Every finding on record at Meadows Nursing and Rehabilitation Center

Based on a review of controlled medication shift count records, select facility policy, and staff interviews, it was determined the facility failed to consistently implement procedures to maintain accurate controlled medication accountability records on three of three medication carts reviewed (Clover Unit, Bluebell Unit, and Dogwood Unit).Findings include: A review of facility policy entitled Controlled Medication-Receipt, Count, and Secure Storage, last reviewed March 1, 2026, revealed that a controlled drug count for controlled drugs (medications regulated by federal law due to their potential for abuse, misuse, dependence, or diversion which is the unauthorized transfer, use, or theft of a medication Accurate shift-to-shift controlled medication counts and documentation help ensure accountability for controlled substances and promote timely identification of discrepancies) will be made at the beginning of each shift by the nurse responsible for controlled drugs on the outgoing shift with the nurse who will be responsible for controlled drugs on the oncoming shift. Paperwork for shift-to-shift narcotic counts is to be complete with legible dates and initials of staff involved in the count. A review of the facility's Shift Narcotic Count Signature Sheet for the Clover Unit medication cart revealed incomplete controlled medication count documentation on the following dates: May 20, 2026: The evening shift incoming nurse failed to sign that the controlled medication count was completed and accurate. May 20, 2026: The evening shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. May 28, 2026: The day shift incoming nurse failed to sign that the controlled medication count was completed and accurate. During an interview on May 28, 2026, at 8:00 AM Employee 6, Licensed Practical Nurse (LPN), confirmed that the required signatures were missing from the Clover Unit controlled medication count record on the dates identified above. A review of the facility's Shift Narcotic Count Signature Sheet for the Bluebell Unit medication cart revealed incomplete controlled medication count documentation on the following dates: May 23, 2026: The night shift incoming nurse failed to sign that the controlled medication count was completed and accurate. May 24, 2026: The day shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. May 28, 2026: The day shift incoming nurse failed to sign that the controlled medication count was completed and accurate. A review of the facility's Shift Narcotic Count Signature Sheet for the Dogwood Unit medication cart revealed incomplete controlled medication count documentation on the following dates: March 6, 2026: The night shift incoming nurse failed to sign that the controlled medication count was completed and accurate. March 7, 2026: The day shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. March 10, 2026: The night shift incoming nurse failed to sign that the controlled medication count was completed and accurate. March 11, 2026: The night shift incoming nurse failed to sign that the controlled medication count was completed and accurate. April 7, 2026: The evening shift incoming nurse failed to sign that the controlled medication count was completed and accurate. April 7, 2026: The night shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. April 7, 2026: The night shift incoming nurse failed to sign that the controlled medication count was completed and accurate. April 8, 2026: The day shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. April 18, 2026: The day shift incoming nurse failed to sign that the controlled medication count was completed and accurate. April 18, 2026: The evening shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. April 26, 2026: The night shift incoming nurse failed to sign that the controlled medication count was completed and accurate. April 27, 2026: The day shift outgoing nurse failed to sign that the controlled medication count was completed and accurate. May 28, 2026: The day shift incoming nurse failed to sign that the controlled medication count was completed and accurate. An interview with Employee 7 Licensed Practical Nurse (LPN) on May 28, 2026, at 8:05 AM confirmed that the required signatures were missing from the Bluebell Unit and Dogwood Unit controlled medication count records on the dates identified above. In an interview on May 28, 2026, at 10:30 AM, the Director of Nursing confirmed the facility failed to consistently implement its policy requiring outgoing and incoming nursing staff to complete and sign shift-to-shift controlled medication count records. The facility failed to consistently maintain complete and accurate controlled medication count records on all three medication carts reviewed, which did not demonstrate consistent implementation of procedures designed to ensure accountability for controlled substances and was not consistent with facility policy. 28 Pa Code 211.9 (k) Pharmacy services. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observations, a review of clinical records, and staff interviews, it was determined that the facility failed to consistently implement preventive interventions to avoid the development of pressure injuries for two of 24 residents reviewed (Residents 18 and 126).Findings include: A clinical record review revealed Resident 18 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of the comprehensive individual care plan revealed Resident 18 had potential for pressure related skin failure related to impaired mobility initiated on October 15, 2024. Interventions implemented to ensure Resident 18 will have intact skin integrity include elevating bilateral lower extremities to keep the resident's heels off the bed or chair surface with pillows. A physician's order for Resident 18 to be out of bed to Broda chair (a specialized medical wheelchair and recliner used for individuals with severe mobility issues who spend most of the day seated, prioritizing advanced posture support, pressure relief, and fall prevention) with calf bumpers (a soft padded or plastic device that covers prominences on a wheel chair to prevent injury) at all times initiated on July 30, 2025. A review of Resident 18's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 1, 2026,, revealed that Resident 18 BIMS evaluation (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact) was not completed because the resident was rarely or never understood. A review of section C1000 Cognitive Skills for Daily Decision Making revealed Resident 18 was severely impaired regarding making decisions for daily life. During an observation on May 27, 2026, at 11:05 AM Resident 18 was observed sitting outside the Unit 3 nursing station in a Broda chair. The chair's leg rest brackets were exposed and no calf bumpers were applied to the chair as indicated in the physician's orders. There were no observable injuries on Resident 18's bilateral lower extremities at the time of the observation. During an interview on May 27, 2026, at 11:07 AM Employee 1, Registered Nurse (RN), confirmed that Resident 18's physician's orders for calf bumpers were not applied to the resident's chair. A clinical record review revealed Resident 126 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and moderate protein-calorie malnutrition (a state resulting from lack of intake or uptake of nutrition that leads to altered body composition). A review of the baseline care plan revealed Resident 126 had potential for pressure related skin failure related to impaired mobility initiated on May 23, 2026. Interventions implemented to ensure Resident 126's will have intact skin integrity included elevating bilateral lower extremities to keep the resident's heels off the bed or chair surfaces. A review of Resident 126's admission MDS assessment dated [DATE], revealed that Resident 126 was severely cognitively impaired with a BIMS score of 7 (a score of 00 through 07 indicates cognition is severely impaired). A physician's order for Resident 126 to be out of bed in a Broda chair with a padded foot buddy board (a single, flat, solid surface that attaches to the front of the wheelchair to support both the user's legs and feet at the same time) and calf bumpers at all times was initiated on May 26, 2026. During an observation on May 27, 2026, at 11:15 AM Resident 126 was observed in the Unit 3 dining room in a Broda chair. The chair's leg rest brackets were exposed, and no calf bumpers were applied to the chair as indicated in physician's orders. Also, the foot buddy/board utilized to elevate the resident's bilateral legs were not applied to the wheelchair. There were no observable injuries on Resident 126's bilateral lower extremities at the time of the observation. During an interview on May 27, 2026, at 11:28 AM Employee 2, nurse aide (NA), confirmed that Resident 126's physician's orders for calf bumpers and a foot buddy board were not applied to the resident's chair. During an interview on May 29, 2026, at 10:00 AM the above information was reviewed with the Nursing Home Administrator (NHA). The facility failed to consistently implement preventive interventions ordered by the physician to avoid the development of pressure injuries for Residents 18 and 126.28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, documentation provided by the facility, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure adequate supervision and timely staff assistance for a resident identified as a high risk for falls to prevent a fall (Resident 63) and failed to ensure planned safety interventions were consistently implemented for a resident (Resident 108) for two out of 24 residents reviewed. Findings include: Review of the facility's Fall Management Policy and Procedure last reviewed March 1, 2026, indicated that it is the policy of the facility to ensure the resident's environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevents accidents. A Fall Risk Evaluation will be completed on admission and readmission (to be completed by the admitting nurse), quarterly, with significant change, and annually by the RNAC (registered nurse assessment coordinator), as well as after each fall by the nurse on duty. Resident and, or family education regarding falls and person-centered fall prevention strategies will be provided on admission and as needed. A review of the clinical record revealed that Resident 63 was admitted to the facility on [DATE], with diagnoses that included acute on chronic congestive heart failure (CHF, sudden, severe, worsening of symptoms of compromised heart function such as acute fluid buildup or severe shortness of breath), chronic obstructive pulmonary disease (COPD, lung condition which restricts airflow and makes breathing difficult), benign paroxysmal vertigo (common inner ear issue that causes sudden, brief feelings of spinning triggered by changes in head position, vertigo spells typically last less than one minute and come on suddenly), and atrial fibrillation (irregular heartbeat). A review of Resident 63's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 1, 2026, revealed that Resident 63 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact), required partial to moderate assistance (helper does less than half the effort) for toileting hygiene, required supervision or touching assistance to get on and off the toilet or commode, and had no falls in the last six months. The resident's Fall Risk Evaluation dated April 25, 2026, indicated the resident scored a 20 (a score of 10 or greater indicates a high risk for falls). A review of Resident 63's current comprehensive care plan initially dated April 25, 2026, indicated the resident had a self care performance deficit due to impaired balance and heart failure. Interventions to improve the resident's current level of function included to ambulate with the assistance of one staff with rolling walker (mobility aid with wheels) and gait belt (strap made of canvas placed around the resident's waste to assist staff to help steady, support, or safely transfer residents who have balance or mobility issues) to and from the bathroom. A review of a health status note for Resident 63 dated May 20, 2026, at 3:34 PM documented increased shortness of breath and +3 edema (severe pitting edema, which indicates a significant accumulation of excess fluid within body tissues) to both lower extremities. The note documented physician notification and new orders to increase Lasix (a medication used to remove excess fluid from the body) to 40 milligrams by mouth twice daily, administer oxygen at 2 liters per minute as needed, and obtain a Basic Metabolic Panel (BMP, a blood test used to evaluate general health, kidney function, fluid balance, and metabolism) within one week. A review of nursing documentation dated May 20, 2026, at 10:45 PM revealed staff found the resident lying face down on the floor, partially inside the bathroom doorway. The documentation indicated a Licensed Practical Nurse (LPN) was applying pressure to the resident's head due to significant bleeding. The note described an approximately 12 cm (centimeter) by 12 cm deep laceration (a tear or cut in the skin) with a skin flap located on the top of the head extending toward the forehead. Nursing staff documented repositioning the skin flap, approximating the wound edges, applying Steri-Strips (thin sterile adhesive strips used to assist with wound closure), covering the area with gauze dressings, and maintaining manual pressure and ice application until Emergency Medical Services (EMS) arrived. The note further documented that blood observed on the inside of the bathroom door suggested the resident fell forward and struck her head on the door. Nursing staff notified the physician, obtained an order for emergency room transfer, and notified the resident representative. A review of hospital emergency department records dated May 21, 2026, revealed the resident reported experiencing dizziness described as vertigo (a sensation of spinning or loss of balance), tripping over her own foot, and falling forward with a head strike. Hospital documentation indicated the resident sustained a head laceration requiring ten staples for closure. The emergency department also diagnosed the resident with acute respiratory failure with hypoxia (a sudden condition in which the lungs cannot adequately deliver oxygen into the bloodstream), resulting in hospital admission. A review of facility investigative documentation related to the fall revealed the resident reportedly stated at the time of the incident on May 20, 2026, that she knew she was not supposed to get up by herself. A written witness statement completed by Employee 12, Nurse Aide, documented that the aide assisted the resident to the bathroom, provided privacy, instructed the resident to use the call bell when finished, and reported to nursing staff prior to the fall that the resident was not herself. Additional facility documentation indicated the resident had been placed on the toilet approximately five minutes before the fall occurred. Although the call bell was documented as being within reach, records indicated it was not activated at the time staff discovered the resident on the floor. During an interview conducted on May 28, 2026, at 1:40 PM, in the presence of Employee 11, Registered Nurse Supervisor (RNS), Resident 63 stated that she rang the call bell before the fall, but no one responded. The resident stated she believed she had waited long enough, attempted to transfer herself from the toilet, began losing her balance due to vertigo, fell, and then yelled for assistance. The resident stated that some staff members remained with her during toileting while others did not. The resident indicated she did not object to staff remaining with her in the bathroom and stated that she knows staff are busy but at times she waits too long for the call bell to be answered. During an interview on May 29, 2026, at 10:00 AM, the Director of Nursing confirmed the facility failed to provide the supervision necessary to ensure Resident 63's safety and prevent the avoidable fall. Review of the facility's policy entitled, Elopement/Wandering Protocol, last reviewed March 1, 2026, revealed the facility required application of a Wander guard device (an electronic monitoring device used to alert staff when a resident at risk for wandering or elopement approaches an exit) for residents identified as attempting to wander or elope, quarterly reevaluation of the intervention, and maintenance of a resident photograph at the receptionist area for identification purposes. A review of Resident 108's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis that included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of Resident 108's quarterly MDS dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 03 (a score of 0 through 7 indicates severe cognitive impairment). A review of an elopement risk assessment completed on September 7, 2025, identified Resident 108 as being at high risk for elopement. Documentation indicated the resident had a history of wandering in the community prior to facility admission and had required relocation on two occasions before placement in the nursing facility. A physician order dated September 7, 2025, directed staff to maintain a Wander guard bracelet on the resident's right lower extremity and wheelchair and required staff to verify placement and proper functioning every shift. Clinical record review for Resident 108 revealed continued evidence of wandering behavior. A nursing progress note dated October 22, 2025, documented the resident wandering through facility hallways and entering and exiting other residents' rooms. A nursing progress note dated January 22, 2026, documented that the resident wandered during nighttime hours. A review of the May 2026 Task Administration Record (TAR) revealed staff documented on May 28, 2026, at 7:00 AM that Resident 108 was wearing a Wander guard device on the right lower extremity. However, direct observation conducted on May 28, 2026, at 1:45 PM revealed no Wander guard device present on the resident's right leg or any other extremity. The resident did not have a personal wheelchair present in the room. Employee 7, Licensed Practical Nurse (LPN), confirmed the absence of the device during the observation and was unable to locate the Wander guard within the resident's room. Employee 7 stated that Wander guard devices are not easily removed. A review of the receptionist's Wander guard monitoring log conducted on May 29, 2026, at 1:25 PM revealed Resident 108 remained listed as requiring Wander guard monitoring; however, no resident photograph was maintained as required by facility policy. During an interview on May 29, 2026, at 1:30 PM, the Director of Nursing reviewed the above findings and confirmed the facility failed to consistently implement and monitor the resident's planned elopement prevention interventions, including maintenance of the Wander guard device and required identification photograph. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d) (1) (3) (5) Nursing services.

