Every finding on record at McMurray Hills Rehabilitation and Healthcare Cente

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for 11 of 49 residents (R1, R2, R12, R13, R14, R15, R16, R17, R18, R19, and R20).Findings include: Review of the facility policy Identifying Exploitation, Theft and Misappropriation of Resident Property dated 9/1/25, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent., indicated misappropriation of resident property is strictly prohibited, with drug diversion (taking the resident's medication) provided as an example of misappropriation. Review of information submitted to the state survey agency indicated that on 3/23/26, at 11:00 a.m., Center supervisor was notified by anonymous male caller that he had found a purse on the side of the road which contained multiple medication cards on several residents of [the facility]. DON (Director of Nursing) and Administrator presented to police station. Shown contents of pink bag with multiple medications and Tuberculin employment skin testing record and orientation sheet - both with name [Licensed Practical Nurse (LPN) Employee E1] written on them. There were eleven resident medications in individual dispense bags. No controlled substances are identified. The medication dates and assignments areas coincided with LPN Employee E1's assignments on these two days / shifts. MARS (Medication Administration Records) reviewed for all residents on these two assignment areas on these dates and shifts - all medications are signed out by this LPN. The submission listed Residents R1, R2, R12, R13, R14, R15, R16, R17, R18, R19, and R20. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property completed 3/27/26, indicated that facility substantiated the allegation of misappropriation and documented, Police will be conducting their own investigation. LPN has been terminated from employment, she has admitted they were in her purse off property. During an interview on 3/30/26, at approximately 1:00 p.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the facility failed to ensure that residents are free from misappropriation of property for 11 of 49 residents. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.28 Pa. Code: 201.29(j) Resident rights.

Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for eleven of sixteen residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11).Findings include: The facility policy Controlled Substances last reviewed 9/1/25, indicated Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detection /follow-up. Review of Resident R1's MAR (medication administration record) for March 2026, revealed an order for oxycodone 10mg (a narcotic pain medication used to treat moderate to severe pain) to be given every morning and additionally every six hours as needed for pain. Three as needed administrations were documented on the MAR from 3/16/26, through 3/30/26. Review of Resident R1's Controlled Drug Record indicated that six additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 3/18/26 (x2 doses), 3/23/26, 3/24/26, 3/26/26, and 3/27/26. Review of Resident R2's MAR for March 2026, revealed an order for Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) to be given every six hours as needed for pain. Zero administrations were documented from 3/1/26, through 3/30/26. Review of Resident R2's Controlled Drug Record indicated that two doses of Tramadol were signed out without corresponding documentation of administration to the resident on 3/15/26, and 3/16/26. Review of Resident R3's MAR for March 2026, revealed an order for oxycodone 5mg to be given every six hours for pain. Seven administrations were documented from 3/20/26, through 3/30/26. Review of Resident R3's Controlled Drug Record indicated that nine additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 3/21/26 (x2 doses), 3/22/26, 3/23/26, 3/24/26 (x2 doses), 3/26/26, 3/28/26, and 3/29/26. Review of Resident R4's MAR for March 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for pain. Five administrations were documented on the MAR from 3/4/26, through 3/30/26. Review of Resident R4's Controlled Drug Record indicated that thirteen additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 3/4/26, 3/6/26, 3/9/26, 3/10/26, 3/12/26, 3/15/26 (x2 doses), 3/16/26, 3/17/26, 3/18/26 (x2 doses), 3/22/26, and 3/24/26 (x2 doses). Review of Resident R5's MAR for March 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for moderate pain. Eight administrations were documented on the MAR from 3/11/26, through 3/30/26. Review of Resident R5's Controlled Drug Record indicated that sixteen additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 3/11/26 (x2 doses), 3/12/26, 3/13/26, 3/14/26, 3/15/26 (x2 doses), 3/16/26 (x3 doses), 3/18/26 (x2 doses), 3/19/26, 3/24/26, 3/25/26, and 3/28/26. Review of Resident R6's MAR for March 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for moderate pain and two tablets every six hours for severe pain. Four administrations of five milligram doses were documented on the MAR from 3/18/26, through 3/30/26. Review of Resident R6's Controlled Drug Record indicated that four additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 3/18/26 (5 mg), 3/18/26 (10 mg signed out, documented on MAR as 5 mg), 3/29/26 (10 mg), and 3/23/26 (5 mg). Review of Resident R7's MAR for March 2026, revealed an order for Tramadol 50mg to be given every six hours as needed for pain. One administration was documented on the MAR from 3/13/26, through 3/19/26. Review of Resident R7's Controlled Drug Record indicated that one additional dose of Tramadol was signed out without corresponding documentation of administration to the resident on 3/16/26. Review of Resident R8's MAR for March 2026, revealed an order for oxycodone 5 mg to be given every four hours for moderate pain. One administration was documented on the MAR from 3/2/26, through 3/23/26. Review of Resident R8's Controlled Drug Record indicated that one additional dose of oxycodone was signed out without corresponding documentation of administration to the resident on 3/10/26. Review of Resident R9's MAR for March 2026, revealed an order for hydrocodone/ acetaminophen 5-325 (hydrocodone, an opiate narcotic pain medication and acetaminophen) to be given twice daily as needed for pain. Two administrations were documented on the MAR from 3/2/26, through 3/9/26. Review of Resident R9's Controlled Drug Record indicated that three additional doses of hydrocodone/ acetaminophen were signed out without corresponding documentation of administration to the resident on 3/3/26 (x2 doses) and 3/4/26. Review of Resident R10's MAR for March 2026, revealed an order for Tramadol 50mg to be given every twelve hours as needed for severe pain. Three administrations were documented on the MAR from 3/15/26, through 3/30/26. Review of Resident R10's Controlled Drug Record indicated that four additional doses of Tramadol were signed out without corresponding documentation of administration to the resident on 3/15/26, 3/26/26, 3/27/26, and 3/29/26. Review of Resident R11's MAR for March 2026, revealed an order for Tramadol 50mg to be given every six hours as needed for severe pain. Three administrations were documented on the MAR from 3/10/26, through 3/30/26. Review of Resident R11's Controlled Drug Record indicated that twelve additional doses of Tramadol were signed out without corresponding documentation of administration to the resident on 3/13/26, 3/14/26, 3/17/26, 3/18/26, 3/19/26 (x2 doses), 3/20/26, 3/21/26, 3/22/26, 3/26/26, 3/27/26, and 3/29/26. During an interview on 3/30/26, at approximately 1:00 p.m. the Nursing Home Administrator and the Interim Director of Nursing confirmed that the facility failed to make certain controlled substances were accounted for accurately for eleven of sixteen residents. 28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide a treatment as per physician's order for one of three residents with wounds (Resident R1).Findings include:Review of the facility policy Wound Treatment Management last reviewed on 9/1/2025, indicated that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the Treatment Administration Record or in the electronic health record.