Every finding on record at Masonic Village at Lafayette Hill

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure safety interventions for falls were in place for one of three residents reviewed (Resident R21).Findings include:Clinical record review revealed Resident R21 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (brain disease that causes memory loss and other cognitive impairment), lack of coordination, and repeated falls. Review of Resident R21's care plan, revised February 10, 2026, revealed floor mat was to be in place. Observation on June 17, 2026, at 9:50 a.m., revealed Resident R21 was lying in bed and did not have a floor mat on the floor next to the bed. Interview on June 17, 2026, at 09:53 a.m., with Employee E4, Registered Nurse, confirmed Resident R21 did not have a floor mat while the resident was in bed. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food stored in the refrigerator and freezer was stored by professional standards for food service safety. Findings Include:The facility policy titled Production, Purchasing, Storage - Food and Supply Storage Procedure, last revised in January 2024, states: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption. Under the procedures section, it further specifies: Most, but not all, products contain an expiration date. The words ‘sell-by,' ‘best-by,' ‘enjoy-by,' or ‘use-by' should precede the date. The ‘sell-by' date is the last date that food can be sold or consumed; do not sell products in the retail area or place them on patient trays/resident plates past the date on the product. Food past the ‘use-by,' ‘sell-by,' ‘best-by,' or ‘enjoy-by' date should be discarded. Cover, label, and date unused portions and opened packages. Complete all sections on a [NAME] orange label or use the MedVanta/FreshDate labeling system. Products are good through the close of business on the date noted on the label. Date and rotate items using the first-in, first-out (FIFO) method. Discard food past the use-by or expiration date. An initial tour of the Food Service Department conducted on July 15, 2025, at approximately 11:00 a.m. with the Food Service Director, Employee E5, revealed the following:In the walk-in freezer, the following items were found:Opened chicken nuggets that were not labeledPureed steak and regular steak, frozen and not labeledBeef burgers, opened in a box, uncovered and not labeledFrozen bisques that were not labeledEmployee E5 discarded the bisques during the tour due to the lack of labeling.The walk-in refrigerator for produce revealed:Opened cauliflower with an expiration date of 7/2/25Fresh opened celery and carrots not labeledOpened cheese in a bin, not labeledColeslaw with an expiration date of 7/10/25Chopped tomatoes with an expiration date of 7/13/25Additional coleslaw with an expiration date of 7/10/25The First refrigerator, which stores premade ready-to-serve items, revealed:Chicken salad expired on 7/13/25Blondie Bars / Brownies (one rack was not labeled)Turkey cold cuts expired on 7/10/25Ham expired on 7/14/25Imitation crab meat expired on 7/14/25Defrosted turkey (from freezer) expired on 7/2/25In dry storage, the following items were noted:Opened rice not labeledBowtie pasta not labeledIsraeli couscous expired on 5/21/25Dye/frosting food coloring not labeledCooked apples expired on 7/14/25Sprinkles expired on 7/11/25Whipping cream not labeledAt 12:03 p.m. the same day, the surveyor went upstairs to the dining room to inspect the dining kitchen, which is a fully equipped meal preparation area. Upon exiting the elevator and approaching the entrance door to the dining kitchen, a rolling tray was found unattended. The tray contained full-sized, un-chopped romaine lettuce and cucumbers.28 Pa. Code 201.14 (a) Responsibility of Licensee.

Number of residents sampled:13Number of residents cited:1 Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of a facility-initiated transfer and the reason for the move in writing and in a language and manner they understand for one of 13 residents reviewed for hospitalization. (Resident R54)Findings include:Review of nursing note for Resident R54, dated May 3, 2025, revealed that Resident R54 was transferred to hospital emergency room for evaluation after a fall.Review of Resident R54's clinical record revealed that there was no documented evidence that the resident and his representative were provided with a written notice of the facility bed-hold policy at the time of Resident R54's facility-initiated transfer to the hospital.Further review of Resident R54's clinical record revealed that there was no documented evidence that the resident and his representative were provided the reason for the move in writing and in a language and manner they understand.Interview with the Social Worker, Employee E4, on July 17, 2025, at 11:02 a.m. confirmed that Resident R54 and his representative were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed hold reserve payment and permitting return to a bed at the facility. Employee E4 also confirmed that the resident and her representative were provided the reason for the move in writing and in a language and manner they understand.Further interview confirmed that there was no system in place to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital and to provide the reason for the move in writing and in a language and manner they understand.28 Pa Code 201.14(a) Responsibility of licensee28 PA Code 201.29(f) Resident rights

Number of residents sampled:13Number of residents cited:1Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of 13 residents reviewed (Residents R3).Findings include:Review of Resident R3's clinical record revealed that the resident was admitted to facility on May 30, 2025.Interview with Resident R3's representative on July 14, 2025, stated the facility did not provide a copy of the baseline care plan after the admission.Review of the clinical record revealed no documented evidence that resident and/or the resident's representative received a written summary of the baseline care plan including physician orders, dietary orders and social service goals.Further review of the care plan revealed no documented evidence that the resident representative received a written summary of the baseline care plan.A request was made to the Infection Control Nurse on July 17, 2025, for the evidence that resident/resident representative received a copy of the baseline care plan.Facility did not provide any evidence that resident/resident representative received a copy of the baseline care plan.Interview with the Director of Nursing on July 17, 2025, at 10:42 confirmed that there was no documented evidence that resident and/or the resident's representative received a written summary of the baseline care plan including physician orders, dietary orders and social service goals.