Every finding on record at Meadowood

Based on resident and staff interviews, it was determined that the facility failed to implement grievance process including required regulatory requirements of grievance policy, maintaining evidence demonstrating the result of all grievances and failed to ensure grievance forms were available for one of one nursing units observed. ( 2nd floor north nursing unit)Findings include: Review of facility policy Grievance/ Complaint Policy dated June 2023, revealed that ach grievance will be investigated and promptly resolved, keeping the resident and resident representative informed throughout the investigation. Information regarding how to file a grievance is provided to the resident/resident representative upon admission and periodically through the resident council and is posted prominently throughout the Health Center. Further review of the grievance policy did not address the required regulatory requirements, S483.10(j)(4) (i) the right to file grievances anonymously; (ii) maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Interview with Resident Representative for Resident R3 on January 30, 2026, at 11:26 a.m. revealed the resident and family brought numerous concerns and grievances to the facility; however, the concerns were not resolved. The representative stated she was unsure of the outcome of the grievances. She reported concerns related to lack of incontinence care, food quality, and failure to receive timely care. The representative further stated that the Ombudsman had been involved a few months prior in an attempt to resolve the concerns. Interview with the Social Worker, Employee E5, who also serves as the facility's grievance official, on February 2, 2026, at 11:13 a.m., confirmed that Resident R3 and the family raised grievances regarding lack of incontinence care, food concerns, and timeliness of care. Employee E5 also confirmed that the Ombudsman was involved when the concerns were raised a few months ago. A request was made to the Administrator on February 1, 2026, and again on February 2, 2026, for copies of the grievances and documentation of investigation and resolution. No grievance documentation was provided. Interview with the Nursing Home Administrator on February 2, 2026, at 11:00 a.m., revealed the facility did not have documented grievances for Resident R3. The Administrator confirmed the facility's grievance process, including documenting all grievances, was not followed. Observation of the facility nursing units with Employee E5 on February 2, 2026, at 11:00 a.m., revealed a posted notice next to the nurses' station indicating grievance forms were available near the elevator. Further observation revealed no grievance forms were available at the indicated location. Additionally, there was no evidence of a process for filing anonymous grievances. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(d)(i) Resident rights

