Every finding on record at Meadow View Nursing Center

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide nutritional interventions to assure that residents received items to maintain proper weight and health for three of ten residents reviewed (Resident 5, 7, 8). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated June 10, 2026, revealed that the resident was cognitively impaired and dependent on staff for daily care tasks. The resident's care plan, most recently most recently revised June 11, 2026, indicated that the resident was a nutritional risk and that she was to have whole milk with all meals and ice cream with lunch and supper. A comprehensive MDS assessment for Resident 7, dated April 14, 2026, revealed that the resident is cognitively impaired and dependent on staff for daily care tasks. The resident's care plan, most recently revised on June 16, 2026, indicated that the resident was at risk for malnutrition and that she was to have yogurt with lunch for additional protein. A quarterly MDS assessment for Resident 8, dated June 1, 2026, revealed that the resident was cognitively impaired and dependent on staff for her daily care tasks. The resident's care plan, dated July 15, 2025, indicated that she was to have ice cream with all meals. Observations of the lunch meal on July 1, 2026, at 11:46 a.m. until 12:18 p.m. revealed that Resident 5's meal ticket stated she was to have ice cream with her lunch, Resident 7's meal ticket stated she was to have pudding, yogurt, or applesauce with lunch, and Resident 8's meal ticket stated she was to have pudding, yogurt, or apple sauce with every meal. Resident 5 did not have any ice cream served on her lunch tray, Resident 7 did not have any yogurt and Resident 8 did not have any ice cream on her lunch tray. Staff present in the dining room during that time called the kitchen to have the items sent to the dining room. Residents 5 and 8 did not have ice cream after their meal. Resident 7 was asked to stay after she finished her meal to eat some yogurt when it would arrive from the kitchen. Interview with Licensed Practical Nurse 1 on July 1, 2026, at 11:58 a.m. revealed that the kitchen had not been sending items like yogurt, ice cream, pudding, or apple sauce on the resident's lunch trays. She stated that they used to, but that it stopped and the resident's have not been getting those items. She stated if there is ice cream in the pantry they could give it to the residents, but it is often not stocked. Interview with Nurse Aide 2 on July 1, 2026, at 11:59 a.m. revealed that the kitchen does not send yogurt, ice cream, or pudding on the resident's trays, even though their tray ticket states they should get it. She stated she will give them something out of the pantry when it is available. Interview with Nurse Aide 3 on July 1, 2026, at 11:59 a.m. revealed that ice cream has not been coming from the kitchen for any resident for some time now. She stated that sometimes the pantry has ice cream and they can get it from there for the residents if they are still in the dining room when staff are finished feeding other residents. Interview with the Nursing Home Administrator on July 1, 2026, at 1:00 p.m. revealed that the kitchen had decided not to put the cold ice cream on the warm lunch trays to prevent it from melting. The nursing staff were to provide ice cream from the pantry for the resident. She offered the education that was provided to the staff regarding the change, however, only one of the four staff members that were in the dining room had attended the training and none of them were aware of that change. She further stated that the nursing staff could have given the residents pudding or yogurt from the pantry if those items were stocked there, but they were not stocked in the pantry on July 1, 2026. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to drink in accordance with the resident's care plan for one of ten residents reviewed (Resident 9). Findings include: The facility's policy regarding adaptive equipment, dated Jun 16, 2026, revealed that residents who require adaptive eating equipment would receive appropriate devices and assistance to maintain the highest practicable level of independence, dignity, nutritional status, hydration, and safety during meals and snacks. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 9, dated April 14, 2026, revealed that the resident was severely cognitively impaired, and required assistance from staff for eating. The resident's care plan, revised June 6, 2026, revealed that the resident had a decreased intake with meals and was at risk of weight loss. The resident's food was to be served in bowls and he was to have a nose out cup (cup with a large U shaped hole in the lip of the cup to cradle the nose when drinking). Observations of Resident 9 on July 1, 2026, at 11:56 a.m. revealed that his drink was served in a regular cup, not a nose out cup. When the nurse aide fed the resident she used the regular cup and once the cup was less than half full the cup hit the residents nose while she was giving him a drink. An interview with Nurse Aide2 on July 1, 2026, at 11:58 a.m. revealed that the resident's nose out cup did not come from the kitchen on the resident's tray. She stated she called the kitchen to have one sent up, but it had not arrived. She further stated that the kitchen staff usually forget to send a nose out cup because there are only a few in house. She stated that when his cup gets less than half full and it is difficult to give him a drink because the cup hits his nose she gets more liquid for in the cup to make it easier. She indicated that he is unable to tilt his head back to get more liquid from the cup which is why it is easier to use the nose out cup. Interview with the Nursing Home Administrator on July 1, 2026, at 1:00 p.m. revealed that Resident 9 should have had his nose out cup for his meal. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on observations and interviews with staff it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for two of three ice machines observed. Findings include: Observations of the ice machine in the second floor nutrition room on February 4, 2026, at 8:48 a.m. revealed a dark, removable substance around the seal of the ice machine lid. The parts in the ice machine that the ice dispenses from were covered with a faint black removable substance. Observations of the ice machine in the third floor nutrition room on February 4, 2026, at 8:58 a.m. revealed that the parts in the ice machine that the ice dispenses from were covered with a brown removable substance that had water tracks leading into the ice. Interview with the Environmental Services/Maintenance Director on February 4, 2026, at 9:14 a.m. confirmed the above-mentioned observations. He stated that the ice machines are on a cleaning schedule quarterly and that the first floor ice machine was cleaned January 28, 2026, as per the cleaning schedule. He indicated that the second and third floor ice machines were due to be cleaned last week; however, they were not. 28 Pa. Code 211.6 Dietary

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:.The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending February 7, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 5, 2026, identified repeated deficiencies related to professional nursing services, safe environment free of accident hazards, proper intravenous care, and timely nurse aide performance reviews. The facility's plan of correction for a deficiency regarding quality of care cited during the survey ending February 7, 2025, revealed that quality of care would be monitored by QAPI. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding quality of care. The facility's plan of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the survey ending February 7, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding safety and accident-free environment.The facility's plan of corrections for deficiencies regarding proper intravenous care, cited during the survey ending February 7, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F694, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding intravenous care.The facility's plan of correction for a deficiency regarding documentation of nurse aides annual performance evaluations, cited during the survey ending February 7, 2025, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F730, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding nurse aide performance reviews.Refer to F684, F689 F694 and F730. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that there was a physician's order for oxygen therapy for two of 40 residents reviewed (Residents 2, 24).Findings include: The facility's policy for oxygen use, dated January 19, 2026, revealed that residents who required oxygen would have a physician's order which included the oxygen flow rate, how the oxygen would be administered (i.e. nasal cannula or mask), if humidified air was required, and how often the oxygen tubing should be changed.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 9, 2025, revealed that the resident was cognitively intact, used oxygen, and had diagnoses that included pulmonary embolism (blood clot that goes to lungs). Nursing notes, dated November 7 at 10:46 a.m., November 10 at 11:14 a.m., November 12 at 10:35 p.m., November 15 at 11:02 a.m., and November 16, 2025, at 10:17 a.m., revealed the resident was using 3 liters per minute (lpm) of oxygen via nasal cannula (tube that delivers oxygen through the nose). There was no documented evidence that a physician's order was obtained for Resident 2 to use oxygen during this time. Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for November 2025 revealed that there was no documented evidence that Resident 2 used oxygen.An admission MDS assessment for Resident 24, dated January 18, 2026, revealed that the resident was cognitively impaired, dependent on staff for daily care tasks, and had diagnoses that included heart disease. A care plan, dated January 4, 2026, indicated that Resident 24's oxygen was to be administered as ordered.A nursing note for Resident 24, dated January 12, 2026, at 11:38 p.m. revealed the resident returned from the hospital and was using 2 lpm of oxygen. Nursing notes dated January 13 at 11:23 a.m., January 14 at 6:36 p.m., January 15 at 8:47 a.m., January 17 at 12:26 p.m., and January 18, 2026 at 11:43 a.m., revealed the resident was using 2 lpm of oxygen via nasal cannula. There was no documented evidence that a physician's order was obtained for Resident 24 to use oxygen during this time. Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for January 2026 revealed that there was no documented evidence that Resident 24 used oxygen during this time.Interview with the Nursing Home Administrator on February 4, 2026, at 1:40 p.m. confirmed that there was no physician's order for Resident 2 and 24's use of oxygen.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for one of three nurse aides reviewed (Nurse Aide 2). Findings include:The facility's policy regarding performance evaluations, dated January 19, 2026, indicated that performance evaluations were to be completed for all employees annually.A review of the annual performance evaluation for Nurse Aide 2 revealed the evaluation was completed on September 21, 2024. As of February 5, 2026, there was no documented evidence that an annual performance evaluation had been completed since September 21, 2024. Interview with the Nursing Home Administrator on February 5, 2026, at 12:36 p.m. confirmed that the annual performance evaluation was not completed as required for Nurse Aide 2.28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed per physician's order and facility policy for one of 40 residents reviewed (Resident 120).Findings include:The facility's policy regarding the flushing of peripheral (PICC) and midline intravenous catheters (a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication), dated January 19, 2026, indicated that the peripheral or midline catheter was to be flushed with 10 cubic centimeters (cc's) of normal saline (sterile salt and water solution) every shift and after each use with 5-10 cc's of normal saline and 5 cc's of Heparin (blood thinner), if physician's orders indicated.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 120, dated December 11, 2025, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received an intravenous medication, and had a diagnosis of cancer. A nursing note, dated December 5, 2025, revealed the resident was admitted to the facility and had a PICC line to his left upper arm.Physician's orders for Resident 120, dated December 5, 2025, included an order for the resident to have each port of his PICC line flushed with 10 cc's of normal saline every shift.Review of the Medication Administration Record (MAR) for Resident 120 for December 2025 and January 2026 revealed that there was no documented evidence that both ports of the resident's PICC line were flushed every shift on December 7, 9, 14, 16, 18, 21, 24, and 30, 2025, and January 6, 12, 14, 17, 18, 19, 21-25, and 29, 2026.Interview with the Nursing Home Administrator on February 5, 2026, at 12:44 p.m. confirmed that there was no documented evidence that Resident 120's PICC line was flushed every shift as ordered by the physician and per facility policy.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 40 residents reviewed (Resident 3) who had an indwelling urinary catheter.Findings include:The facility policy for urinary catheters, dated January 19, 2026, revealed that clean technique was to be used when handling the catheter, tubing or drainage bag.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 21, 2025, revealed that the resident was cognitively impaired, dependent on staff for daily care needs, was frequently incontinent of urine, had pressure ulcers, and had diagnoses that included dementia.Physician's orders for Resident 3, dated December 24, 2025, included an order for the resident to have an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine) for wound healing. Observations of Resident 3 on February 5, 2026, at 9:34 a.m. revealed that she was in bed and her catheter drainage tubing was in direct contact with the floor. Interview with Licensed Practical Nurse 1 on February 5, 2026, at 9:38 a.m. confirmed that the catheter tubing was on the floor and should not have been.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, including an incident report, as well as observations, and staff interviews, it was determined that the facility failed to ensure that fall prevention interventions were in place as care planned for one of 40 residents reviewed (Resident 31), and that a thorough investigation was conducted to determine the safety of the shower chair for one of 40 residents reviewed (Resident 66). Findings include:The facility's policy regarding fall management, dated January 19, 2026, indicated that the purpose was to reduce the risk of falls and prevent injury. The facility would mitigate accidents by providing an environment that remains as free of hazards as possible over which the facility has control and each resident receives adequate supervision and assistive devices. The facility identifies each resident at risk for accidents and/or falls and adequately plans care and implements procedures to manage avoidable accidents.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated January 14, 2026, revealed that the resident was severely cognitively impaired, moderately impaired for vison and speech, sometimes understood and sometimes understands, lived in the memory care unit, had diagnoses that included Alzheimer's disease, dementia, anxiety, history of mental, behavioral and delusional disorders with disturbances that required assistance from two staff to transfer the resident The resident's care plan, revised on May 22, 2025, indicated that she was at risk for falls related to poor safety awareness, confusion and a history of falls, and was to have a sensor pad/alarm/ to her bed and chair. An incident note, dated January 3, 2026, at 7:30 p.m. indicated that the resident had a witnessed fall in the memory unit common area/solarium that resulted in a hip fracture. A review of the fall incident report, and multiple witness statements dated, January 3, 2026, indicated that Resident 31 was restless and was assisted from her recliner to a chair at a round table in the common area/solarium. The resident pushed herself to a standing position and fell. The resident did not have the sensor pad/alarm on the chair she was sitting in, per her care plan, at the time of her fall.Interview with the Nursing Home Administrator on February 5, 2026, at 1:10 p.m. indicated that she questioned that the absence of the chair alarm would have prevented the fall. This surveyor confirmed that Resident 31 did not have her care planned fall intervention, the sensor pad/alarm placed on the chair she was sitting in.The facility's policy for Durable Medical Equipment (DME) dated December 31, 2025 revealed that the facility will ensure that all DME used by residents is clinically appropriate, properly ordered, safely maintained, and in compliance with federal, state, and facility requirements. All DME will be obtained, maintained, and used in a manner that promotes resident safety and quality of care.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated December 24, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care, assistance of one staff for bathing/showers and had a diagnosis of morbid obesity.An incident report for Resident 66, dated January 18, 2025, at 4:20 p.m. revealed that the resident was seated in a shower chair in the shower room. While the resident was sitting in the shower chair one of the supportive connections of the PVC (a rigid, durable and corrosion- resistant thermoplastic) pipe cracked weakening the strength of the chair. Resident 66 did not fall through the chair. A nursing assessment was completed at the time of the incident that revealed no injuries. He was transferred to his wheelchair and taken back to his room. The shower chair was removed from service by the director of maintenance.Interview with the Director of Maintenance and the Nursing Home Administrator February 3, 2026, at 1:35 p.m. revealed that the chair was taken out of service immediately and it was disposed of. The Maintenance Director stated that the shower chairs are inspected monthly and if there are any concerns with the chairs it is immediately corrected and documented as to what the corrective action was. Review of four months of the inspections revealed that the chair was last inspected December 24, 2025 and there were no reported concerns with the shower chair. The inspection documentation listed each shower chair by number and not a specific model number or weight limit.Observation in the second floor shower room February 4, 2026, at 9:36 a.m. revealed 2 shower chairs that were labeled with the model number and the weight limit. Interview with the Maintenance Director at that time revealed that the chairs observed in the shower room were in service and being used by staff for resident care.Interview with the Nursing Home Administrator February 4, 2026, at 2:47 p.m. revealed the she did not have documentation of the model number or the weight limit of the shower chair that was used for Resident 66 on January 18, 2026.Interview with the Nursing Home Administrator February 5, 2026, at 11:23 a.m. confirmed that the investigation that was completed concerning the incident on January 18, 2026 did not determine the safety of the shower chair that was used for Resident 66 and it should have. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 40 residents reviewed (Residents 3, 9, 92)Findings include:The facility's medication administration policy, dated January 19, 2026, indicated that medications were to be administered in accordance with the physician's orders, including any required time frame.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 21, 2025, revealed that the resident was cognitively impaired, had pressure ulcers, and received an antibiotic intravenously.A physician's note for Resident 3, dated November 18, 2025, revealed that the resident had a wound to the left heal that continued to decline. A physician's order was received to administer 3.375 grams of Piperacillin-Tazobactam intravenously every six hours for a left heel wound infection for 14 days.Review of the resident's Medication Administration Record (MAR) for November 2025 revealed Piperacillin-Tazobactam was not administered on November 26, 2025, at 6:00 a.m. and 6:00 p.m.Interview with the Director of Nursing on February 5, 2026, at 1:07 p.m. confirmed that there was no documented evidence that Resident 3's Piperacillin-Tazobactam was administered as ordered on the above date and times.A quarterly MDS assessment for Resident 9, dated December 9, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, received insulin (medication that lowers blood sugar levels), and had diagnoses that included diabetes.Physician's orders for Resident 9, dated September 12, 2025, included an order for the resident to receive Lispro Insulin 100 unit/ml according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals and at bedtime. (scheduled for 5:00 a.m., 12:30 p.m., 5:30 p.m., 9:30 p.m. on Monday, Wednesday and Friday and 7:30 a.m., 12:30 p.m., 5:30 p.m., 9:30 p.m. on Tuesday, Thursday, Saturday and Sunday). The sliding scale included giving 0 units of insulin for a blood sugar of 70-140 milligrams/deciliter (mg/dl), 2 units for a blood sugar of 141-180 mg/dL, 4 units for a blood sugar of 180-220 mg/dL, 6 units for a blood sugar 221-260 mg/dL, 8 units for a blood sugar of 261-300 mg/dL, 10 units for a blood sugar of 301-340 mg/dl, 12 units for a blood sugar 341 mg/dL or greater, and to notify the physician for further orders. Resident 9's Medication Administration Record (MAR) for November 2025 revealed that the residents blood sugar results were greater than 341 mg/dL at 12:30 p.m. on November 17 and 26, 2025; at 5:30 p.m. on November 1, 15 and 16, 2025; at 9:30 p.m. November 18, 2025. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were greater than 341 mg/dL on the dates and times mentioned.Resident 9's MAR for December 2025 revealed that the residents blood sugar results were greater than 341 mg/dL at 12:30 p.m. on December 23, 2025, and 9:30 p.m. on December 22, 2025. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were greater than 341 mg/dL on the dates and times mentioned.Resident 9's MAR for January 2026 revealed that the residents blood sugar results were greater than 341 mg/dL at 7:30 a.m. on January 6, 2026; at 12:30 p.m. on January 26, 2026, and at 9:30 p.m. on January 10, 2026. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were greater than 341 mg/dL on the dates and times mentioned. Interview with the Nursing Home Administrator February 5, 2026, at 11:19 a.m. confirmed that the physician should have been notified when Resident 9's sliding scale results were 341 mg/dL or greater.A quarterly MDS assessment for Resident 92, dated January 15, 2026, revealed that the resident was cognitively impaired, received insulin, and had a diagnosis of diabetes. Physician's orders for Resident 92, dated October 22, 2024, included an order for the resident to have her blood sugar checked before meals and at bedtime and for staff to administer insulin (medication used to lower blood sugar) per a sliding scale (dose is based on a person's blood sugar). Physician's orders for Resident 92, dated July 26, 2024, included an order for the resident to have a blood glucose protocol including steps for blood glucose results of 60-80 milligrams per deciliter (mg/dl), 50-59 mg/dl, less than 50 mg/dl and greater than 400 mg/dl as needed/as follows: If blood glucose 60-80 mg/dl give 120 milliliters (ml) of juice and recheck in 15 minutes. Repeat treatment if blood glucose is less than 80 mg/dl; If blood glucose is between 50-59 mg/dl, administer one Glucose Gel if able to swallow or one Glucagon injection if unable to swallow and recheck glucose in 15 minutes. Repeat treatment if glucose is between 50-59 mg/dl; If blood glucose is less than 50 mg/dl, administer two Glucose gels if able to swallow or two Glucagon injections if unable to swallow. Notify the physician if blood glucose is greater than 400 mg/dl or less than 60 mg/dl. Notify physician during normal office hours if blood glucose was less than 50 mg/dl and interventions were effective. Review of Resident 92's MAR for October 2025 through February 2026 revealed that the resident's blood sugar on October 22, 2025, at 5:30 p.m. was 76 mg/dl; on November 4, 2025, at 7:30 a.m. was 71 mg/dl; on December 12, 2025, at 7:30 a.m. was 73 mg/dl; on December 15, 2025, at 5:30 p.m. was 75 mg/dl ; on January 5, 2026, at 5:30 p.m. was 50 mg/dl ; on January 9, 2026, at 7:30 a.m. was 70 mg/dl ; on January 22, 2026, at 7:30 a.m. was 70 mg/dl; on January 25, 2026, at 7:30 a.m. was 74 mg/dl; on January 29, 2026, at 8:30 p.m. was 72 mg/dl; and on February 1, 2026, at 7:30 a.m. was 74 mg/dl. There was no documented evidence that the blood sugar protocol was followed as ordered. Interview with the Nursing Home Administrator on February 4, 2026, at 12:23 p.m. confirmed that there was no documented evidence that Resident 92's blood sugar protocol was followed as ordered on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and interviews with residents and staff, it was determined that the facility failed to ensure that call bells were within reach for three of 40 residents reviewed (Residents 50, 95 and 97).Findings include: A review of the facility's call bell policy, dated January 19, 2026, indicated that every resident living at the facility will have a means of communicating with staff from their room when they are in need of assistance. Every resident should have the peace of mind knowing that they can summon assistance regardless of their physical limitations. Each call bell is to be strategically located so that it is within the reach of the resident whether lying on their bed or sitting in a chair in their room. Pressure sensitive call bells are available for those residents who have limited dexterity and cannot push the call bell button. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 50, dated January 7, 2026, revealed that the resident was cognitively intact, required assistance with care needs, had a fall since his prior assessment, and had a diagnosis of Alzheimer's disease. A fall risk care plan for Resident 50, dated March 2, 2022, indicated that the resident was at risk for falls due to his impaired vision and had an intervention to keep his call bell in reach to encourage him to use it for assistance. Observation of Resident 50 on February 2, 2026, at 11:23 a.m. revealed that the resident was lying in his bed and his call bell was hanging across his bedside dresser to the left of the resident and behind the resident not within the resident's reach. Interview with the resident at that time indicated that he was unable to locate his call bell. Interview with Licensed Practical Nurse XX (Amber [NAME]) on February 2, 2026, at 11:32 a.m. confirmed that Resident 50's call bell was not in reach and that he is capable of using his call bell for assistance. Observation of Resident 95 on February 2, 2026, at 11:45 a.m. revealed that the resident was sitting in her wheelchair with her overbed table in front of her and her soft touch call bell placed on her bedside dresser located behind her and not in reach. A nurse aide delivered her lunch tray at 11:57 a.m. and left the room without placing her call bell withing reach. Interview with Nurse Aide XX ([NAME]) on February 2, 2026, at 12:00 p.m. confirmed that Resident 95's call bell was not in reach and should have been. Observation of Resident 97 on February 2, 2026, at 11:36 a.m. revealed that the resident was lying in bed, and his call bell was lying across his recliner chair to the left of his bed and not within reach. Interview with Licensed Practical Nurse XX (Amber [NAME]) on February 2, 2026, at 11:44 a.m. revealed that Resident 97 currently had a urinary tract infection and was confused. She confirmed that his call bell was not in reach and stated that they check on him, but the nurse aide probably forgot to put it back in reach after a.m. care. Interview with the Nursing Home Administrator on February 2, 2026, at 3:30 p.m. confirmed that Resident 50, Resident 95 and 97's call bells should have been within reach and they were not. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for four of 40 residents reviewed (Residents 6, 31, 50 and 92 ). Findings include: A facility policy related to psychotropic medications, dated January 19, 2026, indicated that prior to initiating antipsychotic medications, the facility will evaluate the resident's physical, behavioral, mental, and psychosocial signs and symptoms to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment and review the risks versus benefits with the resident and/or responsible party and obtain consent. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 7, 2025, revealed that the resident was cognitively impaired, received psychotropic medications, including antipsychotic, antidepressant and antianxiety medications, and had diagnoses that included bipolar disorder, anxiety, and dementia. Physician's orders for Resident 6, dated January 30, 2026, included an order for the resident to receive one milligram (mg) of Haldol Decanoate (an antipsychotic medication) intramuscularly (injection in the muscle) one time only for agitation and anxiety. There was no documented evidence in Resident 6's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the Haldol Decanoate. Interview with the Nursing Home Administrator on February 5, 2026, at 11:19 a.m., confirmed that there was no documented evidence in Resident 6's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the Haldol Decanoate. A significant change MDS assessment for Resident 31, dated January 14, 2026, revealed that the resident was severely cognitively impaired, had moderately impaired speech and vision, was sometimes understood and sometimes understands, received antipsychotic medications, and had diagnoses that included, dementia, bipolar disorder, major depressive delusional disorder, behavior disturbances/agitation and Alzheimer's disease. Physician's orders for Resident 31, dated January 8, 2026, included an order for the resident to receive 1.5 mg of Brexpiprazole (antipsychotic medication) by mouth at bedtime related to recurrent major depressive disorder, history of mental and behavioral disorders with depression and delusions. There was no documented evidence in the resident's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Brexpiprazole. Interview with the Director of Nursing on February 5, 2026, at 2:23 p.m., confirmed that there was no documented evidence in Resident 31's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Brexpiprazole, and there should have been. An annual MDS assessment for Resident 50, dated January 7, 2026, revealed that the resident was cognitively intact, received psychotropic medications, including antidepressant medications, and had diagnoses that included anxiety, depression and Alzheimer's disease. A nursing note for Resident 50, dated December 18, 2025, at 10:51 a.m. revealed that the resident was seen by the Certified Registered Nurse Practitioner (CRNP) and recommended to increase the resident's Sertraline (an antidepressant) to 100 mg daily. Physician's orders for Resident 50, dated December 18, 2025, included an order for the resident to receive 100 mg of Sertraline daily at bedtime for depression. A nursing note for Resident 50, dated January 27, 2026, at 1:02 p.m. revealed that the resident was seen by the CRNP and recommended to increase the resident's Mirtazapine (an antidepressant) to 30 mg daily. Physician's orders for Resident 50, dated January 27, 2026, included an order for the resident to receive 30 mg of Mirtazapine daily at bedtime for depression. There was no documented evidence in Resident 50's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Sertraline and Mirtazapine. Interview with the Nursing Home Administrator on February 5, 2026, at 11:19 a.m., confirmed that there was no documented evidence in Resident 50's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Sertraline and Mirtazapine. A quarterly MDS assessment for Resident 92, dated January 15, 2026, revealed that the resident was cognitively impaired, received psychotropic medications, including antipsychotic and antidepressant medications, and had diagnoses that included depression and schizoaffective disorder. A nursing note for Resident 92, dated December 18, 2025, at 1:02 p.m. revealed that the resident was seen by the CRNP and recommended to increase the resident's Mirtazapine (an antidepressant) to 15 mg daily. Physician's orders for Resident 92, dated December 18, 2025, included an order for the resident to receive 15 mg of Mirtazapine daily at bedtime for depression. Interview with the Nursing Home Administrator on February 5, 2026, at 11:19 a.m., confirmed that there was no documented evidence in Resident 92's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Mirtazapine. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow care-planned interventions and facility policies for two of four residents reviewed (Residents 2, 3), resulting in harm to Resident 2 due to a fall that resulted in fractured hip and harm to Resident 3 due to a fall from bed that resulted in a hematoma. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding falls, dated September 1, 2024, indicated that a resident-centered fall prevention plan was to be implemented to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The facility's policy regarding a change in status, dated September 1, 2024, indicated that all nursing staff were responsible to ensure pertinent information was communicated to the charge nurse regarding a resident's change in status and all nursing staff were to communicate to the charge nurse if a resident refused care, medications, or interventions at the time of refusal. The charge nurse would encourage the resident to participate in the plan of care. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 1, 2025, revealed that the resident was confused, required assistance from staff with daily care needs, used a walker, and had a history of falls. The resident's care plan, dated April 17, 2025, revealed that the resident was at risk for falls and was to use hipsters (padded hip protectors used to prevent injuries to the hips) at all times. A nursing note for Resident 2, dated May 24, 2025, at 12:41 p.m. revealed that staff witnessed the resident going into the bathroom with her walker and left her walker inside the bathroom door. She then walked out to the hallway, lost her balance, and tripped before staff could get to her. The resident was witnessed falling on her left side and was noted to have shortening of the left leg, and complained of pain to her left hip and upper thigh area. The physician was notified and orders were received to transfer the resident to the hospital for evaluation and treatment. At 5:14 p.m. a report was received from the hospital informing the facility that Resident 2 had a left hip fracture. Information submitted by the facility, dated May 30, 2025, revealed that on May 24, 2025, at 3:00 a.m. Resident 2 was witnessed to be resistant to care and combative throughout the shift. She woke up early in the morning, a shower was given to promote improvement of mood/behaviors, and she refused her hipsters. On May 24, 2025, at 11:40 a.m. Resident 2 had a witnessed fall in the common bathroom on the third floor, was transferred to the hospital, and had a fractured hip. It was discovered that Nurse Aide 1 did not notify any other staff of Resident 2 refusing her hipsters, which prevented the ability to put other interventions in place to prevent injuries from a fall. A written statement from Nurse Aide 1, dated May 24, 2025, revealed that Resident 2 refused to wear her hipsters after receiving a shower at 3:00 a.m. Further interviews, undated, revealed that Nurse Aide 1 confirmed that she did not report to any other staff that the resident refused her hipsters prior to the resident falling. An interview with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 4:23 p.m. confirmed that Nurse Aide 1 failed to follow the facility's policy for reporting a resident's refusal of care, which prevented staff from attempting other interventions to prevent injuries from falls, and the Nursing Home Administrator also confirmed that there was no evidence that Nurse Aide 1 re-approached Resident 2 at a later time to apply the hipsters. The facility's policy regarding positioning the resident bed, dated September 1, 2024, revealed that if a one-person assist is utilized the resident should be rolled toward the attendant and not away from them. This also avoids the potential of the resident rolling out of bed. An annual MDS assessment for Resident 3, dated April 17, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included a cerebral vascular accident (CVA - commonly referred to as a stroke). Care plans for the resident, dated August 11, 2022, revealed that the resident was at risk for falls related to impaired mobility, and that the resident was at risk for complications due to her activities of daily living (ADLs) dependence as evidenced by requiring assistance with her ADLs. A nursing note for Resident 3, dated May 28, 2025, at 2:38 p.m. revealed that the writer was notified by staff that the resident fell out of bed. When the writer arrived at the resident's room, she was on the floor on her back with her head facing the top of her bed and her feet toward the bottom. Per the nurse aide the resident was being provided peri care (the cleaning and care of the genitals and anal area) when she rolled off the bed. The resident hit the left side of her head off the trash can. The resident was unable to answer questions currently. The resident's pupils were sluggish; the resident could not follow the writer's finger. The resident had a one-inch scratch mark on top of her head and a hematoma (a localized collection of blood outside of blood vessels, typically caused by trauma or injury) just above her left temporal (the side of the head between the eyes and the ear) area. The resident had an emesis after hitting floor and was rolled onto her left side. The resident was lifted back up into bed by the mechanical lift and 911 was called at 2:00 p.m. A nursing note at 8:05 p.m. revealed that the resident returned to the facility from the hospital. The resident expressed a complaint of a headache related to the temporal area hematoma that measures four centimeters (cm) by three cm. A statement completed by Nurse Aide 2, dated May 28, 2025, revealed that she was providing care to Resident 3. She had rolled the resident towards the wall. She was on her right side, and as Nurse Aide 2 was changing her, the resident rolled off the bed and onto the floor. Nurse Aide 2 attempted to catch the resident but could not grab her in time. When she fell, she hit her head off the garbage can. Investigative documents for Resident 3, date May 28, 2025, revealed that on May 28, 2025, at approximately 1:55 p.m. Nurse Aide 2 was providing care to the resident. While providing care, Nurse Aide 2 rolled the resident away from herself and the resident rolled from the bed onto the floor. The resident was sent out to the hospital for evaluation. The resident was noted to have a hematoma to her head. The investigation revealed that Nurse Aide 2 rolled the resident away from herself, which did not follow the standard of care as taught in the Nurse Aide program, which Nurse Aide 2 participated in August 2024. The facility investigation revealed that Nurse Aide 2 failed to follow the standard of care by rolling the resident away from herself. Interview with the Director of Nursing on June 12, 2025, at 4:23 p.m. confirmed that because Nurse Aide 2 did not follow the facility's policy by rolling Resident 3 away from her and not towards her since she was the only one assisting the resident. Following the investigation on May 28, 2025, the facility's corrective actions included: Nurse Aide 2 was terminated from employment at the facility. Preformed audits of residents' bed mobility. Any residents with questionable bed mobility status are being evaluated by therapy to determine recommendations. Staff education on bed mobility policy, techniques for transfer, and moving, was completed. Specific bed mobility recommendations were added to the care plan and Kardex (a system, either paper-based or electronic, used by nurses to track and manage key patient information). Audits to identify any issues with care provided to residents were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on June 4, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(10 Management. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of four residents reviewed (Residents 2, 3), resulting in harm to Resident 2 due to a fall that resulted in fractured hip and harm to Resident 3 due to a fall from bed that resulted in a hematoma. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding abuse and neglect, dated September 1, 2024, indicated that the definition of neglect referred to the failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. The facility's policy regarding falls, dated September 1, 2024, indicated that a resident-centered fall prevention plan was to be implemented to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The facility's policy regarding a change in status, dated September 1, 2024, indicated that all nursing staff were responsible to ensure pertinent information was communicated to the charge nurse regarding a resident's change in status and all nursing staff were to communicate to the charge nurse if a resident refused care, medications, or interventions at the time of refusal. The charge nurse would encourage the resident to participate in the plan of care. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 1, 2025, revealed that the resident was confused, required assistance from staff with daily care needs, used a walker, and had a history of falls. The resident's care plan, dated April 17, 2025, revealed that the resident was at risk for falls and was to use hipsters (padded hip protectors used to prevent injuries to the hips) at all times. A nursing note for Resident 2, dated May 24, 2025, at 12:41 p.m. revealed that staff witnessed the resident going into the bathroom with her walker and left her walker inside the bathroom door. She then walked out to the hallway, lost her balance, and tripped before staff could get to her. The resident was witnessed falling on her left side and was noted to have shortening of the left leg, and complained of pain to her left hip and upper thigh area. The physician was notified and orders were received to transfer the resident to the hospital for evaluation and treatment. At 5:14 p.m. a report was received from the hospital informing the facility that Resident 2 had a left hip fracture. Information submitted by the facility, dated May 30, 2025, revealed that on May 24, 2025, at 3:00 a.m. Resident 2 was witnessed to be resistant to care and combative throughout the shift. She woke up early in the morning, a shower was given to promote improvement of mood/behaviors, and she refused her hipsters. On May 24, 2025, at 11:40 a.m. she had a witnessed fall in the common bathroom on the third floor, was transferred to the hospital, and had a fractured hip. It was discovered that Nurse Aide 1 did not notify any other staff of Resident 2 refusing her hipsters, which prevented the ability to put other interventions in place, substantiating neglect. A written statement from Nurse Aide 1, dated May 24, 2025, revealed that Resident 2 refused to wear her hipsters after receiving a shower at 3:00 a.m. Further interviews, undated, revealed that Nurse Aide 1 confirmed that she did not report to any other staff that the resident refused her hipsters prior to the resident falling. Education records for Nurse Aide 1, dated May 22, 2025, revealed that she received education on abuse and neglect. An interview with the Nursing Home Administrator and Director of Nursing on June 12, 2025, at 4:23 p.m. confirmed that Nurse Aide 1 failed to follow the facility's policy for reporting a resident's refusal of care, which prevented staff from attempting other interventions to prevent injuries from falls, and the Nursing Home Administrator also confirmed that there was no evidence that Nurse Aide 1 re-approached Resident 2 at a later time to apply the hipsters. The facility's policy regarding positioning the resident bed, dated September 1, 2024, revealed that if a one-person assist is utilized the resident should be rolled toward the attendant and not away from them. This also avoids the potential of the resident rolling out of bed. An annual MDS assessment for Resident 3, dated April 17, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included a cerebral vascular accident (CVA - commonly referred to as a stroke). Care plans for the resident, dated August 11, 2022, revealed that the resident was at risk for falls related to impaired mobility, and that the resident was at risk for complications due to her activities of daily living (ADLs) dependence as evidenced by requiring assistance with her ADLs. A nursing note for Resident 3, dated May 28, 2025, at 2:38 p.m., revealed that the writer was notified by staff that the resident fell out of bed. When the writer arrived at the resident's room, she was on the floor on her back with her head facing the top of her bed and her feet toward the bottom. Per the nurse aide the resident was being provided peri care (the cleaning and care of the genitals and anal area) when she rolled off the bed. The resident hit the left side of her head off the trash can. The resident was unable to answer questions currently. The resident's pupils were sluggish; the resident could not follow the writer's finger. The resident has a one-inch scratch mark on top of her head and a hematoma (a localized collection of blood outside of blood vessels, typically caused by trauma or injury) just above her left temporal (the side of the head between the eyes and the ear) area. The resident had an emesis after hitting floor and was rolled onto her left side. The resident was lifted back up into bed by the mechanical lift and 911 was called at 2:00 p.m. A nursing note at 8:05 p.m. revealed that the resident returned to the facility from the hospital. The resident expressed a complaint of a headache related to the temporal area hematoma that measures four centimeters (cm) by three cm. A statement completed by Nurse Aide 2, dated May 28, 2025, revealed that she was providing care to Resident 3. She had rolled the resident towards the wall. She was on her right side, and as Nurse Aide 2 was changing her, the resident rolled off the bed and onto the floor. Nurse Aide 2 attempted to catch the resident but could not grab her in time. When she fell, she hit her head off the garbage can. Investigative documents for Resident 3, dated May 28, 2025, revealed that on May 28, 2025, at approximately 1:55 p.m. Nurse Aide 2 was providing care to the resident. While providing care, Nurse Aide 2 rolled the resident away from herself and the resident rolled from the bed onto the floor. The resident was sent out to the hospital for evaluation. The resident was noted to have a hematoma to her head. The investigation revealed that Nurse Aide 2 rolled the resident away from herself, which did not follow the standard of care as taught in the Nurse Aide program, which Nurse Aide 2 participated in August 2024. The facility investigation revealed that Nurse Aide 2 failed to follow the standard of care by rolling the resident away from herself, and the allegation of neglect was substantiated. Nurse Aide 2 was terminated due to the allegation of neglect being substantiated. Education records for Nurse Aide 2, dated July 30, 2024, revealed that she received education on abuse and neglect. Interview with the Director of Nursing on June 12, 2025, at 4:23 p.m. confirmed that the facility's investigation substantiated neglect because Nurse Aide 2 did not follow the facility's policy by rolling Resident 3 away from her and not towards her since she was the only one assisting the resident. Following the investigation on May 28, 2025, the facility's corrective actions included: Nurse Aide 2 was terminated from employment at the facility. Staff education on abuse was completed. Audits to identify any issues with abuse were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on June 4, 2025. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' bathrooms for three of seven residents reviewed (Residents 3, 4, 6). Findings included: The facility's policy regarding cleaning and disinfecting, dated September 1, 2024, indicated that the facility was to provide a sanitary and homelike environment. Observations of Resident 4's bathroom on April 23, 2025, at 11:25 a.m. revealed that the base of the toilet, where the toilet and the floor meet, had a heavy accumulation of dried, yellowish/brown, removable debris. This debris was noted to encompass all sides of the toilet base. Observations of Resident 3's bathroom on April 23, 2025, at 11:57 a.m. revealed that the entire base of the toilet had an accumulation of dried, crusted, yellowish debris, with pieces of caulking coming off. Interview with the Maintenance Director on April 23, 2025, at 12:05 p.m. confirmed that the floor around the toilet bases in Residents 3's and 4's bathroom were in need of cleaning. He indicated that housekeeping cleans the bathrooms daily and the toilet bases should have been clean. Observations of Resident 6's bathroom on April 23, 2025, at 9:58 a.m. and 1:34 p.m. revealed that the floor along the baseboard in the bathroom was scattered with black debris, there was a black stain on the floor under the water shut-off valve that supplied the toilet, as well as a golden/brown stain on the floor beside the toilet on the sink side, and there was an area of the vinyl flooring missing toward the hinge side of the door. Interview with the Maintenance Director on April 23, 2025, at 1:55 p.m. confirmed that the floor in Residents 6's bathroom was in need of cleaning. He indicated that housekeeping cleans the rooms daily and that the they have a schedule to routinely deep clean the rooms, as well as deep clean the rooms when a resident is discharged from the room. 28 Pa. Code 201.18. Management (b)(3)(2.1)

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect specific care needs for three of 43 residents reviewed (Residents 8, 26, 42). Findings include: A facility policy for care plans, dated September 12, 2024, indicated that care plans will be reviewed and revised as necessary by the interdisciplinary team at least quarterly after each Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) or more often as changes occur. An annual MDS assessment for Resident 8, dated December 21, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, used oxygen, and had a diagnosis of hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury). A respiratory care plan for Resident 8, dated December 19, 2024, indicated that the resident was to be provided oxygen as ordered. A nursing note for Resident 8, dated January 25, 2025, at 3:54 p.m., revealed that the resident does not wear his oxygen as ordered and his oxygen saturation (blood oxygen level) was measuring greater than 90 percent on room air (without supplemental oxygen). The doctor was notified, and his oxygen was discontinued. Interview with the Director of Nursing on February 7, 2025, confirmed that Resident 8's care plan was not revised to reflect that his oxygen was discontinued and it should have been. An admission MDS assessment for Resident 26, dated January 15, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and had diagnoses that included pneumonia and clostridium difficile infection (C-Diff-a contagious infection affecting the colon). A care plan for Resident 26, dated January 10, 2025, indicated that the resident was taking an antibiotic related to C-diff infection and pneumonia and was on contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) for the C-diff infection. Physician's orders for Resident 26, dated January 10, 2025, indicated that the resident was to be placed on contact precautions for 10 days through January 19, 2025. Observations on February 3, 2025, at 9:53 a.m. revealed that the resident had signage on her door for contact precautions; however, as of February 5, 2025, there was no documented evidence in Resident 26's clinical record that she was ordered an antibiotic. Interview with the Nursing Home Administrator on February 5, 2025, at 11:53 a.m. confirmed that Resident 26's care plan for the antibiotic related to the C-diff infection and PNA should have been revised to reflect that she was no longer on antibiotic therapy and confirmed that her care plan should have been revised to reflect that the contact precaution for the C-diff were discontinued. A quarterly MDS assessment for Resident 42, dated December 26, 2024, indicated that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included chronic respiratory failure. Review of the care plan for Resident 42, dated September 10, 2024, indicated that the resident was receiving anticoagulant (blood thinner) therapy. Review of Resident 42's clinical record, including his medication administration record, revealed no documented evidence that the resident was receiving an anticoagulant. Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 42 was not receiving an anticoagulant and his care plan should have been revised to reflect that. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for nine of 43 residents reviewed (Residents 3, 9, 12, 18, 45, 58, 85, 88, 131). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Sections N0145B antianxiety, N0415F Antibiotic, N0415G Diuretic, N0415H Opioid (narcotic medications used to treat pain), and N0415K anticonvulsant medications were to be coded if the resident took the medication during the seven-day look-back period. Section O0110J1 (Dialysis) was to be coded if the resident received dialysis services. Section O0110K (hospice care) was to be coded if the resident received hospice services. A significant change MDS assessment for Resident 3, dated November 29, 2024, indicated that the resident had moderate cognitive impairment, required assistance from staff for personal care needs, and had diagnosis that included a displaced trimalleolar fracture of the left lower leg (fracture in the ankle joint on the left leg). Section N0415F-Antibiotic indicated that the resident did not receive any antibiotics during the seven-day look-back period. Physician's orders for Resident 3, dated November 26, 2024, indicated that the resident was to receive 4.5 grams of piperacillin (an antibiotic) intravenously (into a vein) every six hours for seven days. Review of the Medication Administration Record (MAR) for Resident 3, dated November 2024, revealed that the resident did receive piperacillin during the seven-day look-back period. Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 3's MDS, dated [DATE], was inaccurately coded regarding antibiotics. A quarterly MDS assessment for Resident 9, dated January 30, 2025, revealed that the resident was cognitively intact, required assistance from staff for personal care needs, and had diagnoses that included coronary artery disease. Section N0415H (Opioid) indicated that the resident received an opioid during the seven-day look-back period. Review of the MAR for Resident 9, dated January, 2025, revealed that the resident did not receive opioids during the seven-day look-back period. Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 3's MDS, dated [DATE], was inaccurately coded regarding opioid medications. A quarterly MDS assessment for Resident 12, dated January 27, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included diabetes. Section N0415H (Opioid) indicated that the resident did not receive an opioid during the seven-day look-back period. Physician's orders for Resident 12, dated August 1, 2024, included an order for the resident to receive 50 milligrams of Tramadol (an opioid) every 12 hours as needed for pain. Review of the MAR for Resident 12, dated January 2025, revealed that the resident received Tramadol during the seven-day look-back period. Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 8:30 a.m. confirmed that Resident 12's MDS, dated [DATE], was inaccurately coded regarding opioid medication. A quarterly MDS assessment for Resident 18, dated December 10, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia, high blood pressure, and stroke. Section N0415H (Opioid) indicated that the resident received an opioid medication during the assessment period, and Section O0110K (Hospice care) indicated that hospice services were not received. Physician's orders for Resident 18, dated July 15, 2024, included an order for the resident to receive hospice services from the facility's contracted hospice provider. Physician's orders for Resident 18, dated August 30, 2024, included an order for the resident to receive 0.5 milliliters of morphine sulfate (opioid) every two hours as needed for pain. A review of the December 2024 MAR revealed that the medication was not administered during the seven-day look-back period. Interview with the Director of Nursing on February 5, 2025 at 12:25 p.m. confirmed that the quarterly MDS assessment for Resident 18 was inaccurately coded regarding opioid medication and hospice services. A significant change MDS assessment for Resident 45, dated November 25, 2024, revealed that the resident was cognitively intact, required assistance from staff for her daily care needs, required oxygen therapy, and had diagnoses that included atrial fibrillation (irregular heartbeat), high blood pressure, right femur fracture, asthma, and chronic obstructive pulmonary disease. Section N0415F (Antibiotic) and N0415H (Opioid) revealed that the resident received antibiotic and opioid medications during the look-back period. A review of Resident 45's MAR for November 2024 revealed that the resident did not receive an antibiotic or opioid medication during the seven-day look-back period. Interview with the Nursing Home Administrator on February 4, 2025, at 1:18 p.m. confirmed that Residents 45's significant change MDS assessment was inaccurately coded regarding antibiotic and opioid medications. A quarterly MDS assessment for Resident 58, dated January 8, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included end-stage renal disease (disease that affects kidney function) and dependence on renal dialysis. Section O0110J1 (Dialysis) revealed that the resident did not receive dialysis. Physician's orders for Resident 58, dated July 15, 2024, included an order for the resident to receive dialysis on Monday, Wednesday, and Friday. Review of Resident 58's clinical record revealed documentation that the resident received dialysis services during the assessment period. Interview with the Registered Nurse Assessment Coordinator on February 5, 2025, at 2:30 p.m. confirmed that Resident 58's quarterly MDS assessment was inaccurately coded regarding dialysis. A quarterly MDS assessment for Resident 85, dated January 14, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure and dementia. Section N0415G (Diuretic) revealed that the resident did not receive a diuretic medication during the seven-day assessment period. Physician's orders for Resident 85, dated July 16, 2024, included an order for the resident to receive 2.5-6.25 milligram of bisoprolol hydrochlorothiazide (diuretic medication) one time a day for high blood pressure. A review of Resident 85's MAR for January 2025 revealed that the resident received the diuretic medication during the seven-day look-back period. Interview with the Registered Nurse Assessment Coordinator on February 5, 2025, at 2:30 p.m. confirmed that Resident 85's quarterly MDS assessment was inaccurately coded regarding the diuretic medication. A quarterly MDS assessment for Resident 88, dated January 7, 2025, revealed that the resident had severe cognitive impairment, was dependent on staff for care needs, and had diagnoses that included dementia. Section N0415F (Antibiotic) revealed that the resident did not receive an antibiotic during the look-back period and Section N0415K (anticonvulsant) revealed that the resident received an anticonvulsant medication during the look-back period. Physician's orders for Resident 88, dated December 19, 2024, included an order for the resident to receive triple antibiotic ointment topically to his right fourth finger every day for a skin tear. Physician's orders, dated January 6, 2024, included for the resident to receive triple antibiotic ointment to sutures above his right eye twice day until January 13, 2025. Review of the MAR, dated January 2025, revealed that Resident 88 received an antibiotic during the seven-day look-back period but did not receive an anticonvulsant. Interview with the Registered Nurse Assessment Coordinator on February 7, 2025, at 2:02 p.m. confirmed that Resident 88's January 7, 2025, MDS was inaccurately coded regarding antibiotic and anticonvulsant medication. The RAI User's Manual, dated October 2024, indicated that the intent of Section A was to record the discharge status of the resident. Section A2105 was to be coded with the location of the resident's discharge. A discharge tracking MDS assessment for Resident 131, dated January 11, 2025, indicated that the resident was discharged to home. A nursing note for Resident 131, dated January 12, 2025, at 12:14 a.m. indicated that the resident was admitted to the local hospital. Interview with Director of Nursing on February 7, 2025, at 11:09 a.m. confirmed that Resident 131's discharge MDS assessment was coded inaccurately and that the resident was discharged to the local hospital. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of 43 residents reviewed (Resident 9), and failed to ensure that a licensed practical nurse followed professional standards regarding the administration of medications for one of 43 residents reviewed (Resident 81). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 9, dated January 30, 2025, revealed that the resident was cognitively intact, required assistance from staff for personal care needs, and had diagnoses that included coronary artery disease. A physician's order note for Resident 9, dated October 30, 2024, at 1:07 a.m. revealed that the resident was seen by the certified registered nurse practitioner (a registered nurse who has advanced training and education) on October 29, 2024, and new orders were received for the resident to receive 20 milligrams (mg) of escitalopram (antidepressant medication) daily for depression. An incident note for Resident 9, dated November 5, 2024, at 12:15 p.m. revealed that during a pharmacy medication/chart audit, it was noted that the resident was ordered 10 mg of escitalopram daily and 20 mg of escitalopram daily for a combined dose of 30 mg of escitalopram daily from October 30, 2024, to November 5, 2024. A transcription error was identified that the 10 mg of escitalopram was not discontinued when the medication was increased to 20 mg. A physician's progress note, dated December 16, 2024, at 10:58 a.m., revealed that orders were placed to decrease escitalopram from 20 mg to 10 mg daily after a review from a previous hospitalization . An incident note for Resident 9, dated December 19, 2024, at 6:59 a.m., revealed that an order was received from the certified registered nurse practitioner on December 16, 2024, to decrease escitalopram from 20 mg daily to escitalopram 10 mg daily. Escitalopram 20 mg was discontinued. The new order for escitalopram 10 mg daily was not entered into the clinical record. After review of a medication audit, the order was corrected, and the physician approved starting the escitalopram 10 mg daily that day. Interview with the Director of Nursing on February 5, 2025, at 2:49 p.m. revealed that Resident 9 received 30 mg of escitalopram instead of the ordered dose of 20 mg of escitalopram from October 30, 2024, through November 5, 2024, and did not receive the ordered dose of 10 mg of escitalopram on December 17 and 18, 2024. Incident investigations were completed revealing that transcription errors were made in both occurrences. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 (a)(3) indicated that the Licensed Practical Nurse (LPN) is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act. The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering medications must check the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band and checking photograph attached to the medical record, and if necessary, verify resident identification with other facility personnel. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time, and method (route) of administration before giving the medication. An annual MDS assessment for Resident 81, dated December 6, 2024, revealed that the resident was sometimes understood, sometimes understands, and had a diagnosis which included dementia. A care plan for the resident, dated December 16, 2023, revealed that the resident has a communication deficit related to cognitive deficits (refer to impairments in a person's thinking abilities). A nursing note for Resident 81, dated December 17, 2024, revealed that Licensed Practical Nurse 1 reported to this registered nurse that this resident received another resident's medications in error. Agency Licensed Practical Nurse 2 reported that she went to the beauty shop to pick up Resident 93 to return her to room [ROOM NUMBER]-A to administer her medications. The nurse aides realized that Resident 81 was not in her assigned room of 230-A. The nurse aides found Resident 81 in room [ROOM NUMBER]-A. The nurse aides then returned Resident 81 to her room. Resident 81 had a moderate-sized emesis of what appeared to be medications. Licensed Practical Nurse 1 confirmed that she had not administered any medications to this resident this morning. Agency Licensed Practical Nurse 2 stated that she thought this resident was Resident 93, who lives in room [ROOM NUMBER]-A, and attempted to administer Resident 93's medications to this resident. This resident would not accept medications per Agency Licensed Practical Nurse 2. Assessment of the resident revealed that the resident was up in her wheelchair per orders. She was alert to self, no distress noted. She looks at you when you speak to her but does not respond, and this is the resident's baseline. Vital signs were stable. The physician and the resident's responsible party were notified. A statement by Agency Licensed Practical Nurse 2, dated December 17, 2024, revealed that she took the medications to the beauty salon. She asked the hairdresser which resident was Resident 93. She pointed to Resident 81 and stated that was Resident 93. She then tried to administer the medication to Resident 81 thinking that she was Resident 93. Resident 81 spit the medications out and would not take them. An Interdisciplinary Team (IDT) note for Resident 81, dated December 17, 2024, revealed that the incident was reviewed by the IDT. The licensed practical nurse involved was an agency licensed practical nurse. The agency licensed practical nurse's agency was contacted regarding the probable medication error. Agency Licensed Practical Nurse 2 was placed on a do not return to the facility list due to not following the administering medication rights. Interview with the Director of Nursing on February 7, 2025, at 1:05 p.m. confirmed that Agency Licensed Practical Nurse 2 did not follow the facility's policy when administering medications to a resident. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for two of 43 residents reviewed (Residents 10, 57). Findings include: The facility's policy regarding medication administration, dated September 12, 2024, revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time, and method (route) of administration before giving the medication. Physician's orders for Resident 10, dated December 22, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Midodrine (used to treat low blood pressure (hypotension) three times a day for hypotension, and staff was to hold the medication if the resident's systolic blood pressure (the top number of the blood pressure) was greater than 120 millimeters of mercury (mmHg) or if the diastolic blood pressure (the bottom number of the blood pressure) was greater than 80 mmHg. Resident 10's Medication Administration Records (MARs) for December 2024, January and February 2025, revealed that staff administered the one 10 mg tablet of Midodrine on December 22, 2024, at 8:30 a.m. for a blood pressure of 130/75 mmHg; on December 23, 2024, at 8:30 a.m. for a blood pressure of 124/48; on December 24, 2024, at 12:30 p.m. for a blood pressure of 126/60 mmHg; on December 26, 2024, at 12:30 p.m. for a blood pressure of 122/76 mmHg; on December 27, 2024, at 8:30 a.m. for a blood pressure of 169/83 mmHg; and on December 31, 2024, at 8:30 a.m. for a blood pressure of 122/66 mmHg, and at 12:30 p.m. for a blood pressure of 126/72 mmHg; on January 4, 2025, at 12:30 p.m. for a blood pressure of 122/82 mmHg; on January 5, 2025, at 8:30 a.m. for a blood pressure of 146/78 mmHg; on January 8, 2025, at 12:30 p.m. for a blood pressure of 138/74 mmHg, and at 5:30 p.m. for a blood pressure of 130/78 mmHg; on January 10, 2025, at 12:30 p.m. for a blood pressure of 138/62 mmHg, and at 5:30 p.m. for a blood pressure of 152/100 mmHg; on January 11, 2025, at 8:30 a.m. for a blood pressure of 134/52 mmHg; on January 14, 2025, at 5:30 p.m. for a blood pressure of 126/68 mmHg; on January 15, 2025, at 12:30 p.m. for a blood pressure of 126/56 mmHg; and on January 25, 2025, at 8:30 a.m. for a blood pressure of 134/88 mmHg; and on February 2, 2025, at 8:30 a.m. for a blood pressure of 124/82 mmHg. Interview with the Director of Nursing on February 5, 2025, at 10:51 a.m. confirmed that Resident 10's one 10 mg tablet of Midodrine should not have been administered on the above dates. Physician's orders for Resident 57, dated July 16, 2024, included an order for the resident to receive one 10 mg tablet of Midodrine three times a day for hypotension, and staff was to hold the medication if the resident systolic blood pressure was greater than 120 mmHg or if the diastolic blood pressure was greater than 80 mmHg. Resident 57's MARs for December 2024, January and February 2025, revealed that staff administered the one 10 mg tablet of Midodrine on December 9, 2024, at 8:30 p.m. for a blood pressure of 106/88 mmHg; on December 11, 2024, at 8:30 a.m. for a blood pressure of 116/82 mmHg, and at 8:30 p.m. for a blood pressure of 120/88 mmHg; on December 17, 2024, at 8:30 a.m. for a blood pressure of 128/66 mmHg, and at 12:30 p.m. for a blood pressure of 126/64 mmHg; on December 25, 2024, at 8:30 p.m. for a blood pressure of 136/66 mmHg; and on December 27, 2024, at 8:30 a.m. for a blood pressure of 126/78 mmHg; on January 6, 2025, at 8:30 p.m. for a blood pressure of 128/70 mmHg; on January 9, 2025, at 8:30 p.m. for a blood pressure of 124/68 mmHg; on January 14, 2025, at 8:30 a.m. for a blood pressure of 110/84 mmHg; on January 15, 2025, at 8:30 p.m. for a blood pressure of 122/72 mmHg; and on January 23, 2025, at 8:30 p.m. for a blood pressure of 122/73 mmHg; and on February 3, 2025, at 12:30 p.m. for a blood pressure of 118/82 mmHg, and at 8:30 p.m. for a blood pressure of 129/76 mmHg. Interview with the Director of Nursing on February 4, 2025, at 1:18 p.m. confirmed that Resident 57's one 10 mg tablet of Midodrine should not have been administered on the above dates. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush a PICC line (a tube placed in a vein that can be used to deliver fluids and/or medications) and a peripheral intravenous catheter (a small, thin tube inserted into a vein in the arm, hand or foot to administer medications and/or fluids) as ordered by the physician for two of 43 residents reviewed (Residents 8, 117), failed to administer intravenous fluids as ordered by the physician for one of 43 residents reviewed (Resident 8), and failed to change PICC line dressing as ordered by the physician for one of 43 residents reviewed (Resident 122). Findings include: The facility's policy regarding PICC line dressing changes, dated September 12, 2024, indicated that the PICC's will be flushed every shift and after each use with five to 10 cubic centimeters (cc) of normal sterile saline (NSS - a mixture of water and salt with a salt concentration of 0.9 percent) and five cc of Heparin (used to prevent and treat blood clots) if the physician's orders indicate. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 21, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, used oxygen, and had a diagnosis of hemiplegia and hemiparesis (paralysis or weakness to one side of the body due to brain injury). Physician's orders for Resident 8, dated December 15, 2024, included an order for staff to administer 800 milliliters (ml) of sodium chloride solution 0.9 percent intravenously (a way of giving a drug or other substance through a needle or tube inserted into a vein) for low sodium every shift for a total of two liters (2,000 ml) through December 16, 2024. Physician's orders for Resident 8, dated December 16, 2024, included an order for staff to administer sodium chloride solution 0.9 percent intravenously at a rate of 70 ml per hour one time only for hydration for one day for a total of one liter. Physician's orders for Resident 8, dated December 18, 2024, included an order for staff to administer sodium chloride solution 0.9 percent intravenously at a rate of 75 ml per hour every shift for poor intake for a total of one liter. Review of Resident 8's Medication Administration Record (MAR), dated December 2024, revealed that there was no documented evidence that the resident received the ordered amount of sodium chloride solution as per physician orders. Interview with Director of Nursing on February 7, 2025, at 1:29 p.m. confirmed that there was no documented evidence that Resident 8 received the ordered amount of sodium chloride solution as per physician orders. Physician's orders for Resident 8, December 15, 2024, included an order for staff to flush the resident's intravenous line to his left wrist with 10 cc of NSS every shift prior to intravenous medication/fluid administration and 10 cc of NSS every shift after intravenous medication/fluid administration. Physician's orders for Resident 8, dated December 16, 2024, included an order for the resident to receive one gram (gm) of ceftriaxone sodium solution (an antibiotic) intravenously one time a day pending urine culture through December 21, 2024. Review of Resident 8's MARs dated December 2024, revealed that there was no documented evidence that staff flushed the resident's intravenous line with 10 cc of NSS prior to and after administration of ceftriaxone on the day shift on December 16, 2024; on the day shift on December 20, 2024; on the evening shift on December 15 and 19, 2024; and on the night shift for December 19, 2024. Interview with the Director of Nursing on February 7, 2025, at 1:14 p.m. confirmed that there was no documented evidence that the staff flushed Resident 8's intravenous line on the above mentioned dates and shifts. Physician's orders for Resident 117, dated September 16, 2024, included an order for staff to flush the resident's PICC with 10 cc of NSS every shift for six weeks. Review of Resident 117's MARs, dated September 2024, revealed that there was no documented evidence that staff flushed the resident's PICC with the 10 cc of NSS during the evening shift on September 20 through 23, 2024, and during the night shift on September 22, 2024. Physician's orders for Resident 117, dated September 23, 2024, included an order for staff to flush the resident's PICC with 200 units of Heparin every night shift for six weeks. Review of Resident 117's MARs, dated September and October 2024, revealed that there was no documented evidence that staff flushed the resident's PICC with the 200 units of Heparin during the night shift on September 27, and 28, 2024, and on October 4 through 6, and 25, 2024. Physician's orders for Resident 117, dated September 23, 2024, included an order for staff to flush the resident's PICC with 10 cc of NSS every shift for six weeks. Review of Resident 117's MARs, dated September and October 2024, revealed that there was no documented evidence that staff flushed the resident's PICC with the 10 cc of NSS during the day shift on September 26 and 30, 2024, and on October 4, 2024; during the evening shift on September 24, 25, 28, and 30, 2024, and on October 1, 4, 5, 10, 11, 14, 15, 23, and 25, 2024; and during the night shift on September 27 and 28, 2024, and on October 4, 5, 6, and 25, 2024. Physician's orders for Resident 117, dated September 16, 2024, included an order for the resident to receive one gram (gm) of Vancomycin (an antibiotic) intravenously every 12 hours. There was no documented evidence that Resident 117's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration. Review of Resident 117's MARs, dated September 2024, revealed that staff administered the one gm of Vancomycin intravenously on September 16, 2024, at 6:00 p.m.; on September 17, 18, and 19, 2024 at 6:00 a.m. and 6:00 p.m.; and on September 20, 2024, at 6:00 a.m. However, there was no documented evidence that Resident 117's midline was flushed with a saline solution before and after the administration of the Vancomycin. Physician's orders for Resident 117, dated September 23, 2024, included an order for the resident to receive two gms of Ceftriaxone (an antibiotic) intravenously (a way of giving a drug or other substance through a needle or tube inserted into a vein) every 24 hours. There was no documented evidence that Resident 117's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration. Review of Resident 117's MARs, dated September, October, and November 2024, revealed that staff administered the two gms of Ceftriaxone intravenously daily on September 24 through 27, and 30, 2024; on October 1 through 4, 8 through 25, 27 through 31, 2024; and on November 1 through 4, 2024. However, there was no documented evidence that Resident 117's PICC was flushed with a saline solution before and after the administration of the Ceftriaxone. Interview with the Director of Nursing on February 7, 2025, at 12:06 p.m. confirmed that there was no documented evidence that Resident 117's PICC was flushed with the 10 cc of NSS every shift, flushed with 200 units of Heparin every night shift, and flushed with 10 cc of NSS every shift on the above dates. She indicated that the resident's PICC was to be flushed with a saline solution before and after the administration of the antibiotics and confirmed that there was no documented evidence that the resident's physician was contacted for orders to flush the resident's midline with a saline solution prior to and/or after medication administration, and confirmed that there was no documented evidence that the resident's PICC was flushed with a saline solution prior to and/or after the Vancomycin and Ceftriaxone administration on the above dates The facility's policy regarding PICC line dressing changes, dated September 12, 2024, revealed that dressings were changed at 24 hours with new insertion then every seven days and as needed if loose, wet, or soiled. An admission Minimum Data Set (MDS) assessment (a mandated assessment of the resident's abilities and care needs) for Resident 122, dated January 22, 2025, indicated that the resident was cognitively intact, required assistance for daily care needs, received IV medications, and had medical diagnosis that include high blood pressure and sepsis. Observation on February 5, 2025, at 11:00 a.m. revealed that Resident 122 was sitting in his chair PICC line in right arm and was dated January 28, 2025. Physician's orders, dated January 21, 2025, included orders for resident's PICC line to be changed every seven days on nightshift. Resident 122's Medication Administration Record for April 2024 revealed that the residents PICC line was due to be changed February 4, 2025, and that the treatment was not signed off as completed. Interview with the Registered Nurse 3 on February 5, 2025, at 11:06 a.m. confirmed that Resident 122's PICC line was dated January 28, 2024, and that it should have been changed last night per physician orders and it was not. Interview with the Director of Nursing on February 5, 2025, at 2:24 p.m. confirmed that Resident 122's PICC line should have been changed per physician order and it was not. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that eight of nine residents reviewed (Residents 1, 2, 4, 5, 6, 7, 8, 9) were free from abuse perpetrated by a resident with aggressive behaviors (Resident 3), resulting in an incident in which one of nine residents reviewed suffered a fracture (Resident 1). Findings include: The facility's behavior management policy, dated April 24, 2023, revealed that staff were to develop, implement, and maintain behavior management plans. Staff would consult with the attending physician, facility psychiatrist, and other behavior management specialists as a available to develop an individualized behavior management plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 19, 2023, revealed that the resident was cognitively impaired; had physical behaviors directed towards others; verbal behaviors towards others; other behaviors not directed towards others; rejection of care; wandering behaviors; ambulated (walked) with supervision; was receiving anti-psychotic, anti-anxiety, and anti-depressant medications; and had diagnoses that included dementia, traumatic brain injury, anxiety, and depression. The behavior care plan for Resident 3, dated November 11, 2022, and revised on March 5 and June 6, 2023, revealed that staff were to offer diversional activities when the resident was having behaviors which included: listening to music such as the oldies or country music, watching NCIS when available as this was her favorite television show, provide newspapers or magazines to look at, provide word search books, provide the task of folding laundry to occupy her attention, and encourage her to walk in the hallway to divert her attention; staff were to stop giving care if the resident becomes upset and attempt at a later time; approach her calmly and slowly; speak with her calmly and spend time with her to attempt to calm her when she is agitated; when she was agitated or tearful attempt to get her to stay in a supervised area; if agitated offer a snack; if over-stimulated, redirect her to a private/quiet area; maintain consistent and routine care givers; when agitated staff were to call the resident's son so that he could speak with her to calm her down; educate her that physical abuse with others is not acceptable; minimize contact with Resident 1 as much as possible; and discourage her from wandering into other resident's rooms. There was no evidence of routine preventative interventions in order to protect all other residents on a daily basis. A nursing note, dated March 8, 2023, at 7:16 p.m. revealed that Resident 3 was observed grabbing a book out of the hands of Resident 7 and when Resident 7 went to reach for her book, Resident 3 reached out and struck Resident 7 on the left side of her face. Resident 3 was re-directed away from Resident 7 and placed on 15-minute checks and was administered one dose of 1 milligram (mg) of Haldol (anti-psychotic). The resident was seen by psychiatric services due to worsening behaviors, and orders were received to start 0.5 mg of Ativan twice day. A nursing note, dated March 9, 2023, at 2:08 p.m. and 2:15 p.m. revealed that Resident 9 was sitting at a table in the solarium and Resident 3 wandered toward the resident and slapped her on the right cheek. Resident 9 was tearful and her cheek was reddened. The residents were separated and diversional activities were provided. The residents were to be monitored with 15-minute checks. Resident 3 was unable to be re-directed and several diversional activites were offered, but the resident does not have the attention span lasting longer than one minute with activities. The physician was notified, and the resident was ordered a laxative and an antibiotic for a urinary tract infection. A nursing note, dated March 19, 2023, at 2:16 p.m. revealed that Resident 4 was ambulating in the hallway going back up to the solarium when Resident 3 was ambulating from the solarium and stopped, turned around, and with a closed fist struck Resident 4's right cheek. Resident 3 was redirected and monitored closely for approximately two hours by staff. The physician was notified and orders were received to increase the resident's Ativan (anti-anxiety) to three times day. A nursing note, dated April 24, 2023, at 9:17 p.m. revealed that Resident 3 was in another resident's room visiting with the family's dog. She returned later to the room and was rambling incoherently and screaming, and when they attempted to re-direct her, Resident 6 stood up and Resident 3 punched him in the chest. Staff were called and they immediately removed Resident 3 from his room. The physician was notified and the Resident 3 was given 1 mg of Haldol, close supervision so that the resident did not go after anyone else, and snacks and drinks were offered to redirect the resident. A psychiatric service note, dated April 26, 2023, revealed the resident's anti-anxiety medication was changed. A nursing note, dated May 26, 2023, 7:09 p.m. revealed that Resident 5 was arguing with Resident 3 when Resident 3 punched Resident 5 in the face. The nurse aide stepped in between them and Resident 3 reached around the staff member and hit Resident 5 again. The residents were separated and no new orders were received. There was no documented evidence that any changes were made to Resident 3's behavior management plan. A nursing note, dated June 4, 2023, at 6:38 p.m. revealed that Resident 3 was tearful and wandering on the unit, then walked up to Resident 1 while he was seated eating his dinner in the lounge and screamed f*** y**, and slapped Resident 1 across the left side of the face. Both residents were immediately separated and Resident 3's behavior care plan was updated to minimize contact with Resident 1 as much as possible. A psychiatric service note, dated June 7, revealed that Resident 3's current antipsychotic was to be discontinued and 0.5 mg of Rexulti (anti-psychotic) daily be added. A nursing note, dated June 14, 2023, at 7:14 p.m. revealed that Resident 1 was sitting in a chair in the middle of the solarium and had a bedside table set up in front of him so he could have a FaceTime (electronic face-to-face visit) visit with his daughter. Resident 3 tipped the table over onto Resident 1, bumping his feet. Resident 1 was very angry and began to yell out loudly. Resident 3 was re-directed away from Resident 1. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A nursing note, dated June 16, 2023, at 8:16 a.m. revealed that Resident 8 was sitting at a table in the common area eating her breakfast when Resident 3 reached over the resident for her breakfast. Resident 8 shooed Resident 3 away and then Resident 3 hit Resident 8 in the back with an open hand. Resident 3 was redirected, given a baby doll, and toileted. A nursing note, dated June 19, 2023, at 7:01 p.m. revealed that all day Resident 3 was randomly swearing at residents and staff and attempting to strike out at residents and staff to hit them. After staff redirected the resident she would start to cry and kept stating, I'm sorry, I'm sorry. The resident would sit down in a chair, get up swiftly, and target another resident or a staff member. A social service note, dated June 20, 2023, at 4:35 p.m. revealed that Resident 3 was noted daily for numerous behaviors and was easily agitated with others often with little to no provocation. Her agitation often occurred with no warning or indication and appeared to be impulsive. She appeared to respond to certain staff with redirection at times. A nursing note, dated June 21, 2023, at 11:49 a.m. revealed that Resident 4 was walking around the solarium when Resident 3 turned around and punched Resident 4 on the right cheek, while yelling This is my pillow! Staff re-directed both residents away from each other. Resident 3 was to be a one-to-one observation and staff were instructed to keep the residents away from each other. A psychiatric service note, dated June 21, 2023, indicated that Resident 3's Rexulti was to be increased to 1 mg daily due to several aggressive incidents over the past week. A nursing note, dated June 26, 2023, at 11:09 a.m. revealed that staff reported that Resident 1 was reading a magazine and Resident 3 threw fluids onto his lap. Resident 1 stood up and staff redirected him to avoid a resident-to-resident confrontation. A psychiatric service note, dated June 28, 2023, indicated that Resident 3's Rexulti would be increased to 2 mg daily for further aggression. A nursing note, dated July 3, 2023, at 5:07 p.m. revealed that Resident 4 was witnessed walking in the hallway by staff when Resident 3 was walking in the opposite direction and yelled out why are you following me, then smacked Resident 4 on the left side of her face. Both residents were separated and Resident 3 was assigned to a nurse aide for one-to-one observation to prevent recurrence. A psychiatric service note, dated July 12, 2023, revealed that the resident was having daily agitation on the day and evening shift and the current antipsychotics that she was receiving were not managing her distress. A nursing note, dated July 14, 2023, at 8:46 a.m. revealed that Resident 3 had a violent outburst when staff attempted to re-direct her and she scratched the licensed practical nurse on the face and hand. She threw a cup of water onto the licensed practical nurse and raised closed fists to all of the staff that attempted to re-direct her to an activity. She punched two nurse aides and picked up a resident's walker and threw it at a nurse aide. The resident was sent to the hospital and received medications and returned to the facility. A nursing note, dated July 15, 2023, at 7:15 a.m. revealed that Resident 1 was seen by a staff member being pushed down by Resident 3. Resident 3 pushed Resident 1 with both of her hands and Resident 1 fell backwards hitting the back of his head off the floor and injuring his right hip. Resident 3's hip was hurting when touched and his right leg and foot were rotated to the right and he was sent to the hospital. A nursing note, dated July 16, 2023, at 2:14 a.m. revealed that Resident 1 had a fractured right hip and was to have surgery. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A behavior note, dated July 15, 2023, at 8:15 a.m. revealed that Resident 3 was walking down the hall towards the common area when she saw Resident 2 standing in front of the nurse's station door. Resident 3 punched and shoved the resident into the medication cart, which was seen by staff, and Resident 3 was re-directed and staff attended to the resident that was punched and shoved. The nurse aide that came out of the shower room witnessed Resident 3 push Resident 1 backwards with both of her hands causing him to fall backwards sustaining an injury. Resident 3 was sent to the hospital and admitted to the behavioral health unit. A nursing note, dated July 15, 2023, at 12:39 p.m. revealed that Resident 2 was punched in the chest and pushed into the nurse's med cart by Resident 3. Staff re-directed Resident 3 away from Resident 2. Staff ensured Resident 2's safety by keeping Resident 3 within view Following the above incidents, there was no documented evidence that Resident 3's care-planned behavior interventions were revised when they were not effective, and no evidence that an individualized behavior management plan was developed in an attempt to prevent Resident R3's behaviors from affecting the safety of all other residents. Interview with Registered Nurse 1 on July 27, 2023, at 2:30 p.m. revealed that Resident 3 had behaviors of pacing quickly, being combative at times, screaming obscenities, pinching, hitting her, and being combative with other residents. She indicated that Resident 3 was scary to be around because she was volatile and could be really sweet one minute and then could switch on you at the drop of a hat. She revealed that Resident 3 did not have the attention span for activities and would wander, and that sometimes there were staff to do one-to-one supervision and sometimes not. Interview with Nurse Aide 2 on July 27, 2023, at 2:47 p.m. revealed that Resident 3 would wake up in the morning and cry, throw food and drinks during breakfast, beat up and shove staff, hit other residents for no reason, and hit the same resident again. She indicated that staff would keep an eye on her but one-to-one observation was usually added after she hit someone. She did not think any of the medication changes made helped Resident 3's behaviors and that nothing really helped her behaviors. She felt that the other residents were not safe around Resident 3 and now that Resident 3 is no longer there everyone is safe. Interview with the Director of Nursing on July 27, 2023, at 3:30 p.m. revealed that Resident 3 had a very short fuse, and her behaviors came and went. Most of her behavior was crying and at times she would become aggressive and start yelling and swearing with no warning sign. When she was in the common area staff would re-direct her and if Resident 3 was escalating, you could not be beside her. She had hospitality aides on the unit for observation and used them for one-to-one observations. She indicated that when Resident 3 punched and shoved Resident 2, staff attended to Resident 2 and did not stop Resident 3 from approaching Resident 1 and pushing him down. She agreed that the unit was not the safest environment at times for the residents with Resident 3's aggressive behaviors. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed failed to ensure that the residents' environment remained free of accident hazards for eight of nine residents reviewed (Residents 1, 2, 4, 5, 6, 7, 8, 9), caused by a resident with aggressive behaviors (Resident 3), resulting in an accident in which one of nine residents reviewed suffered a fracture (Resident 1). Findings include: The facility's behavior management policy, dated April 24, 2023, revealed that staff were to develop, implement, and maintain behavior management plans. Staff would consult with the attending physician, facility psychiatrist, and other behavior management specialists as a available to develop and individualized behavior management plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 19, 2023, revealed that the resident was cognitively impaired; had physical behaviors directed towards others; verbal behaviors towards others; other behaviors not directed towards others; rejection of care; wandering behaviors; ambulated (walked) with supervision; was receiving anti-psychotic, anti-anxiety, and anti-depressant medications; and had diagnoses that included dementia, traumatic brain injury, anxiety, and depression. The resident's behavior care plan for Resident 3, dated November 11, 2022, and revised on March 5 and June 6, 2023, revealed that staff were to offer diversional activities when the resident was having behaviors which included: listening to music such as the oldies or country music, watching NCIS when available as this was her favorite television show, provide newspapers or magazines to look at, provide word search books, provide the task of folding laundry to occupy her attention, and encourage her to walk in the hallway to divert her attention; staff were to stop giving care if the resident becomes upset and attempt at a later time; approach her calmly and slowly; speak with her calmly and spend time with her to attempt to calm her when she is agitated; when she was agitated or tearful attempt to get her to stay in a supervised area; if agitated offer a snack; if over-stimulated, redirect her to a private/quiet area; maintain consistent and routine care givers; when agitated staff were to call the resident's son so that he could speak with her to calm her down; educate her that physical abuse with others is not acceptable; minimize contact with Resident 1 as much as possible; and discourage her from wandering into other resident's rooms. There was no evidence of routine preventative interventions in order to protect all other residents on a daily basis. A nursing note, dated March 8, 2023, at 7:16 p.m. revealed that Resident 3 was observed grabbing a book out of the hands that Resident 7 was reading and when Resident 7 went to reach for her book, Resident 3 reached out and struck Resident 7 on the left side of her face. Resident 3 was re-directed away from Resident 7 and placed on 15-minute checks and was administered one dose of 1 milligram (mg) of Haldol (anti-psychotic). The resident was seen by psychiatric services due to worsening behaviors, and orders were received to start 0.5 mg of Ativan twice day. A nursing note, dated March 9, 2023, at 2:08 p.m. and 2:15 p.m. revealed that Resident 9 was sitting at a table in the solarium and Resident 3 wandered toward the resident and slapped her on the right cheek. Resident 9 was tearful and her cheek was reddened. The residents were separated and diversional activities were provided. The residents were to be monitored with 15-minute checks. Resident 3 was unable to be re-directed and several diversional activites were offered, but the resident does not have the attention span lasting longer than one minute with activities. The physician was notified, and the resident was ordered a laxative and an antibiotic for a urinary tract infection. A nursing note, dated March 19, 2023, at 2:16 p.m. revealed that Resident 4 was ambulating in the hallway going back up to the solarium when Resident 3 was ambulating from the solarium and stopped, turned around and with a closed fist struck, and Resident 4's right cheek. Resident 3 was redirected and monitored closely for approximately two hours by staff. The physician was notified and orders were received to increase the resident's Ativan (anti-anxiety) to three times day. A nursing note, dated April 24, 2023, at 9:17 p.m. revealed that Resident 3 was in another resident's room visiting with the family's dog. She returned later to the room and was rambling incoherently and screaming, and when they attempted to re-direct her, Resident 6 stood up and Resident 3 punched him in the chest. Staff were called and they immediately removed Resident 3 from his room. The physician was notified and the Resident 3 was given 1 mg of Haldol, close supervision so that the resident did not go after anyone else, and snacks and drinks were offered to redirect the resident. A psychiatric service note, dated April 26, 2023, revealed the resident's anti-anxiety medication was changed. A nursing note, dated May 26, 2023, 7:09 p.m. revealed that Resident 5 was arguing with Resident 3 when Resident 3 punched Resident 5 in the face. The nurse aide stepped in between them and Resident 3 reached around the staff member and hit Resident 5 again. The residents were separated and no new orders were received. There was no documented evidence that any changes were made to Resident 3's behavior management plan. A nursing note, dated June 4, 2023, at 6:38 p.m. revealed that Resident 3 was tearful and wandering on the unit, then walked up to Resident 1 while he was seated eating his dinner in the lounge and screamed f*** y**, and slapped Resident 1 across the left side of the face. Both residents were immediately separated and Resident 3's behavior care plan was updated to minimize contact with Resident 1 as much as possible. A psychiatric service note, dated June 7, revealed that Resident 3's current antipsychotic was to be discontinued and 0.5 mg of Rexulti (anti-psychotic) daily be added. A nursing note, dated June 14, 2023, at 7:14 p.m. revealed that Resident 1 was sitting in a chair in the middle of the solarium and had a bedside table set up in front of him so he could have a FaceTime (electronic face-to-face visit) visit with his daughter. Resident 3 tipped the table over onto Resident 1, bumping his feet. Resident 1 was very angry and began to yell out loudly. Resident 3 was re-directed away from Resident 1. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A nursing note, dated June 16, 2023, at 8:16 a.m. revealed that Resident 8 was sitting at a table in the common area eating her breakfast when Resident 3 reached over the resident for her breakfast. Resident 8 shooed Resident 3 away and then Resident 3 hit Resident 8 in the back with an open hand. Resident 3 was redirected, given a baby doll, and toileted. A nursing note, dated June 19, 2023, at 7:01 p.m. revealed that all day Resident 3 was randomly swearing at residents and staff and attempting to strike out at residents and staff to hit them. After staff redirected the resident she would start to cry and kept stating I'm sorry, I'm sorry. The resident would sit down in a chair, get up swiftly, and target another resident or a staff member. A social service note, dated June 20, 2023, at 4:35 p.m. revealed that Resident 3 was noted daily for numerous behaviors and was easily agitated with others often with little to no provocation. Her agitation often occurred with no warning or indication and appeared to be impulsive. She appeared to respond to certain staff with redirection at times. A nursing note, dated June 21, 2023, at 11:49 a.m. revealed that Resident 4 was walking around the solarium when Resident 3 turned around and punched Resident 4 on the right cheek, while yelling This is my pillow. Staff re-directed both residents away from each other. Resident 3 was to be a one-to-one observation and staff were instructed to keep the residents away from each other. A psychiatric service note, dated June 21, 2023, indicated that Resident 3's Rexulti was to be increased to 1 mg daily due to several aggressive incidents over the past week. A nursing note, dated June 26, 2023, at 11:09 a.m. revealed that staff reported that Resident 1 was reading a magazine and Resident 3 threw fluids onto his lap. Resident 1 stood up and staff redirected him to avoid a resident-to-resident confrontation. A psychiatric service note, dated June 28, 2023, indicated that Resident 3's Rexulti would be increased to 2 mg daily for further aggression. A nursing note, dated July 3, 2023, at 5:07 p.m. revealed that Resident 4 was witnessed walking in the hallway by staff when Resident 3 was walking in the opposite direction and yelled out why are you following me, then smacked Resident 4 on the left side of her face. Both residents were separated and Resident 3 was assigned to a nurse aide for one-to-one observation to prevent recurrence. A psychiatric service note, dated July 12, 2023, revealed that the resident was having daily agitation on the day and evening shift and the current antipsychotics that she was receiving were not managing her distress. A nursing note, dated July 14, 2023, at 8:46 a.m. revealed that Resident 3 had a violent outburst when staff attempted to re-direct her and she scratched the licensed practical nurse on the face and hand. She threw a cup of water onto the licensed practical nurse and raised closed fists to all of the staff that attempted to re-direct her to an activity. She punched two nurse aides and picked up a resident's walker and threw it at a nurse aide. The resident was sent to the hospital and received medications and returned to the facility. A nursing note, dated July 15, 2023, at 12:39 p.m. revealed that Resident 2 was punched in the chest and pushed into the nurse's med cart by Resident 3. Staff re-directed Resident 3 away from Resident 2. Staff ensured Resident 2's safety by keeping Resident 3 within view. A nursing note, dated July 15, 2023, at 7:15 a.m. revealed that Resident 1 was seen by a staff member being pushed down by Resident 3. Resident 3 pushed Resident 1 with both of her hands and Resident 1 fell backwards hitting the back of his head off the floor and injuring his right hip. Resident 3's hip was hurting when touched and his right leg and foot were rotated to the right and he was sent to the hospital. A nursing note, dated July 16, 2023, at 2:14 a.m. revealed that Resident 1 had a fractured right hip and was to have surgery. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A behavior note, dated July 15, 2023, at 8:15 a.m. revealed that Resident 3 was walking down the hall towards the common area when she saw Resident 2 standing in front of the nurse's station door. Resident 3 punched and shoved this resident into the medication cart, which was seen by staff, and Resident 3 was re-directed and staff attended to the resident that was punched and shoved. The nurse aide that came out of the shower room witnessed Resident 3 push Resident 1 backwards with both of her hands causing him to fall backwards sustaining an injury. Resident 3 was sent to the hospital and admitted to the behavioral health unit. Following the above incidents, there was no documented evidence that Resident 3's care-planned behavior interventions were revised when they were not effective, and no evidence that an individualized behavior management plan was developed in an attempt to prevent Resident R3's behaviors from affecting the safety of all other residents. Interview with Registered Nurse 1 on July 27, 2023, at 2:30 p.m. revealed that Resident 3 had behaviors of pacing quickly, being combative at times, screaming obscenities, pinching, hitting her, and being combative with other residents. She indicated that Resident 3 was scary to be around because she was volatile and could be really sweet one minute and then could switch on you at the drop of a hat. She revealed that Resident 3 did not have the attention span for activities and would wander, and that sometimes there were staff to do one-to-one supervision and sometimes not. Interview with Nurse Aide 2 on July 27, 2023, at 2:47 p.m. revealed that Resident 3 would wake up in the morning and cry, throw food and drinks during breakfast, beat up and shove staff, hit other residents for no reason, and hit the same resident again. She indicated that staff would keep an eye on her but one-to-one observation was usually added after she hit someone. She did not think any of the medication changes made helped Resident 3's behaviors and that nothing really helped her behaviors. She felt that the other residents were not safe around Resident 3 and now that Resident 3 is no longer there everyone is safe. Interview with the Director of Nursing on July 27, 2023, at 3:30 p.m. revealed that Resident 3 had a very short fuse, and her behaviors came and went. Most of her behavior was crying and at times would become aggressive and start yelling and swearing with no warning sign. When she was in the common area staff would re-direct her and if Resident 3 was escalating, you could not be beside her. She had hospitality aides on the unit for observation and used them for one-to-one observations. She indicated that when Resident 3 punched and shoved Resident 2, staff attended to Resident 2 and did not stop Resident 3 from approaching Resident 1 and pushing him down. She agreed that the unit was not the safest environment at times for the residents with Resident 3's aggressive behaviors. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to one resident (Resident 3) to ensure safety for eight of nine residents reviewed (1, 2, 4, 5, 6, 7, 8, 9), resulting in an incident in which one of nine residents reviewed suffered a fracture (Resident 1). Findings include: The facility's behavior management policy, dated April 24, 2023, revealed that staff were to develop, implement, and maintain behavior management plans. Staff would consult with the attending physician, facility psychiatrist, and other behavior management specialists as a available to develop and individualized behavior management plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 19, 2023, revealed that the resident was cognitively impaired; had physical behaviors directed towards others; verbal behaviors towards others; other behaviors not directed towards others; rejection of care; wandering behaviors; ambulated (walked) with supervision; was receiving anti-psychotic, anti-anxiety, and anti-depressant medications; and had diagnoses that included dementia, traumatic brain injury, anxiety, and depression. The behavior care plan for Resident 3, dated November 11, 2022, and revised on March 5 and June 6, 2023, revealed that staff were to offer diversional activities when the resident was having behaviors which included: listening to music such as the oldies or country music, watching NCIS when available as this was her favorite television show, provide newspapers or magazines to look at, provide word search books, provide the task of folding laundry to occupy her attention, and encourage her to walk in the hallway to divert her attention; staff were to stop giving care if the resident becomes upset and attempt at a later time; approach her calmly and slowly; speak with her calmly and spend time with her to attempt to calm her when she is agitated; when she was agitated or tearful attempt to get her to stay in a supervised area; if agitated offer a snack; if over-stimulated, redirect her to a private/quiet area; maintain consistent and routine care givers; when agitated staff were to call the resident's son so that he could speak with her to calm her down; educate her that physical abuse with others is not acceptable; minimize contact with Resident 1 as much as possible; and discourage her from wandering into other resident's rooms. There was no evidence of routine preventative interventions in order to protect all other residents on a daily basis. A nursing note, dated March 8, 2023, at 7:16 p.m. revealed that Resident 3 was observed grabbing a book out of the hands of Resident 7 and when Resident 7 went to reach for her book, Resident 3 reached out and struck Resident 7 on the left side of her face. Resident 3 was re-directed away from Resident 7 and placed on 15-minute checks and was administered one dose of 1 milligram (mg) of Haldol (anti-psychotic). The resident was seen by psychiatric services due to worsening behaviors, and orders were received to start 0.5 mg of Ativan twice day. A nursing note, dated March 9, 2023, at 2:08 p.m. and 2:15 p.m. revealed that Resident 9 was sitting at a table in the solarium and Resident 3 wandered toward the resident and slapped her on the right cheek. Resident 9 was tearful and her cheek was reddened. The residents were separated and diversional activities were provided. The residents were to be monitored with 15-minute checks. Resident 3 was unable to be re-directed and several diversional activites were offered, but the resident does not have the attention span lasting longer than one minute with activities. The physician was notified, and the resident was ordered a laxative and an antibiotic for a urinary tract infection. A nursing note, dated March 19, 2023, at 2:16 p.m. revealed that Resident 4 was ambulating in the hallway going back up to the solarium when Resident 3 was ambulating from the solarium and stopped, turned around, and with a closed fist struck Resident 4's right cheek. Resident 3 was redirected and monitored closely for approximately two hours by staff. The physician was notified and orders were received to increase the resident's Ativan (anti-anxiety) to three times day. A nursing note, dated April 24, 2023, at 9:17 p.m. revealed that Resident 3 was in another resident's room visiting with the family's dog. She returned later to the room and was rambling incoherently and screaming, and when they attempted to re-direct her, Resident 6 stood up and Resident 3 punched him in the chest. Staff were called and they immediately removed Resident 3 from his room. The physician was notified and the Resident 3 was given 1 mg of Haldol, close supervision so that the resident did not go after anyone else, and snacks and drinks were offered to redirect the resident. A psychiatric service note, dated April 26, 2023, revealed the resident's anti-anxiety medication was changed. A nursing note, dated May 26, 2023, 7:09 p.m. revealed that Resident 5 was arguing with Resident 3 when Resident 3 punched Resident 5 in the face. The nurse aide stepped in between them and Resident 3 reached around the staff member and hit Resident 5 again. The residents were separated and no new orders were received. There was no documented evidence that any changes were made to Resident 3's behavior management plan. A nursing note, dated June 4, 2023, at 6:38 p.m. revealed that Resident 3 was tearful and wandering on the unit, then walked up to Resident 1 while he was seated eating his dinner in the lounge and screamed f*** y**, and slapped Resident 1 across the left side of the face. Both residents were immediately separated and Resident 3's behavior care plan was updated to minimize contact with Resident 1 as much as possible. A psychiatric service note, dated June 7, revealed that Resident 3's current antipsychotic was to be discontinued and 0.5 mg of Rexulti (anti-psychotic) daily be added. A nursing note, dated June 14, 2023, at 7:14 p.m. revealed that Resident 1 was sitting in a chair in the middle of the solarium and had a bedside table set up in front of him so he could have a FaceTime (electronic face-to-face visit) visit with his daughter. Resident 3 tipped the table over onto Resident 1, bumping his feet. Resident 1 was very angry and began to yell out loudly. Resident 3 was re-directed away from Resident 1. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A nursing note, dated June 16, 2023, at 8:16 a.m. revealed that Resident 8 was sitting at a table in the common area eating her breakfast when Resident 3 reached over the resident for her breakfast. Resident 8 shooed Resident 3 away and then Resident 3 hit Resident 8 in the back with an open hand. Resident 3 was redirected, given a baby doll, and toileted. A nursing note, dated June 19, 2023, at 7:01 p.m. revealed that all day Resident 3 was randomly swearing at residents and staff and attempting to strike out at residents and staff to hit them. After staff redirected the resident she would start to cry and kept stating I'm sorry, I'm sorry. The resident would sit down in a chair, get up swiftly, and target another resident or a staff member. A social service note, dated June 20, 2023, at 4:35 p.m. revealed that Resident 3 was noted daily for numerous behaviors and was easily agitated with others often with little to no provocation. Her agitation often occurred with no warning or indication and appeared to be impulsive. She appeared to respond to certain staff with redirection at times. A nursing note, dated June 21, 2023, at 11:49 a.m. revealed that Resident 4 was walking around the solarium when Resident 3 turned around and punched Resident 4 on the right cheek, while yelling This is my pillow! Staff re-directed both residents away from each other. Resident 3 was to be a one-to-one observation and staff were instructed to keep the residents away from each other. A psychiatric service note, dated June 21, 2023, indicated that Resident 3's Rexulti was to be increased to 1 mg daily due to several aggressive incidents over the past week. A nursing note, dated June 26, 2023, at 11:09 a.m. revealed that staff reported that Resident 1 was reading a magazine and Resident 3 threw fluids onto his lap. Resident 1 stood up and staff redirected him to avoid a resident-to-resident confrontation. A psychiatric service note, dated June 28, 2023, indicated that Resident 3's Rexulti would be increased to 2 mg daily for further aggression. A nursing note, dated July 3, 2023, at 5:07 p.m. revealed that Resident 4 was witnessed walking in the hallway by staff when Resident 3 was walking in the opposite direction and yelled out Why are you following me, then smacked Resident 4 on the left side of her face. Both residents were separated and Resident 3 was assigned to a nurse aide for one-to-one observation to prevent recurrence. A psychiatric service note, dated July 12, 2023, revealed that the resident was having daily agitation on the day and evening shift and the current antipsychotics that she was receiving were not managing her distress. A nursing note, dated July 14, 2023, at 8:46 a.m. revealed that Resident 3 had a violent outburst when staff attempted to re-direct her and she scratched the licensed practical nurse on the face and hand. She threw a cup of water onto the licensed practical nurse and raised closed fists to all of the staff that attempted to re-direct her to an activity. She punched two nurse aides and picked up a resident's walker and threw it at a nurse aide. The resident was sent to the hospital and received medications and returned to the facility. A nursing note, dated July 15, 2023, at 7:15 a.m. revealed that Resident 1 was seen by a staff member being pushed down by Resident 3. Resident 3 pushed Resident 1 with both of her hands and Resident 1 fell backwards hitting the back of his head off the floor and injuring his right hip. Resident 3's hip was hurting when touched and his right leg and foot were rotated to the right and he was sent to the hospital. A nursing note, dated July 16, 2023, at 2:14 a.m. revealed that Resident 1 had a fractured right hip and was to have surgery. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A behavior note, dated July 15, 2023, at 8:15 a.m. revealed that Resident 3 was walking down the hall towards the common area when she saw Resident 2 standing in front of the nurse's station door. Resident 3 punched and shoved this resident into the medication cart, which was seen by staff, and Resident 3 was re-directed and staff attended to the resident that was punched and shoved. The nurse aide that came out of the shower room witnessed Resident 3 push Resident 1 backwards with both of her hands causing him to fall backwards sustaining an injury. Resident 3 was sent to the hospital and admitted to the behavioral health unit. A nursing note, dated July 15, 2023, at 12:39 p.m. revealed that Resident 2 was punched in the chest and pushed into the nurse's med cart by Resident 3. Staff re-directed Resident 3 away from Resident 2. Staff ensured Resident 2's safety by keeping Resident 3 within view Following the above incidents, there was no documented evidence that Resident 3's care-planned behavior interventions were revised when they were not effective, and no evidence that an individualized behavior management plan was developed in an attempt to prevent Resident R3's behaviors from affecting the safety of all other residents. Interview with Registered Nurse 1 on July 27, 2023, at 2:30 p.m. revealed that Resident 3 had behaviors of pacing quickly, being combative at times, screaming obscenities, pinching, hitting her, and being combative with other residents. She indicated that Resident 3 was scary to be around because she was volatile and could be really sweet one minute and then could switch on you at the drop of a hat. She revealed that Resident 3 did not have the attention span for activities and would wander, and that sometimes there were staff to do one-to-one supervision and sometimes not. Interview with Nurse Aide 2 on July 27, 2023, at 2:47 p.m. revealed that Resident 3 would wake up in the morning and cry, throw food and drinks during breakfast, beat up and shove staff, hit other residents for no reason, and hit the same resident again. She indicated that staff would keep an eye on her but one-to-one observation was usually added after she hit someone. She did not think any of the medication changes made helped Resident 3's behaviors and that nothing really helped her behaviors. She felt that the other residents were not safe around Resident 3 and now that Resident 3 is no longer there everyone is safe. Interview with the Director of Nursing on July 27, 2023, at 3:30 p.m. revealed that Resident 3 had a very short fuse, and her behaviors came and went. Most of her behavior was crying and at times she would become aggressive and start yelling and swearing with no warning sign. When she was in the common area staff would re-direct her and if Resident 3 was escalating, you could not be beside her. She had hospitality aides on the unit for observation and used them for one-to-one observations. She indicated that when Resident 3 punched and shoved Resident 2, staff attended to Resident 2 and did not stop Resident 3 from approaching Resident 1 and pushing him down. She agreed that the unit was not the safest environment at times for the residents with Resident 3's aggressive behaviors. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of manufacturer's directions for use, facility policies and investigative reports, residents' clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accident, by failing to follow the manufacturer's directions for use of a shower bed for one of four residents reviewed (Resident 2), resulting in multiple fractures for the resident. Findings include: Operation instructions for the IUP Model TSG700 shower bed, dated February 12, 2008, revealed that the purpose of the shower bed was to transport a person in a horizontal position and to use as a platform for showering. Recommendation of use included showering people who were unable to stand or sit in a chair, and operating information indicated that the shower beds were equipped with four locking casters to be used during user transfer and when wanting the bed to remain stationary. Before transferring, all casters were to be locked, the opposite siderail was to be lifted, and both corner lock pins were to be inserted. After transferring the resident, the other siderail was to be locked into position, the shower bed was to be moved to the desired location, and all casters were to be locked. The instructions indicated that unless transferring, when the resident was on the shower bed, the siderails were to be up at all times. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 7, 2021, revealed that the resident was usually understood, could usually understand, required extensive assistance from two staff for her bed mobility, was totally dependent on one staff for bathing, was totally dependent on two staff for transfers, and medical diagnoses that included dementia and [CONDITION(S)] (a progressive nervous system disorder that affects movement). A quarterly fall risk assessment, dated October 10, 2021, revealed that the resident was at moderate risk for falls and required hands-on assistance to move from place to place. The resident's care plan, dated July 16, 2021, revealed that she was at risk for decline in function due to arthritis and dementia, that staff were to use a mechanical lift (a device that uses hydraulic power to lift and move a resident) for all transfers, that the resident was at risk for falls related to impaired mobility and limited safety awareness, and that staff were to monitor for unsafe behaviors such as leaning over in her chair. Physician's orders, dated June 20, 2016, included an order for the resident to be transferred using a mechanical lift. A progress note for Resident 2, dated October 29, 2021, revealed that the the resident was lying on the floor of the shower room on her back, with the shower cart beside her. Nurse Aide 1 said that he had the resident on the shower cart, she was on her right side facing the wall, the shower cart was not locked, and he turned around to grab a towel from the stand directly behind him. When he turned back to the cart, the resident had rolled off onto the floor. The resident had a large hematoma (a collection of blood outside the blood vessel) to the right temporal area, a skin tear above her right eyebrow, and two skins tears to her right elbow area. The resident complained of pain to both legs when moved slightly, and she was sent to the hospital. A hospital progress note for Resident 2, dated October 29, 2021, revealed that the resident had multiple fractures of the sacral and pubic bones (bones at the base of the spine and in the front of the pelvis), a scalp hematoma, and a right eyebrow laceration that measured 1.5 (length) x 0.5 (depth) centimeters (cm) that was repaired with two sutures. A fall investigation report for Resident 2, dated October 29, 2021, revealed that the resident was on an unlocked shower cart when Nurse Aide 1 turned to get a towel and the resident rolled off the cart onto the floor. Nurse Aide 1 said that the shower cart was not locked. A witness statement by Nurse Aide 1, dated October 29, 2021, revealed that he and another staff member used a mechanical lift to place Resident 2 onto the shower cart. The other staff member left the room and the shower cart was up against the wall. He rolled the resident to undress her. As she was rolled over, he grabbed wipes that were behind him, and as he grabbed the wipes the shower cart kicked out and the resident rolled off the shower cart. A typed interview conducted with Nurse Aide 1 by the Director of Nursing, dated October 29, 2021, revealed that when asked what happened, Nurse Aide 1 stated that he had Resident 2 on the shower bed, and he rolled her onto her side, facing the wall. He turned to get wipes, and while he was turned, the whole shower bed moved and then the resident was on the floor. When asked if the rails and wheels were locked, Nurse Aide 1 stated they were not locked. When asked if the wheels and rails should have been locked, the nurse aide stated, Yes. Review of Nurse Aide 1's personnel file revealed that he received training regarding the facility's fall/accident prevention program, and resident abuse and neglect on August 3, 2021, and was signed off as being competent on the use of the shower cart on August 4, 2021. Interview with the Director of Nursing on November 9, 2021, at 3:00 p.m. confirmed that Nurse Aide 1 should have locked the shower cart's side rails in the up position, locked the wheels on the shower bed, and should not have rolled Resident 2 away from him. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and incident/accident investigations, as well as staff interviews, it was determined that the facility failed to ensure that interventions to prevent injury and/or falls were followed for two of seven residents reviewed (Residents 1, 3), resulting in a burn caused by hot tea for Resident 3. Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated (MONTH) 25, (YEAR), indicated that the resident was severely cognitively impaired, required the extensive assistance of one staff for eating, and had limited range of motion of the upper and lower extremities on one side of her body. A nutrition consultation and diet order, dated (MONTH) 26, (YEAR), indicated that, based on therapy recommendations, the resident was to use two-handled cups with lids. A care plan history report obtained from the Director of Dining and Nutritional Services, dated (MONTH) 25, (YEAR), indicated that the dietary department included the use of a two-handled cup on Resident 3's meal tray slip since (MONTH) 27, (YEAR). An incident note in the clinical record of Resident 3, dated (MONTH) 6, (YEAR), indicated that the resident spilled hot tea on herself during supper and had a couple small, pink areas noted to the right upper lateral leg (the area on the outside of the upper leg) and the right side of her upper and lower abdomen. A health status note, dated (MONTH) 9, (YEAR), indicated that the resident spilled hot tea on herself and had three dark pink areas on her abdomen and her right thigh had two fluid-filled blisters that measured 2.5 x 1.5 centimeters (cm) and 5.5 x 0.9 cm. Investigation information, initiated on (MONTH) 9, (YEAR), indicated that Resident 3 was to be provided liquids in a two-handled cup with a lid, but the resident was served hot tea in a regular cup without a lid and she spilled the tea on herself, causing a burn. The investigation indicated that at the time that the hot water left the kitchen, it was 160 degrees Fahrenheit. A written statement from Nurse Aide 1, dated (MONTH) 12, (YEAR), indicated that Resident 3 told her she wanted tea, so the nurse aide obtained the hot water from the container and asked the confused resident if she normally drank from a regular cup. The resident stated that she did, so the nurse aide gave the resident hot tea in a regular cup. The statement also indicated that the resident's meal tray was sent to the incorrect unit, and staff were in the process of retrieving the tray at the time she provided the hot tea to the resident. Interview with Occupational Therapist 8 on (MONTH) 25, (YEAR), at 1:20 p.m. revealed that at the time of the incident on (MONTH) 6, (YEAR), Resident 3 was to be served liquids in a two-handled cup with a lid, and there were no recommendations to discontinue the two-handled cup with a lid. Interview with the Director of Dining and Nutritional Services on (MONTH) 25, (YEAR), at 1:38 p.m. and 4:30 p.m. confirmed that Resident 3's care plan history report, dated (MONTH) 25, (YEAR), indicated as of (MONTH) 28, (YEAR), the resident was to be served liquids in a two-handled cup with a lid, that this was part of the resident's dietary tray slip since that date, and that staff should have served all liquids to the resident in a two-handled cup with a lid. Interview with the Director of Nursing on (MONTH) 25, (YEAR), at 4:30 p.m. confirmed that Nurse Aide 1 should have served hot tea to Resident 3 in a two-handled cup with a lid on (MONTH) 6, (YEAR). A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 27, (YEAR), indicated that the resident was sometimes understood, could sometimes understand, was severely cognitively impaired, and had a history of [REDACTED]. that alarms if the resident attempts to get up) in place, and that it was to be checked by staff to ensure placement and function. A care plan dated (MONTH) 25, (YEAR), indicated that the resident's Broda chair (a specialized wheelchair that can be reclined) was to be reclined and was to be upright only for transfers and meals. An incident note in Resident 1's clinical record, dated (MONTH) 23, (YEAR), indicated that the resident was found on the floor by a nurse aide, the chair was not in the reclined position, and the alarm was not turned on. A nursing note, dated (MONTH) 23, (YEAR), indicated that the resident was found on the floor and the alarm was not sounding at the time of the incident, and the chair was in the upright position. The facility's investigation of Resident 1's fall, dated (MONTH) 23, (YEAR), indicated that the alarm was not sounding at the time of the fall, and that when asked if the alarm was turned on, Nurse Aide 6 switched the alarm on, then pushed and released pressure on the alarm pad, at which time the alarm sounded. There was no documented evidence that the alarm was turned on at the time of the fall, and no documented evidence to indicate why the resident's chair was not in the reclined position in accordance with the resident's care plan. Interview with the Assistant Director of Nursing on (MONTH) 25, (YEAR), at 4:30 p.m. confirmed that Resident 1's Broda chair was not in the reclined position, and the alarm was not functioning at the time of the resident's fall on (MONTH) 23, (YEAR). 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/21/18, 5/25/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/21/18, 1/18/18, 5/25/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 6/21/18, 1/18/18, 5/25/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/21/18, 1/18/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 6/21/18, 9/15/17, 7/3/17, 5/25/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/23/18, 6/21/18, 4/13/18, 1/18/18, 9/15/17, 7/3/17, 5/25/17.

Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement fall/injury prevention interventions for residents who were at risk for falls for two of 45 residents reviewed (Residents 17, 109), resulting in a fall with fracture(s) for Residents 109 and 17; failed to complete thorough investigations of falls to determine the possible cause(s) and if care-planned interventions were in place for two of 45 residents reviewed (Residents 62, 109); failed to provide adequate supervision during a mechanical lift transfer that resulted in a skin tear for one of 45 residents reviewed (Resident 125); and failed to ensure skin protection sleeves were in place for one of 45 residents reviewed (Resident 69). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated (MONTH) 5, (YEAR), indicated that the resident was understood, could understand, required extensive assistance from staff for her daily care, mobility, and transfers, was not steady and only able to stabilize with staff assistance, had medical [DIAGNOSES REDACTED]. The resident's care plan, initiated (MONTH) 28, (YEAR), indicated that the resident was at risk for falls related to right-sided weakness and poor safety awareness, and staff were to ensure that she wore appropriate footwear - shoes for transfers, slippers at other times, and a two week trial was to be completed for a sensor pad alarm (a pad that alarms when pressure is removed) to the wheelchair and bed, and to check the function of the alarm with each application. Staff were also to respond promptly to the resident's calls. A revision to the resident's care plan, dated (MONTH) 1, (YEAR), indicated that a wedge cushion with dycem (an thin anti-skid material) was to be placed on the resident's Broda chair (an adaptive wheelchair) and that anti-tippers (devices that attach to a wheelchair to prevent the wheelchair from tipping forward and/or backward) were added. The resident's care plan, dated (MONTH) 3, (YEAR), indicated that the resident had a potential for accidents/injury due to her lack of awareness, and staff were to answer alarms promptly and ensure that the resident had appropriate footwear for proper traction if she was self-propelling in a wheelchair. A revision to the resident's care plan, dated (MONTH) 16, (YEAR), indicated that the resident was to continue with the sensor pad alarm to her wheelchair and bed and to check the function of the alarm with each application. A fall investigation report for Resident 109, dated (MONTH) 17, (YEAR), indicated that the resident was found sitting in her bedroom, near her bed in front of her Broda chair. The resident stated, I went to get up and slipped and down I went. There was no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury for Resident 109 following the fall of (MONTH) 17, (YEAR). A fall investigation report for Resident 109, dated (MONTH) 5, (YEAR), indicated that an alarm was heard going off and the resident was found about two feet away from her bed. The resident stated, Sorry, I tripped. I'm fine, help me get up. A revision to the resident's care plan, dated (MONTH) 5, (YEAR), indicated that the resident was to wear a helmet when out of bed for transfers/ambulation, when cooperative, and a revision dated (MONTH) 16, (YEAR), indicated that the resident was to have her bed against the wall with a body pillow for positioning and a winged mattress (a mattress with built-up edges) to her bed. A fall investigation report for Resident 109, dated (MONTH) 30, (YEAR), at 3:36 p.m. indicated that the resident's alarm was going off and upon arrival in the resident's room, she had walked from her, chair near her bed, to the bathroom door and was yelling for help. A nurse aide assisted her back to her chair, and a few moments later the resident fell . A nursing note dated (MONTH) 30, (YEAR), at 4:09 p.m. indicated a nurse aide reported that the resident's alarm was going off and when she went into the room, the nurse saw the resident trying to propel herself in her Broda chair. The resident's buttocks slid off her chair and she landed in a seated position on the floor. An assessment revealed that the resident was scooting herself around saying, Help me. Initially she would not state how she got on the floor, but eventually the resident stated that she was trying to go to bed. The note indicated that the resident had a [DIAGNOSES REDACTED]. The resident moved all extremities freely without pain, denied pain, and there was no redness or areas noted. Staff reported that the resident kicked her shoes off and had on socks with no grip. Gripper socks were put on the resident and she was assisted to stand and walk to bed. Staff were instructed that if the resident did not want to wear shoes, they were to ensure that alternate footwear of gripper socks were applied as the resident was at high risk for falls and needed to have some form of non-slip footwear on at all times. A fall investigation report for Resident 109, dated (MONTH) 14, (YEAR), indicated that staff heard the resident's alarm sounding and when they reached the resident's room, she was observed sitting on the floor in front of her recliner. The resident stated that she was just trying to get up. There was no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury for Resident 109 following the fall on (MONTH) 