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, interviews and review of clinical records, it was determined that the facility failed to ensure that the resident's environment was free of accidents and hazards for a cognitively impaired resident with a history of utilizing razors unsupervised and resulting in a skin abrasion for 1 out of 13 residents reviewed (Resident R8). Findings include: Review of the July 2024 physician orders for the resident included the following diagnosis: arthritis (inflammation of the joints); dependence on wheelchair; chronic obstruction pulmonary disorder (COPD-a term for a group of progressive lung and airway diseases that cause breathing difficulties); dementia (a general term for a decline in cognitive function that affects daily life, including memory, reasoning and language skills); encephalopathy (a broad term for any disease or disorder that affects the brain function or structure); cognitive communication deficit (difficulties in communication that arise from impaired cognitive functions such as attention, memory, reasoning and problem solving); depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and a personal history of other venous thrombosis and embolism (conditions involving blood clots that can obstruct blood flow in the veins).Review of the resident's Annual Minimum Data Set Assessment (MDS- a periodic assessment of a residents needs) dated April 3, 2025 indicated that the resident was cognitively impaired.Review of a nursing note dated May 15, 2025 at 10:37 a.m. indicated that the resident reported that she used her husband's razor: Resident is PI #2 for abrasion to left jaw. Resident stated, Don't tell anyone but I used [husband's] razor to shave my facial hair. Area cleaned and left open to air.Review of a nursing note dated May 15, 2025 at 12:10 p.m. indicated that the resident an abrasion was found on the left side of the resident's jaw as a result of her shaving herself on the above referenced date.Review of the facility incident report regarding the above included a similar account of what was documented in the above referenced note.During an observation in the resident's room on July 17, 2025 at 9:06 a.m. the resident was lying in her bed. A blue razor with the top off was seen in her wheelchair that was next to her bed. During an observation with Employee E8 (licensed nurse) on July 17, 2025 at 9:08 a.m. Employee E8 entered the resident's room and saw the razor present in the resident's wheelchair. The resident's bathroom was entered by Employe E8 and a 2nd blue razor was found in the bathroom's cabinet. An electric razor that belonged to the resident's husband, with who she shares a room with was also observed on the bathroom counter plugged in. Employee E8 removed the two blue razors from the resident's room and informed the resident that she should not have the razors, and that she needed to take them out of her room.The facility failed to ensure that resident's environment was free of accidents and hazards for Resident R8.28 Pa. Code 201.18(a) Management 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 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 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 interviews and the review of clinical records, it was determined that the facility failed to ensure that a resident's weights, were completed in a timely manner for 1 out of 13 residents (Resident R4).Findings include:Review of the undated policy, Monitoring Resident Weight Change, indicated that accurate weight measurements are essential for assessing nutritional status, calculating doses of drugs, indicating fluid status, accurate minimum data set documentation (MDS- a periodic assessment of a resident's needs), and care planning. Review of the July 2025 physician orders for Resident R4 included the following diagnosis: dysphagia (difficulty swallowing); cerebral infarction (a stroke); hypertension (high blood pressure); diabetes (a group of diseases that affect how the body uses blood sugars); glaucoma (a group of eye diseases that cause vision, loss and blindness), and dementia (a general term for a decline in cognitive function that affects daily life, including memory, reasoning and language skills).Review of a note from the clinical dietician (Employee E9) dated March 11, 2025, at 2:12 p.m. indicated that the resident lost 8.4 pounds in 1 month and triggered for a significant weight loss of 6.3% from February 4, 2025 through March 5, 2025. Review of the resident's Weight Summary indicated that a weight taken on February 4, 2025, recorded the resident as weighing 132.8 pounds. Review of the resident's weight taken on March 5, 2025, recorded the resident's weight as 124.4 pounds.Continued review of the resident's clinical records indicated that when the initial significant weight loss was suspected by the facility after the March 5, 2024 weight was recorded, a reweight was not obtained by the facility in a timely manner to ensure that any issues with significant weight loss were addressed, and any needed interventions and/or services are implemented in a timely manner. Review of the resident's Weight Summary indicated that a re-weight to confirm the suspected weight loss from March 5, 2025 was not done until March 11, 2024, which was 6 days after the March 5, 2025 suspected significant weight loss. The Weight Summary report for the March 11, 2025 re-weight documented the resident's weight as being 124.4 pounds, confirming the significant weight loss that was suspected on March 5, 2025.During an interview with the clinical dietician on July17, 2025 at 11:34 a.m. the resident's significant weight loss was confirmed. It was also confirmed during this time that the re-weight was completed March 11, 2025, 6 days after the suspected weight loss. The clinical dietician also reported during this time that the facility's policy is to obtain any re-weight that the resident may need within 7 days of the previous weight.The facility failed to ensure that Resident R4's re-weight was completed in a timely manner. 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.12(d)(1)(3) Nursing services

Number of residents sampled:13Number of residents cited:1Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pain management in accordance with professional standards for one of 13 residents reviewed (Resident R7).Findings include:Review of an undated facility policy Pain Assessment & Management Record Procedure, revealed that Integrative Pain Care and Alternative Interventions - To be used and documented in conjunction with oral medications. The following integrative pain interventions may be documented in the electronic chatting system and on the eMAR (electronic Medication Administration Record) with PRN (as needed) Medication Administration. Alternate interventions will also be documented in the IDPN (interdisciplinary progress notes) as needed.1. Positioning/rest2. Compassionate touch/massage3. Cold4. Heat5. Distraction/humor/activity6. Music7. Aromatherapy8. Spirituality/prayer9. Healing touch10. One on one11. Quiet EnvironmentReview of Resident R7's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses including cellulitis (infection of the skin) of right lower limb and pain in the right leg.Review of Resident R7's care plan revised March 11, 2025, revealed the resident had chronic pain related to the diagnosis of cellulitis and right foot wound. The care plan did not include any non-pharmacological interventions.Review of a quarterly Minimum Data Set (MDS-assessment of resident care needs) for Resident R7 dated June 18, 2025, revealed that the resident had pain frequent pain which frequently interfered with sleep, therapy activities, and day to day activities.Review of physician orders for Resident R7 dated March 11, 2025, revealed an order for Oxycodone (opioid pain medication) 5 milligrams (mg) every 8 hours as needed for severe pain.Further review of physician orders for Resident R7 dated June 2, 2025, revealed an order for Tramadol (opioid pain medication) 50 mg every 8 hours as needed for moderate pain.Continued review of physician orders for Resident R7 dated March 11, 2025, revealed an order for Acetaminophen 325 mg every 4 hours as needed for pain. (The order did not specify the severity of pain for the medication administration.Review of physician order dated March 28, 2025, revealed an order to Assess for Pain PRN and document intervention trialed before administering medications every shift. Interventions included No Pain/No interventions 1. Massage, 2. Heat 3. Ice 4. Relaxation Techniques 5. Healing Touch 6. Compassionate Touch 7. Diversional Activities 8. Repositioning 9. Exercise 10. Pet Visitation 11. Rest 12. Music 13. Spiritual Care/Activities 14. 