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included spinal fusion of neck and upper back vertebrae, high blood pressure, and falls.Review of a MDS (Minimum Data Set- a periodic assessment of care needs) dated 8/7/25, indicated the diagnoses remained current. Review of Resident R1's physician orders dated 9/17/25, indicated cleanse cervical (upper back/neck) incision with NSS (normal saline) pat dry, apply calcium alginate Ag (promotes wound healing) to wound bed, cover with border dressing, and change daily.Review of Resident R1's Treatment Administration Record (TAR) dated September 2025, indicated that the above treatment was not documented as completed on 9/19, and 9/20/25. There was no further documentation in the electronic record that treatment was completed on 9/19, and 9/20/25. During an interview on 10/10/25, at 4:30 p.m., The Director of Nursing (DON) confirmed the above findings and that the facility failed to provide treatment for a wound as per physician's order for Resident R1.28 Pa. Code: 211.10(a)(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a person-centered comprehensive care plan for one of eight residents (Resident R38). Findings include: A review of the facility policy Comprehensive Care Plans reviewed 1/30/23 and 7/19/24, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident\, consistent with resident rights. That include measurable objectives, and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the resident ' s comprehensive assessment. A review of the clinical record revealed Resident R38 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/29/24, indicated the diagnoses remain current. Further review of the MDS Section N: Medications, Question N0350 indicated Resident R38 received insulin injections seven days a week. A review of the Admission Assessment completed 8/7/23, indicated a goal of Resident R38 was to have no complications related to diabetes. A review of a physician order dated 8/7/23, indicated to give glucose gel (to treat low blood sugar) give 15 gram by mouth for glucose 50-69. Review of a physician order dated 12/21/23, indicated to inject Humulin R insulin (short-acting insulin that starts within 30 minutes and peaks in two to three hours, and keeps working for eight hours) per sliding scale. If results are less than 70 follow hypoglycemic protocol. A review of the clinical record failed to reveal a person-centered care plan was developed for Resident R38 to address interventions relating to diabetes care. During an interview on 12/4/24, at 11:35 a.m. Registered Nurse Admission Coordinator (RNAC) Employee E1 confirmed Resident R38 ' s care plan did not include person-centered interventions for diabetes. 28 Pa. Code: 211.12 (d) (1) (5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of five residents reviewed (Residents R7, and R38). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Notification of Change reviewed 7/19/2024, indicated the facility will ensure to promptly inform the resident, consults the resident's physician, and notifies the resident's representative, if applicable, when there is a change requiring notification. Circumstances requiring notification include accidents, significant change is resident status, and circumstances that require a need to alter treatment. Review of the facility policy Hypoglycemic Management reviewed 7/19/2024, indicated if the blood glucose reading is 70 or below, the nurse will utilize the hypoglycemic protocol as per practitioner's orders, with follow up blood glucose as indicated, and notify the practitioner of the results ordered. The blood sugar(s) and treatment will be documented as per facility protocol. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. Review of Resident R7's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/24/2024, indicated the diagnoses remain current. Review of a physician's order dated 8/11/2024 to 8/15/2024, indicated Accuchecks (machine used to check the blood glucose level) three times a day and at bedtime. Call MD (doctor) for blood sugar less than 80 or over 250. A physician's order dated 8/15/2024, indicated to inject Humalog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) eight units every morning and bedtime. Hold if blood glucose is less than 100. Use Freestyle Libre to obtain blood sugar. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 8/13/2024, at 8:50 p.m. CBG was noted to be 299. On 8/14/2024, at 4:43 p.m. CBG was noted to be 273. On 8/14/2024, at 8:24 p.m. CBG was noted to be 311. On 8/28/2024, at 6:44 a.m. CBG was noted to be 53. On 12/3/2024, at 4:32 p.m. CBG was noted to be 431. Review of the care plan dated 5/14/2019, indicated the following interventions: blood sugar as needed for symptoms of hypo/hyperglycemia, monitor/document/report signs and symptoms hyper-/hypoglycemia, diabetes medication as ordered by doctor. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of a clinical record indicated Resident R38 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician's orders dated 8/7/2023, Glucose Oral Gel give 15 grams by mouth as needed for glucose 50-69. An order dated 9/19/2023, indicated Glucose Oral Gel give 30 grams by mouth as needed for low blood glucose. Further review of the physician orders dated 4/22/2024, indicated Freestyle Libre 14-day Sensor (continuous glucose system sensor), one unit every 14 days for blood glucose monitoring. An order dated 12/21/2023, indicated to inject Humulin R insulin (short-acting insulin that starts within 30 minutes and peaks in two to three hours, and keeps working for eight hours) per sliding scale on every Monday, Wednesday, Friday, and Sunday, if below 70 follow hypoglycemic protocol, if greater than 400 call MD. Review of Resident 38's eMAR revealed that the resident's CBG's were as follows: On 12/1/2024, at 5:20 a.m. the CBG was noted to be 54. A review of Resident R38's care plan dated 7/30/2024, indicated the following interventions: Monitor/document/report as needed signs and symptoms of hyper-/hypoglycemia. Review of Resident R38's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, physician orders were not followed, and the physician was not notified of abnormal results. During an interview on 12/4/2024, at 1:50 p.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood glucose results under 70, they would give juice and/or snacks, and recheck the blood glucose in 15 minutes. If blood glucose was greater than 400, they would check the orders for parameters, they would give the ordered dose of insulin, call the doctor, and document in the nurse's notes. During an interview on 12/4/2024, at 1:55 p.m. LPN Employee E5 stated if the blood glucose was under 70, they would give a snack or juice. If the blood glucose was greater than 350 - 400, they would give the ordered insulin, call the doctor, and recheck the blood glucose in 15-30 minutes. They would document in the nurse's notes. During an interview on 12/4/2024, at 2:02 p.m. LPN Employee E3 stated if the blood glucose was less than 70, they would give juice or snacks. If blood glucose was over 400, they call the doctor and follow the orders received. They would document in nurse's notes. During an interview on 12/4/2024, at 2:45 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R7, and R38. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for 24 of 31 residents (Residents R1. R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24). Findings include: Review of the facility policy Transfer and discharge date d 6/20/24, previously reviewed 1/30/23, indicated for emergency discharges, the Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman. Review of the facility provided Hospital Tracking Portal report, reviewed for the dates 6/1/24, through 9/30/24, included the following information: Resident R1 was transferred emergently to the hospital on 6/9/24. Resident R2 was transferred emergently to the hospital on 6/11/24. Resident R3 was transferred emergently to the hospital on 6/24/24. Resident R4 was transferred emergently to the hospital on 6/30/24. Resident R5 was transferred emergently to the hospital on 7/3/24. Resident R6 was transferred emergently to the hospital on 7/5/24. Resident R7 was transferred emergently to the hospital on 7/8/24, and 7/12/24. Resident R8 was transferred emergently to the hospital on 7/26/24, and 7/31/24. Resident R9 was transferred emergently to the hospital on 8/1/24, and 8/16/24. Resident R10 was transferred emergently to the hospital on 8/2/24. Resident R11 was transferred emergently to the hospital on 8/8/24. Resident R12 was transferred emergently to the hospital on 8/18/24. Resident R13 was transferred emergently to the hospital on 8/22/24. Resident R14 was transferred emergently to the hospital on 8/26/24. Resident R15 was transferred emergently to the hospital on 8/26/24. Resident R16 was transferred emergently to the hospital on 9/5/24. Resident R17 was transferred emergently to the hospital on 9/10/24. Resident R18 was transferred emergently to the hospital on 9/11/24. Resident R19 was transferred emergently to the hospital on 9/17/24. Resident R20 was transferred emergently to the hospital on 9/17/24, and 9/23/24. Resident R21 was transferred emergently to the hospital on 9/21/24. Resident R22 was transferred emergently to the hospital on 9/21/24. Resident R23 was transferred emergently to the hospital on 9/27/24. Resident R24 was transferred emergently to the hospital on 9/29/24. Review of the facility provided Discharge Log for June, July, August, and September 2024 failed to include the above residents. During an interview on 10/9/24, at approximately 12:30 p.m. the Business Officer Manager confirmed the above resident transfers were not communicated to the Office of the Long-Term Care Ombudsman. During an interview on 10/9/24 at 1:40 p.m. the Director of Nursing (DON) confirmed the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for 24 of 31 residents. 