirlpool chairs. The staff are then trained on each specific chair once they are assigned to a nursing unit. The staff members are monitored and observed by senior staff during orientation period on the nursing unit including showers and whirlpool baths to ensure safety of residents and staff during bathing. Review of facility investigative document revealed, LPN reported resident had a fall in the whirlpool tub, CNA called LPN on phone to report fall, observed resident lying on her left side in the whirlpool tub, tub empty of water, CNA reported resident slid face forward from the mobility chair in thewhirlpool tub, CNA reported safety belt was in place, resident was assisted in whirlpool to to roll onto back, observed small hematoma to the forehead, abrasion to the L anterior knww, 2 abrasion to the L fifth toe, no s/s of pain or discomfort, resident denies pain or discomfort, no s/s of pain or discomfort with mobility or transfers, able to follow simple commands, answers yes or no questions, [NAME] within her baseline limitations, verbal and written re-education provided, POA notified via phone call, message sent to CRNP to call nursing unit for notification, neurological checks intact, VSS, area free from hazards, function of whilrpool, chair, and safety belt inspected for function, no malfunction noted, area with adequate lighting, resident was assisted out of tub with hoyer lift and assist of 3 to wheelchair, no pain or discomfort noted during transfer, resident was incontinent of BM at the time of the fall. Review of facility investigative documentation revealed, the staff member failed to follow procedure and care plan for resident. Review of facility documentation revealed the facility substantiated neglect by the nurse aide. Employee E4 was subsequently terminated from facility employment. Review of facility investigative documentation revealed a witness statement by nurse aide, Employee E4 as follows; To whom it may concern, on July 24, 2025, resident (Resident CL1) was in the tub chair when (he/she) slipped out of the tub chair. The statement was signed but not dated. Review of information submitted by the facility on July 24, 2025, at 12:45 p.m. to the Department of Health revealed, Aide was providing resident a whirlpool bath. After completing the bath, tub was emptied, resident fell forward from the tub chair face down, striking her head. She sustained a hematoma to forehead, abrasion to left knee, right and left toe, bruise to right lower leg and right and left calf. After further evaluation and inspection, everything was functioning properly, and it appeared that the aide failed to secure the safety belt and arm / lap bar which would have prevented the resident from falling forward. Resident was not sent out to hospital as her injuries were able to be treated in place. Immediate assessment completed, PCP and POA notified, after we determined the incident was due to not following proper safety precautions, aide was placed on administrative leave, and the decision was made to terminate her employment due to an unsatisfactory work orientation. Review of Resident CL1's clinical record revealed diagnoses including but not limited to Alzheimer's Disease (progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability); Dementia with Psychotic disturbances; Anxiety (intense, excessive and persistent worry and fear about everyday situations); Psychosis (abnormal condition of the mind that results in difficulties telling what is real and what is not real); Palliative Care; Chronic Atrial Fibrillation (irregular and rapid heartbeat); and Chronic Heart Failure (CHF). Resident's admission MDS assessment (periodic assessment of resident's abilities and care needs) dated June 3, 2025, revealed that resident was rated as a substantial or maximal assistance needed for showering/bathing as well as maximum assistance required for tub/shower transfers. Further review of the admission MDS assessment revealed the resident was rated 99 for BIMS (brief Interview for Mental Status - cognitive functioning rating) indicating severe cognitive impairment; unable to direct care. Review of Employee E4's personnel record revealed Employee E4 received training for whirlpool safety on April 24, 2025, and demonstrated technique on May 5, 2025. Review of Resident CL1's clinical record revealed, Resident CL1 sustained bruises to the left knee, left 5th toe, bilateral calves, and a hematoma to the forehead. Review of Resident CL1's clinical record including July 2025 MAR (Medication Administrative Record) revealed that resident did not receive pain medication after the fall. Further review revealed that Resident CL1's pain scale ratings were zero after the fall. Interview with Nursing Home Administrator on August 25, 2025, at approximately 3:15 p.m. confirmed the nurse aide was terminated. The Nursing Home Administrator confirmed the allegation of neglect was substantiated. The facility failed to ensure that Resident CL1 was free from neglect when nurse aide, Employee E4 failed to properly secure safety mechanisms of whirlpool chair resulting in a fall of Resident CL1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure behavioral health services were offered in a timely manner for one of two residents reviewed for mood and behaviors (Resident 97). Findings include: Review of Resident 97's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including, but not limited to, anxiety and other symptoms and signs involving emotional state. Review of Resident 97's progress notes revealed a nurse's note on August 14, 2024, which stated, Resident was resting in recliner, resident was crying earlier stating that she was ready to die, she does not want to harm herself but just ready to die. Further review of Resident 97's progress notes revealed a nurse's note on October 4, 2024, which stated, I went in at 10am. to give meds. and resident was still in bed. She said 'I just want to die, I can't get up in the mornings anymore'. I asked her if she feels depressed, she said yes. [Physician] was here and notified. Review of Resident 97's physician progress notes revealed a physician note on October 4, 2024, which stated: I spoke with nursing who reports that patient sometimes wakes up [stating] she does not want to live anymore, and does not want to get out of bed. Further review of the physician note revealed: I did offer her medication, which is not inclined to take, and I agree with her. She does like to have good conversations and appreciates when someone takes the time to listen to her, and I think this will be the best treatment for her. Review of Resident 97's physician's orders revealed an order dated October 18, 2024, for behavioral health (psychology) evaluation and treatment for increased depression and anxiety. Review of Resident 97's progress notes revealed a Behavioral Note from the psychologist on November 27, 2024 to evaluate the resident for depression and anxiety. The delay in obtaining a psychology evaluation for Resident 97 was discussed with and confirmed with the Director of Nursing on December 5, 2024, at approximately 9:30 a.m. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review, it was determined that the facility failed to maintain accurate assessments for two of 35 residents reviewed (Residents 97 and 108). Findings include: Review of Resident 97's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated November 12, 2024, revealed under Section J - Health Conditions that the resident had two falls with major injury (bone fractures, joint dislocations, closed head injuries, or subdural hematomas) since admission/readmission or the prior assessment. Review of Resident 97's clinical record since the resident's admission to the facility on [DATE], failed to reveal evidence of any falls with major injury. Interview with the Director of Nursing on December 5, 2024, at approximately 11:00 a.m. confirmed Resident 97 did not have any falls with major injury since being admitted to the facility and that the resident's MDS was coded inaccurately. Review of Resident 108's Quarterly MDS dated [DATE], revealed Resident 108 had a significant weight loss and a significant weight gain. Review of Resident 108's clinical record and weight summaries failed to reveal evidence of significant weight loss. Interview with the Director of Nursing on December 5, 2024 at 10:58 a.m. confirmed Resident 108 did not have a significant weight loss and that Resident 108's Quarterly MDS was coded inaccurately. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical record review, policy and procedure review, and staff interview it was determined the facility failed to administer as needed pain medications for appropriate pain levels and prior to non-pharmaceutical interventions for two of 40 residents reviewed. (Residents 42 and 270) Findings include: Review of facility policy and procedure titled Pain Assessment and Management Record Procedure, undated, revealed evaluation of pain (pain scale) and alternative interventions are used and documented in conjunction with oral medications. Review of Resident 42's physician orders revealed an order dated June 15, 2023, Hydrocodone (narcotic pain reliever) with Acetaminophen (Tylenol) Tablet 5-325 MG (milligrams); Give 1 tablet by mouth every four hours as needed, for pain/ back/ behavior. A list of interventions are also noted 1-22. Review of Resident 42's Medication Administration Record for September, October, and November 2023 revealed the resident received the medication for undocumentated pain level and undocumented non-pharmaceutical interventions (NPI's) a total of one time (October 27). Undocumented NPI's a total of five times (September 29, October 1 and 7, and November 5 and 19, 2023). Review of Resident 270's physician orders revealed an order dated July 3, 2023, Tramadol (opioid pain medication) by moth every six hours as needed for chronic back pain; behavior. A list of interventions are noted 1-22. Review of Resident 270's Medication Administration Record for October, November, December 2023, revealed the resident received the medication with undocumented NPI's a total of 18 times (October 6, 7, 14, 21, 22, 28, November 12, 17, 26, 28, December 1, 2, 3, 9, 16, 17, 23, 30, and 31, 2023). Interview with the Director of Nursing and the Nursing Home Administrator on January 24, 2024, at 10:30 a.m. confirmed prn pain medications were not administered with documented NPI's and the prn pain medications for Resident 42 did not include a pain level per policy. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based upon review of facility policy and procedure, observation and clinical record review, and staff interview, it was determined that the facility failed to ensure the safety of residents during the administration of medication for one of one resident observed (Resident #183). Findings include: Review of the facility policy titled Flexible Medication Administration, revealed Each person administering medication is to ensure that all medications are given safely in accordance with the orders as prescribed by the physician. Observation of Resident #183 on October 7, 2020, at 9:45 a.m., revealed Resident #183 sitting in a recliner with the bedside table in front of the resident. Further observation revealed a medication cup containing multiple pills and a bottle of eye drop medication sitting on the table. Further observation revealed that no nurse was present in the room at that time. Review of Resident 183's clinical record failed to reveal evidence that Resident #183 was assessed for self-administration of medication. After request for above-mentioned documentation on October 7, 2020, the facility provided a Self-Administration of Medication assessment which was completed on October 7, 2020 at 4:53 p.m. Interview with the Director of Nursing on October 8, 2020, at 9:00 a.m. confirmed that no prior assessment for self-administration of medication was completed prior to October 7, 2020 at 4:53 p.m. The facility failed to ensure the safety of residents during medication administration. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 8/1/19

Based on a review of facility policy, review of clinical record, and staff interviews, it was determined that the facility failed to thoroughly investigate an allegation of abuse and prevent further potential for abuse while the investigation was in progress, for one of 35 residents reviewed (Resident #270). Findings include: Review of undated facility policy, Abuse Prevention, revealed that the facility will ensure that the resident is protected from any further potential further abuse. Additionally, the investigation will begin immediately by interviewing the resident who is suspected of being abused and any witnesses. Review of Resident #270's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) of June 24, 2020, revealed a BIMS (Brief Interview for Mental Status) score of 7, indicating severe cognitive impairment. Review of progress note of August 14, 2020, revealed that resident made an accusation regarding another staff member that 'he attempted to rape her'. Resident identified male caregiver. Interview with the Director of Nursing (DON) and licensed staff, Employee E3, on October 8, 2020, at 10:45 a.m. revealed that a statement was not obtained from the employee to whom the resident reported the incident or any other staff. Additionally, the accused did not provide care to Resident #270, but did remain on the floor during the investigation interacting with other residents. The DON indicated that the accused probably should have been taken off duty during the investigation. 483.12 Investigate/Prevent/Correct Alleged Violation Previously cited 8/1/19 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/1/19 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on a review of facility policy, review of clinical record, and interviews with staff, it was determined that the facility failed to report an allegation of abuse in accordance with State law, including reporting to the State Survey Agency, for one of 35 residents reviewed (Resident #270). Findings include: Review of the undated facility policy, Abuse Prevention, revealed if a resident alleges abuse, the immediate supervisor and/or Nurse Manager will be notified. The Director of Nursing or Administrator will instruct the shift coordinator or manager how to notify the Department of Health via the Electronic Reporting System (ERS). Review of Resident #270's progress note of August 14, 2020, revealed that the resident had made an accusation regarding another staff member that he attempted to rape her. A review of the Department of Health Event Reporting System failed to reveal that Resident #270's allegation of abuse was reported by the facility to the State Agency. Interview with the Nursing Home Administrator on October 8, 2020, at 10:05 a.m. confirmed that the allegation was not reported to the Department of Health. Interview with the Director of Nursing on October 8, 2020, at 10:45 a.m. revealed that the event was not reported to the Department of Health because the allegation was unsubstantiated. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/1/19 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies

Based upon review of facility policy and procedure, observation, and staff interview, it was determined that the facility failed to provide adequate infection control measures during an activity and failed to provide adequate infection control PPE on the quarantine unit. Findings include: Review of the facility policy and procedure titled Guidelines for Management of Suspected/Confirmed Residents with COVID-19 in the Long Term Care Setting revealed The use of N95 masks will only apply to staff who have been fit-tested and are working with residents who have confirmed or suspected COVID-19. Observation on October 5, 2020, at 11:11 a.m., of the 3rd floor nursing unit common area revealed 11 residents attending a Hymn Sing activity. Two of the 11 residents observed were not wearing face masks and 11 of the 11 residents were not socially distanced at six feet apart from other residents. Observation on October 6, 2020, at 10:30 a.m. revealed a staff member on the quarantine unit wearing a face shield, surgical mask and gown in the hallway near the entrance to the unit. Observation on October 6, 2020 at 10:40 a.m. revealed Employee E4 and Employee E5 wearing face shields, surgical masks and gowns in the hallway. Interview with Employee E4 on October 6, 2020, at 10:40 a.m., revealed that the quarantine unit was for residents with pending COVID-19 tests or who had been admitted to the facility from an acute care facility and were under a 14 day quarantine. The facility required staff to wear a face shield, N95 face mask and gowns while working on the quarantine unit. This interview further revealed that the facility ran out of N95 respirator face masks and the staff was wearing surgical masks until the facility obtained more N95 respirator face masks as required. Interview with Employee E5 on October 7, 2020, at 9:35 a.m. revealed that from approximately 6:15 a.m. on October 6, 2020, until the afternoon of October 6, 2020, the quarantine unit had no N95 respirator face masks to wear and the staff was required to wear surgical face masks in place of the N95 respirator face masks until N95 masks could be obtained. Interview with the Nursing Home Administrator and Director of Quality for Health Care on October 8, 2020, at 1:00 p.m. revealed that the facility had N95 respirator masks available and they were uncertain as to why the quarantine unit had no N95 masks available on October 6, 2020. The facility failed to provide infection control procedures to residents attending a group activity and failed to provide adequate infection control equipment on the quarantine unit.

Based on clinical record review, review of facility policy and procedure, and review of documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 35 residents reviewed (Resident #261). Findings include: Review of the facility policy titled Occurrence Prevention, Documentation, and Reporting revealed that injuries of unknown origin are not listed for investigations. Review of Resident #261 clinical chart revealed that on (MONTH) 5, 2019, a red /purple area was noted on the left upper arm during morning care. Review of documentation provided by the facility states that Resident #261 did not know how the bruise occurred. An interview conducted with the Director of Nursing and Nursing Home Administrator on (MONTH) 1, 2019 at approximately 11:45 a.m. revealed that there was not interviews with the staff to determine the cause of the bruise. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 8/10/2018, 1/24/2019, 7/19/2019 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/10/2018, 7/19/2019 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records Previously cited 8/10/2018, 7/19/2019

Based on observation and staff interviews it was determined that the facility did not ensure the dignity of two out of 35 residents reviewed in(NAME)4 dining room (Resident #154 and #312). Findings include: Observation of Resident #154 on (MONTH) 30 at approximately 9:27 a.m. in the dining room, revealed the resident was seated at the table with her gait belt (a gait belt is about 1½ to 4 inches wide and 54 to 60 inches long, used to help hold someone up or assist in walking a resident) around her mid-section. An interview with Resident #154 stated that she hates this thing (pulling on belt). An interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 1, 2019, at approximately 11:45 a.m. revealed that the gait belt should be removed during the dining experience. Observation of Resident #312 on (MONTH) 29, 2019 at approximately 1:54 p.m. in the dining room, revealed the residents [MEDICATION NAME] (surgically formed passage connecting the bladder to the exterior collection device through the abdominal wall) bag uncovered and hanging from the back of her wheelchair. The [MEDICATION NAME] bag was approximately two-thirds full. An interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 1, 2019, at approximately 1:45 a.m. revealed that the bag should have been covered and not visible to other residents. The facility failed to ensure dignity during a dining experience for Residents #154 and Resident #312. 28 Pa. Code 201.29(j) Resident's rights Previously cited 8/10/2018 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 8/10/2018, 1/24/2019, 7/19/2019