1:1 for pain management 15. Offer Food/Beverages 16. Other (document in ID note) 17. Notify Physician 18. Refused to try nonpharmacological intervention.Review of July 2025 Medication Administration Record for Resident R7 revealed that the resident received Tramadol on July 1, 2025, at 11:37 p.m. for pain level of 2.Resident received Tramadol on July 3, 2025, at 11:52 p.m. for pain level of 1, no non-pharmacological intervention attempted.Resident received Tramadol on July 5, 2025, at 11:49 p.m. No pain scale or assessment was documented; no non-pharmacological intervention attempted.Resident received Tramadol on July 8, 2025, at 12:30 a.m. for pain level of 7, no non-pharmacological intervention attempted.Resident received Tramadol on July 9, 2025, at 1:06 a.m. for pain level of 10, no non-pharmacological intervention attempted.Resident received Tramadol on July 11, 2025, at 11:27 p.m. for pain level of 2, it was documented as no pain/no intervention.Resident received Tramadol on July 13, 2025, at 10:30 p.m. for pain level of 0. There was no documented reason for administering as needed pain medication with a pain level of zero.Resident received Tramadol on July 15, 2025, at 6:42 a.m. for pain level of 3, no non-pharmacological intervention attempted.Resident received Tramadol on July 15, 2025, at 12:11 a.m. for pain level of 2, no non-pharmacological intervention attempted.Continued review of July 2025, Medication Administration Record for Resident R7 revealed that Resident R3 received Oxycodone at 2:04 a.m. on July 2, 2025, there was no non-pharmacological intervention administered or attempted.Resident received Oxycodone at 2:00 a.m. on July 6, 2025, with a pain level of 5, no non-pharmacological intervention attempted.Resident received Oxycodone at 6:00 a.m. on July 7, 2025, with a pain level of 5, no non-pharmacological intervention attempted.Resident received Oxycodone at 2:30 a.m. on July 14, 2025, with a pain level of 5, no non-pharmacological intervention attempted.Resident received Oxycodone at 2:51 a.m. on July 16, 2025, with a pain level of 9, no non-pharmacological intervention attempted.Review of Medication Administration Record for Resident R120 revealed that Resident R120 received 3 doses of Oxycodone from June 2 to June 4.Interview with Director of Nursing, Employee E2, on July 16, 2025, at 1:00 p.m. confirmed that Resident R7 was not receiving any non-pharmacological interventions as ordered by the physician and stated staff should attempt non-pharmacological interventions prior to administering pharmacological interventions.Continued interview with Employee E2 stated Resident R3 was receiving two different narcotic pain medications. Employee E2 stated Oxycodone should be administered only for severe pain such as higher pain scale rating of a scale of 1 to 10 with 0 being no pain and 10 being the worst pain and Tramadol should be administered only for moderate pain such as medium pain scale rating. DON confirmed that Resident R7's pain medication administration was not consistent with pain scale/pain intensity.28 Pa Code 211.12(d)(3)(5) Nursing services

Number of residents sampled:1Number of residents cited:1Facility did provide dialysis site was assessed accord to PSP. Based on clinical record review, observations, policy review and staff interview, it was determined the facility failed to monitor residents' dialysis (hemodialysis/ a process of removing waste products and excess water from the body) site for a resident receiving hemodialysis for one of one resident on dialysis (Residents 40).Findings include:Review of an undated facility policy Managing Residents Receiving Hemodialysis, revealed, Masonic Village licensed nurses will provide clinical monitoring and care for theresident which includes:1. Maintaining patency of and caring for the access areaa. Fistula or graft(1) Wash the antibacterial soap each day, and always before dialysis. Discourage the resident from scratching at skin or picking scabs that may form.(2) Monitor for redness, a feeling of excess warmth, or the beginning of a pustule on the access area.(3) Check bruit and thrill every shift and document in the resident's EHR.(4) Do not use arm with dialysis access shunt/tubing for blood draws or blood pressure monitoring.(5) Discourage resident from wearing tight clothing or jewelry on access arm.(6) If the resident returns from the dialysis facility with a temporary dressing on the access site, the licensed nurse will remove and assess area. Dressings should be removed within 6 hours of the dialysis treatment. Review of clinical records for Resident R40 dated August 14, 2024, revealed that the resident was receiving dialysis through left arm fistula (a surgically created connection between an artery and a vein, typically in the arm, used for long-term hemodialysis access).Review of care plan for Resident R40 dated August 14, 2024, revealed that the resident had the potential for skin breakdown/trauma/infection in her left arm AV graft (fistula) that was present for dialysis for end stage renal disease. Interventions included, assess for bruit and thrill in the fistula and monitor reports of pain, numbness, tingling, vascular access, noting redness, swelling, warmth, exudate and tendernessReview of Resident R8's entire clinical record and treatment administration record revealed no documented evidence that the resident's left arm AV graft(fistula) for dialysis was being monitored consistently for complications.Review of physician order for Resident R40 dated on July 16, 2025, revealed no evidence that the staff obtained an order to check bruit and thrill and assessing the left arm AV graft(fistula) site. Interview with the Infection Control Nurse, Employee E3 on July 17, 2025, at 12:30 p.m. confirmed that there was no documentation that the resident's left arm AV graft(fistula) for dialysis was being monitored consistently for Resident R40. Employee E3 stated there should be a physician order for checking bruit and thrill and assessing the site and staff were expected to complete and document it in the treatment administration record every shift. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled and stored with the date that the medication was opened for one of three medication carts reviewed and two of two medication room reviewed. (Wisteria medication cart on the Healthcare unit).Findings Include:Observation of medication administration conducted by Licensed Nurse, Employee E10, on July 16, 2025, at 9:53 a.m. revealed that Resident R55 was waiting to receive her medication by the Wisteria medication cart on the nursing care unit. Employee E10 finished preparing the medication and entered Resident R55's room, leaving the resident sitting in the hallway by the medication cart.Employee E10 placed all of Resident R55's medications on a tray located by the window inside the resident's room and then left the room to get the resident. A total of six medications were left unattended from 9:53 a.m. to 9:54 a.m. Resident R55 had a roommate, Resident R34 who was awake and sitting in a wheelchair near the closet inside the room.Observation of the Wisteria medication cart on July 16, 2025, at 10:31 a.m. revealed two opened bottles of medication-Fluticasone Propionate and Salmeterol-that were not labeled with an open date. One bottle had an arrival date of June 5, 2025, and the second had an arrival date of June 28, 2025.An interview with Licensed Nurse, Employee E10, on July 16, 2025, at 10:31 a.m. confirmed that both opened bottles of medication were not labeled with an open date.An interview with the Director of Nursing, Employee E2, on July 16, 2025, at 10:34 a.m. also confirmed the absence of open dates on the two bottles. It was further revealed that the facility's policy requires medications to be discarded within 30 days of the arrival date. Therefore, the bottle with an arrival date of June 5, 2025, will be discarded, while the bottle with an arrival date of June 28, 2025, remains within the acceptable usage timeframe.An interview with the Director of Nursing, Employee E2, on July 16, 2025, at 11:00 a.m. confirmed that Employee E10 should not have left the medication unattended.28 Pa. Code 211.12 (d)(1) Nursing services.