Based on review of resident records, pharmacy documentation and interviews with staff determined the facility failed to ensure residents' drug regimen was free from unnecessary drugs for excessive duration, without adequate monitoring and/or adequate indications for its use for two of 13 resident records reviewed (Resident R5 and R6). Findings include: Resident R5 was admitted to the facility on [DATE], on hospice, diagnosed with anxiety disorder. Physician orders dated July 5, 2025, instructed to give 0.5 mg of Lorazepam every 4 hours, PRN (as needed) for anxiety with no indication of a stop date or when this medication should no longer be administered. Review of the facility's pharmacist consultant dated July 24, 2025, to the physician , indicated to avoid a potential citation, PRN orders for psychotropic drugs are limited to 14 days and that if the physician believes the order should be extended beyond 14 days, the physician should document the duration and their rationale in the resident's medical record. The physician agreed to the recommendation yet stated to reassess Resident R5 in 6 months. The order for the resident's prn Lorazepam was extended to an end date of 6 months but with no documented evidence the physician provided a rationale or assessment. Review of FDA Food and Drug safety authority guidelines for QUEtiapine Fumarate (SEROQUEL) revealed that Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. SEROQUEL is not approved for elderly patients with dementia-related psychosis. SEROQUEL is an atypical antipsychotic indicated for the treatment of: Schizophrenia, Bipolar I disorder manic episodes and Bipolar disorder, depressive episodes. Risk of death in the elderly with dementia. Medicines like SEROQUEL can increase the risk of death in elderly people who have memory loss (dementia). SEROQUEL is not for treating psychosis in the elderly with dementia. Review of clinical record for resident R6 reveal that. The resident was taking Quetiapine Fumarate 25 milligram half a tablet by mouth at bedtime for agitation/insomnia. Further review of the clinical record did not indicate that the resident had an active and approved diagnosis in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, interviews with staff and reviews of facility policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of neglect for one of 13 residents reviewed. (Resident R5) Findings include: Review of the facility's policy titled, Freedom from Abuse, Neglect, and Exploitation, revised April 2023, states, Each resident will be protected from and free from abuse. The policy defines neglect as failure through inattentiveness, carelessness, or omission to provide timely, consistent, safely adequate, and appropriate services, treatment, or care, including but not limited to supervision and serves that the facility has agreed to provide. One of the seven components to detect and prevent abuse and neglect is that all reports are promptly and thoroughly investigated. The same policy states that the investigation will include written statements from all witnesses. Interviews will be conducted including residents and witnesses involved that may have witnessed the resident's behavior before and/or after the identified event. Resident R5 was admitted to the facility on [DATE], placed on hospice, diagnosed with anxiety disorder and assessed as an elopement risk due to the resident's wandering and previous past medical history. Review of Resident R5 clinical records and facility documentation revealed on July 19, 2025, and September 6, 2025, the resident was found by a facility's security guard wandering off the unit. Review of facility investigation and interview with the Director of Nursing on February 2, 2026, at 11:30 a.m. confirmed the facility failed to obtain written witness statement from the nursing staff and the security guard, nor did the facility determine the length of time the resident was off the unit to rule out any possibility of neglect. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols for one resident that received antibiotics with inappropriate use of 13 resident records reviewed (Resident R4). Findings Include:A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. The guidelines further Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use.Resident R4 was admitted to the facility on [DATE], with chronic mental conditions that included bipolar, major depressive disorder and anxiety. Review of Resident R4's infection control progress note, dated December 20, 2025, indicated the resident was on antibiotic therapy due to a Probable UTI (urinary tract infection). Physician orders dated December 19, 2025, instructed to give an antibiotic, 100 mg of Macrobid two times a day for the UTI for 5 days, that was completed between December 19 thru 24, 2025.Further review of Resident R4 clinical record revealed no indication of a possible UTI nor was a urinalysis completed to confirm this.Physicians note dated December 15, 2025, noted Resident R4 complaining of back pain and ordered Tramadol (a pain reliever), indicating no additional complaints from the resident. Interview with the Director of Nursing (DON) on February 2, 2026, at 12 p.m. confirmed that Resident R4's antibiotic order was inappropriate for use. The DON explained when the resident was complaining of back pain, the hospice nurse initially thought it was a UTI and requested an antibiotic.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to revise one resident's care plan with updated interventions status post fall for one of two residents reviewed for falls (Resident R25). Findings Include: Review of facility policy Care Plan Process, revised October 2017, revealed the plan of care is continually reviewed and updated by members of the interdisciplinary team to reflect the current needs of the resident. Review of facility policy Fall management Guideline, revised December 2022, revealed to reduce the risk of falls or fall related injuries the facility will implement appropriate person-centered interventions and the resident's plan of care will be updated accordingly. Resident specific interventions are put in place initially and ongoing, and the interdisciplinary team will review current falls and fall interventions. Review of Resident R25's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 9, 2023, revealed the resident was admitted to the facility on [DATE], and had diagnoses of muscle weakness, lack of coordination, unsteadiness on feet, and difficulty in walking. Continued review of the MDS revealed the resident required one-person physical assistance for transfers, ambulation, and toilet use. Review of Resident R25's fall risk assessment dated [DATE], revealed the resident was at high risk for falling. Review of Resident R25's care plan dated May 24, 2023, revealed the resident had a decline in his ability to perform independent bed mobility, transfers, and walking with rolling walker safely without falls. Continued review of Resident R25's care plan revised July 18, 2023, revealed the resident was at risk for falls related to his decline in mobility and balance impairment and had unwitnessed falls on June 30, 2023, July 8, 2023, and July 18, 2023. Review of facility incident report dated June 30, 2023, revealed Resident R25 rang call bell to report that he had fallen after coming from the bathroom. Resident R25 did not ring call bell for assistance to and from bathroom. Continued review of the incident report and review of Resident R25's comprehensive care plan revealed no documented evidence new interventions were implemented status post fall. Review of facility incident report dated July 8, 2023, revealed the nurse heard a loud noise coming from Resident R25's room and the resident yelling out. Resident R25 was subsequently found laying on the bathroom floor. Continued review of the incident report and review of Resident R25's comprehensive care plan revealed no documented evidence new interventions were implemented status post fall. Review of Resident R25's clinical record revealed a nursing note dated July 18, 2023, that the resident again had an unwitnessed fall and was observed kneeling on the floor in his bathroom holding onto his walker. Per Resident R25's comprehensive care plan revised July 18, 2023, revealed the resident was attempting to initiate morning care. Resident R25's care plan was subsequently updated on July 18, 2023, with new interventions to offer and encourage early morning get-up per the resident preference and that the resident would be assisted by the 11:00 p.m. to 7:00 a.m. nursing shift. Interview on July 19, 2023, at 12:15 p.m. with Director of Nursing, E1, confirmed Resident R25's care plan was not updated with new interventions status post falls on June 30, 2023, and July 8, 2023. Continued interview on July 19, 2023, at 1:00 p.m. with the Director of Nursing, Employee E1, revealed all three falls happened during the morning hours. 28 Pa. Code 211.10 (c) Resident Care Policies. 28 Pa. Code 211.10 (d) Resident Care Policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for one of one resident reviewed for nutritional status. (Resident R20) Findings include: Review of facility policy Nutrition Risk Guidelines revealed that an undesired significant weight loss qualifies a resident for nutrition risk monitoring. Review of Resident R20's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated April 11, 2023, revealed that the resident was admitted to the facility on [DATE], and had the diagnoses of Alzheimer's Dementia (a disease that destroys memory and other important mental functions), anxiety disorder, and depression. A review of Resident R20's BIMS (Brief Interview of Mental Status) revealed a score of nine, which indicated that the resident had moderately impaired cognition. Review of R20's clinical records revealed Resident R20 had a documented weight of 153 pounds on April 11, 2023, and a weight of 144.2 on July 18, 2023; indicating a significant weight loss of 5.8% weight loss in three months. Further review revealed a documented weight of 174.8 pounds on January 15, 2023, and a documented weight of 144.2 on July 11, 2023; indicating a significant weight loss of 17.5% in six months. Review of physician orders revealed an order dated February 16, 2023, for a dietary supplement, Ensure Clear, two times a day for significant weight loss. This supplement order would provide 480 calories and 16 grams of protein total per day for resident to prevent further weight loss. Review of Resident R20's Medication Administration Records for February, March, April, May, June, and July of 2023 revealed documented evidence that the nutritional supplement had been provided to resident and that it was occasionally refused, but no documented evidence of supplement daily percent intakes by resident. Further review of progress notes revealed no documented evidence regarding an alternative supplement option choice offered to resident when resident had refused the Ensure Clear nutritional supplement. Interview with the Registered Dietitian, Employee E3, on July 18, 2023, at 1:08 p.m. revealed Resident R20 had a history of refusing meals and prefers to eat in her room. Further interview confirmed there was no documented evidence of supplement daily percent intakes by resident to be able to evaluate the effectiveness of this nutrition intervention. Observation of the resident room on July 19, 2023, at 11:03 a.m. revealed an ensure clear with a straw placed on Resident R20's stand. During an interview with Resident R20 this surveyor asked, do you drink all of the ensure? Resident stated, no. Follow-up interview with Resident R20's nurse, Employee E6, on July 19, 2023, revealed Resident R20 can make her needs known by using the call bell, passing it on to the nurse aids, and answering yes and no questions. During interview on July 19, 2023, at 3:05 p.m. with the Director of Nursing, Employee E1, and Administrator, Employee E2, it was confirmed that there was no daily monitoring evidence for Resident R20's nutrition supplement daily percent intakes. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12 (c)(5) Nursing Services