Based on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per a physician's orders for one resident out of 24 residents reviewed (Resident 123).Findings include: A review of the facility's policy titled Oxygen Administration, last reviewed on March 1, 2026, revealed the purpose of the policy was to provide guidelines for safe oxygen administration. The policy directed staff to check the oxygen delivery system, including the mask, oxygen tank, and humidifier bottle (also known as humidifier reservoir, the container that holds sterile or distilled water through which oxygen passes to add moisture before being delivered to the resident) to ensure they were in good working order and securely fastened. The policy required staff to verify there was an adequate water level in the humidifier bottle so that the water bubbled as oxygen flowed through and to periodically re-check the water level to ensure proper humidification. A clinical record review revealed that Resident 123 was admitted to the facility on [DATE], with a diagnosis to include respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a condition where there is inadequate supply of oxygen to the body's tissues). A review of Resident 123's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 26, 2026, revealed the resident had moderately impaired cognition with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of physician's orders dated May 21, 2026, directed that Resident 123 receive oxygen with humidified water at 5.0 liters per minute (L/min) by nasal cannula (a flexible medical tube with two prongs that fit into the nostrils, used to deliver supplemental oxygen), to check oxygen humidification every shift and refill as needed, and directed nightshift staff to fill the humidifier bottle daily. A review of Resident 123's Treatment Administration Record (TAR) for May 2026 revealed that on May 26, 2026, at 11:00 PM, it was signed off that the humidifier bottle was filled, and on May 27, 2026, at 7:00 AM, it was signed off that the water humification level was checked. An observation on May 27, 2026, at 11:15 AM revealed the resident was in bed receiving oxygen at 5.0 liters per minute (L/min) via nasal cannula, with no water in the humidifier bottle attached to the oxygen flowmeter. The humidification bottle was dated May 24, 2026. This observation was confirmed, and humidification water was replaced by Employee 8, a Licensed Practical Nurse, on May 27, 2026, at 11:30 AM. A follow-up observation on May 29, 2026, at 8:00 AM revealed the resident was in bed receiving oxygen at 5.0 liters per minute (L/min) via nasal cannula, with a quarter of the bottle filled with water that was attached to the oxygen flowmeter. The humidification bottle was dated May 27, 2026. During an interview with the Director of Nursing on May 29, at 8:30 AM, the above findings were reviewed and confirmed it is the facility's responsibility to ensure oxygen therapy is administered in accordance with the physician's order. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, and resident and staff interviews, it was determined that the facility failed to comprehensively evaluate, monitor, communicate, and implement appropriate interventions for new onset and worsening pain in accordance with physician orders and facility policy for one of 24 residents reviewed (Resident 41).Findings include: Review of the facility's Pain Assessment and Management policy, last reviewed March 1, 2026, revealed that the purpose of the policy was to help staff identify resident pain and to help develop interventions that are consistent with resident goals. The policy indicated the facility was to conduct a comprehensive pain assessment upon admission to the facility and whenever a resident experienced new pain or worsening pain. Clinical record review revealed that Resident 41 was admitted to the facility on [DATE], with a diagnosis of diabetes (medical condition in which the body is unable to properly regulate blood sugar levels) and fractures of the mid-back area. A review of Resident 41's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2026, revealed that Resident 41 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). The MDS also indicated that over the past 5 days, the resident experienced a moderate degree of pain (pain levels between 4 and 6). A numerical pain scale ranging from 0 to 10 is commonly used to assess pain intensity, with 0 representing no pain, 1 through 3 representing mild pain, 4 through 6 representing moderate pain, and 7 through 10 representing severe pain. Review of the resident's admission pain evaluation revealed documentation indicating the resident was able to respond appropriately and reported no pain during the five-day period prior to admission. Review of physician orders initiated upon admission on [DATE], revealed an order for acetaminophen (a non-opioid pain-relieving medication) to be administered for resident-reported pain levels of 1 through 3, consistent with mild pain. Review of the May 2026 Medication Administration Record (MAR) revealed documented pain assessments on May 14, May 21, May 22, and May 28, 2026, indicating the resident experienced pain that had not been identified on admission. Despite evidence of new onset pain, there was no documented evidence the facility completed a comprehensive pain re-evaluation as required by facility policy. Clinical record review revealed the resident reported a pain level of 4 on May 21 and May 22, 2026, indicating moderate pain that exceeded the parameters of the existing physician order, which only addressed mild pain levels of 1 through 3. There was no documented evidence that the physician was notified of the resident's increased pain level, no evidence the resident's pain management regimen was re-evaluated, and no evidence new or revised physician orders were obtained to address the resident's moderate pain. During an interview conducted on May 28, 2026, at 1:00 PM, and again on May 29, 2026, at 8:45 AM, Resident 41 reported experiencing pain in the neck and mid-back region and rated the pain as an 8 on a 0-to-10 pain scale, indicating severe pain. The resident stated staff occasionally administered something for pain, but it is not effective. Review of Resident 41's comprehensive care plan failed to identify the resident's pain, the location of the pain, or interventions utilized to monitor or alleviate the pain. Documentation reflected pain-related information was not added to the care plan until after surveyor inquiry. It was not until after surveyor notification on May 29, 2026, at approximately 9:15 AM that the facility re-evaluated the resident's pain and obtained additional physician orders, including a stronger pain medication, to address pain levels greater than 3. During an interview on May 29, 2026, at 9:30 AM, the Director of Nursing was unable to provide evidence that the facility had timely re-evaluated the resident's new onset pain in accordance with facility policy, notified the physician of pain levels exceeding the resident's current treatment parameters, or obtained timely physician intervention to address the resident's ongoing pain complaints. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, review of select facility policy, documentation provided by the facility, and staff interview, it was determined the facility failed to ensure that food was served in a form to meet the individual needs of one of 24 residents reviewed. (Resident 94) Findings include: Review of the facility's Thickened Liquids and Pureed Food Policy last reviewed March 1, 2026, indicated that the diet order must include the dysphagia (difficulty swallowing) level of solid foods and the liquid consistency. Never serve regular texture food to a resident ordered a pureed diet. When in doubt about a diet order, verify before serving. The Key Safety Rule is to always serve the correct texture and observe the resident while eating to reduce the risk of choking and aspiration (accidentally breathing food or liquid into the airway or lungs instead of swallowing them). A review of the clinical record revealed that Resident 94 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF-the heart muscle becomes too weak or stiff to pump blood efficiently) and oropharyngeal dysphagia (swallowing problems occurring in the mouth and, or throat). A physician order initially dated March 24, 2026, documented an order for a puree diet (foods that are blended, whipped, or mashed into a smooth, lump-free, and uniform texture that reduces the risk of choking and aspiration) no added salt regular thin liquid consistency diet. A review of Resident 94's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 3, 2026, revealed that Resident 94 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderately cognitively impaired) and required setup or clean-up assistance for meals (the helper sets up or cleans up and the resident completes the activity with the helper assisting only prior to or following the activity). A health status note dated May 14, 2026, documented that the resident was sitting at the nurses station eating a peanut butter and jelly sandwich. The resident started coughing and Employee 9 Licensed Practical Nurse (LPN) and Employee 10 Registered Nurse (RN) assessed the resident. The resident had a piece of sandwich in her throat. Employee 9 LPN stood up the resident while Employee 10 RN did Heimlich maneuver (first aid technique for someone who is choking because food or another swallowed object is obstructing his or her airway. Using an upward abdominal thrust, the Heimlich maneuver compresses the lungs and forces air up into the windpipe until the object causing the choking is ejected from the throat). The sandwich piece popped out. The physician and resident representative were notified. An incident note dated May 14, 2026, noted that the resident was able to breathe and talk without difficulty following the incident. Lung sounds were clear and vital signs (measurements of the body's most basic functions and include body temperature, pulse rate, rate of breathing, and blood pressure) were stable. Staff were to continue to monitor the resident's breathing and lung sounds. Review of documentation provided by the facility dated May 14, 2026, at 12:30 AM revealed that Resident 94 was provided with a peanut butter and jelly sandwich as a snack by Employee 9 LPN) which was not a pureed food item as required based on the resident's prescribed physician diet order. Employee 9 LPN failed to check the resident's diet order prior to providing the sandwich. Staff education was initiated following the incident related to checking for the appropriate diet consistency before providing food, snacks, or drinks at any time to residents. Employee 9 LPN who provided the sandwich was disciplined and reeducated. The physician was notified and a chest xray was ordered. The physician also ordered to monitor the resident's temperature and lung sounds every shift for 72 hours. The facility will provide the resident a puree peanut butter and jelly sandwich for the resident nightly. Interview with the Nursing Home Administrator (NHA) on May 28, 2026, at 1:00 PM confirmed the facility failed to follow Resident 94's physician ordered diet to ensure an appropriate snack in the correct form was provided to the resident. The NHA confirmed the facility failed to provide a peanut butter and jelly sandwich in a form to meet Resident 94's needs for safe swallowing to prevent a choking episode. 28 Pa. Code 201.18 (b) (1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d) (3) (5) Nursing services.

Based on a review of clinical records, facility policy, documentation provided by the facility, and staff interviews, it was determined the facility failed to implement abuse prevention and investigation procedures for one of 24 residents reviewed (Resident 74) following an allegation of resident-to-resident sexual abuse involving Resident 12.Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property, last reviewed by the facility on March 1, 2026, revealed it is the facility policy to implement residents' rights to the fullest intent of the law. To protect the resident and determine the direction of the investigation, the policy requires facility staff to: Immediately separate residents and assess for possible injury.Immediately initiate an investigation and remove the alleged perpetrator.Arrange for medical attention, including a forensic rape exam for suspected sexual abuse.Obtain written statements from appropriate individuals on duty at the time of the incident.Notify the administrator, physician, resident representative, and law enforcement.Report the incident to the Pennsylvania Department of Health and local Area on Aging within 24 hours. A clinical record review revealed Resident 12 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 12's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2026, revealed that Resident 12 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08 through 12 indicates cognition is moderately impaired). A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses including dementia.A review of Resident 74's quarterly MDS assessment dated [DATE], revealed that Resident 74 was severely cognitively impaired with a BIMS score of 03 (a score of 00 through 07 indicates cognition is severely impaired). A review of facility-provided documentation, witness statements, and staff interviews revealed that on May 3, 2026, Employees 3 and 4, Nurse Aides (NAs), reported observing Resident 12 with his hands inside Resident 74's brief in the area of Resident 74's genitals, resulting in an allegation of resident-to-resident sexual abuse. During an interview on May 27, 2026, at 1:20 PM, Employee 4, NA, indicated he was not asked to provide a written statement regarding his observations on May 3, 2026. Employee 4 stated that he was asked to provide information regarding the event on the following workday. During a telephone interview on May 27, 2026, at 2:20 PM, Employee 3, NA, indicated she was not asked to provide a statement on May 3, 2026, regarding her observations of the incident involving Residents 12 and 74. Employee 3 stated that administration contacted her on a later date to obtain information regarding the event. During a telephone interview on May 27, 2026, at 2:48 PM, Employee 5, Registered Nurse Supervisor (RNS), indicated that she did not interview or debrief Employee 3 or Employee 4 regarding their observations of the incident. Employee 5 stated that administration requested a statement from her several days after the event occurred. A clinical record review revealed no documented evidence in either Resident 12's or Resident 74's clinical record that nursing staff completed resident-specific observations, evaluations, assessments, or investigative documentation at the time of the May 3, 2026, incident. Additional review revealed no documented evidence that physicians or resident representatives were notified of the allegation. The clinical records also lacked documented evidence that additional interventions were implemented following the allegation to address Resident 12's behavior or to protect Resident 74 and other residents from further unwanted contact. During an interview on May 29, 2026, at 10:00 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence that the facility fully implemented its abuse investigation and prevention procedures following the May 3, 2026, allegation. Specifically, the facility was unable to provide documented evidence that it immediately initiated and completed a thorough investigation, obtained detailed witness statements at the time of the incident, completed resident evaluations or assessments related to the allegation, notified all required individuals and agencies in accordance with facility policy, or implemented timely interventions to address Resident 12's behavior and ensure ongoing resident safety. The facility was further unable to provide documented evidence that additional protective interventions were implemented following the allegation until Resident 12 was transferred to another nursing unit approximately 16 days later. Refer F60028 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, documentation provided by the facility, and staff and resident interviews, it was determined the facility failed to protect one of 24 sampled residents (Resident 74) from sexual abuse perpetrated by another resident (Resident 12).Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect, or the Misappropriation of Resident Property, last reviewed by the facility on March 1, 2026, revealed it is the facility policy to provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and promote or maintain the resident's highest level of well-being. This includes the protection of residents' rights. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The facility defined sexual abuse as non-consensual sexual contact of any type with a resident, which includes but is not limited to sexual harassment, sexual coercion, or sexual assault. A clinical record review revealed Resident 12 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A comprehensive individualized resident care plan revealed Resident 12 had a behavior problem related to rejection of care with a history of unable or unwilling to care for himself at home, defecating and/or urinating without willingness to clean, watching pornography at a loud volume, on laptop, and inappropriate sexual statements towards staff and other residents initiated on November 7, 2024. Interventions developed to ensure Resident 12 will exhibit appropriate interactions included intervening as necessary to protect the rights and safety of others, redirecting the resident, and removing the resident from situations when necessary. A review of the comprehensive resident-centered care plan revealed Resident 12 had a mood problem initiated on November 7, 2024. Target behaviors identified in Resident 12's care plan include the resident entering other residents' rooms and making inappropriate statements and gestures to male aides. Interventions developed to ensure Resident 12's mood state will not interfere with his daily routine included providing 1:1 (one staff to one resident) support as needed. A review of Resident 12's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2026, revealed that Resident 12 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08 through 12 indicates cognition is moderately impaired). A review of facility documentation revealed prior incidents involving sexually inappropriate behavior. A nursing progress note dated July 18, 2025, at 5:09 PM, documented Resident 12 made a vulgar sexual comment to a nurse aide stating he would like to perform oral sex on the nurse aide if he wanted. Staff counseled the resident regarding the inappropriate behavior and notified the physician and Director of Nursing. A psychosocial progress note dated July 23, 2025, at 6:44 PM documented staff addressed inappropriate conversations involving sexual acts. Resident 12 denied same and stated I just told that guy he was cute. Resident 12 was reminded that staff are available to provide care and support but conversation regarding sexual acts are inappropriate and such conversations were inappropriate in the facility setting. A nursing progress note dated December 1, 2025, at 7:04 PM documented concerns involving Resident 12 invading another resident's personal space. Resident 12 and his roommate (at the time) had a disagreement again over room temperature, lights, TV volume, and space. Resident 12's roommate had complaints about Resident 12 invading his personal space, and again staff requested Resident 12 to not assist or attempt to assist other residents unless it is by activating the call bell for them or going to the hall to get help. A clinical record review revealed no other documentation or behavioral interventions in the electronic clinical record regarding Resident 12's behavior of invading the personal space of others or attempting to provide care for others following the incident with his roommate on December 1, 2025. The facility was unable to provide any additional information regarding this incident. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that include dementia. A review of Resident 74's quarterly MDS assessment dated [DATE], revealed that Resident 74 was severely cognitively impaired with a BIMS score of 03 (a score of 00 through 07 indicates cognition is severely impaired). A review of Resident 74's quarterly MDS assessment Section GG Functional Abilities dated March 18, 2026, revealed that Resident 74 is dependent on staff for lower body dressing (the ability to dress and undress below the waist) and toileting hygiene (the ability to maintain perineal hygiene and adjust clothes before and after voiding). Dependent means the helper does all of the effort and the resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the task. A review of witness statements provided by the facility revealed that on May 3, 2026, Employee 3, Nurse Aide (NA), entered Resident 74's room to provide care and observed Resident 12 with his hands in Resident 74's groin area. Employee 3 documented that Resident 74's pants were partially removed, his brief was open, and his penis was exposed. Employee 3 documented that Resident 12 was attempting to remove Resident 74's brief and stated he was trying to help change the resident. Employee 3 removed Resident 12 from the situation and notified the Registered Nurse Supervisor (RNS). A witness statement completed by Employee 4, NA, documented that upon entering the room, Resident 74 was partially undressed with his pants down with one leg out of his pants and his brief shredded on the floor. Employee 4 documented that Resident 12 was seated beside Resident 74 with his hand on Resident 74's upper thigh. Employee 4 further documented that Resident 12 refused to leave when directed and continued to state he was helping Resident 74. The registered nurse supervisor was notified, and it was addressed. During an interview on May 27, 2026, at 1:20 PM, Employee 4, Nurse Aide (NA), indicated that on May 3, 2026, Employee 3, NA, informed him that Resident 12 was in Resident 74's room. Employee 4 stated that upon entering the room, he observed Resident 74 seated in his Broda chair (a specialized wheelchair designed for individuals requiring extensive positioning and mobility assistance) with his pants pulled down, his brief torn, and his penis exposed. Employee 4 stated that Resident 12 was seated next to Resident 74 with his hand on Resident 74's upper thigh and that he observed Resident 12's hand touching Resident 74's testicles and upper thigh. Employee 4 indicated that he directed Resident 12 to leave the room; however, Resident 12 did not comply and stated, I am helping. Employee 4 reported that Resident 12 remained in the room until Employee 5, Registered Nurse Supervisor (RNS), entered and directed Resident 12 to leave. Employee 4 further stated that Resident 12's hands were covered with absorbent gel beads from the inside of the disposable brief. A review of a witness statement provided by the facility revealed that Employee 5, Registered Nurse Supervisor (RNS), documented that on May 3, 2026, Employee 3, Nurse Aide (NA), notified her that Resident 12 was in Resident 74's room and was attempting to change the resident's brief and clothing. Employee 5 documented that upon entering the room, she observed Resident 12 seated in a chair next to Resident 74, who was seated in a Broda chair. The witness statement indicated that Resident 74's pants were partially pulled down in the front. According to the statement, Resident 12 reported that he was attempting to help Resident 74 by changing him. Employee 5 documented that she directed Resident 12 to leave the room, and Resident 12 complied. The witness statement further documented that Resident 74 stated Resident 12 had saved his life and responded no when asked whether Resident 12 had touched his private parts. Employee 5 additionally documented that she observed no signs of sexual arousal and described Resident 12's demeanor as calm and relaxed. During a telephone interview on May 27, 2026, at 2:20 PM, Employee 3, Nurse Aide (NA), indicated that on May 3, 2026, she entered Resident 74's room and observed Resident 74 seated in his wheelchair with his pants pulled down, one leg out of his pants, and his brief open. Employee 3 stated that Resident 12 was seated next to Resident 74 with both hands underneath Resident 74's brief in the area of his genitals. Employee 3 indicated that although Resident 12's hands were covered by the brief and she could not directly observe contact, it appeared to her that Resident 12 was touching Resident 74's penis. Employee 3 stated that she directed Resident 12 to stop touching Resident 74; however, Resident 12 responded, I am changing his brief. Employee 3 further stated that based on her observations, it did not appear that Resident 12 was attempting to provide personal care or change Resident 74's brief and instead appeared to be touching Resident 74's penis and groin area. Employee 3 indicated that she again instructed Resident 12 to stop, but Resident 12 did not comply. Employee 3 stated that she then left the room, ran into the hallway, and called for assistance. Employee 3 recalled that when she returned to the room with assistance, Resident 74's penis was exposed and appeared bright red. During a telephone interview on May 27, 2026, at 2:48 PM, Employee 5, Registered Nurse Supervisor (RNS), indicated that on May 3, 2026, she responded to Resident 74's room after being notified that Resident 12 was present in the room. Employee 5 stated that upon entering the room, she observed Resident 74 seated in his Broda chair with his pants pulled down and his genitals exposed. Employee 5 stated that Resident 12 was seated next to Resident 74. Employee 5 indicated that she did not personally observe Resident 12 touching Resident 74. According to Employee 5, Resident 12 stated, I am trying to help. Employee 5 reported that she directed Resident 12 to leave the room, and Resident 12 complied with the direction. Employee 5 stated that Resident 74 did not appear distressed and that she observed no visible signs of injury. Employee 5 recalled that Resident 74 stated, He saved my life, and did not indicate that Resident 12 had touched him. Employee 5 stated that she instructed the nurse aides to provide care to Resident 74 and later observed Resident 74 seated near the nursing station without signs of distress. Employee 5 further stated that, based upon her observations of both residents, their statements, and the absence of visible injury, she did not believe the incident constituted sexual abuse. Employee 5 acknowledged that she did not debrief or interview Employee 3, Nurse Aide (NA), or Employee 4, NA, regarding their observations of the incident involving Resident 12 and Resident 74. A clinical record review revealed no documented evidence that the facility completed assessments, evaluations, behavioral reviews, or nursing documentation regarding the observations reported by Employee 3 and Employee 4. The clinical records for both residents lacked documentation regarding the incident, follow-up observations, psychosocial impact, or resident-specific evaluations following the event on May 3, 2026. During an interview on May 27, 2026, at 1:53 PM, Resident 74 was unable to identify any resident by name or recall specific details of the May 3, 2026, incident. However, when asked whether he had experienced any problems with other residents in the facility, Resident 74 stated, There is a guy trying to feel me up. Every time I turned around, he was bothering me. Resident 74 further stated that the resident tried to embrace me and that he told the individual, This is not my way of doing things. Resident 74 indicated that the resident's actions made him feel utterly sick to my stomach and disgusted. Resident 74 stated, I am not looking for someone to play with, especially not a male, and I have no wish to be with him. Resident 74 further indicated that he was not interested in a relationship with the resident and did not want others to get the wrong idea. Resident 74 stated that he told the resident to stop and recalled telling him, I'd smash his head in. During an interview on May 28, 2026, at 12:30 PM, Resident 12 indicated that on May 3, 2026, he was walking down the hallway when he observed Resident 74 in his room waving him in and asking for help. Resident 12 stated that he entered the room because he believed Resident 74 needed assistance. Resident 12 denied touching Resident 74 and stated that he did not provide any care or assistance to him. Resident 12 indicated that he only entered the room to determine what was occurring. Resident 12 further stated that Resident 74 pulled his own pants down. According to Resident 12, when staff entered the room, he left. The reasonable person concept is an objective legal and regulatory standard used to evaluate the degree of actual or potential harm, pain, or mental anguish that a reasonable person would experience under similar circumstances. Although Resident 74 was unable to identify Resident 12 by name or fully recall the events of May 3, 2026, Resident 74 provided statements regarding unwanted interactions with a male resident. These statements were considered together with staff interviews, witness statements, observations, and other evidence obtained during the investigation. During an interview on May 29, 2026, at 10:00 AM, the above information, including clinical record review, witness statements, staff interviews, resident interviews, and observations regarding the May 3, 2026, incident involving Resident 12 and Resident 74, was reviewed with the Nursing Home Administrator (NHA). The facility failed to protect Resident 74 from non-consensual sexual contact by another resident. Refer F60728 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, facility policy, facility-provided documentation, and staff interviews, it was determined the facility failed to ensure timely, comprehensive assessment and monitoring of wounds and failed to ensure implementation of necessary practices to prevent worsening skin breakdown for 1 of 7 residents reviewed (Resident 1).Findings include:According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the best pressure ulcer practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of a facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall assess and document and report vital signs, a full assessment of the pressure sore including location, stage (the classification of a pressure injury based on the depth and extent of tissue damage), length, width, depth, and presence of exudates(fluid) or necrotic tissue (dead tissue). A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], 2025, with diagnoses to include dementia (decline in mental ability such as memory, reasoning, and communication severe enough to interfere with daily life), and peripheral vascular disease (blood circulation disorder causing narrowed, blocked, or spasming vessels arteries or veins outside the heart and brain and increases risk for wounds). A review of the resident's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 10, 2025, revealed the resident was cognitively intact as evidence by a BIMS score of 09 (Brief Interview for Mental Status is a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08-12 indicates moderately impairment). Additionally, this MDS indicated Resident 1 used a wheelchair for mobility, required substantial/maximal assistance with upper dressing and personal hygiene, lower body dressing, bed mobility, and toileting. A review of Resident 1's clinical record revealed an ongoing skin integrity issue related to vascular wounds of bilateral lower extremities. A review of Resident 1's progress notes revealed the following documentation:October 30, 2025, at 8:26 AM: Left lower extremity wound partially covered with slough (non-viable tissue), scant serous (thin clear to pale yellow fluid) drainage noted, no infection. Wounds noted to be improving, the note documented no signs of infection were observed, the note then indicated continue treatment at this time.November 7, 2025, at 12:12 PM: Documentation identical to October 30 entry.December 24, 2025, at 8:51 AM: Discontinue the current wound treatment and a new order was documented to cleanse the upper shin with antiseptic spray, pat dry, and apply Silvadene (topical cream containing silver to prevent and treat infection), cover the wound with a dressing and secure with tape. The note directed to document the condition of the wound daily.January 6, 2026, at 12:01PM: documented the resident's left shin was observed to have five open areas, scattered with scabs, scant serous drainage was noted with no signs of infection.January 14, 2026, at 11:08 AM: Documentation identical to January 6 entry.A progress note dated January 15, 2026, at 12:41 PM documented the resident's left shin as vascular in appearance (relating to blood vessels or circulation) with five open areas and scattered scabs. The wound beds were described as pink with granulation tissue (new healthy tissue indicating healing), with scant serous drainage (a very small amount of thin, clear fluid) and no signs of infection documented. A progress note dated January 20, 2026, at 2:05 PM contained documentation identical to the January 15, 2026, entry, with no additional or updated wound assessment information recorded. A progress note dated January 22, 2026, at 11:58 AM again documented the same assessment findings as the entries dated January 15 and January 20, 2026, without change or added detail. A progress note dated January 27, 2026, at 11:22 AM also contained the same exact wording as the prior entries dated January 15, January 20, and January 22, 2026, with no updated assessment findings documented.The record did not contain documentation of required wound measurements, staging, or complete weekly assessments between October 2025 and February 2, 2026.An interview with the Nursing Home Administrator (NHA) on February 11, 2026, at 10:15 AM revealed the facility utilized an outside provider for in-house wound management services. The NHA stated the contracted wound management company performed full-body skin assessments on all residents on February 2, 2026. Review of Resident 1's clinical record revealed no documentation of a comprehensive lower extremity wound assessment until February 2, 2026, despite documentation indicating the wound had been present since October 2025.An interview with Employee 1 (facility-designated wound nurse) on February 11, 2026, at 12:00 PM revealed it is the facility's expectation that the wound nurse complete and document a full wound assessment weekly for each wound. Employee 1 stated required documentation should include wound location, stage (classification of wound severity based on tissue damage depth), length, width, depth, and presence of exudate (drainage fluid) or necrotic tissue (dead tissue). Employee 1 was unable to provide an explanation as to why Resident 1's lower extremity wounds had not received a complete documented assessment since October 2025 and stated she assessed the wounds but had not documented all required elements in the clinical record.The facility was unable to provide documentation demonstrating that a Registered Nurse completed timely and comprehensive wound assessments for Resident 1's venous ulcer (a wound caused by impaired blood circulation in the veins) including measurements and staging prior to February 2, 2026During an interview with the NHA and Director of Nursing (DON) on February 11, 2026, at 1:45 PM, the above findings were reviewed. No additional documentation was provided. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observations, clinical record reviews, facility policies, facility investigative documentation, manufacturer instructions, and staff and resident interviews, it was determined the facility failed to implement interventions to prevent the development of a pressure injury for two residents (Residents 58 and 6) and failed to implement physician-ordered pressure-relief measures for two residents (Residents 11 and 70) out of 28 residents reviewed. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the best pressure ulcer practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility policy titled Prevention of Pressure Ulcers, last reviewed by the facility on June 30, 2025, revealed it is the facility's policy to ensure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. The policy indicates general preventive measures include identifying risk factors for pressure ulcer development. Interventions include changing position at least every two hours or more frequently if needed, determining if residents need a special mattress, ensuring the special mattresses contain foam or air as indicated, reducing shear by lifting rather than dragging, referring residents to rehabilitation or restorative nursing programs as indicated, and encouraging residents to participate in active and passive range of motion exercises to improve circulation. When in bed every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by the therapist or prescribed by the physician. A clinical record review revealed Resident 58 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (a condition where the kidneys cannot adequately filter waste from the blood) and spinal stenosis (a condition where the spinal column narrows, putting pressure on the spinal cord or the nerves). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 12, 2025, revealed that Resident 58 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). The care plan initiated June 16, 2025, identified the resident as being at risk for pressure ulcers due to dehydration and immobility. The physician's orders revised July 18, 2025, included use of a bariatric air mattress with settings adjusted to the resident's most current weight. A wound note dated July 28, 2025, identified a Stage II pressure injury on the sacrum (lower back area) measuring 0.4 cm x 0.4 cm x 0.2 cm, characterized by partial-thickness skin loss and pink wound bed. According to manufacturer guidance an alternating pressure therapy pump overlay/replacement mattress system operating manual provided by the facility revealed the pump display has a low-pressure function indicator. When an abnormally low pressure occurs, the low-pressure indicator (yellow LED) will light up. Check that the connections are correctly made and that they are correctly installed as per installation instructions. A note indicated that if the pressure level is consistent, check for any leakage (tubes or connecting hoses). If necessary, replace any damaged tubes or hoses. Despite these orders, an observation on July 29, 2025, at 10:05 AM, revealed the air mattress was set to support a resident weighing 500 pounds. The resident's actual weight as of July 2, 2025, was 235.6 pounds. The air mattress pump displayed a yellow low-pressure warning light. Resident 58 reported the mattress had been uncomfortable for several weeks. A follow-up observation on July 29, 2025, at 10:28 AM revealed Resident 58's air mattress pump continued to indicate low pressure. During an interview on July 29, 2025, at approximately 11:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the air mattress pump should be set to match the resident's weight. The DON and NHA indicated the low-pressure indicator light should not continue to be lit. During an interview on July 29, 2025, at 11:25 AM, the Director of Maintenance confirmed the low-pressure indicator light continued to signal. The Director of Maintenance replaced the air mattress pump. After a few minutes, the low-pressure indicator light turned off. During an interview on July 30, 2025, at 1:20 PM, Resident 58 indicated that since the new pump was installed, the bed has been more comfortable. He said he could feel the air circulating, and he had a good night's sleep for the first time in 30 days. He indicated there was less discomfort in his lower back, where he had a skin injury. The facility failed to ensure Resident 58's air mattress was adjusted per manufacturer guidance. Specifically, the facility failed to timely recognize a low-pressure indicator light on the air pressure pump and ensure the weight setting correctly matched the resident's weight which resulted in ineffective pressure redistribution and contributed to skin breakdown. A clinical record review revealed Resident 6 was admitted to the facility on [DATE], with diagnoses that included unspecified fracture of the lower end of the right femur (a break in the bone right above the knee joint), unspecified dementia (a progressive loss of memory and cognitive function caused by brain disease). A review of Resident 6's admission MDS dated [DATE], revealed that Resident 6 was severely cognitively impaired with a BIMS score of 99 (a score of 99 indicates the resident was unable to complete the interview), and required total staff assistance for activities of daily living, rolling in bed, and transfers, and was moderately at-risk for the development of pressure ulcers and injuries. According to the MDS the resident was always incontinent of bladder and bowel. A review of the resident's care plan-initiated March 18, 2025, identified a focus area related to skin integrity with planned interventions which included encourage hydration adequate nutrition and provide assistance as needed, keep skin clean and dry, assist resident with turning and repositioning every hour and as needed, complete skin inspection every 7 days and as needed, an use of a pressure redistribution air mattress. A nursing progress note dated April 7, 2025, revealed the presence of Stage II pressure ulcers (characterized by open wounds or blisters with exposed dermis) on the right hip, right thigh, and lower back. These areas were directly aligned with the edges of the incontinence brief. Staff applied wound gel and dressings. A facility investigation conducted that same day, April 7, 2025, at 11:21PM determined the ulcers followed the brief line. Review of a Wound Evaluation and Management Summary note dated April 9, 2025, completed by the wound care consultant, indicated the pressure area located on Resident 6's right hip was classified as a Stage II that measured 5.5 cm x 0.5 cm x 0.1 cm, with a light amount of serous drainage (clear, thin, watery fluid that is a normal part of the healing process). Treatment recommendations were to apply Skin Prep (specific barrier liquid used to protect the skin from moisture, friction and shearing) once daily for thirty days, to offload wound and reposition per facility protocol. Further review indicated the pressure area on right lower back was classified as a Stage II, measuring 6 cm x 0.3 cm with a fluid filled blister and open areas of exposed dermis (the second layer of skin). Treatment recommendations were to apply Skin Prep once daily for thirty days, to offload wound and reposition per facility protocol. Continued review indicated the pressure area on Resident 6's right medial(middle) thigh measured 4 cm x 0.2 cm with a fluid filled blister and open areas of exposed dermis (the second layer of skin). Treatment recommendations were to apply Skin Prep once daily for thirty days, to offload wound and reposition per facility protocol. An interview with the Director of Nursing on July 31,2025, at approximately 9:30 AM revealed staff are provided with a brief sizing chart which is posted on each nursing unit, to assist in determining the size brief a resident is to use based on a resident's height and weight. Further interviewing revealed that each resident is then evaluated and measured by the Bowel and Bladder Nurse to determine if the brief the staff are using on each resident is the correct size. At the time of the survey, the facility was unable to provide documentation that appropriate sizing had been assessed for Resident 6. An interview with Employee 9, Licensed Practical Nurse (LPN) on July 31,2025 at 9:35 AM revealed when she reviewed the skin areas reported on April 7, 2025, the areas of pressure reported were in direct contact with the brief and indicated the brief too small and this was the cause of the pressure areas. The LPN instructed the C.N.A to use a larger brief on Resident 6 to help deter any further skin concerns. An interview was conducted with the Director of Nursing on July 31, 2025, at approximately 9:50 AM to confirm the above findings related to the facility's failure to prevent pressure ulcers. A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses that included muscular dystrophy (group of genetic diseases characterized by progressive muscle weakness and degeneration). The admission MDS dated [DATE], revealed a BIMS score of 12, indicating mild cognitive impairment, and noted the resident was at risk for pressure ulcer development. A physician order dated June 6, 2025, directed staff to apply bilateral heel offloading boots (protective offloading boots to prevent heel ulcers) at all times, except during physical therapy. An observation on July 29, 2025, at 12:35 PM revealed Resident 11 was sitting in his wheelchair without the boots in place. An observation on July 29, 2025, at 12:45 PM in the presence of Employee 8 (RN) revealed that Resident 11 had left the facility with staff for an outside appointment. Resident 11's offloading boots were observed in the closet despite the physician order for the resident to wear the boots at all times except physical therapy. Interview with Employee 8 (RN) at this time confirmed that staff were to ensure that Resident 11's boots were always worn except physical therapy. Observation on July 30, 2025, at 1:30 PM revealed the resident was sitting in his wheelchair with the boots applied. During an interview with the resident at this time the resident confirmed that the boots were comfortable and were helping to relieve pressure off his feet. Interview with the director of nursing (DON) on July 30, 2025, at approximately 2:00 PM confirmed that Resident 11 was at risk for pressure ulcers. The DON confirmed the physician ordered boots were to be in place at all times except physical therapy and could also be worn when outside the facility on appointments. Resident 70 was admitted on [DATE], with a diagnosis of dementia. A MDS dated [DATE], documented a BIMS score of 4, indicating severe cognitive impairment, and dependence on staff for bed mobility and transfers. The resident was assessed as being at risk for pressure injuries. A physician order dated February 11, 2025, directed staff to keep the resident's heels elevated off the bed to relieve pressure. However, an observation on July 29, 2025, at 1:35 PM revealed the resident's heels were resting directly on the mattress. A heel suspension cushion was observed on top of the mattress but was not in use. The nurse aide confirmed the resident required staff assistance for heel elevation, and the Director of Nursing verified that staff were expected to elevate the heels per the physician's order. An interview with Employee 11 (nurse aide) on July 29, 2025, at approximately 1:40 PM confirmed that Resident 70 was dependent on staff and that staff were to ensure that the resident's heels were elevated in bed and not placed directly on the mattress. Interview with the director of nursing on July 30, 2025, confirmed that Resident 70's heels were to be elevated when in bed as per physician order for pressure relief. The facility failed to implement preventive measures and physician-ordered interventions designed to protect Residents 58, 6, 11, and 70 from the development or worsening of pressure injuries. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on observations, a review of clinical records, documentation provided by the facility, and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's dignity for one out of 28 residents sampled (Resident 83).Findings include:A clinical record review revealed Resident 83 was admitted to the facility on [DATE], with diagnoses to include peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). During an observation conducted on July 29, 2025, at 9:48 AM, Employee 10, Nurse Aide (NA), was seen transporting Resident 83 in a white shower chair through the third-floor 300s unit hallway in route to the shower room. Resident 83 was wearing only a black t-shirt that extended to his waist and was not wearing pants. A white cloth was loosely draped across the resident's lap. Resident 83's buttocks and approximately four inches of his gluteal cleft (the groove between the buttocks) were visibly exposed as he was pushed in the chair through the hallway and into the shower room. An employee statement dated July 29, 2025, revealed Employee 10, nurse aide (NA), was unaware that Resident 83's backside was exposed during the transport. The employee stated, In the future, I will use two bath towels to ensure all areas are covered. During an interview on July 29, 2025, at approximately 1:00 PM, the Nursing Home Administrator (NHA) confirmed that residents have the right to be provided care with dignity. The NHA indicated that Resident 83 should have been properly covered and should have been provided with appropriate clothing to ensure that his backside was not exposed while being transported through a public hallway. The facility failed to ensure that Resident 83 received care in a manner that maintained his dignity.28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (c)(d)(1) Nursing services.