Based on review of facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide a safe temperature meal during lunch for one of one meal observation. Findings Include:The facility policy titled, MV [NAME] Hill Hot Liquids/lids Procedures- for dining rooms (dietary) staff last revised January 2024, stated temperatures for all Hot liquids coming from the kitchen must be below (150 degrees)served all hot liquids with lids on cups.On July 15, 2025, at 12:10 p.m., observations were conducted in the main dining room, where approximately 15 residents were eating lunch and dietary aides were serving lunch to them, starting with pouring pea soup. Dietary Aide, Employee E6, was observed pouring pea soup into three different bowls and directly taking them to three residents (R19, R25, R46) without allowing them to cool off.The surveyor asked, What is the serving temperature for hot liquids? It was revealed by the Dietary Director, Employee E5, that it should be 140 F or below. The surveyor then asked if a temperature could be taken of the pea soup. The Dietary Director, Employee E5, conducted a test tray with hot liquid pea soup, and it was confirmed that the soup was served at a temperature of 159 F. The surveyor notified Employee E5 that it was observed dietary staff were pouring hot pea soup and directly serving it to residents.Employee E5 and the surveyor stepped away from the soup station to continue observations. It was confirmed that another dietary aide, Employee E7, poured pea soup into a bowl and was about to take it to a resident. Before she turned to walk away, Employee E5 prompted her, Don't forget to temp the soup. Employee E7 heard the prompt and asked for a thermometer.On July 15, 2025, at 12:24 p.m., an interview was conducted with Dietary Aide, Employee E6, who confirmed that she did serve hot pea soup to Residents R19, R25, and R46 without letting it sit to cool off. It was further revealed that dietary aides have been trained to always check the temps before serving hot liquids. E6 shared the reason she failed to check the temperatures was because I have a lot on my mind. Residents R19, R25, and R46 are not alert and oriented, and Resident R46 is legally blind.On July 15, 2025, at 12:28 p.m., an interview was conducted with Dietary Aide, Employee E7, who was observed pouring the soup into a bowl and heading toward a resident when prompted by Employee E5 to temp the soup before serving. E7 responded, I should have temped it before he (E5) said something. The last time E7 received training on how to serve hot liquids was two years ago. E7 further explained, I was trying to get the soup to the resident before the meal gets to them because they eat the meal and leave the soup.During the Resident Council meeting held on July 15, 2025, at 1:30 PM, seven alert and oriented residents (R26, R18, R39, R30, R42, R14, and R23) indicated that the soup served that day was hot. Resident R18 reported, My soup was so hot that I needed to wait for it to cool down. I ate my sandwich first, and then the soup was cool enough for me to eat.Resident R26 reported during the meeting, When my friend (R41) was sitting beside me, the soup was hot, and I told her while eating it, ‘Don't go all the way to the bottom, but take it from the top, as it's a lot cooler on the top of the soup. Don't go down to the bottom with your soup.Resident R23 reported, My roommate (R7) placed ice cubes from her iced tea into her soup to cool it down because it was hot. Then Resident R26 said, We all know it's hot, and added, I think most of us are aware that it's hot. I think 10-20 people had soup today. It needs to be checked out to ensure safe temperatures are present.On July 17, 2025, at 10:01, Employee E5 confirmed that hot liquids were not served at the preferred temperatures. 28 PA. Code 201.18(b)(1)(3) Management28 PA. Code 201.14(a) Responsibility of licensee

Based on the Resident Council meeting and interviews with residents and staff, it was determined that the facility failed to ensure the grievance process was posted in a location visible and understandable to residents, grievance forms were not readily available for residents to complete for 7 out of 7 residents reviewed (Residents R26, R18, R39, R30, R42, R14 and R23). During the Resident Council meeting held on July 15, 2025, at 1:30 PM, seven alert and oriented residents (R26, R18, R39, R30, R42, R14, and R23) indicated that they were unaware of how to file a grievance if they had a concern. When Resident R26 was asked if she knew the grievance procedure, she responded that she would talk to the receptionist. An interview with Employee E1, the Administrator, on July 17, 2025, at 10:03 AM, confirmed that E1 serves as the facility's grievance officer. However, there was no posting in the building available to communicate to the residents of this. Grievance forms were not available on the nursing unit nor in the building for residents to file a grievance. Observation of the wall area with Administrator, Employee E1, and Director of Nursing, Employee E2, on July 17, 2025, at 10:20 AM, where information is posted for residents, confirmed no information related to a grievance form or a contact person for a grievance was available. There was no dedicated place to confidentially pick up a grievance form. Additionally, the general grievance procedure was posted with no contact name for the Grievance Officer and was not wheelchair accessible. It was posted at the eye level of a standing person 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of facility documentation, review of clinical record, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance resulting in a fall for one of two residents reviewed for falls (Resident R16). Findings Include: Review of Resident R16's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 7, 2024, revealed the resident was cognitively intact had diagnoses of hemiplegia or hemiparesis and muscle weakness. Continued review of Resident R16's MDS Section GG - Functional Abilities and Goals revealed the resident had impairment on one side of the upper and lower extremity. Review of Resident R16's comprehensive care plan dated February 7, 2024, revealed the resident was at risks for falls related to Cerebrovascular Accident (CVA - an obstruction or bleed from a blood vessel of the brain causing brain damage) with left-sided weakness, ataxia (a condition that affects muscle coordination and can cause clumsy movements and balance problems)/spastic movements and history of falls. Continued review of Resident R16's comprehensive care plan dated February 7, 2024, revealed the resident had a seatbelt on the wheelchair due to poor trunk control/spasticity. Review of Resident R16's physical therapy progress report for dates of service 2/27/2024 through 3/8/2024 revealed during static standing, the resident demonstrated increased lean to left and required minimal assist to maintain an upright posture. Review of Resident R16's physical therapy treatment encounter notes dated 3/18/2024 and 3/20/2024 revealed balance in standing was identified as poor and safety awareness was identified as impaired. Review of facility documentation submitted to the state survey agency on March 25, 2024, revealed Resident R16 sustained a fall on March 24, 2024. Review of the facility incident report dated March 24, 2024, revealed on March 24, 2024, Licensed Nurse, Employee E9, noticed Resident R16's seatbelt was not fastened. Licensed