Based on a review of clinical records, select facility policy, facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision and to implement interventions to prevent accident hazards. This failure resulted in a fall with harm caused by a laceration to the right thumb that required sutures (stitches) to close for one of three residents reviewed (Resident 1). Findings include: Review of the facility policy titled, Falling Star Program, revealed, It is the goal and philosophy at (facility) to provide for and maintain the best quality of life possible for our residents. This includes respecting a resident's right to remain mobile while providing for safety and preventing falls as often as feasible. Residents determined High Risk for Falls days as per the Fall Risk Assessment in the electronic health record and/or resident's experiencing 3 or more falls in the past 30 days will be placed on the Falling Star Program. This program is meant to allow staff to more readily identify residents' risk for falls with the ultimate goal to reduce falls. Review of physician orders current at the time of our visit revealed Resident 1 had a valid and current order for the Falling Star program, which was issued on (MONTH) 19, 2019. Review of the clinical record for Resident 1, revealed he was originally admitted to the facility on (MONTH) 11, (YEAR), with current [DIAGNOSES REDACTED]. Resident 1 was assessed for fall risk on the day of admission, (MONTH) 11, (YEAR). This assessment uses nine categories to ascertain the likely hood that the resident would have a fall. The scoring key printed on this assessment form revealed a score of 0-5 to be a moderate risk for falls, and A score of 6 or more indicates High Risk for Falls. The result of this fall risk assessment revealed a score of 21 more than three times the minimum score for a High Risk for Falls. Review of facility provided documentation revealed multiple falls for Resident 1 during a lookback period of (MONTH) 2019, to (MONTH) 2019. Resident 1 had a fall on (MONTH) 13, 2019, which resulted in an orthopedic implanted device being broken in his right hip. Resident 1 had a fall (MONTH) 3, 2019, in the shower and had to be assisted off the floor by staff and a Hoyer lift. No apparent injury. Resident 1 had a fall (MONTH) 4, 2019, in his room outside the bathroom, he had to be assisted off the floor by four staff. No apparent injury. Resident 1 had a fall (MONTH) 7, 2019, in his room and had to be assisted off the floor by three staff and the use of a gait belt (a safety device used to help someone move such as from a chair to a bed or off the floor, helps the staff provide support while assisting residents). No apparent injury. Review of facility provided documentation revealed Resident 1 had a fall on (MONTH) 13, 2019. The facility incident report revealed, a statement from Licensed Practical Nurse (LPN) 1, I heard yelling help me, his wheelchair was observed in hallway outside his doorway. I entered room, he was on floor lying on left side with two broken glass vases on the floor beside him. additionally the documentation revealed a skin tear, that required sutures by the MD. Revealed in the physician note dated (MONTH) 13, 2019, it was written The patient was seen for follow-up of a fall and a laceration. He does have frequent falls. Often, he is not quite coherent. Revealed in the physician note section titled, Physical Examination, it was revealed On his right thumb, middle phalanx, he has a gaping 1.3 cm (centimeter) laceration. This was approximated with 3 simple sutures after informed consent with patient and power of attorney discussing risk, benefits, alternatives including pain, bleeding, no benefit. Review of the individualized plan of care for Resident 1 revealed a problem area titled Falls. dated (MONTH) 18 (YEAR), There are multiple interventions in this focus care area including, dycem (a non-slip material that grips on both sides) to w/c (wheelchair) seat and provide him with a reacher (a device that enables a disabled or elderly person to pick up objects that are difficult to reach). Dycem to side of bed. non-skid socks when not wearing shoes or slippers, Falling Star Program, administer medications for [MEDICAL CONDITION] as ordered, resident has scissors and some sharp tools in his room for flower arranging. Check frequently that he is using them safely. If he is more confused or mobility is more impaired, may remove tools temporarily until back to baseline. Observe for unsteady/unsafe transfer or ambulation. 4WW (four wheeled walker) for transfers and ambulation with one assist. Provide assist for use with rolling walker for mobility on household. During an interview with the Director of Nursing on (MONTH) 18, 2019, she revealed that the resident makes flowers and sells them in the gift shop. Resident 1 used glass vases to transport these flowers, the glass vases are what broke when he fell . During an interview with the Nursing Home Director on (MONTH) 18, 2019, at approximately 2:00 PM it was revealed that we chose his quality of life over his possible fall. this statement was related to questioning why a resident who is documented as a high fall risk, and who had four previous falls in the past two months was carrying glass vases. The facility failed to provide adequate supervision and interventions to prevent an accident hazard to Resident 1, who is high fall risk for having a fall, who fell while carrying glass vases, which resulted in harm caused by a laceration to the resident that required sutures to close. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(c) Staff development 28 Pa. Code 201.20(d) Staff development 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.5(F) Clinical records 28 Pa. Code 211.5(g) Clinical records 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(a) Nursing services 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record reviews and staff interview, it was determined that the facility failed to maintain clinical records which are complete and accurate for one of three resident records reviewed (Residents 1). Findings include: Review of the clinical record for Resident 1, revealed he was originally admitted to the facility on (MONTH) 11, (YEAR), with current [DIAGNOSES REDACTED]. Review of Resident 1's clinical record revealed Resident 1 had a fall on (MONTH) 3, 2019. Further review of the facility supplied documentation related to this fall revealed an incident report and progress notes. Review of all facility supplied documentation revealed that the physician was not notified of the fall until (MONTH) 6, 2019, at 7:00 AM more than two days later. Review of a facility policy titled: Neurological Checks revealed that neurological checks will be performed by licensed staff on all residents who have a confirmed or suspected head injury and on residents with other conditions where the monitoring neurological status may be warranted. Among the listed other conditions the policy included, any unwitnessed fall with suspected head injury. Further review of the policy revealed Neurological checks will be implemented on the following schedule: 1) at onset/ upon incident. 2) Every 15 minutes for 2 times. 3) Every 30 minutes for 2 times. 4) Every hour for 4 times. 5) Every 4 hours for 24 hours. 6) Every shift for 48 hours. Review of the facility supplied Neurological Checklist for Resident 1's unwitnessed fall on (MONTH) 3, 2019, revealed neurological checks at the time of the incident, 3:40 PM then, 3:55 PM, 4:10 PM, 4:25 PM, 4:55 PM, 5:25 PM, 5:55 PM, 6:25 PM, 7:25 PM, 8:25 PM, 9:50 PM, (MONTH) 4, 2019, 5:23 AM, 9:10 AM, and 1:19 PM. Resident 1 had another fall before the next assessment should have been completed, and the assessments had to restart. There was no assessment documented between 9:50 PM (MONTH) 3, 2019 and 5:23 AM (MONTH) 4, 2019, according to the policy's schedule there should have been two additional assessments. The assessments according to the policy should have been, 3:40 PM, 3:55 PM, 4:10 PM, 4:40 PM, 5:10 PM, 6:10 PM, 7:10 PM, 8:10 PM, 12:10 AM, 4:10 AM, 8:10 AM, 12:10 PM, Resident 1 had another fall before the next assessment should have been completed and the assessments had to restart. Review of facility provided Neurological Checklist for Resident 1's fall on (MONTH) 7, 2019, revealed the fall to have occurred at 9:15 AM. Resident 1 was found on the floor in his room having had an unwitnessed fall. Review of the Neurological Checklist for (MONTH) 7, 2019, revealed a neurological assessment from a previous fall at 12:01 AM (midnight), a neurological assessment at 7:09 AM, again from the previous fall. There is no assessment documented at the time of the fall, or another assessment documented until 12:30 AM on (MONTH) 8, 2019, more than 15 hours after the fall. The assessments according to the policy should have been, 9:15 PM, 9:30 AM, 9:45 AM, 10:15 AM, 10:45 AM, 11:45 AM, 12:45 PM, 1:45 PM, 2:45 PM, 6:45 PM, 10:45 PM, (MONTH) 8, 2019, 2:45 AM, 6:45 AM, 10:45 AM, 2:45 PM, and then one time per shift for another 48 hours. The facility did not document 11 assessments that according to policy should have been completed. Review of facility provided Neurological Checklist for Resident 1's unwitnessed fall on (MONTH) 13, 2019, revealed the fall to have occurred at 11:40 AM. Further review of the Neurological checklist revealed neurological assessments per policy until (MONTH) 14, 2019. The neurological checklist documented an assessment at 1:22 PM, on the day shift. There is no documentation of another neurological assessment until 2:02 AM on (MONTH) 15, 2019, on the night shift. There is no documentation of an assessment on the 3:00 PM to 11:00 PM shift. According to the policy there should have been one assessment on that shift. The neurological check policy revealed, The neurological check consist of the following steps: 1) Temperature, pulse, respiration and BP (blood pressure). 2) Assessment of respiratory pattern. 3) Assessment of pain (location, intensity, and frequency). 4) Pupil check with flashlight for size, reaction and equality of size. 50 Level of consciousness: oriented, disoriented, restless, combative, or comatose. 