Based on observation and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, safe, orderly and sanitary resident environment in the room of one of 28 residents reviewed. (Resident 2) Findings include: Observations of Resident 2's room on the [NAME] unit, on July 29, 2025, at 1036 AM, revealed a fitted bed sheet with an approximately 6-inch x6-inch tan stain noted to be on the left side middle portion of the fitted sheet.An observation to Resident 2's room on July 30, 2025, at 10:47 AM revealed the fitted bed sheet noted an approximately 6 -inch by 6 -inch tan stain noted to be on the left side middle portion of the bed. Further observation revealed a 7- inch by 6-inch tan stain noted on the lower right side of the fitted sheet. Additionally, noted to be at the foot of fitted sheet were 4 8-inch streaks of a dark red substance running along the foot of the fitted sheet.An observation made in Resident 2's room on July 30,2025 at 1:00 P.M. revealed the fitted bed sheet noted an approximately 6- inch by 6- inch tan stain noted to be on the left side middle portion of the bed. Further observation revealed a 7 -inch by 6-inch tan stain noted on the lower right side of the fitted sheet. Additionally, noted to be at the foot of fitted sheet were approximately 4 8-inch-long streaks of a dark red substance running along the foot of the fitted sheet.An interview with Employee 4, Nurse Aide NA on July 30,2025, confirmed the sheets were visibly soiled. During the interview Employee 4 revealed bedding is usually changed on shower days or when visibly soiled. Employee 4 revealed that he was responsible for Resident 2's care during the day shift of July 30th,2025 but did not realize the sheets were soiled. An interview with the Director of Nursing (DON) was conducted on July 30, 2025, at 2:15 PM, to review the above observations and confirmed that the facility failed to maintain a safe, sanitary and orderly environment in Resident 2's room. 28 Pa. Code 201.18 (e)(1) (2.1) Management. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on a review of clinical records and staff interviews, it was determined the facility failed to fully develop and revise a person-centered comprehensive care plan to meet the individualized needs of two residents out of 28 sampled (Resident 7 and 41).Findings included: A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump blood as well as it should) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin (a hormone that helps regulate blood sugar levels) or when the body cannot effectively use the insulin it produces). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 11, 2025, revealed that Resident 7 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review for Resident 7 revealed physician's orders, dated January 3, 2025, for Lispro (short-acting insulin) four times a day subcutaneously (injection under the skin) with a sliding scale insulin coverage (a method used to manage blood sugar levels by giving insulin based on blood sugar readings) dependent on his blood glucose level and Lantus (long-acting insulin), dated January 2, 2025, subcutaneously 20 units in the morning and 20 units at bedtime. Further review for Resident 7 revealed a physician's order dated January 4, 2025, for a daily 1500 milliliter (ml) fluid restriction (360 ml allotted for breakfast, 300 ml allotted for lunch, and 300 ml allotted for dinner) and 540 ml allotted for nursing fluids (180 ml during the 7:00 AM to 3:00 PM shift, 180 ml during the 3:00 PM to 11:00 PM shift, and 180 ml during the 11:00 PM to 7:00 AM shift). A review of the resident's comprehensive plan of care, last revised on January 6, 2025, failed to reflect these updated medical treatments and interventions. A review of Resident 41's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included hypertension (blood pressure that is higher than normal) and hypoxemia (a low level of oxygen in the blood). A review of a quarterly MDS dated [DATE], revealed that Resident 41 was cognitively intact with a BIMS score of 12 (a score of 13-15 indicates cognition is intact). A clinical record review for Resident 41 revealed physician's orders, dated May 31, 2024, for oxygen 2 L/minute via nasal cannula (flexible tube to deliver oxygen by two small prongs in the nose) for shortness of breath. A review of the resident's comprehensive plan of care, last revised on July 7, 2025, failed to reflect these updated medical treatments and interventions. During an interview on July 31, 2025, at approximately 11:00 AM, the Nursing Home Administrator confirmed the facility failed to ensure that comprehensive care plans were fully developed for Resident 7 and Resident 41. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 28 residents sampled (Resident 18).Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on June 30, 2025, revealed it is the facility's policy to provide a restorative nursing program that focuses on achieving and/or maintaining optimal function in accordance with a comprehensive assessment and plan of care. The policy indicated the restorative nurse monitors on an ongoing basis all aspects of the individualized restorative nursing programs offered and oversees documentation by nurse aides. A clinical record review revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include inflammatory Poly arthropathy (a condition where multiple joints are inflamed). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 4, 2025, revealed that Resident 18 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of Resident 18's care plan revealed a restorative nursing walking program initiated on March 24, 2025. Interventions implemented to assist the resident towards a goal of walking in the corridor with the assistance of one person up to 350 feet or to tolerance include restorative training in a walking program with rollator walking (a mobility device) and the assistance of one staff member for distances upwards of 350 ft., initiated on July 7, 2025. During an interview on July 30, 2025, at approximately 10:30 AM, Resident 18 indicated she was upset because she wants to walk every day, but staff do not walk with her. She said in the last month she had only walked one time. Resident 18 explained she has not been asked to walk and would not refuse to walk with staff. A clinical record review revealed an ambulation task for Resident 18's restorative training in the walking/ambulation program. RNP (restorative nursing program) ambulation with RW (rollator walker) and A (assistance) of 1 staff for distances upwards of 350 feet or as tolerated was documented as completed on July 30, 2025, at 10:47 AM. During an interview on July 30, 2025, at 11:45 AM, Resident 18 confirmed no one walked with her this morning. She explained that she was in an interview with the healthcare surveyor at that time. In a subsequent interview on July 30, 2025, at 11:50 AM, Employee 3, Nurse Aide (NA), acknowledged that she documented the RNP ambulation task as completed for Resident 18. Employee 3 further stated that she had not yet performed the ambulation task but had documented it prior, with the intention to provide the service later that afternoon Further clinical record review revealed Resident 18's RNP ambulation task was marked as completed 25 times from July 7, 2025, through July 29, 2025, and marked as the resident refused 19 times during that same period. During an interview on July 30, 2025, at approximately 1:00 PM, the Nursing Home Administrator (NHA) confirmed facility staff should not document plan of care tasks as complete when the care did not occur. The NHA acknowledged that Resident 18 reported not receiving her scheduled ambulation interventions as documented. The NHA was unable to explain the discrepancy between the documentation indicating that the ambulation program was being consistently provided and the resident's statement that she had only been walked once in recent weeks. 28 Pa. Code: 211.5(f)(ix) Medical records. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(3)(5) Nursing services.

Based on observations, review of clinical records, facility investigative documentation, and resident and staff interviews, it was determined the facility failed to ensure the residents environment remains free of accident hazards for one out of 28 residents sampled (Resident 92).Findings include: A clinical record review revealed Resident 92 was admitted to the facility on [DATE], with diagnoses that include peripheral vascular disease (condition in which narrowed arteries reduce blood flow to the arms or legs) and neuropathy (a condition in which nerve damage interferes with the functioning of the nervous system). A review of an Annual Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 25, 2025, revealed that Resident 92 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A progress note dated June 20, 2025, at 2:09 PM revealed Employee 1, Registered Nurse (RN), was called to Resident 92's room. Upon assessment, the resident's right foot was noted to have +2 pitting edema (swelling graded on a scale from 0 to 4, based on the depth and duration of the indentation left when pressure is applied to the swollen area) with a 2.0 cm x 2.0 cm bruise located medially on the dorsum of the right foot (the top-side middle of her foot). No open areas or complaints of pain were indicated. Employee 1, RN, described the bruise as light purple in color and circular in shape. The progress note indicated a description of the event by Resident 92: I was getting a shower, and the aide accidentally dropped the showerhead, and it fell on my foot. Documentation confirmed the incident was reported to maintenance and that both the physician and resident representative were notified. Documentation provided by the facility dated June 20, 2025, described that Employee 2, Nurse Aide (NA), accidentally dropped a showerhead onto Resident 92's foot. It further revealed that all shower stalls had broken hooks, preventing the showerheads from being safely secured during care. The staff reportedly placed the showerheads on grab bars, which led to the incident. This was communicated to maintenance. Review of a written witness statement dated June 20, 2025, Employee 2, NA, indicated that she gave Resident 92 a shower and the showerhead fell. She recalled Resident 92 saying something about the showerhead falling, but nothing about Resident 92's foot having pain or the resident complaining about pain at that time. A right foot x-ray ordered on June 23, 2025, was initially inconclusive due to a bandage, prompting a repeat order. The second x-ray on June 24, 2025, revealed an age-indeterminate deformity of the second toe, with no evidence of bone infection. A pain evaluation document dated June 26, 2025, revealed Resident 92 had experienced pain over the last five days related to her right foot. The document indicated the resident also had pain related to chronic arthritis. Resident 92 indicated the pain was an 8 out of 10 (numeric scale to rate pain 00 being the least amount of pain and 10 being the worst). Resident 92 indicated rest, elevation, ice, and acetaminophen reduced her discomfort. A progress note dated June 30, 2025, at 9:34 AM revealed the resident requested the nurse to look at the resident's right foot related to pain and swelling. Upon assessment, the right foot appeared to be swollen, red, warm, tender, and painful to touch. The physician was notified and an order for the antibiotic cephalexin 500 mg twice daily for 10 days was initiated for cellulitis (a potentially serious skin infection that occurs when bacteria enter broken skin. It causes redness, warmth, swelling, and pain, and typically requires antibiotics for treatment.). A physician progress note dated July 2, 2025, documented a diagnosis of cellulitis of the right foot secondary to trauma from the showerhead. The resident's pain and swelling were reported to be improving with antibiotic treatment. Cephalexin was administered as ordered through July 10, 2025. A podiatry consultation form dated July 9, 2025, revealed Resident 92 had pain, edema (fluid buildup), and fluctuance (boggy sensation felt on touch) on the right distal foot (top side of the foot). The consultation indicated concern with hematoma/fluid buildup in the right foot. The resident had cellulitis resolved with antibiotic therapy. Recommend magnetic resonance imaging (MRI medical test that uses strong magnet and radio waves to create detailed pictures of the inside of the body) without contrast. The resident may need incision and drainage of the right foot. Discussed with nursing. On July 11, 2025, the resident was scheduled for an MRI to occur on August 6, 2025. However, on July 17, 2025, the resident declined the MRI and an order for an ultrasound was obtained instead. A soft tissue ultrasound conducted that same day identified a moderately complex hematoma/seroma (a buildup of fluid) on the top of the right foot resulting from the trauma. A progress note dated July 18, 2025, at 6:21 PM confirmed the physician reviewed Resident 92's ultrasound report with no new orders noted. During an interview on July 30, 2025, at 10:30 AM, Resident 92 explained that on June 20, 2025, a nurse aide put the showerhead on top of the grab assist bar while she was getting a shower. Resident 92 indicated the showerhead was not secured; it fell off the grab assist bar and struck her in the top of her right foot. Resident 92 indicated it did not hurt at first, but it started to bother her over the next few days. She indicated that it is painful, but her medicine relieves the pain. She indicated her injury has not prevented her from carrying out her normal daily activities. During an observation on July 30, 2025, at 11:00 AM, the Director of Nursing (DON) removed Resident 92's right sock, which revealed a raised half-circle area measuring approximately 2.0 inches in diameter on the top of her foot. The area was raised approximately 1.0 inch and light purple in color. An observation on July 30, 2025, at 1:35 PM on the second-floor nursing unit revealed three resident shower stalls with broken plastic showerhead hooks in each stall. In each stall the showerheads were observed resting loosely on grab bars or hanging from the hose. During an interview on July 30, 2025, at approximately 2:00 PM, the Nursing Home Administrator (NHA) confirmed the showerheads should be secured in a manner that prevents a showerhead from falling and striking a resident. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, facility-initiated transfer notices, and staff interviews, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for 2 out of 28 residents reviewed (Residents 41 and 70).Findings include: A review of the clinical record revealed that Resident 41 was transferred to the hospital on May 13, 2025, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 70 was transferred to the hospital on April 28, 2025, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the Nursing Home Administrator on July 31, 2025, at approximately 12:00 P.M., confirmed there was no documented evidence that copies of facility-initiated transfer notices for Residents 41 and 70 were sent to a representative of the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on a review of clinical records, the facility's abuse prohibition policy, select investigative documentation, and interviews with the resident and facility staff, it was determined the facility failed to protect one of five sampled residents (Resident 18) from neglect by not implementing the physician-ordered use of a mechanical lift for all transfers, resulting in actual harm in the form of a comminuted right tibia and fibula fracture requiring surgical intervention. Findings include: A review of the facility policy titled Investigation of Allegations of Abuse, Neglect or Misappropriation of Resident Property provided on May 30, 2025, revealed the facility will provide each resident with the highest practicable physical, mental and psychological services to meet their individual needs and promote or maintain the resident at their highest level of wellbeing. This includes the protection of Resident's Rights. Allegations of abuse will be thoroughly investigated by the facility. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of Resident 18's clinical record revealed admission to the facility on November 6, 2023 with diagnosis that included osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down), rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing joint pain, stiffness, inflammation, and eventually joint damage), and a periprosthetic fracture around the internal prosthetic right knee joint (a bone fracture that occurs near the knee replacement implant). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 7, 2025, revealed that Resident 18 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). Continued review revealed the resident required total staff assistance to shower and total staff assistance for transfers. Review of the resident's plan of care dated November 6, 2023, indicated that Resident 18 had an ADL self-care performance deficit related to impaired balance, rheumatoid arthritis, osteoarthritis, and periprosthetic fracture of the right knee. Interventions included non-weight bearing to the right lower extremity (leg), and use of a Hoyer lift with a green sling (a lift that uses hydraulic power to transfer a person while cradled in a sling). A physician's order dated February 18, 2024, revealed an order for Resident 18 to maintain non-weight bearing through the right lower extremity and to use a Hoyer lift with a green sling for transfers. Review of Resident 18's electronic Kardex (quick reference for staff that includes summary of resident information to provide care) also noted the resident was non-weight bearing to the right lower extremity and the resident transfers using a Hoyer lift with a green sling. Nursing documentation dated May 13, 2025, at 12:08 AM revealed Resident 18 was complaining of pain in her right shin and foot on the 11PM-7AM shift. The resident told the night shift nurse she had hurt it while getting a shower on the 3PM- 11PM shift the prior evening, May 12, 2025. The night shift supervisor contacted the physician and an X-ray was obtained, which showed a moderately comminuted fracture of the mid shaft of the right tibia and mildly displaced slightly angulated and comminuted fracture of the mid shaft of the right fibula. The resident was transferred to the emergency department and underwent an open reduction and internal fixation (ORIF) with intramedullary nailing (intramedullary nail-a metal rod that is inserted into the bone to stabilize fractures) and anteromedial plating (surgical implant used in the fixation of fractures) on May 14, 2025. A review of facility-provided investigative documentation dated May 13, 2025, at 11:40 AM revealed the nurse aides involved did not follow the physician-ordered plan of care requiring the use of a full body mechanical lift for transfers. The documentation indicated the facility initiated an internal investigation into the incident, and the staff members were suspended from duty pending the outcome of that investigation. Review of the witness statement provided by Employee 1 (nurse aide) via telephone interview, by the facility, dated May 13, 2025, at 10:10 AM revealed the following: We transferred (Resident 18) from her wheelchair into the shower chair. When questioned as to whether the nurse aide knew Resident 18 was a mechanical lift, Employee 1 replied Yes, she was aware, and the lift was in the shower room at the time. When asked why the mechanical lift was not utilized, Employee 1 responded I don't know. Employee 1 stated she and Employee 3 (nurse aide) lifted the resident while Employee 2 (nurse aide) pulled the resident's pants down to put her in the shower chair. Review of the witness statement provided by Employee 2 via a telephone interview by the facility, dated May 13, 2025, at 10:25 AM revealed the following: Employee 1, Employee 2 and Employee 3 transferred Resident 18 into the shower chair. The resident was complaining of her leg hurting before the shower and after the shower, so I told Employee 4 (licensed practical nurse). Employee 4 gave her a pain medication. Resident 18 complains of pain on and off, all the time. When we transferred her, we did not use a Hoyer, three of us transferred her. The resident was thankful for the shower. When questioned as to whether the nurse aide knew Resident 18 was a mechanical lift, the aide replied that it was her mistake, I am sorry. Resident 18 was on the edge of her chair; there was no way to get the sling under her. When questioned why the nurse aides did not boost Resident 18 back in her wheelchair if she was on the edge. Employee replied, we didn't have time. Review of the witness statement provided by Employee 3 via a telephone interview by the facility, dated May 13, 2025, at 4:45 PM revealed the following: I was doing a shower (for another resident), and they asked me to help stand her up (Resident 18). I know she is a Hoyer lift. The asked me to stand her up. They brought her in the shower room, and we put her in the shower chair. We lifted her. Employee 2 pulled out the wheelchair and pushed the shower chair under the resident. When we lifted her up, she was okay. When her pants were coming down, she yelled out. When we sat her down, she started complaining about the right side of her leg. They asked me to lift her, I knew she required a Hoyer lift. Resident said Ow after the transfer. The leg she complained of pain was her right leg. Employee 1 was on her right side. Resident 18 was sitting normal in her wheelchair; she did not turn or twist. I then proceeded to give the other resident a shower after Resident 18 was in the shower chair. When questioned about why the mechanical lift was not in use, Employee 3 replied, I know better, I use the lifts. It is in her chart to use it. They asked for my help, and they just wanted to get her in the shower chair. I did not want the girls to be mad at me. I just didn't want to throw anyone under the bus. They told me to say we used the Hoyer. When questioned about the location of the lift at the time of the transfer, Employee 3 reported that Employee 1 got the lift after Resident 18 was in the shower chair. I'm sorry, Resident 18 does not like to use the machine, they brought her to the shower and needed my help quick. Review of the facility's investigative documentation provided by the facility dated May 15, 2025, at 2:00 PM revealed the incident occurred on May 12, 2025, at 4:00 PM. Findings of the facility investigation are as follows: After interviewing the resident and the nurse aides it was concluded that Employee 1 and Employee 2 brought Resident 18 to the shower room in her wheelchair. Employee 3 was already in the shower room providing a shower to another resident when Employee 1 and Employee 2 asked Employee 3 for help to transfer Resident 18. Employee 3 and Employee 1 stood Resident 18 while Employee 2 pulled down her pants. Employee 1 and Employee 3 proceeded to transfer the resident onto the shower chair. During the transfer Resident 18 stated she felt her leg give out and then felt severe pain and she yelled out. Employee 3 confirmed the resident yelled out in pain with the transfer and that she was complaining of right leg pain. After the resident was transferred to the shower chair, Employee 3 stated that Employee 1 went and got the full body mechanical lift and sling and brought it into the shower room and told Employee 3 that if anyone asks, they used the lift. Continued review confirmed that Resident 18 had a physician order to be transferred with use of a full body mechanical lift and non-weight bearing on the right lower extremity. All three nurse aides admitted to not following the physician order and not using the mechanical lift to transfer Resident 18 to the shower chair. Resident 18 has the following diagnosis which increase her risk of injury: osteoarthritis, osteoporosis, rheumatoid arthritis, periprosthetic fracture around the internal prosthetic right knee joint and right knee pain. Further review of the facility's documented conclusion of the investigation revealed the three nurse aides had not followed the physician order for the use of the full body mechanical lift and the non-weight bearing status to Resident 18's right lower extremity, which resulted in fractures to her right tibia and fibula with hospital admittance for surgical repair. The investigation substantiated caregiver neglect causing serious physical injury. During an interview with Resident 18 on May 30, 2025, at 10:45 AM, the resident reported that she requires the use of the lift to get in and out of her wheelchair. She stated, That's where they were wrong, they never used the lift. She continued I was falling, and they said, we have you and I said, no you don't. I told them I was falling, and they said you're all right, but I wasn't all right. A voicemail message was left for Employee 1, 2, and 3 on May 30, 2025, between 11:00 -11:10 AM in an attempt to conduct a telephone interview, however, the surveyor's messages were not returned. The facility's investigation substantiated neglect resulting in serious physical injury. All three aides involved were suspended during the investigation and subsequently terminated, as confirmed by the Nursing Home Administrator (NHA) during an interview on May 30, 2025. The NHA acknowledged that the nurse aides knowingly failed to implement required safety protocols, resulting in actual harm, right tibia and fibula fracture to Resident 18, requiring hospitalization and surgical repair. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on a review of clinical records, resident council meeting minutes, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one resident out of 23 sampled (Resident 40) and experiences expressed by two residents during a group interview (Residents 78 and 79). Findings include: A review of policy titled Restorative Nursing Policy, last reviewed by the facility on April 3, 2024, revealed it is the policy of the facility to provide a restorative nursing program that focuses on achieving and maintaining optimal function in accordance with the comprehensive assessment and plan of care. The policy indicates that residents who are referred by physical therapy, physician, or nursing will be evaluated by the restorative nurse for a restorative program. Also, it is the commitment of the facility to assist residents to restore or maintain their functional capacities to improve their overall quality of living. A review of resident council meeting minutes dated April 25, 2024, revealed that residents in attendance had concerns regarding staff changes to the restorative nursing programs. The minutes indicated the Director of Nursing (DON) would discuss the changes with individual residents. A response to concerns raised during the April 25, 2024, resident council meeting indicated the facility will no longer have designated restorative aides, related to changes in budgeting. Nurse aides are now responsible for walking any of the residents on walking programs (restorative nursing ambulation). Residents were informed that if they are not being walked, then inform the nurse aide and nurse for that shift. A clinical record review revealed Resident 79 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 21, 2024 revealed that Resident 79 is moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). A review of Resident 79 ' s physical therapy discharge instructions dated January 2, 2024, revealed the resident is discharged (from physical therapy) to the facility with a restorative nursing program for ambulation up to 150 feet with a rollator walker(a mobility device). Further review of the clinical record revealed a care plan, initiated on January 4, 2024, indicating Resident 79 is unable to walk independently and requires assistance. An intervention implemented to increase Resident 79 ' s self-performance and stamina when walking is to include her in a restorative nursing program for ambulation of 150 feet with a rollator walker. A review of Resident 79 ' s restorative ambulation participation record indicated Resident 79 declined participation on 36 occasions, and it was documented that ambulation was not applicable on 3 occasions from August 22, 2024, through September 20, 2024. The record indicated Resident 79 participated in 19 restorative ambulation sessions. A clinical record review revealed Resident 78 was admitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy (reduction in muscle mass and strength due to the loss of muscle tissue) and inflammatory polyarthropathy (a condition characterized by inflammation affecting multiple joints). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 30, 2024, revealed that Resident 78 is moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). A review of Resident 78's Physical Therapy Discharge Summary dated June 24, 2024, revealed the resident is to continue with her current restorative program and indicated her prognosis to maintain her current level of functioning is good with consistent staff follow-through. A review of Resident 78's care plan, initiated on November 23, 2022, revealed she is unable to walk around the unit independently. An intervention implemented to maintain Resident 78 ' s ability to ambulate is a restorative nursing program for ambulation a the rollator walker up to 100 feet. A review of Resident 78 ' s restorative ambulation participation record indicated Resident 78 declined participation on 30 occasions, and it was documented that ambulation was not applicable on 4 occasions from August 22, 2024, through September 20, 2024. The record indicated Resident 78 participated in 25 restorative ambulation sessions. During a group interview on September 18, 2024, with alert and oriented residents, Resident 78 and 79 indicated they are upset because they are not receiving their scheduled ambulation program. During the group interview, Resident 78 indicated that she has not walked with nursing for months since the restorative nurse staff changed positions at the facility. Resident 78 explained that nursing staff does not provide ambulation therapy, and she has brought this up to everyone that will listen to me. Resident 78 expressed frustration as walking and being independent is a personal goal and important for her well-being. During the group interview, Resident 79 indicated she only receives restorative services when she has physical therapy. She explained it has been a few months since she was discharged from therapy. Resident 79 indicated her restorative nursing program for ambulation is not occurring. A review of Resident 40's clinical record revealed admission to the facility on [DATE], with diagnoses which included polyosteoarthritis (any type of arthritis that involves 5 or more joints simultaneously), diabetes with diabetic autonomic neuropathy (damage to nerves that control automatic body functions caused by diabetes), and peripheral vascular disease. An Annual Minimum Data Set assessment (MDS a standardized assessment completed at specific intervals to identify specific resident care needs) dated July 28, 2024, indicated the resident was moderately cognitively impaired with a BIMS score of 12 and required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with ambulation and toileting hygiene. Interview with Resident 40 on September 17, 2024, at 10:39 AM indicated that nursing staff does not provide her restorative ambulation nursing services. She stated that she was excited for the nursing students to come into the facility, because that's when she gets to walk. A review of Physical Therapy Discharge Summary dated July 29, 2024, indicated that Resident 40 required setup/clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with ambulation. A review of Resident 40's Kardex (a nursing worksheet that provides a summary of patient's information) on September 19, 2024, indicated the resident was on a restorative ambulation program with a rollator was and Supervision/SBA (stand-by assistance) of one staff member for up to 150 feet. A review of Resident 40's Documentation Survey Report dated September 2024, indicated from September 1, 2024, through September 18, 2024, the resident's RNP ambulation program with rollator walker and supervision for 150 feet was only provided by nursing staff 5 times out of 36 opportunities. During an interview on September 20, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) and DON were unable to explain why residents were indicating they were not receiving their restorative ambulation program. The NHA confirmed it is the facility's responsibility and policy to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. 28 Pa. Code: 211.12(d)(3)(5) Nursing services

Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical needs for one of 23 residents reviewed (Residents 34). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A clinical record review revealed Resident 34 was admitted to the facility on [DATE], with diagnoses that include degenerative disease of the nervous system (a condition that affects many of the body's activities, such as balance, movement, talking, breathing, and heart function) and ataxia (progressive - affecting a person's ability to walk, talk, and use fine motor skills). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 23, 2024, revealed that Resident 34 is severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). A progress note dated August 7, 2024, indicated Resident 34 was observed with a skin tear to her upper right arm measuring 2.0 cm x 0.5 cm x 0.1 cm. A progress note dated August 22, 2024, at 9:17 PM indicated Resident 34 became combative and hit her right forearm with her left nail, causing a 1.0 cm x 4.0 cm skin tear on her right forearm. A physician's order for Resident 34 to have Geri Sleeves (fabric worn over the arms to protect the skin from skin tears and abrasions) on bilateral upper extremities (arms) at all times was initiated on August 23, 2024. A care plan indicating Resident 34 has potential for pressure-related skin failure related to impaired mobility and general weakness was initiated on July 27, 2021. An intervention implemented to assist Resident 34 to maintain intact skin integrity included skin sleeves to bilateral upper extremities initiated on August 23, 2024. During an observation on September 17, 2024, at 10:40 AM, Resident 34 was seen sitting in her room wearing a short-sleeve shirt. Her arms were uncovered, and no protective skin devices were observed on her arms. In a follow-up observation on September 18, 2024, at 1:25 PM, Resident 34 was seen participating in a therapy session. Her arms were bare, and no protective skin devices were observed. Another observation on September 20, 2024, at 9:50 AM revealed Resident 34 sitting in her room wearing a short-sleeve shirt. Her arms were bare, and no protective skin devices were observed. During an interview on September 20, 2024, at 9:55 AM, Employee #3, Registered Nurse, confirmed Resident 34 was not wearing her bilateral protective skin devices. Employee 3 was unable to explain why the resident was not wearing the protective devices and was unable to locate the resident's protective sleeves. During an interview on September 20, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical needs, including interventions and physician's orders to be implemented to maintain residents' skin integrity. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, select facility policy review, and staff interview it was determined the facility failed to ensure a physician ordered fluid restriction was maintained for one of 23 sampled residents (Resident 1). Findings include: Review of the facility Intake and Output Monitoring Policy, last reviewed April 3, 2024, indicated that intake and output (intake refers to the amount of fluids the resident ingests, and output refers to the amount of fluids that leave the body) will be monitored on residents as necessary with documentation in the Electronic Medical Record. All residents on fluid restrictions will remain on intake and output if specifically ordered, and as clinical needs indicate. Intakes will be reviewed daily by the 3:00 PM to 11:00 PM RN Charge Nurse/designee to see if resident is meeting estimated fluid requirement or is over fluid restriction. The physician is to be made aware if the resident is over fluid restriction times two days or is under estimated fluid requirement times three days. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and congestive heart failure (a chronic condition in which the heart does not pump as well as it should causing shortness of breath). A quarterly Minimum Data Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 7, 2024, indicated the resident is moderately cognitively impaired with a BIMS (brief interview for mental status) score of 10 (8 to 12 indicates moderate cognitive impairment), received dialysis treatment and required assistance of staff for activities of daily living. A physician order dated June 24, 2024, noted an order for 1500 mL fluid restriction per 24 hr. Indicating 960 mL of fluids provided/allowed by dietary (360 mL breakfast, 300mL lunch, 300mL dinner) and 540 mL provided/allowed by nursing staff (180 mL 7-3 shift; 180 mL 3-11 shift; 180 mL 11-7 shiftt ) related to acute and chronic congestive heart failure. A review of Resident 1's daily calculated Fluid Requirement Monitoring Record from August 25 through September 18, 2024, revealed Resident 1 exceeded the physician ordered fluid restriction on the following days: August 29, 2024 2040 cc (ml) daily total August 30, 2024 16000 cc (ml) daily total September 2, 2024 1900 cc (ml) daily total September 3, 2024 1920 cc (ml) daily total September 4, 2024 1710 cc (ml) daily total September 5, 2024 1710 cc (ml) daily total September 6, 2024 1710 cc (ml) daily total September 7, 2024 1788 cc (ml) daily total September 8, 2024 2145 cc (ml) daily total September 12, 2024 1900 cc (ml) daily total September 13, 2024 1740 cc (ml) daily total September 15, 2024 1900 cc (ml) daily total September 16, 2024 1780 cc (ml) daily total September 17, 2024 2390 cc (ml) daily total September 18, 2024 2250 cc (ml) daily total Further review of the clinical record revealed no documented evidence the physician was notified of the resident exceeding the fluid restriction as per facility policy. There was no documented evidence the fluid restriction was evaluated for reasons to explain how the resident, who is dependent on staff to provide fluids was exceeding the fluid restriction. Interview with the director of nursing on September 19, 2024, at approximately 11:30 AM failed to provide documented evidence that Resident 1's fluid restriction was maintained as per physician order. The director of nursing (DON) failed to provide documented evidence the physician was notified of the resident exceeding the fluid restriction as per facility policy. 28 Pa. Code 211.5 (f)(ii) Medical Records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical record and select facility incident reports, and staff interview it was determined that the facility failed to assure that one resident of five sampled (Resident CR1) was free from a significant medication error that compromised the resident's clinical condition and health due to Tacrolimus toxicity. Findings include: Clinical record review revealed that Resident CR1 was admitted from the hospital to the facility on [DATE], with diagnoses, which included pneumonia and history of a kidney transplant. Review of medications listed on Resident CR1's Hospital Discharge Instructions revealed that active medications to continue at the long term care nursing facility included Tacrolimus (immunosuppressive agent used in the prevention and treatment of solid-organ transplant rejection) 0.5 mg capsule, take 2 capsules in the morning, and 1 capsule in the evening. Review of Resident CR1's admission physician orders dated [DATE], revealed an order for Tacrolimus 5 mg 2 capsules by mouth once daily (morning) and Tacrolimus 5 mg one capsule by mouth in the evening for a diagnosis of kidney transplant. Review of Resident CR1's [DATE] Medication Administration Record revealed that from [DATE], through [DATE], Resident CR1 received 4 doses of Tacrolimus 10 mg in the morning and 4 doses of Tacrolimus 5 mg in the evening instead of 1 mg in the AM (2 - 0.5 mg capsules in the AM) and 0.5 mg in the evening as ordered upon discharge from the hospital. Review of a nurses note dated [DATE], at 7:29 PM revealed that Resident CR1 was noted to be cold, with altered mental status, pulse oxygen (blood oxygen saturation, crucial measure of how lungs are working) 80% (normal level is 95 to 100%) on 4 liters/minute oxygen; pulse 60 (normal range 60 to 100 beats per minute). Physician at the bedside and ordered to transport to the emergency room for further evaluation. Resident representative at bedside. A nurses note dated [DATE], noted that Resident CR1 was admitted to the hospital. Review of the hospital Discharge Summary report dated [DATE], revealed that the resident expired on [DATE], and the preliminary cause of death was listed as Tacrolimus toxicity, acute renal failure, and acute hypoxic respiratory failure. The hospital course noted that Resident CR1 received Phenytoin (anticonvulsant medication) for Tacrolimus toxicity. Review of a facility Medication Error Report dated [DATE], indicated that the resident representative contacted the facility on [DATE], at 5:00 PM to notify the facility that the physician at the hospital informed the resident representative that the facility had been administering Resident CR1 the wrong dose of Tacrolimus during the resident's stay. Further review of the Medication Error Report noted that upon investigation of the resident's representative's claim that the wrong dose of medication had been administered, the facility identified that the Tacrolimus was verified correctly, but transcribed incorrectly by Employee 1 (registered nurse). The physician was notified of the error. The resident representative was informed that the wrong dose of Tacrolimus had been administered to Resident CR1 due to the transcription error. Interview with the Director of Nursing (DON) on [DATE], at 11:00 AM confirmed that from [DATE], through [DATE], Resident CR1 received 4 doses of Tacrolimus 10 mg instead of Tacrolimus 1.0 mg in the morning and 4 doses of Tacrolimus 5 mg in the evening instead of Tacrolimus 0.5 mg in the evening. The DON confirmed that the facility failed to ensure that Resident CR1 was free from significant medication errors. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5 (f) Medical records

Based on review of select facility policy, investigative reports, information submitted by the facility and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from physical abuse, which caused multiple lacerations to one resident (Resident 38) and minor injury to one resident (Resident 51) and neglected to provide necessary care as planned to avoid physical harm to one resident (Residents 68) resulting in minor injury, out of six sampled residents. Findings include: A review of the facility policy entitled investigation of allegations of abuse, neglect or the misappropriation of resident property, last reviewed by the facility January 5, 2022, revealed that residents have the right to privacy, dignity, and confidentiality for all aspects of care and services. Physical abuse includes but is not limited to hitting, slapping, pinching, kicking and shoving. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm. A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident CR1's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 21, 2022, revealed that the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status - a tool to assess cognitive function). A review of Resident 38's clinical record revealed admission to the facility on [DATE], with diagnoses, which included congestive heart failure, gastro-[CONDITION(S)] reflux disease (GERD), diabetes, peripheral vascular disease (PVD - a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), acute and chronic respiratory failure, left and right below the knee amputation (BKA), and muscle weakness. A review of Resident 38's Significant change MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14. Nursing documentation in Resident CR1's clinical record dated, April 15, 2022, at 8:48 PM, revealed that Resident CR1 had demonstrated extreme behaviors this PM. Nursing noted that the resident had kicked and punched the nurse and knocked nurse to floor. The resident was packing belongings, exhibiting paranoid behavior and was very combative wander-hall looking for family to pick him up. He was making claims he had double brain surgery. Nursing noted Support offered, calmly, walking with resident. Responsible party (RP) and MD aware. A nursing note in Resident CR1's clinical record dated April 17, 2022, at 10:10 PM, indicated that a thumping sound was heard and a man's voice yelling out. Resident CR1 was found lying on his left side with upper body against shower room door. When questioned what happened, resident stated, I'll sue your %*%es off. RP made aware and expressed concern about resident's increasing cognitive and behavioral issues. MD aware of incident and RP concern including resident receiving 2 milligrams (mg) of straight [MEDICATION(S)] (a medication which can be used to treat anxiety) and still very agitated. Will address in the morning. A nursing note entry dated April 18, 2022, at 6:28 AM, in Resident CR1's clinical record indicated that MD visit (physiatry) was in with no new orders (NNO). RP, MD made aware. Resident CR1's clinical record revealed a nursing note entry dated, April 18, 2022, at 4:00 PM, which indicated resident being very combative and abusive at this time. Stating he had to take a sh*t. When approaching resident to wheel down to bathroom resident then jumped onto feet and punched nurse in the face, he then grabbed onto nurses both wrists and began shaking nurse and twisting arms stating, I'm going to break them and you. Approached by second nurse and scheduler at this time to unbind resident's hands from nurse and he then let go and punched second nurse in the chest. He then grabbed, ripped and broke her necklace stating, I'm going to choke you and kill you too. Resident was then sat back down into wheelchair and left alone in hallway outside of nurse's station to diffuse situation. Safe at this time with no employee or resident within arms - reach. Resident CR1's clinical record revealed a nursing entry dated April 18, 2022, at 4:25 PM, indicated resident was seated outside the nurses station attempting to self- transfer. When nurse approached to assure his safety while standing, he punched nurse in face and grabbed her shirt and begun shaking nurse back and forth. A second nurse then approached the situation to remove resident's hands from other nurse, and the resident then punched the second nurse in face. A Nurse was able to seat the resident in a wheelchair. RP and physician aware, new orders were obtained to transfer resident to local hospital ER for evaluation. A nursing note dated April 19, 2022, at 1:02 AM, in Resident CR1's clinical record indicated that Resident CR1 returned from hospital ER at this time. ER stated no behaviors while there, however, did document patient has a history of dementia and behaviors which were appreciated multiple times throughout his recent hospital stay! No behaviors at present, however, to be anticipated secondary to recent activity and history, monitor. A review of Resident CR1's clinical record dated, April 20, 2022, at 5:41 AM, indicated resident was verbally aggressive toward staff stating, Get out of my room and shut the door. When explaining that the door needs to be cracked in order to hear safety alarms, resident began yelling out and cursing at staff again stating, what do you think i'm stupid. A review of Resident CR1's clinical record revealed a nursing note dated April 21, 2022, at 6:07 AM, which was indicated as a late entry, noting Dr in in am and examined resident with no order change. Nursing noted on April 21, 2022, at 5:58 PM, in Resident CR1's record that new orders received to discontinue (D/C) [MEDICATION(S)] 2 mg by mouth (PO) at hour of sleep (HS). Change to [MEDICATION(S)] 1 mg by po at 4 PM and HS. RP aware. Nursing notes in Resident CR1's clinical record dated April 26, 2022, at 12:47 PM, indicated that the nurse practitioner was in and examined the resident on April 25, 2022, with no new recommendations at this time. The CRNP noted to continue with current medications. According to a review of Resident CR1's clinical record on April 30, 2022, at 9:16 AM, a nurse intervened when Resident CR1 was stabbing Resident 38 with a metal fork and butter knife. Nursing noted that Resident CR1 was redirected from Resident 38, while securing utensils from him. Staff alerted, 911 called, Resident CR1 secured with blanket wrapped around him until police arrived. Resident CR1 repeatedly screamed out welcome to the murder scene, it's a blood bath, who's next? Nursing noted that on April 30, 2022, at 9:45 AM, Resident CR1 was transferred to the local hospital ER for a psych evaluation and treatment with a police escort. RP and MD made aware. A nursing entry in Resident CR1's clinical record dated, May 2, 2022, at 2:06 PM, indicated that the resident was not returning to the facility. A review of Resident 38's clinical record dated, April 30, 2022, at 9:15 AM, indicated that nursing heard Resident 38 yelling out from her room. Staff went into Resident 38's room and saw Resident CR1 stabbing Resident 38 with fork and butter knife. Redirected resident (Resident CR1) away, alerted staff and secured utensils. Attended to Resident 38's wounds with pressure. 911 called, on scene, treating. A review of Resident 38's clinical record dated, April 30, 2022, at 9:16 AM, indicated that Resident 38 was sent via 911 emergency transfer out to local hospital ER for evaluation and treatment. RP called, MD made aware. A further review of Resident 38's clinical record revealed nursing documentation dated April 30, 2022, at 5:55 PM, which indicated resident returned from hospital ER at this time, accompanied by ambulance staff. Made comfortable in bed, changed out of clothes into gown, comforting words and touches offered from staff. Vital signs (VS) obtained, within normal limits (WNL). Food/drink provided by brother/sister-in-law, who are at bedside at this time. Dressing to left forearm laceration and hematoma, laceration to left axilla, laceration to left elbow, laceration to left hand, laceration to left neck and lower left face; 19 stitches total. A review of Resident 38's hospital documentation entitled Emergency Department Discharge Instructions, dated April 30, 2022, indicated that Resident 38 was assaulted at home sustaining lacerations to her left axilla (armpit), left elbow, left hand, left forearm and neck. A review of information dated April 30, 2022, submitted by the facility and facility investigation report, dated April 30, 2022, reported that Resident CR1 had physically assaulted Resident 38, attacking her, and stabbing her with a knife and fork. Interview with Resident 38, on May 24, 2022, at approximately 2:29 PM, revealed that the resident recalled the incident with Resident CR1. She stated that she was asleep and felt something and awoke to Resident CR1, standing over her with a knife and fork, stabbing her. The facility failed to ensure that Resident 38 was free from physical abuse, perpetrated by Resident CR1. An interview with the Nursing Home Administrator (NHA) on May 24, 2022, at approximately 2:07 PM, confirmed the facility failed to ensure that Resident 38 was free from physical abuse perpetrated by Resident CR1. A review of Resident 51's clinical record revealed that the resident was most recently admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A continued review of Resident 51's quarterly MDS assessment dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 5, (a score of 0-7 equates to being severely cognitively impaired). A review of Resident 49's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Narrowing, blockage, or spasms in a blood vessel), and seizures. A review of Resident 49's quarterly MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired with a BIMS score of 4, (a score of 0-7 equates to being severely cognitively impaired). Nursing notes dated January 6, 2022, at 10:29 PM, indicated Resident 51 was heard yelling out for help. Upon arrival, staff observed Resident 49 quickly rolling away in her wheelchair. Resident 51 was holding her arm and stated that Resident 49 had grabbed her arm and pinched and twisted the skin. A small, crescent-shaped skin tear, measuring 1.0 cm x less then .01 cm in size was observed. No active bleeding. The skin tear was cleansed, covered with an absorbent dressing. Residents separated, and put on 15-minute safety checks. RP and MD aware. A further review of Resident 51's clinical record, progress notes dated January 14, 2022, at 1:32 PM, indicated Resident 51 skin tear to right anterior forearm resolved. Skin intact and fleshtone. New order noted to discontinue (D/C) treatment. Call placed to RP to make aware of same. A review of facility provided incident investigation, physical, investigation forms, and facility provided documentation indicated on January 6, 2022, at 10:29 PM, noted the incident as described above during which Resident 49 had grabbed and twisted Resident 51's arm and caused a skin tear to her right forearm. The facility failed to ensure that Resident 51 was free from physical abuse, perpetrated by Resident 49. An interview with the Nursing Home Administrator (NHA) on May 24, 2022, at approximately 2:07 PM, confirmed the facility failed to ensure that Resident 51 was free from physical abuse perpetrated by Resident 49. A review of Resident 69's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 69's Admission MDS assessment dated [DATE], revealed the resident was cognitively intact with a BIMS score of 14 (a score of 13-15 equates to being Cognitively Intact). A review of current Resident 69's care plan (a tool - instructions used to guide care) dated May 17, 2022, indicated that the resident was to be transferred by assist of 2 staff members with a rolling walker (rw). A nursing note in Resident 69's clinical record dated, May 19, 2022, at 6:45 PM, revealed that Resident 69 had sustained a skin tear to the left lower extremity, outer shin. The skin appears split, top layer laying flat, approximately 1 centimeter (cm) opening, less then 0.1 cm depth, sanguineous (leakage of fresh blood from an open wound) fluid seeping. No complaints of pain, indicating she believes it was bumped on the chair. Area cleansed with antiseptic spray, measured and steri strips applied. RP and Physician made aware. Resident resting quietly in no distress. A review of facility provided incident investigation, skin, investigation forms, and provided documentation indicated on May 19, 2022, at approximately 7:30 PM, Employee 5 (Certified Nursing Assistant - CNA employed by a staffing agency), was in the process of transferring Resident 69, by herself, from the resident's wheelchair into her bed. During the transfer, Resident 69 sustained a skin tear on her left lower leg (front) measuring 5.0 centimeter (cm) x 1.0 cm x 0.1 cm. Review of Employee 5 (agency CNA), witness statement dated May 19, 2022, indicated that Resident 69 had requested to go to bed, and Employee 5 requested help from fell ow staff members, but they were in the process of assisting other residents. According to Employee 5's statement Resident 69 was eager to go to bed, so {Employee 5, agency CNA} hugged her and pivoted her to the bed and believes during this stand and pivot transfer, {Resident 69}hit the side of the wheelchair leg rest. The facility failed to provide Resident 69 with the necessary care and services to prevent injury and physical harm by failing to provide sufficient staff assistance and use proper technique during a transfer as care planned for the resident. An interview with the NHA on May 24, 2022, at approximately 2:07 PM, confirmed that Employee 5 neglected to provide necessary staff assistance and appropriate technique as care planned and required by the resident resulting in minor injury to Resident 69. 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(e)(1) Management 28 Pa. Code 201.29(a)(c)(d) Resident Rights 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services