28 Pa. Code 201.29(a)(c)(3)(2) Resident rights.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings: Review of facility policy Documentation in Medical Record indicated each resident's medical record shall contain an accurate representation of the actual experience of the resident. Documentation shall be factual, objective, and resident centered. Documentation shall be accurate, relevant, and complete. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, anxiety, and diabetes. Review of the clinical record Blood Pressure Summary revealed documentation of the following: On 7/1/24, at 6:36 a.m. 126/78 (lying r/arm). Indicating Resident R1's position, and where the blood pressure was taken. On 6/20/24, at 12:55 p.m. 137/55 (sitting r/arm). On 6/12/24, at 10:22 p.m. 128/70 (lying r/arm). On 6/12/24, at 4:20 p.m. 136/72 (lying r/arm). Review of a progress note dated 6/10/24, at 9:55 p.m. indicated on admission resident had a right AV Fistula (a connection that's made between an artery and a vein for dialysis access). A progress note dated 6/24/24, at 12:42 a.m. indicated that at 10:30 p.m. the nurse was notified of Resident R1 having swelling in her right arm, with decreased bruit and thrill (rumbling or swooshing sound of a dialysis fistula bruit is caused by the high-pressure flow of blood through the fistula and felt through the skin). During an interview on 7/30/24, at 12:12 p.m. Registered Nurse (RN) Employee E1 stated if resident's have an access site (PICC, IV, Fistula, graft, etc.) on their body, that body part is not to be used for blood pressures or blood draws. The facility does not hang signs in the residents rooms due to privacy. During an interview on 7/30/24, at 12:20 p.m. RN Employee E2 stated she would not use the PICC/IV/fistula arm for blood pressures or blood draws. She was the nurse that documented the use of the right arm for blood pressures on 6/20/24. She stated she knows for sure that she did not use the right arm for blood pressures. RN Employee E2 stated she also works for at a dialysis center on Monday-Wednesday-Friday's and knows not to do that. She stated Resident R1 was very alert and would make sure to tell staff not to use that arm, she was very adamant about it. RN Employee E2 states it was a documentation error on her part, body parts are listed in a drop-down box when charting vitals, and she must have scrolled to the wrong arm. During an interview on 7/30/24, at 1:00 p.m. the DON stated the right arm swelling started on 6/24/24, and the resident was sent to the hospital for evaluation. During a telephone interview on 7/30/24, at 2:44 p.m. RN Employee E3 stated she remembered Resident R1 and the resident would tell her which arm to use. She was also a staff member who documented using right arm for blood pressures. She stated it was a documentation error. During a telephone interview on 7/30/24, at 2:47 p.m. RN Employee E4, stated she knows for a fact that she did not use Resident R1's right arm because her mother receives dialysis treatments and she knows how important the fistula limb is. She is listed as a staff member that documented using the right arm. She stated it was a documentation error. During a telephone interview on 7/30/24, at 2:49 p.m. Licensed Practical Nurse Employee E5 stated she remembers taking Resident R1 ' s vital signs in the left arm. She is listed as a staff member that documented using the right arm. She stated it was a documentation error. During an interview on 7/30/24, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure documentation was accurate and complete for Resident R1. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, observations and staff interviews it was determined that the facility failed to maintain food equipment in a clean, sanitary condition, to prevent the potential for cross-contamination. (Main Kitchen) Findings include: A review of the facility Handling Clean Equipment and Utensils reviewed 1/30/23, indicated clean equipment and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust During an observation of the Main Kitchen on 11/7/23, at 9:40 a.m. pots and pans were observed being stored hanging over the two-compartment sink where soiled pots and pans are washed. During an interview on 11/7/23, at 9:42 a.m. the Dietary Manager Employee E5 confirmed the hanging pots and pans should not be stored over the dirty sink. 28 Pa. Code 211.6(c)(f) Dietary services.

Based on review of facility policy, resident clinical record, investigation documentations and staff interview, it was determined that the facility failed to report an injuries of unknown sources which caused severe bruising requiring xrays for two of four residents (R15 and R20), failed to report neglect when staff failed to making certain alert equipment was properly functioning to prevent a potential injury for one of four residents (Resident R24) and failed to protect a resident from further potential neglect and retaliation for one of four residents (Resident R131). Findings include: Review f the facility policy Abuse Policy and Procedure last reviewed on 1/30/23, indicated that the facility staff are trained to identify abuse, neglect, etc. and understanding that an injury that is unusual can also indication of alleged violations, protecting the victim during the investigation, and reporting allegations to the appropriate agencies. Review of the clinical record indicated that Resident R15 was admitted to the facility on [DATE], with diagnoses which included Dementia with psychotic episodes, history of falls, anxiety and vascular disease. A Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 9/25/23, indicated the diagnoses remained current. Review of Resident R15's plan of care included staff encourage Resident R15 the wear non skid socks and/or shoes prior to attempting to ambulate and to ensure equipment is readily available for Resident R15 and Resident R15 is a transfer with assistance of two staff and a Hoyer lift (total lift). Review of a progress note dated 9/30/23, indicated that Resident R15 had developed a bruise on the top and bottom of her right great toe extending down the foot including other toes. Review of the incident report dated 9/30/23, did not include a full investigation to determine the root cause and also indicated xrays had been ordered, which were indicated as negative for fracture. The document did not include that the State agency or other agencies had been notified of the injury of unknown origin. Review of the clinical record indicated that Resident R20 was admitted to the facility on [DATE], with diagnoses which included history of falls, with a fracture of her right arm, macular degeneration (poor vision), dementia, difficulty with ambulation and refusal of care. A MDS dated [DATE], indicated that diagnoses remained current with the healing of the right arm fracture. Review of Resident R20's plan of care indicated the placement of upper siderails to Resident R20's bed for mobility and weakness. Resident R20 was a transfer with assistance of one staff. Review of a progress note dated 9/17/23, indicated that Resident R20 developed a bruise to her right forearm from the top of the right arm extending to the elbow. Review of an incident report dated 9/17/23, indicated xrays had been ordered and were identified as no fractures. The document did not include that the State office and other agencies had been notified of the injury of unknown origin. Review of the clinical record indicated that Resident R24 had been admitted to the facility on [DATE], with diagnoses which included heart failure, bladder cancer, heart block, dementia and repeated falls. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R24's plan of care indicated siderails placed on Resident R24's bed for mobility and weakness. Resident R24 is a transfer of two staff. Resident R24 on a fall protocol which included determination of root causes and try to remove the potential for falls and placement of bed and chair alarms to alert staff of Resident R24's rising. Review of a progress note dated 5/27/23, indicated that the nurse heard Resident R24's alarm sounding and found Resident R24 on the floor when he attempted to place himself in bed. This occurred at 9:45 p.m. Review of a progress note dated 6/20/23, indicated that a Hospice aide had taken Resident R24 to the bathroom and had Resident hold grab bar for her to remove wheelcahir. Resident R24 became dizzy and had to be lowered to the floor. Resident R24 required assistance of three staff to transfer back into wheelchair. Review of an incident report dated 6/20/23, indicated that the resident was educated to use the shower chair instead of standing in the shower. The incident was not fully investigated to include whether one staff had transferred the resident, was he in the bathroom or shower, etc. The incident was not reported to the State agency or other agencies as required. Review of progress note dated 7/4/23, at 3:15 a.m., indicated that Resident R24 had fallen from his wheelchair. The staff identified that Resident R24 bed alarm was not plugged in. Review of an incident report dated 7/4/23, indicated that two nurse aides came down hall and found Resident on floor beside wheelchair with bed alarm not sounding as it was not plugged in. Resident R24 had self transferred. The incident report indicated that Resident R24 stated he had to poop and was trying to get to his wheelchair and he slid . The bed was in high position and he did not have non skid socks on. The report indicated that the bed pad plug would not stay in unless the alarm box was kept upright, the bed alarm was broken. The report did not indicate the State agency and other agencies being notified. Review of the clinical record indicated that Resident R131 had been admitted to the facility on [DATE], with diagnoses which included enlarged prostate with lower urinary tract symptoms, heart flutter, blood cancer, blindness, pressure ulcer of his sacrum and buttocks and clostridium difficile( C-Diff-causing frequent liquid stools related to a intestinal infection). A MDS dated [DATE], indicated the diagnoses remained current. Resident R131 had been admitted with a urinary catheter. Review of the Facility Grievance logs dated from 12/30/22, through October 2023, indicated that Resident R131's daughter had submitted a grievance on 3/15/23, related to Resident R131 being in therapy for 15 minutes and needing to get changed as he had soiled his brief with stool. The grievance indicated that once upstairs, he waited for a total of an hour and a half for someone to change him and then he was not returned to therapy to finish his session. Review of the grievance log indicated that on 5/31/2, Resident R131's daughter submitted a grievance realte to Resident R131 having issues with two Nurse Aides, because he had been incontinent of bowel due to his C-Diff and his being embarrassed about not being able to control it. The one specifically named Nurse Aide had made comments of I don't get paid enough, Why can't you take yourself to the bathroom. Resident R131's daughter stated that the named Nurse Aide gets angry. The daughter went on to state that she was afraid to say anything as she did not her dad to be retaliated against. Review of the staffing sheets on dates of June 2nd, 3rd, 4th etc. revealed the facility schedule did not protect Resident R131 from potential retaliation; employees named in the greivance were not removed from the schedule pending an investigation. During an interview on 11/8/23, at 12: 48 p.m., the Director of Nursing confirmed that the facility failed to report potential abuse/neglect for four of four residents. Failed to protect one of four residents from potential for continued neglect (Resident R131). 28 Pa. Code: 201.4(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(2) Management. 28 Pa. Code: 201.29(a)(c)(d)(j)(m) Resident rights.

Based on review of facility policy, personnel records, and staff interview, it was determine that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. Findings include: Review of the Activity Supervisor job description indicated the qualifications were as required by State and Federal Regulations. Review of Activities Director Employee E3's personnel record indicated she was hired on 8/9/23. Review of Activities Director Employee E3's personnel record did not include evidence that Activities Director Employee E3 had proper qualifications as an Activities Director. The personnel record did not include previous history as an Activity Director within the last five years, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During a interview on 11/8/23, at 12:05 p.m. Activities Director Employee E3 confirmed that she did not have education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During an interview on 11/8/23, at 12:30 p.m. the Nursing Home Administrator confirmed Activities Director Employee E3 was hired on 8/9/23, and the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program. 28 Pa. Code: 201.18(b)(3) Management.

Based on a review of facility policy, facility documentation and staff interview, it was determined the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055)published by the Centers for Medicare and Medicaid Services which provides information to residents/resident representatives so they can decide if they wish to continue skilled nursing services that may not be paid for by Medicare and assume financial responsibility for one of three residents (Resident R182). Findings include: Review of facility policy titled Advance Beneficiary Notices last reviewed 1/30/23, informed it is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. The current CMS approved version of forms shall be used at the time of issuance to the beneficiary (resident or resident representative). For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS-1005. A review of Resident R182's clinical record documented the resident was admitted to the facility on [DATE], and discharged [DATE]. A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form CMS-20052 (published by the Centers for Medicare and Medicaid Services and used to determine if nursing care facilities are in compliance with notifying residents/resident representatives of a termination/denial/resident discharge from Medicare Part A services) documented Resident R182 had a Medicare Part A termination date of 7/6/23. The facility failed to provide Resident R182 with a Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) which provides information to residents/resident representatives so that they can decide if they wish to continue receiving skilled nursing services that may not be paid for by Medicare and assume financial responsibility. During an interview on 11/8/23, at 12:45 p.m. Social Worker Employee E1 confirmed the facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055) to decide if residents/resident representatives wish to continue skilled nursing services that may not be paid for by Medicare and assume financial responsibility. 28 Pa. Code 201.18(e)(1) Management.

Based on facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to review and revise the comprehensive care plan after a fall for two of six residents. (Resident R12 and R62) Findings include: A review of the facility policy Care Plan Revisions upon Status Change reviewed 12/23/22 and 1/30/23, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment A review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), major depressive disorder, an artificial hip joint, history of falling, and ataxic gait (poor muscle control and clumsy voluntary movements). A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/2/23, indicated the diagnoses remained current. Further review of the MDS dated [DATE], Section C: Cognitive Patterns indicated the resident had a Brief Inventory for Mental Status (BIMS) score of 03. A review of a physician orders dated 11/9/2023, indicated Resident R12 was ordered a Wander Guard bracelet on 7/6/22, and it was discontinued on 1/5/23. A review of Resident R12's progress notes revealed on 9/21/23, the resident self propelling self in w/c [wheelchair] out front door. He was redirected by CNA [certified nursing assistant]. Wanderguard was applied. A review of the care plan dated 9/7/23, failed to include Resident R12's elopement on 9/21/23. A review of the comprehensive care plan did not include interventions for Resident R35 ' s fall. A review of the clinical record indicated Resident R62 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and anxiety. A review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs Question O0100; K: Hospice Care, indicated Resident R62 receives hospice care. A review of a physician order dated 9/30/2022, indicated Resident R62 was admitted to hospice services as of 9/7/2022. A review of the care plan failed to include hospice services. During an interview on 11/8/23, at 1:05 p.m. Registered Nurse Admission Coordinator (RNAC) Employee E4 confirmed that Resident R12 and R62's comprehensive care plan was not revised to reflect the resident's current status. 28 Pa. Code 211.11(d) Resident Care Plans.