6) Assessment of speech: clear, rambling,garbled, and non-verbal. Review of Resident 1s neurological Checklist for an unwitnessed fall on (MONTH) 3, 2019, revealed an entry for a neurological assessment being completed on (MONTH) 3, at 8:25 PM. That assessment does not document assessments for level of consciousness, right pupil reaction, right pupil size, left pupil reaction, left pupil size, pupil equality, motor assessments including, right arm, left arm, right leg, left leg, flexion, extension, speech, response, headache, or blurred vision. Further review of the Neurological Checklist noted above revealed an entry for a neurological assessment being completed on (MONTH) 3, at 9:50 PM. That assessment does not document assessments for level of consciousness, pain, right pupil reaction, right pupil size, left pupil reaction, left pupil size, pupil equality, motor assessments including, right arm, left arm, right leg, left leg, flexion, extension, speech, response, headache, blurred vision, or [MEDICAL CONDITION]. There is a note for each of these entry's, Pt sleeping at this time. Unable to do full assessment. Review of the Neurological assessment policy did not reveal an exception to the scheduled assessments for residents sleeping. Resident 1 was not documented to have a pupil size and reaction assessment for approximately 15 hours. During an interview with the Director of Nursing on (MONTH) 18, 2019, at approximately 3:50 PM, it was revealed that the assessments should be done per policy. 28 Pa. Code 211.5(f) Clinical records.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide evidence that the results of Resident CL1's PT/INR screening was communicated to the physician. This placed one out of three residents reviewed (Resident CL1) in an immediate jeopardy situation with the continued administration of an anticoagulant medication (slows down body's process of clotting blood). Subsequently, Resident CL1 developed an abnormal low hemoglobin level and critical PT/INR levels requiring an emergent transfer to the hospital resulting in the transfusion of two units of blood and intravenous Vitamin K and Kcentra (to reverse the effects of anticoagulation medication). Findings include: Review of the facility policy, Change in Condition, effective date (MONTH) 8, (YEAR), revealed that nursing was to notify the physician when there is a need to alter the resident's medical treatment significantly. Review of the facility policy, Anticoagulation Therapy (medication used as blood thinners), undated, revealed that the anticoagulation management provider will review each INR (laboratory test used as a standard for monitoring the effects of anticoagulant treatment) result within 8 hours. The provider may adjust anticoagulant dosing if the INR is above or below the therapeutic range specified. The facility must seek physician orders for initiating or stopping anticoagulant therapy. Review of Resident CL1's [DIAGNOSES REDACTED]. Review of Resident CL1's (MONTH) (YEAR) physician's orders included orders dated (MONTH) 5, (YEAR), for an anticoagulant medication, Jantoven 2.5 mg (milligrams) daily and INR screening on (MONTH) 7 and 9, (YEAR). Resident CL 1's INR screening results from (MONTH) 7, (YEAR), revealed the resident's INR was 2.6 (therapeutic range is between 2-3). The physician responded to continue the same dose of Jantoven and obtain INR on (MONTH) 9, (YEAR). Review of Resident CL1's Medical Provider Communication Form dated (MONTH) 9, (YEAR), revealed the physician was notified that the resident's INR was 3.3. The physician responded with an order to hold the resident's Jantoven on (MONTH) 9, (YEAR), and to recheck the resident's INR on (MONTH) 10, (YEAR). Review of Resident CL1's INR results from (MONTH) 10, (YEAR), revealed that the resident's INR was documented on the resident's electronic clinical record flow sheet as 3.1. There was no hospital laboratory report form nor Medical Provider Communication Form to support that the physician was notified and ordered to continue the Jantoven medication daily on (MONTH) 10, (YEAR). Review of Resident CL1's medication administration records from (MONTH) 10, (YEAR) to (MONTH) 1, (YEAR) revealed that the resident received Jantoven 2.5 mg daily. Review of Resident CL1's progress notes revealed a nurse's note on (MONTH) 1, (YEAR), at 3:45 p.m. stating, Family in to visit today and concerns about (resident) not feeling well. Per family/POA wife this has been a few days and today his speech is worse and color is pale and jaundice looking. (Vital signs stable) O2 sats (oxygen saturation) hard to get due to poor circulation in his fingers, but 98% when finally gotten. Nurse's note further stated Resident CL1 feels like he is having generalized muscle pain all over and in his buttock from sitting .New orders noted to get stat CBC (complete blood count) and CMP (comprehensive metabolic panel) to start with today. Further review of the progress notes revealed a note on (MONTH) 1, (YEAR), at 6: 55 p.m. stating, Report received from Lab with critical values reviewed with family, (resident), and on call MD .new order to send to (emergency room ) to evaluate low and critical labs. 911 called at (6:35) and arrived on unit at 6:42. Review of Resident CL1's labs from (MONTH) 1, (YEAR), revealed the resident's hemoglobin was 5.1 (low - normal is 14-18), hematocrit was 15.6 (low - normal is 42-52), and red blood cell count was 1.61 (low - normal is 4.6-6.2). Review of emergency hospital records revealed that Resident CL1 was found with a critical hemoglobin level of 5.1, an INR above 15.6, and an 11 cm x 3 cm x 14 cm right gluteal hematoma (collection of blood outside the blood vessels.) The resident required 2 units of packed red blood cells (blood transfusion) and 10 units of intravenous vitamin K (vitamin which aids in blood clotting). Review of Interdisciplinary Notes from (MONTH) 26-30, (YEAR), reported the following: November 26, (YEAR) small nose bleed in a.m. November 27, (YEAR) complaint of shortness of breath November 30, (YEAR) large, loose stool in a.m. November 30, (YEAR) was very pale at dinner, requested to go back to bed Review of staff statements (related to hematoma identified in emergency roiagnom on (MONTH) 1, (YEAR)) from (MONTH) 6-31, (YEAR), reported the following: November 29, (YEAR) slight nose bleed at 4:30 p.m. (reported to LPN (licensed practical nurse)) - 'color was off' and he didn't feel good, when transferring resident from wheelchair to bed after dinner 'noticed again, how pale he was' November 30, (YEAR) he still looked pale and wasn't feeling good when getting resident up for dinner; at beginning of supper he looked paler and was feeling sick and wanted to go to bed, very pale at dinner There was no evidence that comprehensive nursing assessments, subsequent monitoring or physician notification occurred prior to CL1's emergent transfer to the hospital for these possible symptoms of internal bleeding. Interview with the NHA and DON on (MONTH) 15, (YEAR), at approximately 4:20 p.m. confirmed that there was no documented evidence that Resident CL1's PT/INR values of (MONTH) 10, (YEAR), were communicated to the resident's physician. Interview with the Director of Quality Assurance, Employee E3 on (MONTH) 22, 2019, at 3:10 p.m. confirmed that the resident continued to receive Jantoven 2.5 mg daily until the resident's hospitalization on (MONTH) 1, (YEAR). Interview with facility physician on (MONTH) 24, (YEAR), at 12:15 p.m. confirmed that it was expected for the resident's physcian to be notified of the PT/INR values as ordered. It was further stated during interview that if the values were not received within 24 hours, the facility should check for the values. In addition, it was expected for the licensed nursing staff to know the facility anticoagulant policy. The facility failed to communicate the results of Resident CL1's PT/INR screening of (MONTH) 10, (YEAR), to the physician and to ensure the proper monitoring of Resident CL1's PT/INR, which placed Resident CL1 in an immediate jeopardy situation. Immediate Jeopardy was identified on (MONTH) 22, 2019, at 3:39 p.m. for the facility's failure to properly monitor Resident CL1's PT/INR values. An immediate action plan was requested at this time to immediately put systems in place to ensure residents on anticoagulant medications have received proper laboratory test follow ups to ensure medications are within a proper therapeutic level. The facility submitted and implemented an action plan which included an audit of all residents currently receiving Jantoven, education of licensed nursing staff on the policies for anticoagulation therapy and changes in resident condition, establishing a protocol for changes in level of care (short term to long term care) and more frequent monitoring when residents are on antibiotics, and ensuring that the registered nurse on the unit will be responsible for placing the orders on the medical record and recording lab results received and having a second registered nurse sign the results to ensure proper follow up with the physician has been completed. Furthermore, the facility will audit 100% of residents on anticoagulants which require laboratory monitoring weekly for four weeks and then monthly for three months. The results will be shared with the quality assurance committee for further follow up and recommendations. Immediate Jeopardy was removed on (MONTH) 24, 2019, at 2:00 p.m. based on the facility's implementation of an acceptable plan of action. Review of Resident R2's electronic [DIAGNOSES REDACTED]. Review of (MONTH) (YEAR) physcian's orders confirmed that Resident R2 had an order for [REDACTED]. Review of the resident's clinical record revealed no documented evidence that the INR screening was completed in the month of (MONTH) (YEAR). The next available INR screening completed was not until Janaury 16, 2019. Interview with the Director of Quality Assurance, Employee E3 confirmed that the resident did not have an INR screening completed in (MONTH) (YEAR). 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/10/18 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 08/10/18 28 Pa. Code 211.5(f) Clinical records Previously cited 08/10/18 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies Previously cited 07/17/17 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 08/10/18, 07/17/17 28 Pa Code 211.12(d)(3) Nursing services