Based on observations of the dietary services department, interviews with staff, and a review of facility policies and documentation, it was determined that the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Food and Supply Storage, revised January 2018, under Frozen Storage, stated wrap food tightly to prevent cross contamination. During the initial tour of the Food Service Department conducted on August 30, 2021 at approximately 10:00 a.m. with Employee E6, Food Service Director, revealed the following: Observations in the walk-in freezer revealed a tray marked ribs containing what appeared to be bone-in short ribs which were partially covered with the plastic covering, exposing the meat to circulating air on the end of the tray. Further observation revealed two more trays of pastries which were also not covered properly with loosely fitting plastic leaving the food products exposed to the circulating air. Observations in the hot food production area revealed two sets of convection ovens both with the insides of the lower ovens having a heavy build up of black baked on substance on the sides and bottom surfaces of the ovens. Further observations revealed the table above the [NAME] had a heavy build up of blackish brown grease and dirt on the sides and on the electric boxes, wires and connections. During an interview with the Employee E6 at approximately 10:20 a.m. on August 31, 2021, these findings were confirmed. 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.6(d) Dietary services

Based on individual interviews and a group meeting with residents, observations, review of facility documentation and staff interviews, it was determined that call bells were not being answered in a timely fashion for a majority of the residents of the facility. Findings include: A resident interview with Resident R13, during the initial tour of the facility, on (MONTH) 6, 2019, at 10:30 a.m. indicated, Often fall asleep before my call bell is answered. Resident R13, further indicated, Call bell response time is delayed during all three shifts. An additional resident interview with Resdient R50, on (MONTH) 6, 2019, at 11:20 a.m. also indicated Call bell response time overall is not very good. Upon the conclusion of the interview with R50, surveyor asked R50, to press call bell, to observe call bell response time. Resident R50, pressed call bell indicator on at approximaately, 11:55 a.m. which was responded to by Employee E4, CNA, at approximinatley, 12:10 p.m. fifteen minutes from when it was initially turned on by Resident R50. During the group meeting with five alert and oriented residents, identified by the facility, on (MONTH) 7, 2019, at 10:30 a.m. it was indicated by each of the five residents, (Residents R7, R13, R15, R27 and R35), Takes a long time to get assistance after turning on call bell at all times. Resident R35, further indicated, Staff will come into room, see what you want and than say, I will be right back. Resident R7, followed up to what R35, was saying, by indicating, They never come right back. Resident R35, shared during the group meeting her call bell experience from earlier in the morning, to get ready to attend the resident meeting. Resident R35, indicated she needs assistance with getting dressed, she turned on her call bell, shortly before 10:00 a.m. for the 10:30 a.m. meeting, to get help with getting dressed, her call bell was responded to by a Certified Nurse Aide, (CNA - nursing assistant), who told, R35, I will be right back. Resident R35, further indicated, She never came back, I'm not suppose to get dressed on my own, but I had to not to be late for the meeting. An interview with Employee E5, CNA, assigned to Resident R35, for (MONTH) 7, 2019, at 1:20 p.m. the day of the group meeting with Residents, confirmed that Resident R35, did get dressed indepently, earlier in the day and does require assistance with all activities of daily living. Review of the call bell indicator log on (MONTH) 10, 2019, at 2:00 p.m. revealed that Resident R35, did turn call bell on, (MONTH) 7, 2019 at 9:56 a.m. as she had indicated. Continued observations on all days of the survey at various times, in different locations of the facility, revealed that call bell response times were delayed in being responded to. Further review of the call bell indicator response log, in the presence of the Nursing Home Adminstrator and Director of Nursing on (MONTH) 10, 2019, at 2:00 p.m. revealed in some occassions it took up to 20 minutes and/or longer for a staff person to respond to a residents call bell. During the same interview the Nursing Home Adminstrator and Director of Nursing, indicated, that call bell response time should be with in five to eight minutes, no more than 10 minutes. An interview with the Nursing Home Adminstrator and Director of Nursing, on (MONTH) 10, 2019, at 2:15 p.m. confirmed that call bell response time is not accommodating the individual needs of the residents. Facility has not insured that call bell response time is accommodating the individual needs of the Residents. Pa. Code: 201.19(b)(1) Management Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 07/20/18, 03/08/18

Based on a resident group meeting, review of facility policy and procedure and interview with facility staff, it was determined that the facility failed to provide the opportunity for residents to vote in the most recent primary election for three of five residents that attended the group meeting (Residents R7, R27 and R35). Findings include: Review of facility policy and procedure, titled, Voting Policy, dated, (MONTH) 7, 2019, indicated, Every resident with cognitive ability and desire shall vote in every and all elections they choose. During a group meeting with five residents identified by the facility as being cognitively intact, held on (MONTH) 7, 2019, at 10:30 a.m. three of the residents, R7, R23 and R35, stated that they had not been offered the opportunity to vote during the most recent primary election on Tuesday, (MONTH) 21, 2019 and they would have liked to vote. An interview with Employee E3, Social Worker, on (MONTH) 7, 2019, at 2:00 p.m. indicated that the designated polling location for the facility was at a nearby church and further indicated that the facility offers transporation. Employee E3, confirmed Residents R7, R23 and R35, were not offered the opportunity to vote during the recent primary election held on (MONTH) 21, 2019 and each of them are cognitively able to exercise there right to vote. The facility failed to ensure residents were given the opportunity to vote during the recent primary election. 28 Pa. Code: 201.29(i) Resident Rights Previously cited 07/20/18 06/10/16

Based clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that showers were provided in accordance with residents' preferences for one of 18 residents reviewed (Resident R15). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R15, dated (MONTH) 29, 2019, revealed that the resident had intact cognition, required one person physical assist for bathing. The facility's current shower schedule for Resident R15 revealed that the resident was scheduled to receive a shower during the night shift on Thursdays and Mondays. During the intitial tour of the facility on Thursday, (MONTH) 6, 2019, Resident R15 stated that he did not receive a shower, because the staff who was assigned to the resident told him there was a staff meeting and there was no time to assist the resident in the shower. Review of Resident R15's clinical record revealed no documented evidence on (MONTH) 6, 7, 8, or 9, 2019, regarding the status of the resident's missed shower. Further review of the facility's shower log revealed no documented evidence Resident R15 received a shower on (MONTH) 6, 7, 8, or 9, 2019. Interview on (MONTH) 10, 2019, at 11:50 a.m. with the DON where she stated that the facility's protocol would be if a shower was missed on the resident's shower day, then the resident would be added to the next day for a shower. Further, the DON confirmed that there was no documentation that the resident received a shower or refused a shower on Thursday, (MONTH) 6, 2019, and the DON confirmed there was no documentation that the resident received a shower on (MONTH) 7, 8, or 9, 2019. The facility failed to ensure that showers were provided in accordance with residents' preferences 28 Pa. Code 201.29(i) Resident rights. 28 Pa. Code 201.29(j) Resident rights.