14, (YEAR). A nursing note for Resident 109, dated (MONTH) 19, (YEAR), at 4:09 p.m. indicated that staff heard the resident's alarm sounding and responded to find her sitting on her buttocks on the floor in front of her chair. The floor was free from clutter, was dry, and the area was well lit. The resident was wearing non-skid foot wear when found, she was alert per usual, and denied pain. She was assisted to a standing position by two staff, and then assisted into a recliner per her request. A nursing note at 5:50 p.m. indicated that the resident's pressure alarm was sounding and the nurse aide found the resident sitting upright on the floor. She was unable to tell staff what she was doing or where she was going. The registered nurse was notified. The resident had a small 1.0 x 1.0 centimeter (cm) red mark to the medial (inside) side of the right knee, stated that she was in minor pain, and was given Tylenol (an over-the counter pain medication). There was no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury for Resident 109 following the fall on (MONTH) 19, (YEAR). A nursing note for Resident 109, dated (MONTH) 20, (YEAR), at 7:21 a.m. indicated that the resident was awake and in her Broda chair since 3:30 a.m. She was restless and complained of pain in the left ankle, stating, Ouch, ouch, when transferring. A nursing note at 8:32 a.m. indicated that staff reported the resident's complaint of pain and noted a decrease in ambulation (walking). The resident was assessed and pointed to her right knee when asked where her pain was. The right knee was swollen, slightly reddened and warm to touch. When lifting the resident's leg to a straight position, the resident yelled, Ouch. The physician was notified and ordered an X-ray of the right knee stat (immediately). An event note for Resident 109, dated (MONTH) 20, (YEAR), at 9:29 a.m. indicated that staff stated that the resident's alarm was sounding and the licensed practical nurse found the resident lying on the floor in her room. She had a helmet on her head, but removed it after lying on the floor. The resident did not have shoes on at the time of the fall, just regular non-skid socks. Nurse aides reported that when they were last in the resident's room, she was sitting in her Broda chair and had her shoes on. The resident verbalized no pain, was able to be assisted to stand, but had difficulty getting to bed. She was limping on her right leg, which had been occurring with ambulation since her fall of yesterday. No redness or bruising was noted. An X-ray of right knee was already ordered because the resident had pain, swelling and a decrease in ambulation related to right knee pain and staff were waiting for the contracted X-ray provider to arrive. A nursing note at 1:17 p.m. indicated that the X-ray results showed an acute, right patellar (knee cap) fracture. There was also no documented evidence that witness statements were obtained from all staff working when the incident occurred, or that the investigation determined if all of the resident's care-planned interventions were in place at the time of the above falls. Interview with the Director of Nursing on (MONTH) 21, (YEAR), at 5:25 p.m. confirmed that there were no new interventions attempted to prevent further falls and/or injury for Resident 109, and that the investigations of the resident's falls were not thorough because they did not include statements from all staff involved in the resident's care. A comprehensive significant change MDS assessment for Resident 17, dated (MONTH) 3, (YEAR), revealed that the resident was confused, usually incontinent of bowel and bladder, and required extensive assistance for her care. The resident's care plan, initiated on (MONTH) 14, (YEAR), indicated that the resident was at risk for falls related to Alzheimer's (a type of dementia that causes declines in a person's abilities to think and remember). A fall investigation report for Resident 17, dated (MONTH) 14, (YEAR), revealed that staff found the resident lying on her right side in a fetal position in the level three lounge area, which was crowded with other residents at the time the resident was found. A reddened area was noted to the resident's right forehead. Predisposing factors were listed as crowding, noise, confusion, gait imbalance, impaired memory, weakness and a history of wandering and ambulating without assistance. There was no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury for Resident 17 following the fall on (MONTH) 14, (YEAR). A fall investigation report for Resident 17, dated (MONTH) 18, (YEAR), revealed that the resident was observed in her room lying on her back, in the middle of the floor, while another resident was holding her hand and singing to her. The fall was unwitnessed, and predisposing factors were listed as confusion. There was no documented evidence that any changes or new interventions were initiated to prevent further falls and/or injury for Resident 17 following the fall on (MONTH) 18, (YEAR). A fall investigation report for Resident 17, dated (MONTH) 19, (YEAR), revealed that a visitor saw the resident scooting across the floor at the end of the hall. When staff investigated they found moderate active bleeding to Resident 17's face and a laceration across the bridge of her nose. There was blood on the floor in an adjacent room and on the outside of the bathroom door, including the door knob. The resident was transferred to the hospital and diagnosed with [REDACTED]. Interview with the Director of Nursing on (MONTH) 21, (YEAR), at 3:00 p.m. confirmed that there were no new interventions attempted to prevent further falls and/or injury for Resident 17. An annual MDS assessment for Resident 62, dated (MONTH) 3, (YEAR), indicated that the resident was alert and oriented, was dependent for transfers, and had a history of [REDACTED]. An incident report for Resident 62, dated (MONTH) 2, (YEAR), at 8:57 p.m. revealed that the resident was found sitting on the floor. She stated that she was leaning over to pick something up and slid right out of the chair. There was no documented evidence that an investigation was completed to determine if the surface of the wheelchair seat could be a possible cause of the resident slipping out of the chair. An incident report for Resident 62, dated (MONTH) 3, (YEAR), at 10:14 p.m. revealed that the resident was found sitting on the floor in her bedroom. She stated that when she reached forward to get a garbage bag, she slid off the chair, the wheelchair tipped forward, and she fell to the floor. There was no documented evidence that an investigation was completed to determine if the surface of the wheelchair seat could be a possible cause of the resident slipping out of the chair. An incident report for Resident 62, dated (MONTH) 20, (YEAR), at 12:53 p.m. revealed that the resident was returning from an appointment in the wheelchair van when she slipped out of her seat, but did not hit the floor. The resident stated that she slipped because the lift sling that was under her was slippery. Interview with the Nursing Home Administrator on (MONTH) 21, (YEAR), at 6:20 p.m. confirmed that there were no investigations into Resident 62's falls to determine if the surface of the wheelchair seat was a possible cause of the falls. A quarterly MDS assessment for Resident 125, dated (MONTH) 5, (YEAR), revealed that the resident was dependent for transfers, had impaired range of motion in both legs, and had [DIAGNOSES REDACTED]. Resident 125's care plan, dated (MONTH) 24, 2014, revealed that the resident had the potential for accidents and injury related to a lack of safety awareness, and during transfers, staff were to ensure that all extremities were free and clear of obstacles, and also provide safety with transfers by making sure the resident's feet were positioned, An incident and accident investigation for Resident 125, dated (MONTH) 22, (YEAR), at 7:50 p.m. revealed that while transferring the resident back into bed with a mechanical lift (device that used hydraulic power to lift and transfer a resident from surface to surface), the resident suffered a laceration (cut) of her right foot, between the first and second toes, that measured approximately 2.5 centimeters (cm) in length. The investigation report indicated that Resident 125 stated that while being transferred she bumped her toes on something and a written statement from Employee 28 indicated that the resident's toe was cut on the mechanical lift. A wound specialist progress note for Resident 125, dated (MONTH) 26, (YEAR), indicated that the resident obtained a linear laceration to the right great toe that measured 3.5 (length) x 0.2 (width) x 0.3 (depth) cm during a mechanical lift transfer, and was ordered to have the wound cleansed and treated with an antibacterial ointment and dry dressing twice a day and more often if needed. Interview with the Director of Nursing on (MONTH) 21, (YEAR), at 4:05 p.m. confirmed that one of the two staff members who performed Resident 125's transfer should have ensured that the resident's feet remained free of any obstacles during the transfer process, and that the investigation was not thorough to include which staff member was monitoring the resident's lower extremities during the transfer. A quarterly MDS assessment for Resident 69, dated (MONTH) 7, (YEAR), revealed that the resident was cognitively impaired and had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 24, (YEAR), revealed that the resident had the potential for accidents and injury related to a lack of safety awareness, was able to self-propel in a specialized wheelchair, and included an intervention for the resident to wear leg sleeves (footless sock-like shin protectors) on both legs when up in her wheelchair. Observations on (MONTH) 18, (YEAR), at 2:39 p.m. and (MONTH) 19, (YEAR), at 1:30 p.m. revealed that Resident 69 was sitting in a specialized wheelchair in the hallway, directly across from the nursing station entrance. The resident had on Capri-length pants and did not have leg sleeves on, leaving her bare skin exposed from her knees to her ankles. Interview with Nurse Aide 29 on (MONTH) 19, (YEAR), at 1:40 p.m. confirmed that Resident 69 was to have leg sleeves on but did not. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/25/17, 12/27/16, 10/6/16, 6/27/16. 28 Pa. Code 201.18(b)(1) Management Previously cited 1/18/18, 5/25/17, 10/6/16, 6/27/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/18/18, 5/25/17, 10/27/16, 10/6/16, 6/27/16. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 1/18/18. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 5/25/17, 6/27/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/15/17, 5/25/17, 12/27/16, 10/27/16, 6/27/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/15/17, 7/3/17, 5/25/17, 7/21/16, 6/27/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/13/18, 1/18/18, 9/15/17, 7/3/17, 5/25/17, 12/27/16, 10/27/16, 10/6/16, 7/21/16, 6/27/16.

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 were free from non-consensual sexual contact for five of seven residents reviewed (Residents 2, 3, 4, 5, 6) resulting in sexual abuse and psychosocial harm. Findings include: The facility's policy regarding abuse, dated (MONTH) 6, (YEAR), revealed that allegations of actual or suspected sexual abuse would be immediately reported to the registered nurse supervisor, attending physician, Director of Nursing, the Nursing Home Administrator, and to other officials in accordance with state law, including the State Survey and Certification Agency (Department of Health). An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 1, dated (MONTH) 21, (YEAR), contained a standardized interview to determine the resident's mental status, which indicated that the resident scored a 13 out of 15 (cognitively intact). The assessment also indicated that the resident could make his needs known, could understand others, was able to ambulate (walk) about the unit independently, and had [DIAGNOSES REDACTED]. The resident's care plan regarding mood and behavior, dated (MONTH) 15, (YEAR), revealed that the resident tried to become intimate with female residents, and staff were to encourage re-direction. A quarterly MDS assessment for Resident 2, dated (MONTH) 25, (YEAR), revealed that the resident was severely cognitively impaired, was rarely understood, could rarely understand, had short and long-term memory problems, required moderate to extensive assistance from staff for ambulation and care, and had [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident 3, dated (MONTH) 11, (YEAR), revealed that the resident was severely cognitively impaired, could sometimes understand, was sometimes understood, had short and long-term memory problems, required extensive help with bathing and dressing, ambulated with minimal assistance, and had [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident 4, dated (MONTH) 17, (YEAR), revealed that the resident was severely cognitively impaired, was rarely understood, could rarely understand, had short and long-term memory problems, required maximum assistance from staff for all care, and had [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident 5, dated (MONTH) 22, (YEAR), revealed that the resident was severely cognitively impaired, was rarely understood, could rarely understand, had short and long-term memory problems, required moderate assistance from staff for all care, and had [DIAGNOSES REDACTED]. A quarterly MDS assessment for Resident 6, dated (MONTH) 16, (YEAR), revealed that the resident was severely cognitively impaired, had no speech, rarely understood, could rarely understand, had short and long-term memory problems, required moderate assistance from staff for her care, and had [DIAGNOSES REDACTED]. Clinical record review for Resident 1 indicated that the facility admitted him on (MONTH) 14, (YEAR). Nursing documentation for Resident 1 dated (MONTH) 20, (YEAR), at 2:15 p.m. revealed that the resident was newly admitted to the facility, he had an increase in behaviors throughout the shift that included holding hands and embracing other residents, and he was redirected each time. The nursing note did not identify the residents. A nursing note for Resident 1 dated (MONTH) 21, (YEAR), at 3:37 p.m. revealed that the resident had become very friendly with female residents, and the registered nurse supervisor was notified. A facility event note dated (MONTH) 22, (YEAR), at 10:42 a.m. revealed that Resident 1 was seeking out Resident 3, and they were both noted to seek each other out. Staff re-directed and separated the residents, but they continued to rub each other's arms and bodies. Resident 1 grabbed Resident 3's breast while they were sitting together. Resident 3 had no recollection of the event afterward. Staff spoke with Resident 1's family member on (MONTH) 22, (YEAR), and he stated that the resident had an extensive psychiatric history, can become agitated, and can be like a bull and go wild. The physician was made aware on (MONTH) 22, (YEAR), and a new order was received for behavioral/psychiatric services to evaluate and treat the resident. The note indicated that staff would offer diversional activities and would encourage re-direction of Resident 1 if he tried to become intimate with female residents. Nursing documentation for Resident 1 dated (MONTH) 24, (YEAR), at 2:00 p.m. revealed that he was observed holding hands and caressing Resident 3 numerous times. Staff also observed them kissing. Staff re-directed the residents several times. A nursing note for Resident 1 dated (MONTH) 26, (YEAR), at 10:05 p.m. revealed that behavioral/psychiatric services saw the resident due to agitation. A physician's orders [REDACTED]. A health status note for Resident 1 dated (MONTH) 27, (YEAR), at 10:43 p.m. revealed that the resident had increased sexual behaviors that shift. Staff reported that when they were putting another male resident to bed, Resident 1 was lying in the other resident's bed with his pants down kissing Resident 4, who was also lying in the bed. When staff walked in the room, Resident 1 got up, pulled his pants up, went to his own bed, closed his eyes, and pretended to be asleep. The note indicated that Resident 1 would be checked every 15 minutes. A facility event note dated (MONTH) 29, (YEAR), at 7:57 a.m. revealed that a nurse was passing medications when she observed Resident 1 sitting on a bed beside Resident 4, in a room that was neither Resident 1's nor Resident 4's. As the nurse entered the room, she observed Resident 1's hand under Resident 4's covers. The nurse asked Resident 1 to leave the room and he went to sit in a common area. The note indicated that Resident 1 was on 15-minute checks, and would have a behavioral/psychiatric consultation. There was no documented evidence that 15-minute checks were effective for ensuring that Resident 1 had no inappropriate sexual contact with other residents and no documented evidence that any additional interventions were initiated to monitor Resident 1. A care plan note for Resident 1, dated (MONTH) 29, (YEAR), at 8:31 a.m. indicated that an order for [REDACTED]. A health status note for Resident 1 dated (MONTH) 29, (YEAR), at 7:15 p.m. revealed that the resident was due for a 15-minute check and was found in room [ROOM NUMBER] with Resident 2, who was lying on the bed with her pants down. Resident 1 was touching Resident 2's exposed private area. Resident 1 was told to stop, staff pulled Resident 2's pants up, and removed her from the room. The note indicated that 15-minute checks continued. There was no documented evidence that 15-minute checks were effective for ensuring that Resident 1 had no inappropriate sexual contact with other residents, and no documented evidence that any additional interventions were initiated to monitor Resident 1. A health status note for Resident 1 dated (MONTH) 31, (YEAR), at 1:07 p.m. revealed that the resident continued to be quite amorous toward female residents and staff. Staff reported that he has been close to female residents today and trying to fondle them, and staff must intervene constantly by trying to keep him in the common areas in full view. A health status note for Resident 1 dated (MONTH) 31, (YEAR), at 1:20 p.m. revealed that the resident was still on 15-minute checks. At 11:20 a.m. he was trying to push Resident 2 down the hallway and staff re-directed him to his room and relocated Resident 2 to a common area. At 11:30 a.m., Resident 1 was found in room [ROOM NUMBER] with his hand down the front of Resident 5's shirt. Staff redirected Resident 5 to the common area and Resident 1 back to his room. As a nursing measure, Resident 1 was placed on a behavior management sheet (a worksheet that is to be used by all staff on the unit to document observations and interventions for seven days), and the registered nurse was notified. The certified registered nurse practitioner (CRNP - an advanced practice nurse who performs some of the functions of a physician) was made aware and orders were received to increase [MEDICATION NAME] to 1.0 mg, twice a day, to increase [MEDICATION NAME] (used to treat depression) to 100 mg, twice a day, and to consider a gero-psych admission (a treatment center for behaviors) if behaviors continued. Nursing documentation for Resident 1 dated (MONTH) 31, (YEAR), at 4:50 p.m. revealed that the writer of the note was going back the hallway to do the next 15-minute check and when she went to knock on the door she heard heavy breathing. She knocked, went into the room, and found Resident 1 lying in his bed on top of Resident 6, kissing her. A health status note for Resident 1, dated (MONTH) 1, (YEAR), at 1:53 p.m. revealed that Resident 3 got up and walked down the hallway, Resident 1 stood up and walked briskly down the hallway, walked beside Resident 3, and was leaning over to say something. Resident 3 stopped and laughed, then Resident 1 walked in front of her and tried to use his body to redirect her into a room. Resident 3 walked around him and continued down the hallway. Resident 1 then ambulated briskly once again, went into a room, and motioned for Resident 3 to follow him. Resident 3 waved and continued to walk down the hallway to her room. Resident 1 continued to peek out of the room a few times, then walked down the hall to the solarium and then back up to his room. An interview with Licensed Practical Nurse 1 on (MONTH) 19, (YEAR), at 2:37 p.m. revealed that Resident 1 knew that what he was doing was wrong because he would immediately stop the behavior and get that deer in the headlight look when caught. He also knew that staff were watching him because he would go into rooms that were not his and peek from around the doorways to see if any residents were coming his way. Resident R1's clinical record revealed that he was placed on 15-minute checks on (MONTH) 27, (YEAR), and while on 15-minute checks, he continued to have sexual contact with female residents. There was no documented evidence that any new or additional interventions were initiated to protect female residents from Resident 1's inappropriate sexual behaviors. A care plan note for Resident 1, dated (MONTH) 2, (YEAR), at 8:15 a.m. revealed that due to the repetitive nature of the resident's behaviors and failed attempt at 15-minute checks, medication adjustments, chronic re-direction and offering diversional activities, it was recommended that the resident be transported to gero-psych for evaluation, and one-on-one monitoring would be completed until the time of transfer. A statement from Nurse Aide 2, dated (MONTH) 18, (YEAR), revealed that on (MONTH) 2, (YEAR), she was assigned to provide one-on-one care with Resident 1 until the ambulance arrived. A social service note for Resident 1 dated (MONTH) 2, (YEAR), at 10:39 a.m. revealed that the behavioral health unit was contacted, and it was determined that the resident was appropriate for a 302 admission (an involuntary commitment into a mental health institute for emergency psychiatric evaluation). A nursing note, dated (MONTH) 2, (YEAR), at 2:29 p.m. revealed that the resident left the facility via ambulance at 11:15 a.m. During an interview with the Nursing Home Administrator on (MONTH) 17, (YEAR), at 3:20 p.m. she indicated that one-on-one supervision should have been initiated on Resident 1 on (MONTH) 29, (YEAR), when the 15-minute checks were not effective. She also confirmed that based on a recommendation from the care plan team, one-on-one supervision for Resident 1 was initiated on (MONTH) 2, (YEAR), at 8:15 a.m. until 11:15 a.m. when the resident was sent to the hospital for his 302 admission. Interview with the Nursing Home Administrator on (MONTH) 18, (YEAR), at 3:00 p.m. confirmed that Resident 1 was seen by mental health services and was ordered medications, but when the 15-minute checks were ineffective, there were no new interventions put into place to protect other residents from Resident 1's inappropriate sexual behaviors. She confirmed that after the 15-minute checks were initiated, Resident 1 was caught having sexual contact with female residents on two occasions at the time the 15-minute checks were completed. 42 CFR 483.12(a)(1) Free from Abuse and Neglect Previously cited 5/25/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/25/17, 6/27/16 28 Pa. Code 201.18(b)(1) Management Previously cited 5/27/17, 10/6/16, 6/27/16 28 Pa. Code 201.18(e)(1) Management Previously cited 5/27/17, 10/27/16, 10/6/16, 6/27/16 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(j) Resident rights Previously cited 10/8/17, 6/27/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 9/15/17, 7/3/17, 5/25/17, 12/27/16, 10/27/16, 10/6/16, 7/21/16, 6/27/16