Nurse, Employee E9, then asked Resident R16 to stand up so the licensed nurse could adjust the seatbelt. Resident R16 subsequently stood up, holding onto a walking, and fell to the left. Review of statement dated March 25, 2024, from Licensed Nurse, Employee E9, revealed the licensed nurse noticed Resident R16's seatbelt was not on. Licensed Nurse, Employee E9, could not retrieve the set belt while Resident R16 was in the chair. Licensed Nurse, Employee E9, placed a stand-up walker in front of Resident R16 so the resident could stand up while Licensed Nurse, Employee E9, attempted to retrieve the seatbelt on the wheelchair. Per the statement by Licensed Nurse, Employee E9, once Resident R16 was steady with the stand-up walker and Resident R16's friend who was in the room offered to stand by the resident, Licensed Nurse attempted to retrieve the seatbelt, but it was found to be stuck. The friend went to assist Licensed Nurse, Employee E9, leaving Resident R16 unassisted, when Resident R16 subsequently fell sideways without warning, landing on his left side and hitting his head on the wall. Interview on September 19, 2024, at 12:06 p.m. with Director of Therapy, Employee E10, confirmed Resident R16 was not safe to stand up, holding onto the stand-up walker, unassisted. Director of Therapy, Employee E10, indicated that Resident R16 was impulsive, not steady, and required hands on contact guard assistance. Interview on September 19, 2024, at 12:50 p.m. with Director of Nursing, Employee E2, revealed having a friend of Resident R16 to assist was not appropriate as the friend was not trained by the facility and it was not deemed safe. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observation, facility documentation, facility policy review and staff interview, it was determined that the facility failed to store and label drug according to professional standards of practice on one of one medication room. (Second Floor) Findings include: Review of facility policy provided, titled Medication Storage from the Department of Health and Human Services, Centers for Medicare, and Medicaid Services, revealed medications and biologicals that are stored in medication rooms, carts, boxes, and refrigerators will be maintained within secured locks and accessible only to designated staff. A sufficient detailed record of receipt and disposition of controlled medications are to be maintained to enable an accurate reconciliation. Review of the medication Lorazepam's insert revealed risks of use with opioids including Lorazapam may result in profound sedation, respiratory depression, coma, and death. Lorazepam has a potential for abuse and may lead to dependence. Observation of the only medication room shared within three nursing units on the facility second floor on September 19, 2024, at 11:29 a.m. accompanied with Licensed nurse, Employee E3 revealed the medication/ vaccine refrigerator was observed with a large sign on the door stating that the medication refrigerator must be always locked. The door was checked to verify it was locked and the door was found to be unlocked. Employee E3 confirmed the observation. Continued observation of the medication refrigerator found containing vaccines, insulin, and other medications that require a low tempeture. Examined contents of the refrigerator revealed a total of four boxes of lorazepam (the brand name Ativan is a prescription medication control drug use the management of anxiety disorders insomnia panic attacks and alcohol withdrawal) one box was noted to be in an open container labeled with a resident name a dosage information. One box was noted to be enclosed in a see-through locked box with no resident name or prescription on the label. Two boxes of the unopened Lorazepam with no name on the label or prescription were noted to be set on the shelf with no closed, locked, or secured disposition for anyone in the medication room to access. Interview with Licensed nurse, Employee E3 reveal the one box with the resident name identified on the label is recorded in the narcotic book on the medication cart. The other boxes with no name or prescription on the label are pharmacy extra. According to Employee E3, the boxes of any narcotics in the medication refrigerator are supposed to be in a locked box. The key can only be obtained from the pyxis (machine that provides secure medication storage along with electronic tracking of the use of narcotics and other controlled medications) by a supervisor. The act of removing the medication from the pyxis is witnessed and documented. Interview with Director of Nursing, Employee E2 on September 19, 2024, at 11:55 a.m. confirmed that the boxes of lorazepam should be in the locked box. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12 (d) Nursing services

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to ensure proper infection control practices were followed during medication pass between two resident and by implementing proper use of personal protective equipment (PPE) when practicing enhanced barrier precautions during care for three of 12 residents reviewed. (Resident R32, R42 and R5) Findings include: Review of facility policy titled Infection Prevention and Control revealed that in accordance with state and federal guidance the facility has established and will maintain, and infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections this policy defines our overarching infection prevention and control program. Further review of this policy revealed hand hygiene a general term that applies to washing hands with water or thoroughly applying an alcohol-based hand sanitizer. Exercising general infection control practices Hand hygiene is the single most important means of reducing risk of transmitting microorganisms from one person to another or from 1 site to another on the same resident. Review of facility policy titled Hand Hygiene revealed that the facility has established and will maintain an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Further view of this policy reveals when to wash your hands before eating before direct contact with a resident skin and then serving invasive devices The alcohol hand sanitizer may be used routinely for hand hygiene unless hands are visibly soiled then soap and water hand washing is required. According to Centers for Disease Control and Prevention (CDC- United States federal agency under the department of Health and Human Services, its main goal is to protect public health and safety through the control and prevention of disease) website https://www.cdc.gov/cleanhands/hcp/clinical-safety / describes the hand washing must be done immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal. Review of facility policy titled Infection Transmission Prevention and Intervention revealed that enhanced barrier precautions infection control intervention to prevent the spread of MDRO(multi drug resistant organisms, which is a microorganism that is resistant to multiple class of antimicrobials, such as antibiotics and antifungals. MDROs are bacteria that can cause serious infections). Enhanced barrier precautions pertain to residents that have a history of MDRO infection, are now colonized residents that have an indwelling medical device such as inner dwelling urinary catheter, a feeding tube, a central line, residents that have a wound or wounds must apply a gown and gloves during high contact activities such as dressing, bathing, transferring, changing