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that the resident's wishes for Advance Directives (one's wishes on life-sustaining medical or surgical treatment) were reflected accurately in the clinical record, for one of 18 residents' records reviewed (Resident R11). Findings include: Review of the facility policy Advance Directives and Self Determination, dated last revised (MONTH) 15, 2009 and last reviewed (MONTH) 16, (YEAR), stated that it was the policy of the facility to respect a person's right as defined by the U.S. Constitution and Commonwealth of Pennsylvania Law to make decisions about his/her medical care. The purpose of the policy, as stated, was to ensure that the rights of the resident - including dignity, privacy, autonomy - are protected whether exercised by the resident or the healthcare agent or healthcare representative; to prevent confusion at the time of decision making by identifying the resident's choices or the person responsible for expressing the resident's decision by their knowledge of the residents wishes; and to ensure the health care providers (physician, nurses, social workers and the facility) meet appropriate legal guidelines for treatment limitations/Advance Directives. The same policy continued that upon admission to the facility the Admissions Coordinator and/or social Worker will provide information regarding the preparation of an Advance Directive and will ascertain whether the resident has completed an Advance Directive. The policy also noted that the resident would be given the information and the opportunity to complete one (Advance Directive) or to acknowledge in writing that he/she has been given the information and the opportunity to complete an Advance directive and does not wish to do so. Review of the clinical record for Resident R11 revealed that the resident was readmitted to the facility on (MONTH) 21, 2019 from an acute care hospital with [DIAGNOSES REDACTED]. Review of the physician's orders for Resident R11, dated (MONTH) 21, 2019, and monthly thereafter, indicated in the Advance Directives section No data to display, indicating that there was no physician's order for an Advance Directive (code status- level of emergency medical interventions one wishes to have started if their breathing or heart stops ) for Resident R11. Further review of the resident's electronic record under the clinical tab revealed at the top left side of the display screen in bold letters DNR (Do Not Resuscitate - do not perform chest compressions to keep the heart beating). Further review of the record revealed under the Advance Directive tab that Resident R11 was DNR (Do Not Resuscitate and was dated (MONTH) 22, 2019. During an interview with the Director of Nursing on (MONTH) 7, 2019,at approximately 12:30 p.m., it was confirmed that the physcian's order for Resident R11 did not accurately reflect the wishes of the resident for DNR (Do Not Resuscitate) The facility failed to ensure accurate documentation was maintained regarding residents' wishes for resuscitation upon life-threatening medical conditions. 28 Pa. Code 201.18(b)(1)Management Previously cited 07/20/18 28 Pa. Code 201.29(i) Resident rights 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 07/20/18

Based on clinical record review and interview with facility staff, it was determined that the facility failed to provide documentation that the required notification to the office of the State Long-Term Care, (LTC) Ombudsman had been performed after a facility - initiated transfer to an acute care hospital had occurred for six of 18 residents reviewed that were transferred to the hospital (Resident R203, R204, R13, R11, R35, and R78). Findings include: Review of Resident R203's clinical record revealed the resident was admitted to the facility on (MONTH) 3, 2019, with a [DIAGNOSES REDACTED]. Further, review of Resident R203's, clinical record revealed that the resident was transferred to the hospital on (MONTH) 7, 2019, for [MEDICAL CONDITION] (the heart doesn't pump blood as well as it should) and [MEDICAL CONDITION] (bacterial infection the deep layers of skin and tissue beneath the skin). Review of Resident R204's clinical record revealed the resident was admitted to the facility on (MONTH) 10, 2019, with a [DIAGNOSES REDACTED]. Further, review of Resident R204's, clinical record revealed that the resident was transferred to the hospital on (MONTH) 19, 2019, related to the [MEDICAL CONDITION]. Clinical record review for Resident R13, on (MONTH) 7, 2019, revealed on (MONTH) 12, 2019, R13, was transferred via 911 ambulance to the local hospital for evaluation and treatment related to an infection. Review of the clinical record for Resident R11 revealed that the resident was readmitted to the facility on (MONTH) 21, 2019 from an acute care hospital with [DIAGNOSES REDACTED]. Further review of the clinical record revealed that the resident was transferred to the hospital on (MONTH) 11, 2019 with shortness of breath. Review of the clinical record for Resident R35 revealed that the resident was readmitted to the facility on (MONTH) 17, 2019 from an acute care hospital with [DIAGNOSES REDACTED]. Further review of the clinical record revealed that Resident R35 was transferred to the hospital (MONTH) 11, 2019 with pain in left hip area following a fall in the bathroom. Review of the clinical record for Resident R78 revealed that the resident was readmitted to the facility on (MONTH) 10, (YEAR) from an acute care hospital with [DIAGNOSES REDACTED]. Further review of the clinical record revealed that Resident R78 was transferred to the hospital on (MONTH) 5, (YEAR) with pain in right hip area following a fall in her room. An interview with the administrator on (MONTH) 10, 2019, at 11:15 a.m., where she confirmed that the State Long- Care, (LTC) Ombudsman was not notified of Residents R13, R203 and R204, R11, R78, and R35's transfer to the hospital. The facility failed to notify the Office of the State Long - Term Care Ombudsman of a facility initiated hospital transfers. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/20/18, 03/08/18; 06/10/16

Based on observations, facility policy and clinical record review, and staff interviews, it was determined that the facility failed to maintain appropriate infection prevention and control practices during wound treatment for one resident (Resident R6). Findings include: Review of facility policy Infection Control - Hand Hygiene, dated (MONTH) (YEAR), revealed that the purpose of the policy is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of the transmission of infections. Review of Resident R49's clinical record revealed the resident was admitted to the facility on (MONTH) 3, (YEAR), with a [DIAGNOSES REDACTED]. Review of Resident R49's active physician orders [REDACTED]. Observation of Resident R49's wound care on (MONTH) 7, 2019, at 1:40 p.m. revealed Employee E5, RN, removed Resident R49's old soiled wound dressing with her gloved hands, then with the same gloves she cleaned the resident's wound with normal saline, and then with the same gloved hands she put on a new clean dressing on Resident R49's rear ankle. Interview on (MONTH) 7, 2019, at 1:45 p.m. with Employee E5, RN, where she confirmed that she did not remove her used gloves after removing Resident R49's soiled wound dressing and perform hand hygiene. The facility failed to maintain infection prevention and control practices during wound treatment. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 03/08/18, 07/20/18