APPEAL FILED Based on review of position descriptions, clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to monitor and supervise staff performance to ensure the health and safety of the residents. Findings include: The position description of the Nursing Home Administrator (NHA) last revised (MONTH) (YEAR) revealed that the NHA has responsibility for ensuring that the operation of the entire skilled nursing facility delivers high quality health care. The position description for the Director of Nursing (DON) last revised (MONTH) (YEAR) revealed that the DON has responsibility for the overall management of the healthcare center nursing department. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care 483.25 revealed that the NHA and DON failed to supervise subordinate staff to assure that laboratory results for a resident on anticoagulation medication were communicated to the resident's physician, resulting in subsequent hospitalization requiring a blood transfusion, placing the health and safety of the residents in Immediate Jeopardy. Refer to F684. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/10/18 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 08/10/18 28 Pa. Code 211.12(c)(d)(1) Nursing services Previously cited 08/10/18, 07/17/17 28 Pa. Code 211.12(d)(3) Nursing services

APPEAL FILED Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's physican reviewed the licensed pharmacist's report for a medication irregularity for one of 10 residents reviewed. (Resident R2) Findings include: Review of the facility policy titled, Medication Regimen Review, dated (MONTH) 1, (YEAR), revealed that the findings and recommendations are reported to the Director of Nursing and the attending physican and to the appropriate Medical Director and/or Adminsitrator. Review of Resident R2's clinical record revealed [DIAGNOSES REDACTED]. Review of a monthly drug regimen review completed by the consultant pharmacist on (MONTH) 25, (YEAR), revealed a recommendation of Resident's TSH ([MEDICAL CONDITION] stimulating hormone) level on 10/16/18 was 9.19. Consider increasing her [MEDICATION NAME] Dose to 75 mcg daily and recheck her level in 8 to 12 weeks. Further review of Resident R2's clinical record failed to reveal documented evidence that the resident's physician was aware of or responded to this pharmacy recommendation. Review of a monthly drug regimen review completed by the consultant pharmacist on (MONTH) 21, (YEAR), revealed a recommendation of Resident's TSH level on 10/16/18 was 9.19. Resident's level on 10/30/18 was 7.22. Consider increasing her [MEDICATION NAME] Dose to 75 mcg daily and recheck her level in 8 to 12 weeks. Further review of Resident R2's clinical record failed to reveal documented evidence that the resident's physician was aware of or responded to this pharmacy recommendation. An interview with the Assistant Director of Nursing on (MONTH) 24, (YEAR), at 11:00 a.m. confirmed that the physician did not respond to or act upon the above pharmacy recommendations. The interview also revealed the expectation that the physician should have responded to the pharmacy recommendations. 28 Pa. Code 211.5(f) Clinical records Previously cited 08/10/18 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services. Previously cited 08/10/18, 07/17/17 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure one of nine residents reviewed (Resident #569) was free of accident hazards, which resulted in actual harm to Resident #569 sustaining a fall, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. Findings include: Review of facility policy and procedure titled, Resident Transfers To/From and Within Equipment, reviewed (MONTH) 8, (YEAR), revealed Employees will utilize appropriate body mechanics and safety techniques to prevent injury to the residents and themselves while transferring a resident to/from and with resident care equipment, i.e., beds, chairs, etc. A total lift is used with all residents who are non weight bearing and dependent for transfers. Use two (2) staff to assist with all total lifts. Never leave resident unattended while in the lift. Lift should not be present in front of resident unless resident is actively being lifted. Review of Resident #569's [DIAGNOSES REDACTED]. of the blood vessels which supply the heart with blood and oxygen) and Anxiety (intense, excessive ans persistent worry and fear about everyday situations), Review of Resident #569's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 15, (YEAR), revealed the resident required extensive assistance for bed mobility, transfers and toilet use with the assistance of two persons, using a total mechanical lift. Review of Resident #569's care plan initiated (MONTH) 3, (YEAR), identified the resident's deficit with activities of daily living related to assistance needed for dressing/personal hygiene, bilateral above the knee [MEDICAL CONDITION], dementia, pain and muscle weakness. The interventions revealed staff assistance with upper and lower body care, encourage resident to wash face and hands and to maneuver extremities as possible for care. Encourage resident to help choose clothing. Provide staff assistance to dress, encourage resident to maneuver extremities as possible to help with dressing. Further review of the resident's care plan indicated the potential for falls related to dementia with behaviors, use of [MEDICATION NAME] and [MEDICAL CONDITION] medications, bilateral above the knee [MEDICAL CONDITION], impaired balance/trunk control, muscle weakness and hypertension. The interventions revealed provide total assist of two staff and use of a total mechanical lift for all transfers. Leave lift pad under resident as to assure proper placement for transfers. Reinforce need for seatbelt to be engaged at all times when resident is in his wheelchair. Resident is able to open the seatbelt and engage it, if asked. Review of Resident #569's interdisciplinary note dated (MONTH) 5, (YEAR), at 7:40 p.m. revealed RN (registered nurse) notified that resident was on the floor. RN, LPN (licensed practical nurse) and CNA (nurse aide) responded. Observed resident on his stomach with his stumps still up on the edge of his wheelchair, face against the metal base of the lift on the floor. There was a large amount of blood under his face, he was alert and talking. Denied pain upon assessment, a laceration measuring 2.0 centimeters was noted. We instructed him not to move his head/neck. Call placed to physician, RN was instructed to send resident out to ER (emergency room ), ASAP (as soon as possible). EMS (emergency medical services) was called. Resident was moved and transported by EMS to hospital. Vital signs were unable to be obtained due to the fact resident was laying on both arms on the floor. A interdisciplinary note dated (MONTH) 6, (YEAR), at 3:16 a.m. indicated, this nurse called hospital and was made aware that resident was admitted at 10:18 p.m. with a [DIAGNOSES REDACTED]. Review of facility's investigation documentation dated (MONTH) 5, (YEAR), revealed nursing assistant Employee E3 stated, the resident is a total two assist. As I do every night with resident. I prepare him for bed in his w/c (wheel chair) with him hooked to the lift. I went to take care of another resident who is extensive two assist. I put her on the toilet. My plan was while she was on the toilet, I would have my helper, help me with my resident. I must of unlocked the belt and didn't realize it, which I usually let it hooked until I have help to put him in bed to finish his care. Further review of facility investigation documentation dated (MONTH) 7, (YEAR), at 7:41 p.m. revealed nursing assistant Employee E4 received a phone call from nursing assistant, Employee E3, and was asked to assist nursing assistant Employee E3 with transferring Resident #569 and Resident #399. Employee E4 was in the middle of assisting another resident into bed and once done would come to help Employee E3. After Employee E4 left resident's room, she saw Employee E3 sitting at the desk down the south hall. While walking toward Resident #399's room, Employee E4 heard Resident #569 call out to Employee E3. Employee E3 never went to check on Resident #569. Both nursing assistants proceed to Resident #399 room to transfer onto the toilet. Employee E3 stated, she was o.k. now, she can finish up from here. Employee E4 said, o.k., I will be going into Resident #569's room, so we can transfer him. I knocked on Resident #569's door before entering, I entered the room, that is when I saw resident lying face down on the floor in a pool of blood. During an interview with Director of Nursing on (MONTH) 10, (YEAR), at 12:50 p.m. confirmed that the seat belt should have been hooked. Review of Resident #569's readmission nursing note dated (MONTH) 9, (YEAR), at 4:15 p.m. revealed, resident was readmitted from hospital, status [REDACTED]. Bilateral upper and lower eyelids ecchymotic (bruise). Generalized bruising right lower extremity and right hand. Splint with ace wrap intact from left hand knuckles to mid left, upper arm. Resident has a cervical collar in place to neck. Review of Resident #569's physician's history and physical dated (MONTH) 12, (YEAR), indicated, resident who was admitted to hospital from 3/05 until 3/09/2018, after a fall from Hoyer lift (mechanical lift) during a transfer on 3/05/18 with multiple injuries including a C3 through C5 (top portion of the spinal cord comprising vertebrae in the neck) fracture, bilateral rib fractures, right nasal bone fracture, left distal radius (larger bone of the forearm near the wrist) fracture and facial laceration. During an interview with Director of Nursing on (MONTH) 10, (YEAR), at 12:50 p.m. confirmed that the resident's seat belt should have been hooked. During an interview with Nursing Home Administrator and Director of Nursing on (MONTH) 10, (YEAR), at 2:15 p.m. confirmed that the nursing assistant did not follow policy by leaving the resident connected to the total mechanical lift unattended and failed to secure the waist seatbelt as care planned. The facility failed to ensure Resident #569 was free of accidents which resulted in actual harm to Resident #569 sustaining a fall, requiring transfer to the hospital via emergency medical services and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 01/13/17 28 Pa. Code 201.29(c) Resident rights Previously cited 01/13/17 28 Pa. Code 211.5(f) Clinical records Previously cited 01/13/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/13/17 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 07/17/17, 01/13/17