linens, providing incontinence care, device care, and wound care. Entrance to a residence's room identified by CDC enhanced barrier precautions should display a sign on the door. Observation of Licensed nurse, Employee E8 on September 18, 2024 at 9:10 a.m. revealed this employee was completing the task of taking a residents vitas in the hallway. After completing the vitals and recording the data in the computer,Llicensed nurse, Employee E8 prepared medication for Resident R32 . Resident R32 was waiting in the hallway for Employee E8 to administer the medications, Employee E8 handed her a medication cup containing pills, she dropped one, he picked it up off of her shirt and handed it to her, then handed her a cup of water. Licensed nurseEmployee E8 then prepared medication for Resident R42 who was also waiting in the hallway . He prepared the medication and placed the pills in a medication cup and handed the cup to Resident R42. Employee E8 then handed Resident R42 a cup of water. Employee E8 was observed not washing hands or hand sanitzer proper between residents. Interview with Licensed nurse, Employee E8 revealed that the sanitizer was located on the wall , Employee E8 then walked over to the the hand sanitizer on the wall and pointed it to surveyor. The surveyor asked why he did not use the sanitizer between resident employee stated if you say so he then denied the observation to the Director of Nursing, Employee E2. Observation of sign on the resident R5's door revealed that the resident is under enhanced barrier precautions and everyone must clean hands before entering and leaving the room. Providers and staff must wear gloves and gown for the following activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. All devise care of central line, urinary catheter, feeding tube, tracheostomy, and all wound care requiring dressing. Review of Resident R5's Minimum Data Set (MDS-a federal mandated process for clinical assessments of all residents) admission assessment dated [DATE], revealed that Resident R5 was admitted into the facility on [DATE] with a diagnosis of urinary tract infection and fractured hip. Resident R5 had a urinary catheter and required use assisted devices of a wheel chair and walker. Resident R5 required maximal assists for Activities Daily Living's such as oral hygiene, toileting,bathing,dressing, and personal hygiene. Observation of Resident R5 on September 17, 2024 at 10:05 a.m. revealed that this resident was receiving morning care and dressed by nursing assistant, Employee E6 and Employee E5. Both employees, nursing assistant Employee E6 and nursing assistan, Employee E5 were observed with gloves, neither employee donned a gown. Interview with Employee E5 revealed that the resident is not currently on any precaution, the sign was left on the door mistakenly. Interview with Infection Preventionist, Employee E4 , during the above observation,confirmed the Resident R5 is under enhanced barrier precaution and gowns must be worn when providing care. Employee E4 confirmed that Employee E6 and Employee E5 were not applying the proper infection prevention practice. 28 Pa. Code 211.12 (d)(1) Nursing services 28 pa code 211.12 (d)(5) Nursing services

Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents reviewed. (Resident R1) Findings Include: Review of the facility policy titled, Infection Transmission Prevention and Interventions undated states The facility has established and will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. iii. Droplet precautions 1. These precautions protect staff, visitors, and other residents from droplets that are expelled during coughing, sneezing, or talking. 2. Masks are to be worn when working in close proximity to the resident. 3. Specific guidelines may be needed during the transport and placement of residents. The environmental management of equipment, etc. should be used according to each category's requirement. Review of facility training for Droplet Precautions, Hand Hygiene-Why it Matters, Respiratory Illness Refresher/Guidance and Tool Kit for Respiratory Pathogens trainings completed with staff during the month of July 2024 revealed only licensed nurses and nurse aides were trained and signed off on being trained. Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 at 9:20 a.m. to obtain access to clinical records and facility information. At this time the signage in the lobby regarding an Upper Respiratory Infection outbreak was discussed. Employee E1 and Employee E2 stated that during the month of July 2024 there was an outbreak of the HIB (Haemophilus Influenzae Disease) virus. Review of reportable documentation submitted to the Department of Health from July 17, 2024 revealed Starting on July 5, 2024 some of the healthcare center residents started showing signs of respiratory illness. Infection control policies and procedures were implemented and remain ongoing. Residents were placed into isolation, testing completed per CDC guidelines. PCR sent to lab. Per our previous reports, 3 cases over the time since July 5 were positive for COVID however all other testing was coming back negative. Over the course of this time since 7/5, 32 residents have presented with respiratory illness and testing continued to result negative including testing for Legionella. On July 16, 2024, the DON received a call from public health department to report a positive swab they obtained from CHH on a resident that lives in our retirement living section. The swab was positive in the hospital for Haemophilis Influenzae. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Acute Embolism, Acute Respiratory Failure with Hypoxia, Essential Hypertension, Dysphagia, Chronic Pain, Hearing loss, Lack of Coordination, Osteoporosis, Cognitive Communication deficit, Abnormalities of Gait, Urinary Incontinence, and a contracture of the left knee. Resident R1 was put on isolation and on droplet precautions on July 31, 2024 for wheezing and possibility of infection. During observations on the unit signage stating Before entering this room, please see the nurse, thank you and PPE (personal protective equipment) was observed outside of the resident R1's room. During observation outside of the resident's room, two staff were observed going into the room without putting on appropriate PPE. Observation of the second-floor unit revealed a licensed nurse, Employee E5 went into resident R1's room after putting on PPE including a mask, face shield, and gloves at 10:08 a.m. At 10:09 a.m. a contracted phlebotomist worker went into Resident R1's room with mask on without putting on additional PPE including gloves and a face shield. A minute later the phlebotomist came out of the resident's room and started to look in the drawers for PPE. The licensed nurse Employee E5 then came out of the room and asked the phlebotomist if she could not find the appropriate PPE. Employee E4 stated that she could not find any face shields in the drawers and license nurse Employee E5 stated that she would retrieve some. Interview held with the phlebotomist revealed that she was not aware precautions were needed as she was just here to obtain the resident's blood samples. The phlebotomist was asked if she was obtaining samples for any other residents in the building today and she stated, no. The phlebotomist was asked if she was aware Resident R1 was on droplet precautions, and she stated no. Interview held with licensed nurse