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Food and Supply Storage Policy #B003, Revised (MONTH) (YEAR), states Store dry and staple items at least 6 above the floor and 18 from ceiling, consistent with local food protection codes. An initial tour of the Food Service Department conducted on (MONTH) 11, (YEAR) at 8:45 AM with Employees E3, Senior Director of Dining, revealed the following: Observation in the loading dock and receiving area revealed a large pile of empty pallets leaning against the wall on the loading dock and some lose trash on the ground including paper and plastic and bottle cap. Observation in the emergency food and dry storage area on the ground floor adjacent the loading dock revealed multiple cardboard boxes of paper supplies, including three cases of paper cups, napkins, spoons, foam plates and Dinex lids all stored less than the required 18 from the ceiling. Observation in the Outer room for paper storage revealed several boxes sitting directly on the floor including paper cups, paper baking cups, and large cardboard storage boxes, and there were multiple boxes stored less than the required 18 from the ceiling including paper doilies, solo cups, several boxes of hinge food containers, aluminum pans, aluminum lids, plastic wine glasses, microwave containers and coffee cups. Observations in the kitchen revealed several missing base board wall tiles at the floor level near the walk-in coolers. Observation in the walk-in refrigerator revealed cut up chunks of honey dew melon spilled into the bottom of an enclosed metal tray rack which contained prepared desserts. Observation in the back hall way revealed a wire shelving rack containing 3-4 cardboard boxes of paper supplies on the top shelf were less than the required 18 from the ceiling. Observations on a follow-up visit to the dry storage room in the kitchen on 07/18/18 at 10:52 AM revealed two cardboard boxes of Frito Lay products and a box of Chex Mix were stored less than the required 18 from the ceiling. Observations on a follow-up visit to serving pantry on 07/19/18 at 11:40 AM revealed the temperature reading on the thermometer setting on the upper shelf read 30 degrees and the ice cream on this shelf was very soft, also this shelf had a dark brownish, rust colored appearance in contrast to the rest of the white interior surface. Interview with Employee E3 on (MONTH) 19, (YEAR) at 11:55 AM confirmed the above findings. The facility failed to store and prepare food in accordance with professional standards for food service safety. 28 PA Code: 201.14(a) Responsibility of licensee. Previously cited 03/08/18, 06/10/16 28 PA Code: 201.18(e)(1) Management. Previously cited 03/08/18 28 Pa. Code 201.18(b)(3) Management Previously cited 06/10/16

Based on review of clinical records, facility policies and procedures and facility documentation, and interviews with staff, it was determined that the facility failed to complete a thorough investigation for an incident of alleged neglect, for one of 16 residents reviewed (Resident R33). Findings include: Review of facility policy, Freedom from Abuse, Neglect and Exploitation, dated revised (MONTH) (YEAR), defined neglect as the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy further indicated that all allegations of neglect would be thoroughly investigated including interviewing any witnesses to the incident, the resident (if able), and any staff members having contact with the resident during the period of the alleged incident. Review of facility policy, Private Duty Personnel (PCP), dated revised (MONTH) (YEAR), revealed that residents may hire private duty personal to perform tasks for them and that facility employees are responsible for the primary care for all residents. The policy defined a Non-Home Care Agency Employee as an individual working independent of an agency, with the scope of practice including meal preparation, housekeeping, laundry, accompanying resident to recreational activities and medical appointments, engaging residents in social interests i.e. reading, playing cards, listening to music and active listening. The policy went on to clarify that only certified private duty personnel (certified nursing assistants, licensed practical nurses and registered nurses) are allowed to provide hands-on care. Review of the clinical record for Resident R33 revealed a significant change Minimum Data Set assessment (MDS-a periodic assessment of needs) dated (MONTH) 14, (YEAR), indicating the resident had [DIAGNOSES REDACTED]. The MDS indicated that Resident R33 had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 6, indicating the resident was severely cognitively impaired. The MDS additionally revealed that for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) Resident R33 required extensive, two plus person physical assistance with transfers. Review of a nursing progress note, dated (MONTH) 17, (YEAR), at 4:27 a.m., revealed Resident R33 had left sided weakness and that the resident had, 1 on 1 around clock (resident had a private companion providing one to one supervision at all times). Review of a nursing progress note dated (MONTH) 15, (YEAR), at 8:39 a.m., indicated that at approximately 6:55 a.m. that day, Resident R33 was found on the floor, after companion was heard calling for help, and that the resident was observed supine (lying on a person's back) between the bed and chair. Review of a nursing progress note, dated (MONTH) 15, (YEAR), at 10:57 a.m., revealed that during the time of discovery of Resident R33 being found on the floor, the resident was observed with feet and knees on the floor and head on bed against side rail, as reported by her companion who stated he (companion) heard her (resident) say ouch and observed this situation. He (companion) stated he called for help and rang bell and then repositioned resident into her w/c (wheelchair). He (companion) then placed resident on the floor for safety reasons and he left the room to get help. Floor and bed were soiled with BM (bowel movement-feces). Review of a nursing progress note dated (MONTH) 16, (YEAR), at 6:00 a.m., revealed that at the time of the resident's fall on (MONTH) 15, (YEAR), the resident's companion was present in room, who was witnessed sleeping prior to (the resident's) fall from bed. Review of facility documentation, dated (MONTH) 15, (YEAR), with incident time of 6:55 a.m., revealed that, Day shift aide saw companion sleeping approx. (sic) 5 minutes prior to the fall. The callbell was on and staff went into the room to find resident laying flat on her back on the floor between the chair and the bed. Resident was covered in feces which had leaked out of her brief onto the chair and carpet. Found resident companion hovering over her, noticed he had placed a pillow under her head. Companion stated he sets his alarm to wake up every 20 minutes to check on resident and that he found her with her head wedged between the mattress and siderail, and that her restless legs propelled her out of the bed and onto the floor. Per the companion, he then placed her (resident) onto the chair and put her back onto the floor and called for help. Further review of facility documentation revealed no witness statement from Resident R33's companion, a witness statement from the staff member who observed the companion sleeping, and no witness statements (other than the nursing progress notes) from any other staff who may have had contact or were on duty when the incident occurred on (MONTH) 15, (YEAR). Interview with the Director of Nursing on (MONTH) 20, (YEAR), at approximately 12:30 p.m., revealed that the private duty companion who was involved in the incident when Resident R33 was found on the floor on (MONTH) 15, (YEAR), was a family friend, was not employed by any professional home health or private duty companion agency, and there was no documented evidence that the companion had any professional credentials (ex. certified nursing assistant or licensed nurse) to provide any type of hands-on care to Resident R33, including assessing a resident after a fall and proper transfer of a resident. Further interview with the Director of Nursing confirmed that a private duty companion, hired by Resident R33's family, was witnessed asleep by facility staff prior to the resident's fall out of the bed; that the resident was, found wedged between the mattress and siderail by the companion; that the companion transferred the resident by himself from the bed to a chair, then from the chair to the floor; and that the resident was found incontinent of feces. The interview confirmed Resident R33 required two staff members to transfer her and that the companion performed two transfers on his own, after the resident experienced a fall, instead of obtaining facility staff to provide the care and services as per facility policy. Additionally, the interview confirmed that there was no documented evidence that the staff member who saw the companion sleeping on duty reported this to a nurse or any staff member in charge at that time, and confirmed that sleeping is not allowed by any staff or private duty staff in the facility. The interview confirmed that there was no documentation that witness statements were obtained from the staff member who saw the companion sleeping, or by any other staff members who were present during the incident (other than what was documented in the nursing progress notes). The interview also confirmed the facility did not identify or investigate this incident as possible resident neglect. The facility failed to complete a complete and thorough investigation for an incident of alleged neglect by a private duty companion related to a fall sustained by Resident R33. 42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation Previously cited 03/08/18, 06/10/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/08/18; 06/10/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 03/08/18, 06/10/16 28 Pa. Code 201.18(e)(1) Management Previously cited 03/08/18 28 Pa. Code 201.29(a)(c) Resident rights Previously cited 06/10/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/10/16 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services Previously cited 03/08/18, 06/10/16