Based on clinical and facility record review, facility policy review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for two of six residents (Resident R35 and R12). Findings include: Review of the facility policy Accidents and Supervision reviewed 1/30/23, indicated the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. All staff are to be involved observing and identifying potential hazards while taking into consideration the unique characteristics and abilities of each resident. Implementation of interventions includes development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. Review of the facility policy Use of Assistive Devices reviewed 1/30/23, includes wheelchairs and indicated the nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use will be documented in the medical record. Modifications to the care plan will be made as needed. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment A review of the clinical record revealed that Resident R35 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), high blood pressure, and muscle weakness. Review of Resident R35's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/15/23, indicated the diagnoses remain current. Further review of the MDS dated [DATE], indicated Resident R35's BIM score was 11. Review of a nurse progress note dated 10/6/23, indicated that Resident R35 was self-propelling her wheelchair in the hallway on her way back to her bedroom. Staff asked Resident R35 if she needed assistance as she had two cups of ice in one hand and one of juice in her other hand. Resident R35 stated she did need assistance, but refused to allow the nurse to attach the leg rests. When the nurse reached the resident's room, she placed her feet on the floor and fell face forward onto the floor. A review of a physician order dated 10/7/23, indicated neuro checks every four hours for 48 hours, post-fall 10/6/23, every shift until 10/9/23, at 7:00 p.m., Further review of the physician orders dated 10/7/23, indicated to apply ice pack to head injury for 10-15 minutes every two hours every shift for head injury, and Tylenol Extra Strength 500 milligrams (mg) one 500 mg tablet as needed for head injury. Review of the care plan dated 4/17/23, indicated Resident R35 had Activities of Daily Living (ADL) self-care deficit and wheels herself in wheelchair. Further review of the care plan dated 4/17/23, revealed the resident was at risk for falls and instructed staff to encourage resident to have staff carry her items to her desired location. Monitor/anticipate/intervene for causative factors, and follow facility fall protocol. Care plan dated 4/21/23, indicated resident had impaired cognition related to dementia and to cue, reorient, and supervise as needed. During an interview on 11/7/23, at 1:05 p.m. Rehab Director Employee E7 stated therapy assesses each resident on admission and quarterly for walkers, wheelchairs, and other assistive devices. If residents self-propel in their wheelchairs, leg rests are provided for emergency use, and stored in the resident's room. If a self-propelling resident is alert and oriented and able to hold their legs up, they are sometimes pushed without leg rests. He was unsure how the nurses or nurse aides assist the residents on the units. During a telephone interview on 11/8/23, at 3:00 p.m. Licensed Practical Nurse (LPN) Employee E6 stated Resident R35 was carrying two 8 ounce (oz) cups of ice in one hand and another 8 oz cup of juice in the other. She asked Resident R35 if she would like help and was told yes. LPN Employee E6 stated she offered leg rests, that are stored in the resident's room, and the resident refused. LPN Employee E6 stated she told Resident R35 that she would help and to keep her legs up, Resident R35 put her feet down a few times on the way to her room. When they reached Resident R35's room, she was asked if she needed a break from holding her legs up, she stated she did not. Resident R35 then placed her feet on the floor and fell face forward onto the floor. There was a little bit of blood noted from Resident R35's mouth where a tooth might have hit her lip. LPN Employee E6 noted bruising from a previous fall, and a goose egg above her left eyebrow. When asked how well Resident R35 responds to being educated on leg rests, LPN Employee E6 replied that it depended on the topic of education and Resident R35 had short term memory loss. When asked how LPN Employee E6 evaluated Resident R35 for the ability to hold her legs up, she answered Resident R35 was sore from her previous fall so she couldn't hold them up that long. LPN employee E6 stated that the residents are still pushed in their wheelchairs even if they refuse leg rests. During an interview on 11/8/23, at 10:30 a.m. the Director of Nursing stated if a resident asked for assistance, and they are alert and oriented they can be pushed without leg rests. If the resident had dementia and self-propelled their wheelchair, they should not be pushed without leg rests as they are at a higher risk of putting their feet down. The Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent a fall for Resident R35. A review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included dementia, major depressive disorder, an artificial hip joint, history of falling, and ataxic gait (poor muscle control and clumsy voluntary movements). A review of the MDS dated [DATE], indicated the diagnoses remained current. Further review of the MDS dated [DATE], Section C: Cognitive Patterns indicated the resident had a Brief Inventory for Mental Status (BIMS) score of 03. A review of a physician orders dated 11/9/2023, indicated Resident R12 was ordered a Wander Guard bracelet on 7/6/22, and it was discontinued on 1/5/23. A review of Resident R12's progress notes revealed on 9/21/23, the resident self propelling self in w/c [wheelchair] out front door. He was redirected by CNA [certified nursing assistant]. Wanderguard was applied. During an interview on 11/8/23, at 12: 48 p.m., the Director of Nursing confirmed that the facility failed to provide proper supervision to prevent an elopement for Resident R12. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical record reviews, observation and staff interviews, it was determined that physician-ordered treatments for wound care were not completed for two of four residents reviewed (Residents R1, and R2). Findings include: Review of the facility policy Wound Treatment Management dated 1/30/23, indicated wound treatments will be provided in accordance with physician orders, including the cleansing, method, type of dressing, and frequency of dressing change. Review of Admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/9/22, indicated the diagnoses of diabetes (sugar problems in the body), anxiety, and high blood pressure. Review of Resident R1's physician order dated 10/29/22, indicated to cleanse left plantar (the sole of the foot) heel with normal sterile saline (a cleanser), pat dry, apply skin prep (a barrier protectant) allow to dry, cover with Opti foam (adhesive foam dressing), and change daily. Review of Resident R1's treatment administration record (TAR) indicated the treatment was completed on 2/11/23 and 2/13/22. Observation on 2/14/23, at 8:51 a.m. indicated a dressing to Resident R1's left heel dated 2/10/23. Interview on 2/14/23, at 10:23 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the treatment was dated 2/10/23 and was not changed as indicated on the TAR 2/11/23, or 2/13/23, as ordered. Review of Admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure and heart failure (the heart doesn't pump blood as well as it should). Review of Resident R2's physician orders dated 2/7/23, indicated the wound treatment cleanse left lower extremity with soap, rinse with water, and dry thoroughly. Apply thin coat of Betamethasone (a steroid medication) lotion 0.5% to left lower extremity, then apply adaptic (a non-adherent dressing), every other day and as needed. Observation on 2/14/23, at 1:21 p.m. indicated Resident R2 lying in bed, with Resident R2's permission, Registered Nurse (RN) Employee E2 removed the blanket to reveal no treatment present to left lower extremity as ordered. Interview on 2/14/23, at 1:22 p.m. RN Employee E2 confirmed the physician-ordered treatment for wound care was not completed as ordered for Resident R2. Interview on 2/14/23, at 1:47 p.m. RN Employee E2 confirmed that physician-ordered treatments for wound care were not completed as ordered for two of four residents reviewed (Residents R1, and R2). 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, record review and staff interview, it was determined that the facility failed to conduct inspections of bed rails to identify areas of possible entrapment for three of three residents reviewed (Residents R29, R58 and R74). Findings include: Review of the facility's restraint policy, revealed that side rails while having potential benefits also create the risk for entrapment or injury. A review the clinical record revealed that Resident R29 was admitted to the facility on [DATE]. The minimum data Set (MDS- a periodic assessment of care needs) dated 10/18/22 included diagnoses of cancer, hypertension, and dementia. Review the MDS Section G0110 indicated that Resident R29 required extensive assistance of one person for bed mobility. During an observation of Resident 29's bed on 12/28/22, at 12:34 p.m. revealed that one quarter side rails were present on both sides of the bed. Review of Resident 29's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails were conducted to identify areas of possible entrapment. A review the clinical record revealed that Resident R58 was admitted to the facility on [DATE]. The MDS dated [DATE] included diagnoses of diabetes, hypertension, and Alzheimer ' s disease. Review the MDS Section G0110 indicated that Resident R58 required extensive assistance of two persons for bed mobility. During an observation of Resident R58's bed on 12/29/22, at 9:55 a.m. revealed that one quarter side rails were present on both sides of the bed. Review of Resident R58's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails were conducted to identify areas of possible entrapment. Review of the clinical record revealed that resident R74 was admitted to the facility on [DATE]. The MDS dated [DATE] included diagnoses of seizures, Cerebrovascular Accident (stroke), Dementia, and Dyskinesia of the Esophagus (swallowing disorder). Review of section G0100 indicated Resident R74 required extensive assistance of one person for bed mobility. During an observation of Resident R74's bed on 12/27/22, at 12:13 p.m. revealed that one quarter side rails were present on both sides of the bed. Review of the Physician orders indicate the use of a low air loss mattress was implemented on 11/29/22. Review of Resident R74's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails were conducted to identify areas of possible entrapment since 8/24/21, and the facility failed to reassess the use of bed rails upon implementation of a new mattress on 11/29/22. During an interview on 12/28/22, at 2:35 p.m. the Director of Nursing confirmed that the facility failed to perform assessments of the bed rails to identify any areas of possible entrapment. 28 Pa code 201.18(b)(1) Management.