Employee E5 who confirmed that Resident R1 was on isolation and droplet precautions which required staff to wear a mask, face shield, and gloves when entering the resident's room. The phlebotomist on August 1, 2024 at 10:12 a.m. put on a face shield and gloves and went back into Resident R1's room. After obtaining a blood sample, the phlebotomist left Resident R1's room, took off her gloves at the PPE station outside of the room and placed the gloves into her sweatshirt pocket. The phlebotomist then put on new gloves and went back into the resident's room. At 10:16 a.m. the phlebotomist left the resident's room without gloves but still wearing a mask and a face shield. The phlebotomist took off the face shield, hung it around her wrist and walked off the unit with it. At 10:19 a.m. a nurse practitioner, Employee E3 knocked on the door and went into Resident R1's room without putting on any PPE. Employee E3 had no mask, no face shield, and no gloves on. Employee E3 came out of Resident R1's room at 10:25 a.m. Employee E3 was asked how come she went into the room without PPE and nurse practitioner Employee E3 stated, I'm sorry, I was not aware, I was only aware that the resident was having nausea. Interview held with the Director of Nursing Employee E1 at 12:10 p.m. and confirmed that all staff going into any resident room with droplet precautions should wear PPE into the room and the worn PPE should be discarded prior to leaving the resident's room. The facility was unable to provide evidence that nurse practitioner Employee E3 and phlemobotomist were made aware of Resident R1's droplet precaution status prior to them having contact with the resident on August 1, 2024. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of clinical records, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous lines, for two of 13 residents reviewed (Resident R10 and R13). Findings include: Review of the facility's policy, PICC (peripherally inserted central catheter-a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) and Midline Management and Protocol, (not dated) stated, Change dressing 24 hours after insertion, then weekly. Review of Resident R10's nursing progress note dated November 30, 2021, revealed she was readmitted to the facility status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The same note indicated the resident was being treated with one gram of [MEDICATION(S)] (an antibiotic) daily. Review of Resident R10's November 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Continue review of Resident R10's nursing progress notes, dated December 1, 2021, stated Double lumen PICC intact. PICC flushed with normal saline and [MEDICATION(S)] (a blood thinner) as ordered. Further review of Resident R10's clinical record revealed the facility failed to maintain the PICC line to prevent infections and/or patency related to not changing the IV dressings were changed and/or adequately assessed during the duration of the IV therapy. Review of Resident R15's nursing progress note dated December 6, 2021, revealed the resident was discharged from the hospital and readmitted to the facility, diagnosed with [CONDITION(S)] (a blood infection). The same note indicated the resident was noted with a midline to his right arm to finish his course of the antibiotic [MEDICATION(S)], for eight more days. Continue review of Resident R15's nursing progress notes, dated December 8, 2021, stated the resident complained of pain in his right upper arm near the midline, midline dressing was damp and his right upper arm had a hardened area that was tender to touch. Orders were received to insert a new midline. Resident R15's current care plan indicated the PICC line would remain intact and patent with no signs and symptoms of infection. Interventions included to See Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's clinical record revealed no documented evidence that the PICC line dressings were changed and/or adequately assessed during the duration of the IV therapy. On February 18, 2022, at 1:38 p.m. the Director of Nursing stated she reviewed Resident R10's and R15's clinical charts and no documentation was found that both residents' IV dressings were changed and/or adequately assessed during the duration of the IV therapy. 28 Pa Code 211.12(d)(1) Nursing services. 28 Pa Code 211.12(d)(5) Nursing services.

Based on observation, staff interviews and review of facility policy and procedure, it was determined the facility failed to maintain an effective infection control program related to laundry personnel removing of soiled gown and gloves, hand washing and readily available hand sanitizer within the entrance/ext to the skilled nursing facility and for three of three nursing units (Rose, Magnolia and Wisteria). Findings include: Review of an undated facility policy, Handwashing, revealed that the facility . has established and will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Futher review of the policy indicated, When to wash your hands, After, Direct contact with blood, body fluids or excretions, mucous membranes. Review of facility operations manual tilted, Environmental Services Laundry Operations, indicated, under the section titled, Hand Hygiene, All employees should use an alcohol -based hand sanitizer or wash with soap and water. Under the section related to Alcohol Hand Sanitizer, indicated, Washing hands with soap and water is the best way to get rid of germs in most situations. If soap and water are not readily available, you can use an alcohol - based hand sanitizer. Lastly the operations manual indicated in bold letters, Perform Hand Hygiene immediately after removing all PPE, (Personal Protective Equipment). Under the section, titled, Personal Protective Equipment, it indicated, gown is to be removed, before removing gloves, discard in designated trash/biohazard and than perform hand hygiene. During the initial tour of the laundry department, in the presence of the Director of Nursing, on July 2, 2020, from 1:15 p.m. - 1:50 p.m., the following observations were made of the laundry department: A tour of the laundry area, where dirty laundry is sorted, along with an interview with Employee E1, Laundry Aide, in the presence of The Director of Nursing, revealed that no hand sanitizer, (Alcohol - based hand rub), (ABHR 60 - 95 %, [MEDICATION(S)] or [MEDICATION(S)] containing preparation base designed for application to the hands to reduce the number of viable microorganisms), was readily available to Employee E1 while sorting dirty laundry. Employee E1, indicated during the interview that the sink for hand washing is located on the other side of the laundry area. At the time of the interview, the Director of Nursing confirmed that no hand sanitizer was readily available within the dirty side of the laundry department. Additionally during the interview, the laundry aide indicated that she removes her dirty gloves from her hands before removing the protective gown that she wore while sorting dirty clothes and/or linen. At the conclusion of the interview with Employee E1, the Director of Nursing confirmed that Employee E1, did not indicate the correct process for removing a soiled gown and gloves, after handling soiled linens and/or clothing. Interview with The Director of Nursing at the conclusion of the tour of the laundry department, confirmed that an effective infection control program was not in place as needed, related to hand washing and removal of soiled PPE. Observation of the elevator area and the main entrance area, on July 2, 2020, at 3:15 p.m. revealed, the skilled nursing facility did not have hand sanitizer readily available for use by residents, staff and/or visitors. It was revealed upon entering onto the skilled nursing unit that no hand sanitizer was available to use, before one would exit the main doors of the skilled nursing facility. In continuing the initial tour of each of the three wings of the skilled nursing facility it was observed that hand sanitizer was not readily available within each hallway for staff, residents and/or visitors to use. Interview with the Director of Nursing at 4:05 p.m. confirmed that each of the three nursing units, the main entrance area and before exiting back through the main doors, that no hand sanitizer was readily available for personal use. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department conducted on (MONTH) 25, 2019, at 11:20 a.m. with Employee E3, the Food Service Director, which revealed the following concerns: Observation in the chemical room in the kitchen receiving area revealed a large crack in the plaster wall above the bulk chemical rack. Observation in the walk-in freezer revealed an open box of breaded country fried beef steaks unwrapped and exposed to the circulating air. Above observations were confirmed by Employee E3, Food Service Director on (MONTH) 25, 2019, at approximately 11:45 a.m. Observations during a tour of the first floor kitchenette adjacent to the main dining room with the Food Service Manager at 1:10 p.m. on (MONTH) 25, 2019 revealed brownish rust colored stains on the inside surface, the bottom lip and exterior surface of the the stainless steel hood above the dish machine. This observation was confirmed by the Food Service Manager on (MONTH) 25, 2019, at approximately 1:30 p.m. The facility failed to store, prepare and serve food in accordance with professional standards for food service safety. 42CFR §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(3) Management

Based on observation and staff interview, it was determined that the faciltiy failed to ensure that cardboard waste was properly contained and the dumpster area was properly maintained. Findings include: Observations in the dumpster area on (MONTH) 25, 2019, at 11:20 a.m. revealed a tall recycling dumpster full of cardboard boxes with the lid open and cardboard hanging out of the top of the dumpster, and a stack of cardboard on the ground next to the dumpster, an old electric motor sitting on top of a stack of cardboard, lose paper and an empty plastic motor oil container on the ground near the dumpster. The observation of the dumpster area was confirmed with Employee E3, Food Service Director on (MONTH) 25, 2019, at 11:20 a.m. 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(3) Management

Based on a clinical record review and staff interviews, it was determined that the facility failed to implement a comprehensive care plan for weight loss for one of 17 clinical records reviewed (Resident R22). Findings include: Review of Resident R22's clinical record revealed [DIAGNOSES REDACTED]. Review of the Registered Dietary Note dated (MONTH) 9, 2019 stated Resident R22 had a 8.9% weight loss within past 30 days and would continue to monitor the resident for high nutrition risk. Review of Resident R22's plan of care revealed a self-care performance deficit with eating dated (MONTH) 1, 2019, with interventions stating to monitor and record the percentage of meals consumed. On (MONTH) 27, 2019 at 11:11 a.m. Registered Dietitian Employee E7 stated that the nursing staff did not monitor and record the percent of the meal Resident R22 eats during her meals. The Director of Nursing on (MONTH) 2, 2019, at approximately 11:00 a.m. confirmed the facility did not implement Resident R22's care plan by failing to monitor and document the resident's meals percentage. 28 Pa Code 211.5(f) Clinical records Previously cited 1/3/2017, 12/4/2017 28 Pa Code 211.11(d) Resident Care Plan Previously cited 12/4/17 28 Pa Code 211.12(c)(d)(3) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 12/4/17

Based on clinical record review, incident investigation reports, facility policy, and staff interviews, it was determined that the facility failed to monitor and supervise staff during the transfer of one of 16 residents reviewed resulting in harm to Resident R10. Findings include: A review of the clinical record of Resident R10 revealed a re-admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Facility Event Report dated October 18, 2013, indicated that Resident R10 was totally dependent on staff for all ADL tasks. Review of a nursing progress note, revealed that on October 18, 2013 at 7:30 p.m., Employee E5, nurse aide, reported finding a "lump" on Resident R10 ' s right thigh area, resident was reportedly crying, guarding right thigh area and stated "it was hurting today". Review of nursing progress note on October 18, 2013 at 8:00 p.m. revealed that while awaiting transport to the hospital, the resident presented with swelling at the site, point tenderness, and the femur viewable directly under the skin. The physician was notified and ordered the resident transferred to the hospital for further evaluation. The resident was later transferred with the hospital contacting the facility of an admission to the hospital with a [DIAGNOSES REDACTED]. Interview with Employee E5 on October 21, 2013 at 2:15 p.m. revealed that she was preparing to transfer Resident R10 into her bed at 7:30 p.m. unassisted. Review of facility incident investigation report dated October 18, 2013 at 7:30 p.m. revealed the following , " That the Employee E5 attempted to transfer Resident R10 by grabbing the back of her pants, assisting her to stand, and then pivoting her on her strong leg, the left leg. The resident began to buckle and Employee E5 overcompensated by putting her in the bed as quickly as she could. In the process of doing this, the right leg got twisted. As Employee E5 was undressing the resident, the nurse aide noted her leg looked funny. " An investigation was begun by the facility into the incident with Employees E2 and E6 interviewing Employee E5 on October 21, 2013, regarding her moving the resident into bed and the resulting fracture. Employee E5 admitted transferring this resident unassisted with the resident not presenting with any distress. The resident had been assessed as a high fall risk since January, 2012 and a review of Resident R10's care plan indicated a transfer requiring four persons when using a bedsheet or use of a mechanical lift. A Resident Transfer Assessment Form dated October 2, 2013 directed a transfer did, in fact, require a mechanical lift and review of the undated facility Resident Transfer Policy further directed "All mechanical lift transfers will be done with two people present." (Procedure, #6 `) Lastly, a review of Resident R10's quarterly MDS ( Minimum Data Set - an assessment tool identifying resident needs ) dated July 17, 2013 further identified the resident as requiring a two person assist for transfers. These findings were validated in an interview with Employee E2 on December 4, 2013. The facility failed to insure adequate supervision of staff and further failed to follow established facility policy during an unsafe transfer resulting in a fracture and harm to Resident R10. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services