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure one of nine residents reviewed Resident #569 was free of neglect, which resulted in actual harm to Resident #569 sustaining a fall, requiring transfer to the hospital via emergency medical services and the [DIAGNOSES REDACTED]. Findings include: Review of the facility policy and procedure titled, Abuse Prevention, last revised (MONTH) 3, (YEAR), revealed the facility maintains procedures that are geared to protect resident from abuse. Further review of the facility policy indicated that if a resident alleges abuse or neglect or a staff member, witness or has reason to suspect abuse, the immediate supervisor and/or nurse manager will be notified. A holistic resident assessment will be conducted for any alleged or suspected cases of resident abuse or neglect. Specifically, the resident will be assessed for injury, harm, mental anguish and the need for immediate care or services. Review of Resident #569's [DIAGNOSES REDACTED]. of the blood vessels which supply the heart with blood and oxygen) and Anxiety (intense, excessive ans persistent worry and fear about everyday situations), Review of Resident #569's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 15, (YEAR), revealed the resident required extensive assistance for bed mobility, transfers and toilet use with the assistance of two persons, using a total mechanical lift. Review of Resident #569's care plan initiated (MONTH) 3, (YEAR), identified the resident's deficit with activities of daily living related to assistance needed for dressing/personal hygiene, bilateral above the knee [MEDICAL CONDITION], dementia, pain and muscle weakness. The interventions revealed staff were to provide assistance for upper and lower body care, encourage resident to wash face and hands and to maneuver extremities as possible for care. Encourage resident to help choose clothing. Provide staff assistance to dress, encourage resident to maneuver extremities as possible to help with dressing. Further review of the resident's care plan indicated the potential for falls related to dementia with behaviors, use of [MEDICATION NAME] and [MEDICAL CONDITION] medications, bilateral above the knee [MEDICAL CONDITION], impaired balance/trunk control, muscle weakness and hypertension. The interventions revealed to provide total assist of two staff and use of a total mechanical lift for all transfers. Leave lift pad under resident as to assure proper placement for transfers. Reinforce need for seatbelt to be engaged at all times when resident is in his wheelchair. Resident is able to open the seatbelt and engage it, if asked. Review of Resident #569's interdisciplinary note dated (MONTH) 5, (YEAR), at 7:40 p.m. revealed, RN (registered nurse) notified that resident was on the floor. RN, LPN (licensed practical nurse) and CNA (nurse aide) responded. Observed resident on his stomach with his stumps still up on the edge of his wheelchair, face against the metal base of the lift on the floor. There was a large amount of blood under his face, he was alert and talking. Denied pain upon assessment, a laceration measuring 2.0 centimeters was noted. We instructed him not to move his head/neck. Call placed to physician, RN was instructed to send resident out to ER (emergency room ), ASAP (as soon as possible). EMS (emergency medical services) was called. Resident was moved and transported by EMS to hospital. Vital signs were unable to be obtained due to the fact resident was laying on both arms on the floor. A interdisciplinary note dated (MONTH) 6, (YEAR), at 3:16 a.m. indicated, this nurse called hospital and was made aware that resident was admitted at 10:18 p.m. with a [DIAGNOSES REDACTED]. Review of facility's investigation documentation dated (MONTH) 5, (YEAR), revealed nursing assistant Employee E3 stated, the resident is a total two assist. As I do every night with resident. I prepare him for bed in his w/c (wheel chair) with him hooked to the lift. I went to take care of another resident who is extensive two assist. I put her on the toilet. My plan was while she was on the toilet, I would have my helper, help me with my resident. I must of unlocked the belt and didn't realize it, which I usually let it hooked until I have help to put him in bed to finish his care. Further review of facility investigation documentation dated (MONTH) 7, (YEAR), at 7:41 p.m. revealed nursing assistant Employee E4 received a phone call from nursing assistant, Employee E3, and was asked to assist nursing assistant Employee E3 with transferring Resident #569 and Resident #399. Employee E4 was in the middle of assisting another resident into bed and once done would come to help Employee E3. After Employee E4 left resident's room, she saw Employee E3 sitting at the desk down the south hall. While walking toward Resident #399's room, Employee E4 heard Resident #569 call out to Employee E3. Employee E3 never went to check on Resident #569. Both nursing assistants proceeded to Resident #399's room to transfer onto the toilet. Employee E3 stated, she was o.k. now, she can finish up from here. Employee E4 said, o.k., I will be going into Resident #569's room, so we can transfer him. I knocked on Resident #569's door before entering, I entered the room, that is when I saw resident lying face down on the floor in a pool of blood. Interview with Director of Nursing on (MONTH) 10, (YEAR), at 12:50 p.m. confirmed that the seat belt should have been hooked. Review of Resident #569's readmission nursing note dated (MONTH) 9, (YEAR), at 4:15 p.m. revealed, resident was readmitted from hospital, status [REDACTED]. Bilateral upper and lower eyelids ecchymotic (bruise). Generalized bruising right lower extremity and right hand. Splint with ace wrap intact from left hand knuckles to mid left, upper arm. Resident has a cervical collar in place to neck. Review of Resident #569's physician's history and physical dated (MONTH) 12, (YEAR), indicated, resident who was admitted to hospital from 3/05 until 3/09/2018, after a fall from Hoyer lift (mechanical lift) during a transfer on 3/05/18 with multiple injuries including a C3 through C5 (top portion of the spinal cord comprising vertebrae in the neck) fracture, bilateral rib fractures, right nasal bone fracture, left distal radius (larger bone of the forearm near the wrist) fracture and facial laceration. During an interview with the Director of Nursing on (MONTH) 10, (YEAR), at 12:50 p.m. confirmed that the resident's seat belt should have been hooked. Interview with Nursing Home Administrator and Director of Nursing on (MONTH) 10, (YEAR), at 2:15 p.m. confirmed that the nursing assistant did not follow policy by leaving the resident connected to the total mechanical lift unattended and failed to secure the waist seatbelt as care planned. The facility failed to ensure Resident #569 was free of neglect which resulted in actual harm to Resident #569 sustaining a fall, requiring transfer to the hospital via emergency medical services and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 01/13/17 28 Pa. Code 201.29(c) Resident rights Previously cited 01/13/17 28 Pa. Code 211.5(f) Clinical records Previously cited 01/13/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/13/17 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 07/17/17, 01/13/17

Based on observations and staff interview, it was determined that the facility failed to treat four of 35 residents observed (Resident 95, 106, 311, 313) in(NAME)West unit in a dignified manner. Findings include: Review of facility policy titled, Resident's Rights, reviewed on (MONTH) 19, (YEAR), under Attachment A: Resident's Rights revealed the following statement You have the right to be treated with respect and dignity. Observation of the lunch meal on (MONTH) 7, (YEAR), from approximately 12:00 p.m. to 12:17 p.m. revealed non-licensed staff, Employee E5 assisting Resident 95 and Resident 311 eating their meal. Employee E5 was observed not engaging either resident in conversation. Further observation revealed that non-licensed staff, Employee, E6 assisting Resident 106 and Resident 313 with their noon meal. Employee E6 failed to engage either resident with conversation. Employee E5 and Employee E6 were observed only speaking with each other while assisting the residents with the noontime meal. Additional observations of the lunch meal on (MONTH) 8, (YEAR), from approximately 12:18 p.m. to 12:29 p.m. revealed non-licensed staff, Employee E5 assisting Resident 95 and Resident 311 with meal consumption without engaging either resident in conversation. Employee E5 was observed conversing with two fell ow employees at the same table while assisting residents with the noontime meal. Interview with Director of Nursing on (MONTH) 10, (YEAR), at approximately 8:15 a.m. confirmed the nurse assistants did not ensure that the residents were treated in a dignified manner during meal observation. The facility failed to ensure dignity during a dining experience for Residents 95, Resident 106, Resident 311, Resident 313. 28 Pa. Code 201.29(j) Resident's rights Previously cited 01/13/17 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 07/17/17, 01/13/17