Based on review of facility policy and clinical record review, and resident and staff interview, it was determined the facility failed to identify bilateral leg straps as potential restraint or implement interventions and monitor the use of bilateral leg straps for one of one resident reviewed (Resident R30). Findings include: Review of facility policy Restraints dated 3/2/22, indicated physical restraints are any manual, physical or mechanical device, material, or equipment, attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the body. Examples include but are not limited to, leg restraints. Review of Resident R30's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/28/22, indicated the resident was admitted to the facility on [DATE], Brief Interview for Cognitive Status indicated little to no impairment, and current diagnosis included high blood pressure, diabetes, and arthritis. During an observation and interview on 12/28/22, at 12:57 p.m., revealed Resident R30 was seated in a wheelchair with both feet placed on the wheelchair leg rests. Long velcro straps were wrapped around each of Resident R30's lower legs and attached to the individual leg rests. Resident R30 stated the straps were to prevent feet from falling off the leg rests while seated and I can not remove them. Review of Resident R30's current physician orders reviewed on 12/28/22, did not include orders for bilateral leg straps. During an interview on 12/28/22, at 2:05 p.m. Physical Therapist Employee E2 revealed that Resident R30 had no recommendation for the use of bilateral leg straps, or being evaluated for legs straps, and the leg straps have been in use since prior to 2021 when he started working at the facility. Therapy Employee E2 confirmed that therapy has not evaluated Resident R30 for the use of the leg straps. Review of Resident R30's plan of care revised 12/22/22, did not include interventions for the use of bilateral leg straps while in the wheelchair. Review of Resident R30's clinical record on 12/28/22, did not include documentation of evaluation, or monitoring for the use of bilateral leg straps. During an interview on 12/28/22, at 2:35 p.m., the Director of Nursing confirmed that the facility failed to identify bilateral leg straps as potential restraints or implement interventions and monitor the use of bilateral leg straps for Resident R30. 28 Pa. Code 211.8(e)(f) Use of Restraints. 28 Pa. Code 211.10(d) Resident Care Policies.

Based on observations and staff interviews, it was determined that the facility failed to properly store biologicals and medications securely on one of four units (C2 Even unit). Findings include: Review of the facility policy Storage of Medications dated 3/2/22, states that drugs and biologicals used in the facility are stored safely, securely and properly and only accessible to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an observation on 12/27/22, at 12:31 p.m. the C2 Treatment cart was noted to be sitting unlocked and unattended across from the resident pantry area. During an interview at that time, License Practical Nurse Employee E3 confirmed the cart was unlocked and accessible to unauthorized personnel. During an observation on 12/29/22, at 9:44 a.m. the C2 Even medication cart was noted to be unlocked and unattended in the hallway. During an interview on 12/29/22, at 9:45 a.m. Registered Nurse Employee E4 confirmed that the cart was unlocked and accessible to unauthorized personnel. 28 Pa Code: 211.9 (a)(1)(h)(1) Pharmacy Services. 28 Pa. Code: 211.12 (d)(1)(2) Nursing Services.

Based on review of facility policy, observations and staff interview it was determined that the facility failed to maintain infection control procedures and prevent the potential for cross contamination for one of four nursing units (B-unit) Findings include: The facility Standard precautions infection control policy dated 3/2/22, indicated that the facility has developed a process to be used in the care of residents regardless of their diagnoses. Standard precautions presume blood, body fluids, non-intact skin may contain transmissible infectious agents. During observations of the B-wing nursing unit on 12/27/22, at 12:11 p.m. the nursing station was found with resident refrigerator. On top of the resident refrigerator was observed a specimen refrigerator (refrigerator used to keep human bodily fluids for laboratory testing). To the left of the resident refrigerator was a centrifuge (device used to separate bodily fluids). During an interview on 12/27/22, at 12:20 p.m. the Director of Nursing (DON) stated the specimen refrigerator and centrifuge were still in use and the observed specimen refrigerator was the only one in the facility. During an interview on 12/27/22, at 12:22 p.m. the Director of Nursing (DON) confirmed that the facility failed to maintain infection control procedures and prevent the potential for cross contamination for one of four nursing units (B-unit) 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy, clinical record review, and interviews, the facility failed to assess and identify the potential risk of elopement for one of four residents in the facility (Resident R1), placing the resident in Immediate Jeopardy. The Facility policy Elopement management program dated 3/1/22, identifies the following conditions when a resident should be evaluated for elopement risk and interventions put in place: upon admission, per the MDS schedule, significant change and as needed. If a resident triggers an elopement risk per assessment, the following interventions may be implemented: Elopement care plan; a wander guard bracelet; a photograph and information sheet will be placed in the elopement risk binder, which will be kept by the front entrance office and/or nursing station. Resident R1 was admitted to the facility on [DATE], with diagnoses that include Non-Traumatic [NAME] dysfunction, Alzheimer's disease, heart disease, and diabetes mellitus. Review of the quarterly Minimum Data Set(MDS- periodic assessment og care needs) dated 2/25/22 indicates the diagnoses remained current. Clinical record review revealed on 4/29/22 Resident R1 as having wandering behavior occurs daily as a part of the weekly nursing note, identifying as a change in condition from previous assessments. Clinical documentation revealed the facility failed to assess the resident for elopement risk at that time. During an interview on 5/19/22 at approximately 3:30 