Based on review of clinical records, select facility policy and resident incident reports and staff and resident interviews it was determined that the facility failed to provide staff assistance as planned to prevent an accident and injury for one resident (Resident 86) out of 23 sampled. Findings include: A review of the facility's policy, entitled Fall Management Policy And Procedure, last reviewed by the facility June 2013, revealed that it is the facility's policy to prevent/reduce falls, reduce injury and ultimately improve the quality of life for all residents and enhance the resident's sense of security and safe environment. The facility's purpose is to limit and/or prevent the occurrence of falls within the parameters that can be controlled through structured program interventions. To minimize the severity of injuries sustained by a resident resulting from a fall. Resident 86 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an admission (MDS) Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively intact. A review of a Resident Incident Report, dated October 30, 2012, at 9:45 AM, revealed that Resident 86 was transferring from his recliner when he felt woozy and fell to the floor. A nurse aide was in the room and witnessed the fall. According to the nurse aide's statement, the resident was standing with his walker, getting his glasses off his bedside table. The nurse aide stated that she was cleaning the resident's bed when she noticed the resident fell backwards. A review of an preliminary x-ray report, dated October 30, 2012, revealed that the resident sustained [REDACTED]. A review of the facility's ADL self-performance record for Resident 86, dated October 1 through October 31, 2012, revealed that on October 30, 2012 (the day of the resident's fall and fracture) it was documented on the 7 AM to 3 PM shift that the resident was transferred with extensive assistance of one staff person. A review of the resident's plan of care in place at that time and the incident report revealed that the resident was a SBA (stand by assist) of 1 staff member for transfers. A review of the resident's fall risk evaluation, dated September 18, 2012, revealed that the resident was considered (score of 18) at high risk for falls. During an interview with the NHA (Nursing Home Administrator) on July 9, 2013, at 2:30 PM, it was confirmed that SBA meant that staff should be next to the resident during the transfer, to break a fall, if needed. During an interview with the Physical Therapy Director on July 10, 2013, at 10:15 AM, it was revealed that she evaluated the resident on October 17, 2012 and determined that the resident required a SBA, due to the resident's safety awareness. According to the therapist, SBA meant that a staff member was required to be next to the resident during transfers. During an interview with Resident 86 on July 10, 2013 at 9:15 AM, he revealed that he was sitting in his recliner, got up to go to his motorized wheelchair that was approximately 10 feet from his recliner, when he felt woozy and fell to the floor. He stated that a nurse aide was in the room at the time, but that she was on the other side of his bed and not next to him when he fell . 483.25(h) Free of Accident Hazards/Supervision/Devices previously cited 8/24/12 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 8/24/12 28 Pa. Code 211.10(a)(d) Resident care policies previously cited 8/24/12

Based on clinical record review, observation and staff interview, it was determined that the facility failed to consistently apply a splint and/or devices to prevent decrease in range of motion for one of 24 sampled residents (Resident 31) and failed to timely re-evaluate and modify a resident's restorative programming following a change in condition to prevent a decline in range of motion and resulting contractures for one resident out of 24 sampled (Resident 66). Findings include: A review of the facility Restorative Nursing Care policy reviewed by the facility June 30, 2011, indicated that restorative nursing care would be provided to each resident admitted . The facility has an active program of rehabilitative nursing care which is developed and coordinated through the resident's plan of care. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes, but is not limited to maintaining good body alignment and proper positioning and assisting residents with their routine range of motion exercises. Through the resident care plan, the goals of restorative nursing care are reinforced in the activities program, therapy services, etc. The facility Restorative Nursing Philosophy policy, reviewed, June 30, 2011, indicated that periodic functional assessments and screening by the interdisciplinary team to determine potential for increasing and/or maintaining function capabilities and development and implementation of a care plan that will be managed to assure the services are provided in a planned, consistent manner to accomplish the goals mutually agreed upon by the resident, family, and facility staff. Clinical record review revealed that the Resident 66 was admitted to the facility November 30, 2010, with [DIAGNOSES REDACTED]. A review of a Significant Change Minimum Data Set assessment dated , February 18, 2011, indicated that the resident was severely impaired cognitively, required staff assistance for all activities of daily living, did not ambulate, and had no functional limitations in range of motion, had no pain, had no pressure sores, and was not on a restorative program. A review of a Quarterly minimum data set assessment dated , August 21, 2011, indicated that the resident was severely impaired cognitively, did not ambulate, and required staff assistance for all activities of daily living, and now had a functional limitation in range of motion to both lower extremities, had pain or possible pain in the past five days, had an unstageable pressure ulcer, which measured 6 cm by 5 cm with necrotic tissue, and received passive range of motion with restorative nursing. Review of the resident's Restorative/Maintenance Care Plan Range of Motion initiated, January 11, 2011, with a goal date of April 2011, revealed that the resident had functional limitation bilaterally to the feet and legs, was unable to ambulate, was able to follow direction, and was in need of a restorative/maintenance/complication plan. The goal was to maintain current status, ambulate, maximize safety with transfers and ambulation, and be free of pain and discomfort. Interventions included active range of motion 15 minutes per day/ 7 days per week with verbal prompts. Evaluation of the care plan by Employee 2 (the LPN Restorative Nurse) on May 15, 2011, noted that the resident receives both passive and active range of motion depending on the resident's level of condition. No changes were noted in functional range of motion of bilateral lower extremities; monitor for contractures now that the resident is in a Broda chair. All exercises tolerated ten to fifteen minutes per day. Further review of the Restorative/Maintenance Care Plan revealed no evidence that the resident's problem/needs, goals, or interventions were ever re-evaluated and revised in response to the resident's changing needs as reflected on the resident's quarterly MDS assessment dated [DATE]. On August 11, 2011, Employee 2, LPN Restorative Nurse noted that the resident receives primarily passive range of motion at this time to decrease contracture risk secondary to declining medical condition. All exercises completed per resident's tolerance (no description of the resident's actual tolerance). No visible changes in range of motion noted. All exercises completed 15 repetitions times two times at least six days per week. Review of the resident's Restorative Care Program developed by physical therapy and dated, April 2, 2011, revealed that the resident's goal for the Restorative Program included: to maintain ambulation with Rolator walker and supervision for 300 feet and contact guard on turns, maintain bilateral lower extremity strength, and maintain bilateral lower flexibility. Approach/Recommendations for implementation of the above goals included: ambulating the resident with Rolator walker and assist times one with increased assistance on turns, standing squats with rail 3 times 15, and bilateral hamstring stretches. Review of the resident's April 2011 Restorative Mobility AM and PM participation record revealed no evidence that the above recommendations were implemented. The plan on the participation record noted to maintain lower extremity strength, to maintain safety with transfers, and ambulation, and contained no information specifics to how this was to be accomplished for this resident. A review of the resident's Restorative Summary for May 2011 dated, June 1, 2011, noted that the resident had no real change in ability to transfer and ambulate, but a decline was noted in the resident's endurance secondary to frequent refusals and increased periods of agitation. There was no mention if a referral was made to physical therapy or if adjustments in the resident's restorative nursing program were needed to increase participation. A Physical Therapy Rehabilitation Screen dated, July 13, 2011, revealed that the resident was having increased difficulty with transfers and ambulation secondary to pain related to the resident's left heel ulcer. It was determined that physical therapy would not be appropriate and was recommended that nursing follow-up with possible pain management adjustments for the resident. The adequacy and appropriateness of the resident's Restorative Program was not addressed. Review of the resident's July 2011 Restorative Mobility AM participation record revealed that from July 1 through July 18, 2011, the resident was actively participating in range of motion to the bilateral lower extremities. On July 19 and July 20, 2011, it was noted that the resident was sick. From July 21 through July 31, 2011, passive range of motion was noted. A Restorative Summary note dated, August 8, 2011, noted that staff were unable to fully range the resident's lower extremities due to resistiveness (there was no date noted as to when the resident started to become resistive with range of motion or a date as to when it became difficult for staff to fully range the resident's lower extremities due to the resident's resistiveness). A physical therapy weekly progress note dated, August 25, 2011, noted that the resident now had contractures of the left hip and left knee. Orthotics were ordered August 19, 2011, to help reduce knee and hip contractures. Interview with the director of therapy on September 16, 2011, at 12:25 p.m., confirmed that the resident had definite moderately severe contractures to the left hip and knee. Interview with the director of nursing (DON) on September 15, 2011, at 1:00 p.m., confirmed that there was no documented evidence that the facility developed an individualized restorative program based on the resident's changing clinical needs and functional abilities. The DON was unable to provide documented evidence that the facility timely identified and acted upon changes in the resident's ability to participate in the restorative program to prevent the development of contractures to the resident's left hip and knee. Clinical record review revealed that Resident 31 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required staff assistance for most activities of daily living and had range of motion limitations of the hand. The physician's orders [REDACTED]. Observations of the resident on September 15, 2011, at 11:05 a.m., and at 1:55 p.m., revealed that the blue grip splint was not in place and on September 16, 2011, at 8:17 a.m., 9:35 a.m., and at 10:20 a.m., the blue grip splint again was not in place. Interview with Employee 1 on September 16, 2011, at 10:45 a.m., confirmed that the resident's blue grip splint left was not in place. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 10/29/10 28 Pa. Code 211.11 (c)(d) Resident care plan. Previously cited 10/29/10

Based on review of clinical records, select incident/accident reports, select facility policy and procedures and resident and staff interviews, it was determined that the facility failed to provide planned measures to prevent a fall with injury for one resident out of 24 sampled (Resident 71). Findings include: Clinical record review revealed that Resident 71 had diagnoses, which included Alzheimer's disease, hypertension, arthritis, and a history of falls. Review of a quarterly minimum data set assessment dated , July 22, 2011, indicated that the resident was severely cognitively impaired , required staff assistance for activities of daily living, and had one fall with no injury. A review of the resident's Fall Risk assessment dated , July 19, 2011, revealed that the resident scored a 16 (a score of 15-21 was indicative of a moderate risk for falls). The resident's fall risk care plan dated, October 3, 2010, indicated that the resident was a fall risk and had a potential for injury secondary to ambulatory dysfunction. Interventions to prevent falls included maintaining a clear pathway, keeping needed items in reach, and Dycem (a non-skid material applied under cushions to prevent the cushion from sliding) below the cushion on wheelchair. A review of a nurse's note dated, August 26, 2011, at 8:30 p.m., revealed that the resident was observed on the floor at the end of the hall. The resident was positioned on her back with her knees bent to her chest. The wheelchair was positioned behind the resident. The incident was witnessed by a nursing assistant. The resident was assessed for injuries and returned to bed. The resident complained of pain to the right hip and right lateral thigh; range of motion was within the resident ' s norm. No visible injuries, no ecchymosis, redness, or swelling was noted. At the of the fall, the resident was sitting on an incontinence pad (a cloth quilted material placed on a surface to prevent soiling) placed on the wheelchair, on top of the resident's wheelchair cushion. A nurses note dated, August 27, 2011, at 11:50 a.m., noted that the resident was admitted to the hospital with [REDACTED]. A review of a resident incident report dated, August 26, 2011, noted that interventions to prevent falls prior to this fall were the use of an alarm to the resident's bed and wheelchair and Dycem under the wheelchair cushion. New interventions to prevent future falls included staff education regarding pads (incontinence pads) and Dycem on wheelchair cushion. A review of the Post Fall and Incident Investigation dated, August 26, 2011, noted that Dycem was not under the resident's Roho cushion (a pressure reducing cushion with a cloth cover which can be removed for laundering) as care planned, but instead a cloth incontinence pad was placed on top of the Roho cushion. The conclusion of the facility's investigation was that the resident had slid out of the wheelchair when she pulled herself using the aid of a stationary chair to assist with her mobility. Interview with the director of nursing (DON) on September 16, 2011, at 10:00 a.m., confirmed that prior to this incident, wheelchair and wheelchair cushion cleaning was completed by housekeeping monthly at 5:00 a.m. The DON confirmed that the incontinence pad was placed on the resident's wheelchair cushion on the morning of the resident's fall because the resident's wheelchair cushion was still wet from cleaning. The DON confirmed that the use of the cloth incontinence pad atop of the Roho cushion was unsafe and may have contributed to the resident sliding from the wheelchair. 28 Pa. Code 211.12 (a)(d)(5 ) Nursing services Previously cited 10/29/10 28 Pa. Code 211.11 (d) Resident care plan Previously cited on 10/29/10