Based on observation and staff interview, it was determined that the facility failed to promote and enhance residents dignity during meal time in one out of 10 dining rooms. (Roosevelt 2) Findings include: Observation on July 12, 2017 at approximately 12:20 p.m. during observation of the lunch meal in Roosevelt 2 dining room, non- licensed Employee E2 was observed standing while feeding Resident E16. Non-licensed Employee E2 stood while spoon feeding Resident E16. During this time, non-licensed Employee E2 would walk around to opposite side of the same table and assist Resident E36 with eating. Non-licensed Employee E2 would scoop food onto a spoon and while standing over Resident E36 proceed to feed. Non-licensed Employee E2 walked back and forth between both Residents E16 and E36 assisting them with lunch while standing over them to feed. Observation on July 17, 2017 at approximately 8:30 a.m. during observation of breakfast in Roosevelt 2 dining room, non-licensed Employee E4 was observed standing while feeding Resident E13. Non-licensed Employee E4 stood while spoon feeding Resident E13. At approximately 8:35 a.m., non-licensed Employee E3 came over and started feeding Resident E13 while standing over resident. Non-licensed Employee E4 went over to Resident E34 and while standing next to wheelchair proceeded to spoon fed Resident E34. An interview conducted with the registered nurse, unit manager, Employee E1 on July 17, 2017 at approximately 8:50 a.m., confirmed that staff should sit while feeding residents. The facility failed to promote and enhance dignity during meal time for Residents E13, E16, E34, E36. 28 Pa.Code:211.12 (c) (d)(1)(5) Nursing services Previously cited: 8/30/16, 1/13/17

Based on clinical record review, facility policy and staff interview, it was determined that the facility failed to provide alternate nutritional interventions for two residents out of 27 reviewed with gradual continued weight loss (Resident AA3 and AH15) which resulted in actual harm to one resident. (Resident AH15) Findings include: Review of the facility's policy entitled Weighing of Residents (reviewed January 23, 2015) stated that nutrition services will notify nursing if the resident should be reweighed. Resident AH15 was admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of May 2015 physician's orders [REDACTED]. Review of the resident's weight record revealed that the documented weight on admission February 9, 2015 was 193 pounds. During an interview with Employee E7, on July 21, 2015 11:45 a.m., she stated that she was unsure if this weight was accurate because the resident was clothed and the staff used a different scale than for the weight obtained a week later, on February 15, 2015 when the resident's documented weight was 184 pounds, a difference of nine pounds. There was no indication in the facility weight documentation that a reweigh was completed or that nutrition services requested a reweigh. The nutritional admission assessment completed February 17, 2015 revealed that the the clinician chose to monitor the resident secondary to a high normal BMI (body mass index which is the measure of body fat based on height and weight). The resident's weight on February 22, 2015 was documented as 181 pounds. On February 24, 2015, the resident was seen by the physician who requested a dietary consult secondary to weight loss and in addition ordered a liquid supplement [MEDICATION NAME] 90 cc (3 ounces) three times daily. Documentation in the interdisciplinary notes dated February 27, 2015 indicated that the certified dietary manager completed the consult. The notes indicated that the nursing staff related that the resident had poor intakes and would continue to monitor the resident's weight for changes. On March 16, 2015, the resident's weight was documented as 180 pounds. The physician again requested a dietary consult for weight loss on March 18, 2015. The dietitian documented in the interdisciplinary notes dated March 19, 2015 that the resident had a 2.2 percent decrease in thirty days. No new interventions was added secondary to only one weight obtained on the current unit and having had several moves since admission. On May 26, 2015 the resident's weight was documented as 170 pounds, a loss of eight pounds in two weeks (4.5%) from the resident's weight on May 12, 2015 (178 pounds). A nutrition assessment was completed on June 10, 2015 when the weight was documented as 166 pounds, a loss of an additional four pounds. A note included in the assessment revealed that the resident's son who assists at the meal reported prolonged chewing and difficulty with meats. During an interview on July 21, 2015, Employee E7 stated that a speech screen/evaluation was not obtained. On June 23, 2015, thirteen days later, the resident's weight was documented as 164 pounds, and in a progress note dated June 24, 2015 by nutrition staff, Employee 7 recommended an increase of the supplement to [MEDICATION NAME] 120 cc (4 ounces) four times daily. Review of the resident's July 2015 Medication Administration Record [REDACTED]. Review of the weight records revealed that on July 7, 2015 the resident weighted 161 pounds for an additional 3 pounds weight loss. The resident's weight on July 16, 2015 was recorded as 160.5 pounds, a loss of 32.5 pounds (16.8%) since admission to the facility on [DATE]. Review of the June 2015 Medication Administration Record [REDACTED]. Review of July 2015 Medication Administration Record [REDACTED]. Nutrition services chose to increase the supplement amount and frequency despite the fact that the resident was not accepting the supplement as already ordered. There is no evidence that the facility explored additional interventions specific to the resident with the health care team, family and physician that might increase caloric/protein intake for a resident with continued weight loss. Review of resident AA3 demographic sheet revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nutrition Assessment, dated April 14, 2015, revealed the resident had a weight of 145 pounds and listed resident AA3s problems as altered skin integrity and may be at nutritional risk. The goal was for meal intake to meet the needs of the resident and the plan was to evaluate the resident need for nutritional supplement and weight and laboratory studies to be evaluated. The nutritional assessment determined that the resident was at moderate nutritional risk. Review of resident AA3s Medication Administration Records (MAR) for the month of April revealed on April 22, 2015 the resident was ordered one tablespoon of Prosource (protein supplement), in four ounces of choice liquid, twice a day. Resident AA3 continues with an order for [REDACTED]. Review of the weights for resident AA3 revealed the resident had a weight of 136 on May 23, 2015 a decrease of 9 pounds since admission. Review of resident AA3s MAR for the month of May 2015 revealed that the resident was order Two-Cal (nutritional supplement), 60 milliliters, twice a day on May 26, 2015 and was discontinued on May 14, 2015. Further review of resident AA3s weight revealed the resident had a weight of 131 pounds on July 12, 2015 a total loss of 14 pounds (9.7%) since admission. Review of the MARs for May 2015, June 2015, and July 2015 revealed the resident was offered the supplement a total of 100 times and refused the supplement a total of 96 times. Further review of the clinical record revealed there were no attempts to change the nutritional supplement due to the number of resident refusals despite the continued decline in weight until July 11, 2015 when it was recommended to increase the Two-Cal from 60 milliliters twice a day to 120 milliliters twice a day. Interview with Licensed Dietary Employee E10 on July 21, 2015 revealed there were no interventions put into place between the time of the start of the supplements until the current date, to address the resident ' s refusals of the supplements and the continuing need of protein supplements and the decline in resident AA3s weight. 28 Pa Code: 211.5(f) Clinical records Previously cited 09/19/14 28 Pa Code: 211.10(d) Resident care policies Previously cited 09/19/14, 7/11/13 28 Pa Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 09/19/14, 7/11/13

Based on a review of clinical records, facility documentation and staff interview, it was determined that the facility failed to provide adequate and timely interventions to prevent falls in the dining room for one resident and to provide adequate supervision and monitoring and consistently implement interventions to ensure the safety of a resident at risk for falls resulting in actual harm for one resident (Resident AH372 and D43). Findings include: Review of Resident D43's June 2013 physician orders [REDACTED]. Review of nursing note on April 27, 2013 revealed that the resident was observed lying on the floor with bleeding and a hematoma (solid swelling of clotted blood) on the back of her head at 9:00 p.m. An investigation report concerning this fall indicated that a new fall intervention would be to ensure that nonskid socks were worn by the resident after the evening meal. Review of nursing note on June 6, 2013 revealed that the resident was observed sitting on her buttocks on the floor with no apparent injury at 8:30 p.m. The investigation report for this fall indicated that a new fall intervention would be to have the resident screened by physical therapy for strength and balance. Review of nursing note on June 12, 2013 revealed that the resident fell in her room with no apparent injury at 8:05 p.m. The investigation report for this fall indicated that a new fall intervention would be to have the resident remain in the common living area for supervision until she is ready for bed. Review of nursing note on June 15, 2013 revealed that the resident fell in her room at 9:10 p.m. with no injury. The investigation for this fall indicated that staff would assist with evening care and supervise the resident transferring into bed. Review of the nursing note on June 24, 2013 revealed that the resident was observed on her back on the floor beside the bathroom door at 7:45 p.m. The resident complained of left hip pain and was transferred to the hospital where she was admitted with a left hip fracture. The investigation report for this fall stated "The resident was getting ready for bed in her room. Staff heard resident yelling and entered the room to observe her on the floor near the bathroom." Review of the report revealed no caregiver statement indicating why the resident was getting herself ready for bed when the fall interventions clearly indicate the the resident should remain in the common living area for supervision until she is ready for bed and that staff would assist with evening care and supervise the resident transferring into bed. The administrator on July 10, 2013 at approximately 9:00 a.m. was apprised of the aforementioned fall details