Based on review of manufacturer's instructions, clinical records, and written safety information, as well as observations and staff interviews, it was determined that the facility failed to ensure that transfers using mechanical lifts were completed in a safe manner for three of 30 residents reviewed (Residents R1, R5, R15), placing the safety of the residents in Immediate Jeopardy. The facility also failed to ensure that appropriate lift slings were used to transfer three of 30 residents reviewed (Residents R1, R5, R16), failed to ensure that residents' wheelchairs were maintained in a manner to prevent possible injury for one of 30 residents reviewed (Resident R1), and failed to ensure a safe environment in one of five shower rooms (A Corridor of the 100 Level). Findings include: The manufacturer's instructions for the use of the Invacare Reliant 600 mechanical lift (a device that uses hydraulic power to lift and transfer residents between surfaces), dated 2011, revealed that a diagram indicated that there were three hooks on each swivel bar and there was a safety clip located at the end of each hook. The maintenance instructions for the swivel bar indicated that after the first year of use, the hooks of the swivel bar and the mounting brackets of the boom were to be inspected every three months for wear, and that regular maintenance of the lifts and accessories was necessary to ensure proper operation. Observations on June 20, 2016, at 12:45 p.m. revealed that an Invacare Reliant 600 mechanical lift on the second floor did not have safety clips on the hooks where the lift sling straps were hooked to the lift (resident is placed in the sling which attaches to the frame of the lift). An interview with Rehab Specialist 15, a representative of the mechanical lift's manufacturer, on June 20, 2016, at 4:05 p.m. revealed that not having the safety clips on the hooks of the Invacare Reliant 600 mechanical lift was a safety issue because the clips ensured that the lift sling loops were secured on the lift hooks and prevented the sling loops from coming off the hooks. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R5, dated April 26, 2016, revealed that the resident required total assistance with transfers, and a physician's orders [REDACTED]. Observations on June 20, 2016, at 1:10 p.m. revealed that Nurse Aides 12 and 14 transferred Resident R5 from her wheelchair to her bed using an Invacare Reliant 600 full body mechanical lift. There were no safety clips on the lift hooks to prevent the loops of the sling straps from coming off the hooks. Interview with Nurse Aide 12 on June 20, 2016, at 1:20 p.m. revealed that the safety clips on the mechanical lift had been missing for awhile and probably should be on the lift. A quarterly MDS assessment for Resident R1, dated March 28, 2016, revealed that the resident was confused and required assistance of staff with transfers and care. Observations on June 20, 2016, at 3:52 p.m. revealed that Nurse Aides 2 and 5 transferred Resident R1 from his wheelchair to his bed using an Invacare Reliant 600 full body mechanical lift, and during the transfer, the resident placed his hands on the cross bar of the mechanical lift. There were no safety clips on the lift hooks to prevent the sling loops from coming off the lift's hooks. A quarterly MDS assessment for Resident R15, dated April 14, 2016, revealed that the resident was confused and was totally dependent for transfers and care. Observations on June 20, 2016, at 4:10 p.m. revealed that Nurse Aides 18 and 19 transferred Resident R15 from his wheelchair to a shower bed using an Invacare Reliant 600 full body mechanical lift. There were no safety clips on the lift hooks to prevent the sling loops from coming off the lift's hooks. Interview with Nurse Aides 18 and 19 at that time revealed that Nurse Aide 18 thought the safety clips were on the lift at one time but could not recall when the clips were no longer present, and Nurse Aide 19 indicated that she never saw safety clips in place on the lift. Interview with the Nursing Home Administrator on June 23, 2016, at 12:47 p.m. revealed that she was not aware that anyone reviewed the updated manufacturer's instructions for the Invacare Reliant 600 mechanical lifts. Interviews with the Director of Nursing and Maintenance Worker 11 on June 20, 2016, at 5:35 and 5:39 p.m. respectively, revealed that they were not aware that the Invacare Reliant 600 mechanical lifts were to have safety clips. A list of residents who required transfers with a full body mechanical lift, dated June 20, 2016, revealed that there were 19 residents on the first and second levels who required transfers with the Invacare Reliant 600 full body mechanical lift. On June 20, 2016, at 6:34 p.m. the Nursing Home Administrator was informed that the health and safety of residents who were transferred using the Invacare Reliant 600 mechanical lifts were in Immediate Jeopardy due to the mechanical lifts not being equipped with the required safety clips to prevent accidents. The facility submitted and implemented a plan to ensure residents' safety by placing safety clips on two of their Invacare Reliant 600 mechanical lifts to ensure safety during transfers and by using another type of mechanical lift that did not require the use of safety clips, and the Immediate Jeopardy was removed on June 21, 2016, at 11:07 a.m. The manufacturer's instructions for the use of the Invacare Reliant 600 mechanical lift, dated 2011, indicated that the lift sling to be used was an approved Invacare sling, which was to be checked each time it was removed and replaced to ensure that it was properly attached before the resident was moved from a stationary object. The Invacare slings were made to be used specifically with the Invacare patient lifts, and for the safety of the resident, slings and lifts from different manufacturers were not to be intermixed. Observations of Resident R5 on June 20, 2016, at 8:00 p.m. revealed that the resident was sitting in her wheelchair on a mechanical lift sling, and the sling did not have a label on it. Therefore, there was no way to confirm that it was an Invacare sling as per the manufacturer's instructions. Interview with Nurse Aide 16 on June 20, 2016, at 8:00 p.m. confirmed that there was no identification on the sling, and he was not aware of what type of sling was in use for Resident R5. physician's orders [REDACTED]. Observations on June 20, 2016, at 6:10 p.m. and 7:10 p.m. revealed that the resident was in the dining room sitting in her wheelchair and she had a mechanical lift sling under her that was labeled, Drive. There was no evidence that the lift sling was an Invacare sling. Observations on June 20, 2016, at 8:00 p.m. revealed that Resident R1 was in a wheelchair with a lift sling under him, and there was no tag on the lift sling to identify the manufacturer. Interview with the Nursing Home Administrator on June 21, 2016, at 5:35 p.m. confirmed that the manufacturer of several of the facility's mechanical lift slings was not identifiable. The Nursing Home Administrator could not provide any information from the Invacare lift manufacturer to ensure that Drive slings were safe to use with Invacare lifts. A quarterly MDS assessment for Resident R1, dated March 28, 2016, revealed that the resident was confused and required the assistance of staff with care. Observations on June 20, 2016, at 8:00 p.m. and June 21, 2016, at 11:50 a.m. and 1:15 p.m. revealed that the vinyl on the left arm rest of Resident R1's wheelchair had an approximate six-inch split at the seam. Interview with Licensed Practical Nurse 10 on June 21, 2016, at 2:10 p.m. revealed that staff did not notify her about the split in the vinyl on the arm rest of Resident R1's wheelchair, and that it should have been reported to maintenance. Interview with Maintenance Worker 11 on June 23, 2016, at 11:17 a.m. confirmed that he was not made aware of the split vinyl on Resident R1's wheelchair until June 21, 2016. He indicated that any staff member who identified a problem with a wheelchair was to submit a work order to the maintenance department. He stated that staff who worked on the units, including nursing and custodial staff, should have been looking at residents' wheelchairs. Interview with the Assistant Director of Nursing on June 23, 2016, at 1:05 p.m. revealed that the facility did not have a written policy related to the maintenance of residents' wheelchairs. Observations in the unlocked resident shower room on the A Corridor of the 100 Level on June 20, 2016, at 1:10 p.m. revealed that an unlocked cabinet in the room contained a bottle of Dermavera skin and hair cleanser. The Material Safety Data Sheet (MSDS - gives information about handling and safety procedures) for Dermavera, dated October 4, 2013, revealed that the product could cause irritation if placed in the eyes or if ingested. Interview with the Director of Nursing on June 20, 2016, at 1:45 p.m. confirmed that Dermavera was to be secured in the locked cabinet. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 4/14/15, 6/6/14. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/6/14. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/14/15, 6/6/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/20/15, 4/27/15, 4/14/15, 6/6/14.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's severe pain was reported and treated in a timely manner for one of 30 residents reviewed (Resident R21), resulting in harm for the resident. The facility also failed to assess and/or reassess the effectiveness of a resident's pain management for one of 30 residents reviewed (Resident R10); failed to follow physician's orders regarding pain treatment, skin treatment, laboratory specimens, bowel protocol, and protective padding for five of 30 residents reviewed (Residents R1, R2, R10, R16, R19); failed to assess and provide care for a scalp laceration with staples for one of 30 residents reviewed (Resident R3); failed to notify the physician regarding elevated blood sugar results, which resulted in a lack of treatment for one of 30 residents reviewed (Resident R13); and failed to ensure that a physician's order was obtained prior to performing an invasive straight catheterization procedure for two of 30 residents reviewed (Residents R1, R13). Findings include: A current [DIAGNOSES REDACTED]. Physician's orders, dated April 30, 2016, included an order for [REDACTED]. Observations of Resident R21 on June 22, 2016, at 2:25 p.m. revealed that the resident was writhing in his chair, moaning, holding his right foot area, breathing rapidly, and grimacing. Nurse Aide 37 was in the room making the resident's bed, then she walked out of the room and entered another resident's room. Interview with Resident R21 at that time revealed that when asked by the surveyor if he was having pain, he cried out, Yes! My right leg! as he held onto his right leg and rocked back and forth, grimacing and moaning. At 2:45 p.m., the surveyor went to the nursing station and informed Licensed Practical Nurse (LPN) 10 about the resident's condition. Observations on June 22, 2016, at 2:45 p.m. revealed that LPN 10 interviewed Resident R21 about his pain level, which the resident rated as an 8 out of 10 on the pain scale, and he was medicated with 5 mg of [MEDICATION NAME]. Interview with Nurse Aide 37 on June 22, 2016, at 3:30 p.m. revealed that Resident R21 never asks for pain medication, and she was intending to tell the nurse about his pain; however, she got busy with another resident. Interview with the Director of Nursing on June 22, 2016, at 3:40 p.m. confirmed that Nurse Aide 37 should have reported Resident R21's pain to the nurse right away. Physician's orders for Resident R10, dated June 6, 2016, and originally dated June 4, 2015, included orders for the resident to receive 650 mg of [MEDICATION NAME] (Tylenol - an over-the-counter pain medication) every 4 hours as needed for mild pain, 10-325 mg of [MEDICATION NAME]-[MEDICATION NAME] (a narcotic pain medication) every 6 hours as needed for moderate/severe pain, a 25 microgram (mcg) per hour [MEDICATION NAME] (narcotic pain medication absorbed through the skin) that was to be changed every three days, and 10-325 mg of [MEDICATION NAME] (a narcotic pain reliever) two times daily. Pain evaluation tools, dated October 7 and 15, 2015, and April 1, 2016, indicated that the resident frequently had pain. Resident R10's MAR's for January through June 2016, revealed that the as needed [MEDICATION NAME]-[MEDICATION NAME] was administered to the resident 25 times in January, 20 times in February, 25 times in March, 22 times in April, 24 times in May and 19 times in June, all between the hours of 2:45 a.m. and 6:00 a.m. There was no documented evidence that the facility assessed Resident R10's ongoing pain and the pattern of the resident having frequent pain that required the as needed pain medication during the early morning hours, and no documented evidence that the physician was notified about the frequency and pattern of the resident's pain. Interview with the Director of Nursing on June 21, 2016, at 1:00 p.m. confirmed that Resident R10 always woke up in the morning and requested the pain medication. She confirmed that there was no evidence that an assessment of the resident's pain and an analysis of the effectiveness of the resident's pain regime were completed. A nursing note for Resident R19, dated June 15, 2016, revealed that the resident had an open area on her left buttock and irritation on the right buttock. Physician's orders, dated June 22, 2016, revealed that the resident was to have a mixed cream of [MEDICATION NAME] and zinc oxide 40 percent (antibacterial, antifungal, and protective cream) applied to both of her buttocks and covered with an ABD (large dressing pad) that was to be changed every shift and as needed when soiled. Observations during incontinent care for Resident R19 on June 23, 2016, at 9:35 a.m. revealed that the resident's ABD dressing was soiled and was removed by Nurse Aide 37. After the resident was cleansed, Nurse Aide 37 left the room and upon return indicated that the licensed practical nurse was not able to complete the treatment to the resident's buttocks at that time. The resident's wound was uncovered and Nurse Aides 37 and 38 applied a clean incontinent brief and then transferred her out of bed into her wheelchair. Observations during incontinent care for Resident R19 on June 23, 2016, at 12:15 p.m. revealed that when the resident's soiled brief was removed, the resident's wound did not have a dressing on it, nor was there cream visible on the buttocks area. After the resident was cleansed, Nurse Aide 39 indicated that the licensed practical nurse informed her that she was going to apply the treatment to the resident's buttocks around 1:00 to 1:30 p.m. The resident's wound was uncovered and Nurse Aides 39 and 40 applied a clean incontinent brief and then transferred her out of bed into her recliner. Interview with the Assistant Director of Nursing on June 23, 2016, at 12:35 p.m. revealed that the ordered treatment to Resident R19's buttock should have been provided after incontinent care was completed. The facility's policy regarding their routine bowel program, dated April 25, 2016, indicated that the routine bowel program included giving 30 cubic centimeters (cc's) of Milk of Magnesia (MOM - a laxative) on the morning of the third day, without a bowel movement. Physician's orders for Resident R10, currently dated June 6, 2016, and originally dated June 4, 2015, included an order for [REDACTED]. However, the resident's MAR for June 2016, revealed that there was no documented evidence that the resident was offered MOM on June 12, 2016. Interview with Registered Nurse 9 on June 21, 2016, at 9:20 a.m. confirmed that there was no evidence that Resident R10 was offered MOM as ordered by the physician. A [DIAGNOSES REDACTED]. However, the resident's MAR for May 2016, revealed that there was no documented evidence that MOM was administered until May 26, 2016, the fourth day without a bowel movement. Interview with the Assistant Director of Nursing on June 22, 2016, at 2:19 p.m. confirmed that Resident R2 should have received MOM sooner for constipation. A [DIAGNOSES REDACTED]. MOM in the a.m. of the third day without a bowel movement, a [MEDICATION NAME] suppository at bedtime on the third day without a bowel movement, and a Fleets enema on the fourth day without a bowel movement, and if the enema was ineffective, the registered nurse was to be notified. The resident's bowel movement records for June 2016, revealed that the resident did not have a bowel movement from June 7 through 10, 2016. However, the resident's MAR for June 2016, revealed that MOM was not administered until June 10, 2016 (the fourth day without a bowel movement), MOM was administered again on June 11, 2016 (the fifth day without a bowel movement), a Fleets enema was not administered until June 11, 2016 (the fifth day without a bowel movement), and a [MEDICATION NAME] suppository was not administered when the MOM was not effective. Resident R16's bowel movement records also indicated that the resident did not have a bowel movement on June 14 through June 17, 2016. However, the resident's MAR for June 2016, revealed that although MOM was given on June 16, 2016 (the third day without a bowel movement), it was given again on June 17 (the fourth day), and a [MEDICATION NAME] suppository was also administered on June 17, 2016 (the fourth day, instead of the third day as ordered). Interview with Registered Nurse 22 on June 11, 2016, at 10:35 a.m. confirmed that Resident R16's physician's orders for bowel medications were not followed. Physician's orders for Resident R10, dated June 2, 2016, included an order for [REDACTED]. A laboratory report, dated June 9, 2016, indicated that the first stool sample was obtained and blood was present in the stool. There was no documented evidence regarding why there was a delay in obtaining the first stool sample, and no documented evidence that the second and third stool specimens were obtained as ordered. Interviews with Registered Nurse 9 and the Director of Nursing on June 21, 2016, at 9:20 a.m. and June 22, 2016, at 10:03 a.m. respectively, confirmed that there was no documented evidence regarding the delay in obtaining the first stool sample, and no documented evidence for why the second and third stool specimens were not obtained as ordered by the physician. Physician's orders for Resident R1, dated June 4, 2016, included an order for [REDACTED]. Observations during incontinent care on June 20, 2016, at 3:52 p.m. revealed that Resident R1 did not have an ABD on his coccyx when his old brief was removed, and a new ABD was not applied when his new brief was secured. Observations during incontinent care on June 21, 2016, at 1:50 p.m. also revealed that an ABD was not present when the resident's old brief was removed. Interview with Licensed Practical Nurse 10 on June 21, 2016, at 2:10 p.m. confirmed that Resident R10 should have had an ABD under his brief as ordered by the physician. Physical therapy notes for Resident R16, dated April 19 and 20, 2016, revealed that the resident had pain in both legs and her right foot, and a nursing note, dated April 21, 2016, indicated that the resident complained of severe foot and heel pain. Physician's orders, dated April 21, 2016, included an order for [REDACTED]. Interview with the Rehabilitation Manager on June 23, 2016, at 1:15 p.m. confirmed that the ultrasound treatment was not provided as ordered by the physician because the [MEDICATION NAME] cream was not provided to them to apply with the ultrasound treatment. Interview with the Director of Nursing on June 21, 2016, at 2:20 p.m. revealed that the pharmacy should have been contacted on the first day that the [MEDICATION NAME] cream was not available, and the physician should have been notified if the medication was unable to be provided; however, there was no documented evidence that the physician or the pharmacy were notified. Physician's orders for Resident R13, dated June 17, 2016, included an order for [REDACTED]. Resident R13's MAR for June 18, 2016, at 8:00 a.m. revealed that the resident's blood sugar was 373 mg/dL. However, there was no documented evidence that the physician was notified that the resident's blood sugar result was greater than the upper limit of the sliding scale insulin coverage of 300 mg/dL, and there was no documented evidence that the resident received any additional insulin coverage. Interview with the Assistant Director of Nursing on June 23, 2016, at 10:54 a.m. confirmed that the physician was not notified about Resident R13's blood sugar result of 373 mg/dL, and the resident did not receive any insulin coverage for the elevated blood sugar result. A nursing note for Resident R3, dated June 6, 2016, revealed that the resident fell resulting in a laceration (a deep cut to the skin) to the back of head that required staples (used to repair a laceration). There was no documented evidence that physician's orders for the care of the laceration and staples were obtained, and no documented evidence of ongoing monitoring, assessment, or care of the resident's injury. Interview with the Director of Nursing on June 21, 2016, at 11:50 a.m. confirmed that a doctor's order should have been obtained to care for and monitor Resident R3's injury site, and that nursing should have performed and documented assessments and care of the injury. Physician's orders for Resident R1, dated May 14, 2016, included an order for [REDACTED]. A laboratory report, dated May 17, 2016, indicated the urine specimen was obtained via straight catheterization. Physician's orders for Resident R13, dated May 27, 2016, included an order for [REDACTED]. Interview with the Director of Nursing on June 21, 2016, at 12:35 p.m. confirmed that there were no physician's orders to obtain urine specimens via straight catheterization for Residents R1 and R13, and orders should have been obtained. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 8/20/15, 6/6/14. 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. Previously cited 8/20/15, 4/27/15, 4/14/15, 6/6/14.