p.m. Nurse Aide Employee E3 reported that on 5/8/22 at approximately 9:00 p.m., a passerby called into the facility to alert staff a resident was along the road. Resident R1 was found sitting in his wheelchair in the facility driveway at the intersection of the public road trying to get across. Employees Nurse Aide E3 and the Assistant Director of Nursing (ADON) returned Resident R1 to the building. A wander guard (an alarmed bracelet which alerts the facility when a resident attempts to exit) was placed on Resident R1 upon return to the building by the ADON. Review of the clinical record revealed the facility failed to document the resident was reassessed for elopement risk at that time. During a telephone interview on 5/19/22 at approximately 3:10 p.m., Dietary Cook Employee E2 reported that on 5/11/22, at approximately 3:30 p.m., Resident R1 was witnessed in the main kitchen doorway external exit and was caught on the doorway threshold attempting to get his wheelchair over the doorway threshold into the parking lot. Staff was forced to intervene to prevent Resident R1 from exiting the building. Dietary Cook Employee E2 reported the incident to the facility NHA immediately. Dietary Cook Employee E2 reported no alarms were sounding and that the door from the dining room into the kitchen, which is usually closed, had been open. Dietary Manager Employee E4 confirmed at that time that the external door is not alarmed as it is not a resident accessible door. Review of the clinical records indicated that the facility failed to document the resident was reassessed for elopement risk at that time. Review of the facility elopement binder on 5/19/22 indicated Resident R1's photo and information were not added to the binder until 5/19/22. During an interview on 5/19/22 at 2:12 p.m. Corporate Consultant RN Employee E2 confirmed the facility failed to identify the resident as a potential elopement risk, complete an updated elopement risk assessment with the initiation of wandering behaviors noted on 4/29/22, after the first elopement on 5/8/22, and the second elopement on 5/11/22. The facility failed to follow through with elopement risk assessment, and policies and procedures for residents at risk for elopement when a resident was identified as having a change in condition. Immediate Jeopardy was identified placing residents at ongoing risk and facility was provided the template on 5/19/22, at 7:25 p.m. On 5/19/22, at 10:01 p.m. an acceptable action plan was approved which included the following interventions: Corrective action taken: 1. Resident R1 was identified outside of facility on 5/8/22. He was then returned inside of facility to unit. Wander guard was applied to resident and care plan was updated. 2. An updated Elopement assessment was completed on 5/19/22 for Resident R1. Elopement book updated with resident information and photo on 5/19/22. 3. Resident R1 was transferred to localER on [DATE] and returned to facility same day with no new orders. 4. Resident was evaluated by physician on 5/19/22 with new order for therapy evaluation. 5. On 5/19/22 elopement assessments initiated in all residents to identify potential risk for elopement. Care plans to be updated in the electronic medical record for these identified residents as needed. A current elopement form which includes Resident's name, room number, and picture will be placed in the elopement binders and place at each nursing station and the receptionist desk as identified. Elopement binders are designed to keep staff aware of all residents who have been identified at a risk for elopement and are wearing a wander guard device. Will be completed by 5/20/22 by 0800. 6. On 5/19/22 The Staff Development nurse began education for present staff. The education included the facility's elopement policy and change in condition. Remaining staff will be educated prior to the start of their next shift until we reach 100%. Facility's elopement policy will be provided to each contracted agency. A signed copy of the facility's elopement policy must be presented prior to agency staff receiving a shift or assignment. If in the future an elopement occurs, the resident will be re-assessed immediately upon return to the premises. Education of all staff will be completed 5/20/22 by 3:00 PM. 7. The Director of Nursing, NHA and/or Designee will perform weekly audits on all new admissions and residents identified as elopement risks for 3 months. The results of the audits will be reviewed and revised by the QAPI committee. 8. On 5/19/22 Kitchen staff has been educated to leave the kitchen door to resident area closed unless kitchen staff is present in kitchen. 9. Elopement drill was held on 5/19/22 with staff responding appropriately. Weekly elopement drills will be conducted by Administrator or designated staff every week for 4 weeks and then once a month for 2 months. During observations and document review the facility educated in-person staff and contacted all staff and provided preliminary education offsite by telephone from 5/19/22 10:01 p.m. through 5/20/22 at 2:33 p.m. Observations of training in house for staff members as they entered for work along with question and answer sessions was ongoing throughout the period and review of signature sheets verified the training sessions. The Immediate Jeopardy was removed on 5/20/22 at 2:33 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/03/21 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 28 Pa. Code 211.10(c) Resident care policies. Previously cited 12/03/21 28 Pa Code 211.10(d) Resident Care policies Previously Cited 12/3/21 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/03/21

Based on staff interview, it was determined that the facility failed to have Director of Nursing (DON) working full-time in the building for the periods of 4/22/22-5/16/22, and 5/17/22-5/20/22. Findings include: During an interview on 5/20/22, at 3:02 p.m. the Nursing Home Administrator (NHA) confirmed that the DON had abruptly resigned her position on 4/22/22. The NHA confirmed that the additionally the facility did not have a designated full-time DON from 4/22/22-5/12/22, and that the most recent DON quit abruptly by test message on 5/18/22 at 6:00 a.m. and the facility was without a DON until 5/20/22. 28 Pa. Code: 201.3 Definitions. 28 Pa. Code: 201.14(a) Responsibility of licensee. previously cited 12/03/21 28 Pa. Code 201.18(a) Management 28 Pa. Code: 211.12(b) Nursing services.