The facility provided a statement dated July 11, 2013 (18 days after the June 24, 2013 fall) from the nurse supervisor who interviewed the caregiver on July 11, 2013. The statement indicated that the caregiver did assist the resident to bed but then she got up again and fell . This statement contradicts the investigation report which stated that the resident was getting ready for bed in her room. . The facility failed to put into place measures to adequately monitor and supervise the resident during the time of the day when she had the greatest risk for falls who fell and sustained a fractured left hip.. Review of Resident AH372's [DIAGNOSES REDACTED]. A review of the Resident Annual Assessment completed on February 26, 2013 indicated supervision is required and one person assist for walking in corridor and locomotion on the unit and transfer. A review of nurses notes dated March 18, 2013 indicated that the resident was observed sitting on the floor in the dining room in front of the dining chair. The incident occurrence report dated March 18, 2013 stated that the resident ambulates with a walker with supervision and uses a wheelchair as needed. The report stated that the resident did have the walker at the time of the fall. The report states when she attempted to sit in the chair the chair rolled back causing her to sit on the floor. This report stated all interventions were followed. . A request to the administrator for the facility investigation of the incident was made on July 9, 2013 in the afternoon, on July 10, 2013 at approximately 3:00 p.m. and again on July 11, 2013 at approximately 1:00 p.m. On July 11, 2013 approximately 2:30 pm the administrator provided a duplicate copy of of what had been provided but no written statements from staff interviewed were provided to support the statement that all interventions were followed. The quarterly assessment completed on May 28, 2013 revealed the AH372 had declined and required extensive assistance with two person assist with walking in the corridor or locomotion on the unit and that a one person assist was required for transfer. On June 16, 2013, July 5 and July 6, 2013 nursing notes stated that the resident was in the dining room with the rolling walker and fell to the floor while trying to sit down on the dining room chair. The Occurrence Investigation reports dated June 16, 2013, July 5 and July 6, 2013 stated the resident fell in the dining while trying to sit down in a dining room chair and that the resident ambulated without supervision. The facility documentation supports that the resident did not have appropriate measures in place to adequately monitor and supervise the resident during transfer from the rolling walker to a dining room chair. Observation on all days of the survey revealed that the dining room chairs have wheels on the front legs and no wheels on the back legs. This increases the risk of the movement of the dining room chairs when the resident transferred into the chair with a rolling walker without supervision for the four falls (March 18 2013, June 16, 2013, July 5 and 6, 2013. 28 PA Code 201.18(b)(1) Management Previously cited 8/24/2012 28 PA Code 201.18(b)(3) Management Previously cited 8/24/2012 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 8/24/2012

Based on clinical record review, staff and resident interview, it was determined that the facility failed to implement effective safety interventions and/or provide adequate supervision to prevent falls for two of 30 sampled residents (Resident 108 and 319). Findings included: Clinical record review revealed that Resident 108 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] indicated that the resident was cognitively impaired and required the assistance of one staff member for walking/locomotion and hygiene. A review of nurse's notes and the facility completed summarization of falls occurring between October 27, 2010 through December 31, 2010 revealed that the resident had six falls: October 27, 2010 at 11 AM and 12 PM, October 30, 2010, November 27, 2010, December 8, 2010, and December 31, 2010). Five of the six falls occurred when the resident fell out of bed in her room. One fall occurred when the resident fell outside her room in the hallway. In four of the six falls (falls occurring on October 30, 2010, November 27, 2010, December 8, 2010, December 31, 2010) an alarm was sounding, but staff was unable to respond timely to prevent the fall. A review of the fall that occurred on October 30, 2010, at 2:30 a.m., revealed that a bed alarm was sounding and staff responded to find the resident on the floor. A nurse ' s note completed later that evening at 6:30 p.m., revealed that the resident's right wrist was noted to be swollen and black/purple in color. X-rays completed November 5, 2010, confirmed that the resident had an acute impacted right wrist fracture. A nurse's note dated November 28, 2010, at 3:00 p.m., and December 9, 2010, at 2:00 a.m., revealed that the resident had fallen out of bed and that staff was unable to respond timely to prevent the falls. A nurse's note dated December 31, 2010, at 8:25 p.m., revealed that the resident had a fall outside her room in the hallway. It was noted that an alarm had sounded, but staff were unable to respond timely to prevent this fall. Upon assessment by staff it was noted that the resident had complaints of pain in the right hip and shoulder area. X-rays completed after physician notification revealed a fracture of the right arm (humerus). There was no evidence that the facility had evaluated the effectiveness of their reliance on alarms in preventing falls for this resident and had developed and implemented additional or alternate safety measures, including increased staff supervision, to prevent falls with serious injuries. Interview with the Assistant Nursing Home Administrator on July 21, 2011, at 9:00 a.m., confirmed that the resident fell from bed while utilizing an alarm on October 30, 2010, November 27, 2010, December 8, 2010. The alarm was connected into the facility's main alarm notification system and the facility would be able to monitor how long the alarm was sounding before staff interceded to prevent a potential unsafe act. However, the facility was unable to provide the report due to current system upgrades which did not allow access. The facility was unable to demonstrate that staff responded timely in effort to prevent falls or that intervention provided by staff was effective to prevent recurrence of falls. The facility's Incident/Accident reporting policy revealed that the last time this policy was reviewed was May 7, 2009, and there had been no written updates or revisions to the policy. Resident 319 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Clinical record review revealed a nursing note dated December 31, 2010 at 6:45 p.m. which stated that "resident fell in dayroom while trying to sit down." Review of a Facility Occurrence Report and Resident 319's care plan revealed her to be independent with transfers and independent to supervision with ambulation. Employee 4 (RN, Unit Manager) confirmed during interview on July 21, 2011, at 9 AM that no additional safety interventions were implemented as a result of this event. Review of a Quarterly MDS assessment, reference date December 9, 2010, and an Annual MDS assessment, reference date March 10, 2011, revealed that Resident 319 required extensive assistance of staff, one person physical assistance for transfers, walking in the corridor and locomotion on unit. A nurse's note dated February 17, 2011 at 1:50 p.m. stated "Observed on floor in CLA (Common Living Area) by staff. " Review of a Facility Occurrence Report and Resident 319's care plan revealed she was independent with transfers, although the resident's quarterly MDS assessment dated [DATE], indicated that the resident required assistance with transfers. Employee 4, RN stated during interview on July 21, 2011 at 9 AM that additional safety interventions implemented as a result of this event involved verbal cuing when resident was observed attempting to ambulate and/or transfer without walker. A nurse's note dated March 18, 2011 at 6:50 p.m. stated, " at 1835 resident was observed by CNA (nurse aide) sitting on floor with back against wall in the common living area. resident had been ambulating independently ... " . Employee 4, RN stated during interview on July 21, 2011, at 9:15 AM that as the result of this fall the facility discussed the addition of chair alarms with resident's daughter, but this intervention was not implemented at daughter's request. A nurse's note dated March 22, 2011 at 10:20 p.m. stated, "at 1645 staff heard a thud. Res (resident) was observed sitting on her buttocks on the floor in the DR (dining room). A visitor was present (and) stated that she tried to sit on the arm of the chair." Facility Follow Up Summarization revealed Resident 319 sustained a " right hip fracture and acute proximal right femur fracture with minimal displacement " as a result of this fall. A physical therapy evaluation dated August 16, 2010, (the most recent evaluation prior to the above noted falls) revealed that the resident was referred for evaluation secondary to failed attempts to sit and confusion with seated walker. Nursing reports resident often forgets to use 4WW (four wheel walker) and walks all over unit. This evaluation further stated that the resident requires constant cues for safe sit-stand transfers, and that no further skilled physical therapy intervention indicated secondary to no carry over due to dementia. There was no evidence that the facility consistently provided this resident with the assessed amount of assistance with transfers and ambulation and developed and implemented a safety plan to increase staff supervision of the resident to prevent repeated falls. Interview with the ANHA on July 21, 2011 at approximately 9:30 a.m. and interview with Employee 4 on July 21, 2011 at 10:00 a.m. failed to provide evidence that the facility implemented or utilized effective safety interventions, including staff assistance, to prevent a fall with injury for this resident with a recent history of multiple falls. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services previously cited 8/24/10