Based on facility policy and clinical record review, observations and staff interviews, it was determined that the facility failed to maintain appropriate infection prevention and control practices during wound treatment for one resident (Resident R6). Findings include: Review of facility policy Dressings, Dry/ Clean, dated revised (MONTH) 2013, directed staff to wash and dry hands thoroughly; put on clean gloves; remove soiled dressing; pull glove over dressing and discard into biohazard bag; wash and dry hands thoroughly; put on clean gloves; assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stage; cleanse the wound with ordered cleanser; apply the ordered dressing; discard disposable items into the designated container; remove disposable gloves and discard into designated container; and wash and dry hands thoroughly. A physician order [REDACTED]. During wound treatment observation on (MONTH) 19, (YEAR), at 11:30 AM, Employee E4, Registered Nurse (RN), washed her hands, donned gloves, removed the old dressing from the sacral wound of Resident R6, and placed it in a red biohazard bag, discarded the gloves and washed her hands. Employee E4 donned new gloves, and cleansed the wound as ordered. Without changing the unclean gloves and washing hands, Employee E4, opened and applied the prescribed capsule powder into the sacral wound of Resident R6. Employee E4, without changing the unclean gloves and washing hands, then, placed the prescribed dressing to the wound opening and covered the wound with a foam dressing. During an interview on (MONTH) 19, (YEAR), at 11:42 AM, Employee E4 confirmed that she did not change the unclean gloves, did not wash her hands, and did not put on clean gloves before applying the prescribed medication, placing the prescribed dressing to the wound; and covering the wound opening with foam dressing . The facility failed to maintain infection prevention and control practices during wound treatment. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 03/08/18, 06/10/16

Based on clinical record review, review of facility documentation, and interviews with residents, family members, and staff, it was determined that the facility failed to ensure that two residents were free from neglect (Resident CL1 and Resident R2), resulting in actual harm to one of 4 residents reviewed (Resident CL1). Findings include: Review of the clinical record for Resident CL1 revealed a Minimum Data Set (MDS - assessment of need), dated (MONTH) 19, (YEAR), revealed that Resident CL1 had [DIAGNOSES REDACTED]. This MDS also indicated that the resident required extensive assistance of two staff persons for transfers. Review of information dated (MONTH) 5, (YEAR) submitted by the facility to the Department of Health, revealed that on (MONTH) 30, (YEAR), Resident CL1 slipped and was lowered to the floor during the process of being transferred. Review of a Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property, submitted to the Department of Health on (MONTH) 5, (YEAR), indicated that Employee E6, a nursing assistant, acknowledged that she attempted to transfer Resident CL1 by herself, without the assistance of an additional staff person, when the resident slipped onto the floor. Continued clinical record review revealed a progress note on (MONTH) 30, (YEAR), indicating that Resident CL1 had complained of pain 15 minutes after the fall. A nursing note on (MONTH) 2, (YEAR), at 11:00 a.m. indicated that Resident CL1 complained of left knee pain. The physician ordered an X-ray, the results of which were inconclusive. A nursing note on (MONTH) 3, (YEAR), indicated that a repeat X-ray was ordered. The results of this X-ray showed a [MEDICAL CONDITION] left femur (leg bone) and the resident was ordered to be transferred to the hospital for evaluation. A nursing note later this same day indicated that the resident returned from the hospital with an immobilizer placed on her left leg which she was to wear at all times, including when she was sleeping in bed. It was also recommended that the resident remain in bed for two weeks. Nursing notes indicated that the resident was administered medication for pain on (MONTH) 3, (YEAR), (MONTH) 4, (YEAR), (MONTH) 6 and (MONTH) 10, (YEAR). Review of the clinical record for Resident R2 revealed an MDS, dated (MONTH) 23, (YEAR), which indicated this resident had [DIAGNOSES REDACTED]. This MDS also indicated that the resident was cognitively impaired, that he was incontinent of bowel and bladder, and that he required extensive assistance with ambulation. In an interview with the resident and his wife, at approximately 2:45 p.m. on (MONTH) 28, (YEAR), the resident's wife stated that when the resident needed to use the bathroom or get into bed at night, she frequently transferred the resident by herself without staff assistance. She also stated that the staff were aware that she provided this assistance. In an interview at approximately 3:00 p.m. on this date with Employee E7, a licensed nurse, this nurse confirmed that she was aware that the resident's wife often assisted the resident with transfers without assistance. The facility had no documentation for review, including specific interventions on the care plan, to indicate that facility staff had taken steps to ensure that the resident was consistently transferred in a safe manner. The facility failed to ensure that two residents were free from neglect. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) Previously cited 07/07/17, 06/10/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/10/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 06/10/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 06/10/16