Based on review of facility policies, job description, a facility specific document, clinical records and facility reports and resident and staff interviews, it was determined that the facility failed to provide adequate supervision of two during a transfer, utilize a mechanical lift as per the physician orders for assistance during a transfer resulting in actual harm for one of 11 residents reviewed (Resident R1). Findings include: The facility policy Transferring the Resident Using a Mechanical Lift dated [DATE], indicated that the mechanical lift (device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) was to be used for those residents who were dependent, non-weight bearing or had inconsistent weight bearing. The facility policy Care Plan Goals and Objectives dated [DATE], indicated that care plans were completed by incorporating measurable goals and objectives based on the resident's needs to assist in the resident attaining an optimal level of functioning and that the care plan was available to all disciplines caring for the resident to make certain their required needs, goals and objectives are known so that the resident's desired outcomes are achieved. A review of the facility job description for the Certified Nursing Assistant indicated that the nursing assistant performed care on residents to include bathing, repositioning and transfers and was responsible to use the care plan for the basis of all resident care. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included a stroke which resulted in left-sided weakness, [CONDITION(S)] (a condition that restricts breathing), high blood pressure and heart disease. A physician order dated [DATE], indicated that Resident R1 was to be transferred with assistance of two and a mechanical lift. The Quarterly Minimum Data Set (MDS-periodic assessment of resident care needs) dated [DATE], indicated that Resident R1 did not have memory problems, could make independent decisions regarding tasks of daily life and was totally dependent for transfers which required the extensive assistance of two or more people. The plan of care for Resident R1, reviewed by the facility staff on [DATE], identified continuing concerns in the areas of activities of daily living due to the left arm being flaccid (hangs loosely or limply) and safety concern related to mobility problems. The outlined approach in both of these areas of the care plan indicated that staff were to use a mechanical lift for transfers. A review of the [DATE] physician recapitulation orders (summary of physician orders) indicated that Resident R1 still required the use of the mechanical lift and the assistance of two for transfers. A review of the Transfer/Shower Schedule (a form utilized by nursing staff that lists residents' care needs based on their respective care plans) indicated that Resident R1 was scheduled to receive a shower on Wednesdays and Saturdays during the daylight shift and that the resident required the use of a mechanical lift for transfers. A review of information from the facility provided to the State Survey Agency on [DATE], indicated that on [DATE], Resident R1 reported left arm pain and a small bruise was noted on the arm. The report indicated that on [DATE], the bruise had changed significantly and pain increased. X-rays were ordered, performed and revealed that the resident had a fracture of the left upper arm (humerus - the long bone in the arm that runs from shoulder to elbow). An orthopedic consult was made and the facility began an investigation in to the cause of the fracture. A review of the x-ray report, dated [DATE], revealed that Resident R1 had a non united (permanent failure of healing) fracture of the anatomical neck of the left humerus (the groove separating the top of the humerus from where the muscle is attached to the bone) with mild displacement of the distal fragment (lower portion of the bone is out of alignment). A review of a written statement documented by the Director of Nursing during an interview conducted with Resident R1 on [DATE], revealed that the resident thought the left arm injury may have occurred when a nurse aide (NA) did not use the lift to get the resident out of the shower chair. Resident R1 gave a description of the male NA. The male NA was later identified as NA Employee E1. A review of the written statements of two staff members, NA Employees E1 and E2, dated [DATE], indicated that they transferred Resident R1 on [DATE], from the shower chair to the wheelchair without using the mechanical lift. While NA Employee E2 steadied the shower chair; NA Employee E1 lifted Resident R1 under the arms and pivoted the resident from the shower chair to the wheelchair. In the written statement NA Employee E2 indicated that Resident R1 said ouch as the resident was lowered into the wheelchair. NA Employees E1 and E2 acknowledged in their written statements that they knew that Resident R1 required a mechanical lift for transfer and that they did not tell the nurse about the improper transfer or Resident R1's expression of pain. During an interview on [DATE], at 11:50 a.m. Resident R1 reported My arm (left) hurts when they move it but they are careful. I got this because he didn't use the lift. During an interview on [DATE], at 2:00 p.m. NA Employee E2 reported that I knew that (Resident R1) needs a lift for transfers and I did not say anything to (NA Employee E1) prior to the transfer on [DATE], when I steadied the shower chair as he lifted the resident under the arms . NA Employee E2 confirmed the use of the Transfer/Shower Schedule and care plan as the basis for all resident care. During interviews on [DATE], at 4:00 p.m. and on [DATE], at 1:00 p.m. the Director of Nursing confirmed that the facility failed to follow the physician orders for assistance during a transfer resulting in actual harm to Resident R1. 28 Pa. Code 201.29(a) Resident rights. Previously cited [DATE] 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 201.29(d) Resident rights. Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE]

Based on review of facility policies, job description, clinical records and facility reports and resident and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary assistance for a safe transfer resulting in harm to the resident and failed to promptly report and provide timely intervention following the incident for one of 11 residents reviewed (Resident R1). Findings include: The facility Abuse Policy dated [DATE], defined neglect as, a failure to provide the care necessary to avoid physical harm, mental anguish or mental illness, or deterioration of a resident's physical or mental condition and that any reports of neglect were promptly reported and investigated. The facility policy Transferring the Resident Using a Mechanical Lift dated [DATE], indicated that the mechanical lift (device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) was to be used for those residents who were dependent, non-weight bearing or had inconsistent weight bearing. The facility policy Care Plan Goals and Objectives dated [DATE], indicated that care plans were completed by incorporating measurable goals and objectives based on the resident's needs to assist in the resident attaining an optimal level of functioning and that the care plan was available to all disciplines caring for the resident to make certain their required needs, goals and objectives are known so that the resident's desired outcomes are achieved. A review of the facility job description for the Certified Nursing Assistant indicated that the nursing assistant was responsible to use the care plan for the basis of all resident care and observes and reports any changes in resident's mental and physical status to the nurse. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS-periodic assessment of resident care needs) dated [DATE], indicated that Resident R1 did not have memory problems, could make independent decisions regarding tasks of daily life and was totally dependent for transfers which required the extensive assistance of two or more people. The plan of care for Resident R1, reviewed by the facility staff on [DATE], identified continuing concerns in the areas of activities of daily living due to the left arm being flaccid (hangs loosely or limply) and safety concern related to mobility problems. The outlined approach in both of these areas of the care plan indicated that staff were to use a mechanical lift for transfers. A review of the [DATE] physician recapitulation orders (summary of physician orders) indicated that Resident R1 still required the use of the mechanical lift and the assistance of two for transfers. A review of a information from the facility provided to the State Survey Agency on [DATE], indicated that on [DATE], Resident R1 reported left arm pain and a small bruise was noted on the arm. The report indicated that on [DATE], the bruise had changed significantly and pain increased. X-rays were ordered, performed and revealed that the resident had a fracture of the left upper arm (humerus- the long bone in the arm that runs from shoulder to elbow). An orthopedic consult was made and the facility began an investigation in to the cause of the fracture. A review of the x-ray report, dated [DATE], revealed that Resident R1 had a non united (permanent failure of healing) fracture of the anatomical neck of the left humerus (the groove separating the top of the humerus from where the muscle is attached to the bone) with mild displacement of the distal fragment (lower portion of the bone is out of alignment). A review of a written statement documented by the Director of Nursing during an interview conducted with Resident R1 on [DATE], revealed that the resident thought the left arm injury may have occurred when a nurse aide (NA) did not use the lift to get the resident out of the shower chair. Resident R1 gave a description of the male NA. The male NA was later identified as NA Employee E1. A review of the written statements of two staff members, NA Employees E1 and E2, dated [DATE], indicated that they transferred Resident R1 on [DATE], from the shower chair to the wheelchair without using the mechanical lift. While NA Employee E2 steadied the shower chair; NA Employee E1 lifted Resident R1 under the arms and pivoted the resident from the shower chair to the wheelchair. In the written statement NA Employee E2 indicated that Resident R1 said ouch as the resident was lowered into the wheelchair. NA Employees E1 and E2 acknowledged in their written statements that they knew that Resident R1 required a mechanical lift for transfer and that they did not tell the nurse about the improper transfer or Resident R1's expression of pain. During an interview on [DATE], at 11:50 a.m. Resident R1 reported My arm (left) hurts when they move it but they are careful. I got this because he didn't use the lift. During an interview on [DATE], at 2:00 p.m. NA Employee E2 reported that I knew that (Resident R1) needs a lift for transfers and I did not say anything to (NA Employee E1) prior to the transfer on [DATE], when I steadied the shower chair as he lifted the resident under the arm . NA Employee E2 confirmed that Resident R1 did say ouch when lowered into the wheelchair and that the incident and resident's expression of pain was not reported to the nurse. During interviews on [DATE], at 4:00 p.m. and on [DATE], at 1:00 p.m. the Director of Nursing confirmed that the facility failed to provide the necessary assistance for Resident R1 during a transfer, resulting in harm, and failed to promptly report and provide timely intervention following the incident. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited [DATE] 28 Pa. Code: 201.29(a) Resident rights. Previously cited [DATE] 28 Pa. Code: 201.29(b) Resident rights. Previously cited [DATE] and [DATE] 28 Pa. Code: 201.29(d) Resident rights. Previously cited [DATE] 28 Pa. Code: 211.10(d) Resident care policies. Previously cited [DATE] 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited [DATE]