Based on observations, review of clinical records, facility policy and procedures and interviews with staff, and review of facility documentation, it was determined that the facility failed to provide adequate supervision and monitoring for two of 15 residents' records reviewed, to avoid a burn for one resident (Resident R6), and to provide a safe and properly supervised environment for one resident (Resident R12) who was identified as an elopement risk. Findings include: A review of Resident R6's clinical record revealed physician's orders dated July 2017, that revealed Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait (manner of walking), anxiety, and Non-Alzheimer's Dementia (progressive degeneration of the brain resulting in loss of reality contact and functioning ability). A review of Resident R6's quarterly Minimum Data Set assessment (MDS - a periodic assessment of needs) dated August 1, 2016, revealed that the resident's cognitive skills were severely impaired; her functional status related to eating indicated that the resident was of total dependence with a one person physical assist. A review of the Event Detail Report submitted by the facility to the PA Department of Health by way of the electronic Event Reporting System, revealed an incident related to a burn from soup that occurred on October 12, 2016 and submitted by the facility on October 21, 2016. It was revealed that Resident R6 grabbed a bowl of soup from server (dining aide) and spilled it on herself. Resident Incident Reporting form, dated October 12, 2016, revealed that after lunch, the Certified Nursing Assistant (CNA) undressed the resident for her nap and found a 13 cm by 4 cm (approximately 5 inches by 1 and 1/2 inches) redness to right inner thigh. It was noted to be superficial and the physician ordered to clean with saline solition and leave open to air. Resident R6's plan of care, dated September 2016, revealed that the resident was on a mechanically altered diet with thickened liquid and needed assistance at meals. Interview with Employee E3, on July 6, 2017, revealed that the Review of Temperature Log and Checklist used on October 12, 2016, revealed that the standard for soup was 160 degrees Fahrenheit. Documentation reveals that the beginning and ending holding temperature of the soup was 170 degrees Fahrenheit. The facility failed to provide adequate supervision and monitoring to a resident who was totally dependent for eating and failed to provide a safe temperature for soup resulting in a burn to a resident. Review of the facility policy Elopement/Wandering Resident, dated effective March 15, 2010, and last revised on July 27, 2016, stated as a policy statement, that the Facillity strives to provide a safe environment for all residents. Wandering was defined as to move about without a definite destination or purpose and/or exhibit exit seeking behaviors. Elopement was defined as when a resident who is cognitively, physically, mentally, and/or emotionally impaired departs from the Health Center unsupervised or unwitnessed without authorization when the departure presents a threat to the safety of the resident or others. The same policy stated that the facility staff would properly assess residents and plan their care in an effort to prevent events related to wandering behavior or elopement. Review of the clinical record for Resident R12 revealed that the resident was admitted to the facility on [DATE], and had diagnoses, including but not limited to dementia (progressive irreversible loss of memory cause by physical changes in the brain), depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite, and/or routine), and hypertension (elevated blood pressure). Review of the resident's comprehensive, annual Minimum Data Set (MDS - periodic assessment of resident care needs) dated August 28, 2016, revealed the resident was severely cognitively impaired. Review of the Wandering/Elopement Risk Assessment, dated August 25, 2016, and completed by a licensed registered nurse, at the time of resident's admission to the facility, noted that Resident R12 had wandering behavior which occurred for one to three days, and that the resident was at risk of getting to dangerous place. The same assessment noted that resident's wandering was worse. Also noted on the assessment of August 25, 2016 was that Resident R12 previously attempted to leave a residence or other place unescorted, and that resident was cognitively impaired and independently ambulatory. Review of the clinical notes, Subject - Exit seeking, wandering for Resident R12 on August 8, 2016, at 7:48 a.m. stated that the day shift CNA (Certified Nursing Assistant) reported that the night shift CNA had found the resident outside of the auditorium when leaving the building. The same note stated that the licensed registered nurse contacted the night shift CNA via phone and confirmed with that CNA that at approximately 6:45 - 6:55 a.m., the resident was seen outside the auditorium of the facility. According to the same clinical note the licensed nurse was finishing nightshift duties, when my attention was called by the dayshift nurse that a day shift CNA was bringing resident back around the CAFE, an unsecured dining area located outside the confines of the skilled unit and separated by double doors. The same clinical noted also noted that the Resident R12 stated that she was trying to leave. The clinical note added that earlier this evening the resident was seen walking down the hall and was easily redirected back to bed. It should be noted that the surveyor observed the location of the auditorium which was located off the main lobby, and it was found to be approximately 200 feet from the skilled unit, and in an unsecured area of the building, where independent residents can function independently. Also, it should be noted that the auditorium is located adjacent to the entrance of the building and across from the auditorium is an opened staircase leading to the lower level of the building. It should also be noted that Resident's room was located in the opposite direction, and the resident would have to ambulate through two additional hallways. Review of the reportable event submitted through the Event Reporting System (electronic system utilized by facilities to report incidents to the Pennsylvania Department of Health) revealed that Resident R12 was last seen by nurse at 6:15 a.m. while still in bed. The report also noted that a care conference was held on December 5, 2016 and resident's daughter requested that the wanderguard (monitoring device for safety) be discontinued, and the facility removed the device from the resident's left wrist. There was no evidence that a WanderingElopement Risk Assessment was completed at the time of the daughter's request, to assess the resident's risk or potential to wander and/elope from a safe area. There was no evidence that the facility conducted a thorough investigation, including statements from other staff members, to determine how the resident got to the main lobby and auditorium. During an interview with the Nursing Home Administrator on July 7,. 2017, at approximately 1:00 p.m., it was confirmed that the facility did not provide a safe environment and did not properly supervise one resident who had been identified as an elopement risk. The facility failed to provide adequate supervision and monitoring for two residents. 483.25(h) Accidents and Supervision Previously cited deficiency 6/10/16. 28 Pa. Code: 201.14(e)Responsibility of licensee

Based on observations, review of clinical records, faciltiy documentation, and facility policies and procedures and interviews with staff, it was determined that the facility staff failed to conduct a complete and thorough investigation for an injury of unknown origin, to rule out resident neglect and abuse for one of 15 resident records reviewed (Resident R38). Findings include: Review of the clinical record for Resident R38 revealed [DIAGNOSES REDACTED]. and dementia (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability) with behavioral disturbance (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite, and/or routine). Review of the 14-day Minimum Data Set assessment (MDS - assessment of care needs), dated April 6, 2016, indicated that there was no BIMS (brief interview for mental status) score for resident, and noted that resident is rarely/never understood. The Minimum Data Set also noted that Resident R38 was severely cognitively impaired. Review of the clinical notes for Resident R38 for June 1, 2016, at 1:09 p.m., noted that the nurse was called to the resident's room by the private duty companion for a concern of bruise to resident's right eye. The clinical notes also noted that according to private duty, resident had apparently been restless early this morning and was shifting around in bed frequently, as resident often pulls on side rail when restless. The clinical notes further stated that apparently resident bumped his face on the wall-side, side rail. Clinical notes of June 1, 2016, at 11:03 p.m., and June 2, 2016, at 4:28 p.m. stated that bruise to Resident R38's right eye was dark purple. The facility's policy Incident - Accident Reports (and Follow - Up), dated last revised May, 2015, stated that it is the policy to complete a report on all incidents/accidents. The policy also stated that the incident/accident may include Injuries of unknown origin. The policy also stated that the licensed nurse will obtain statements from the resident and any witnesses to the event, and do an investigation to include the current shift and two prior shifts for any incident of unknown origin. The facility's policy Abuse, last revised February, 2014, stated that upon receiving an incident or suspected incident of injury of an unknown source, the Administrator/designee will conduct an investigation .Witness reports shall be in writing. Witnesses will be required to sign and date such reports. The policy defined injuries of unknown source as: when both, the source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. There was no evidence that the facility conducted a comprehensive investigation into the cause of Resident R38's bruise. The facility failed to complete a thorough investigation, including interviews and statements from staff and resident, to rule out abuse or neglect, and to properly protect residents. The Nursing Home Administrator and Director of Nursing confirmed, during an interview on June 10, 2016, at approximately 1:00 p.m., written statements were not obtained from staff regarding the bruise, and the cause of the bruise was not completely investigated. 28 Pa. Code: 201.14(e) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.

Based on interviews with residents in a group setting, individual resident interviews, interview with a family member, interviews with staff, and review of clinical records and facility documentation, it was determined that the facility failed to insure that residents who wanted to go outside in good weather were able to do so (Residents R22, R30, and R42). Findings include: During a group interview, conducted at 10:00 a.m. on June 9, 2016, all three of the residents in attendance indicated that they would like to go outside in good weather to enjoy the fresh air. Two of these residents, R30 and R42, indicated that they have not been outside during periods of time when they would have liked to do so. Review of the clinical record for Resident R22 revealed a Minimum Data Set (MDS - assessment of need), dated December 23, 2015, that indicated that this resident was cognitively intact and that going outside in good weather was important to him/her. In an interview with Resident R22, at 10 a.m. on June 10, 2016, this resident stated that s/he used to go outside weekly when taken out by a friend. Resident R22 further indicated that, because this friend was no longer available, s/he had not been taken outside to enjoy fresh air in good weather since some time last year. Review of the activity participation log for the months of April, May, and June 2016 revealed that there was no indication that the resident had been outside for the purpose of enjoying fresh air during this entire time period. Review of the clinical record for Resident R42 revealed an MDS, dated [DATE], that indicated that this resident was cognitively intact and that is was very important for him/her to go outside to enjoy fresh air in good weather. During the group interview with residents, Resident R42, stated that S/he must rely on his/her spouse to take him/her outside for this purpose. Resident R42 further stated that his/her spouse was not always available to do so; in addition, the resident's spouse found it difficult to take the resident outside because of a bad back. In an interview with Resident R42 and his/her spouse, at approximately 11:00 a.m. on June 10, 2016, the latter indicated that s/he had a bad back which made it difficult to take the resident outside. Both Resident R22 and his/her spouse indicated that, following the spouse's medical procedure, Resident R42 had not been taken out to enjoy fresh air during the spouse's period of recovery. Review of the clinical record for Resident R30 revealed an MDS, dated [DATE], that indicated that going outside for fresh air in good weather held importance for this resident. During the group interview, this resident indicated that, while s/he would have liked to do so, s/he had not been outside for over a month to enjoy fresh air in good weather. Review of the activity participation log for Resident R30, reflecting activities this resident participated in during the months of April, May, and June 2016, revealed that this resident had not been taken outside to enjoy fresh air at any time during these months. In an interview with facility staff, at approximately 2:00 p.m. on June 9, 2016, the Director of Nursing stated that the activity department is responsible for keeping track of when residents go outside for fresh air. In interviews on June 10, 2016, with three nursing assistants, Employees E8, E9, and E10, it was confirmed that they do not take residents outside for the purpose of enjoying fresh air. In an interview with Employee E7, at approximately 10:00 a.m. on June 10, 2016, it was confirmed that, while residents who require no assistance may do so on their own, the activities department does not take residents outside for the primary purpose of enjoying fresh air and does not keep track of whether residents who wish to do so are taken outside for this purpose. It was further confirmed that Employee E7 was not aware of whether Residents R22, R30, and R42 had the opportunity to go outside for this purpose. In an interview with the Administrator at approximately 1:00 p.m. on June 10, 2016, it was confirmed that the facility had not ensured that residents who wished to go outside for fresh air in good weather were afforded that opportunity as part of their activities program. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(j) Resident rights.28 Pa. Code 211.10(d) Resident care policies.