Every finding on record at Monroeville Post Acute

Based on review of facility policies, resident interviews, and nursing unit observations, it was determined that the facility failed to make certain that necessary care and services were provided for ten of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11).Findings include: Review of facility policy Answering the Call Light last reviewed January 2026, indicated staff will, Answer the resident's call as soon as possible and as practicable. During an interview on 8/21/26, at approximately 12:50 p.m. Resident R2 stated, It (call light response) takes too long. I have to sit in dirty briefs for longer than I would like. Staff get irritable they (the residents) complain, aides get annoyed. I have IBS (irritable bowel syndrome, which causes uncomfortable abdominal symptoms, including constipation, diarrhea, gas and bloating) and if I have more than one bowel movement they say they won't change me more than twice a shift. During an interview on 8/21/26, at approximately 12:54 p.m. when asked about call light response, Resident R3 stated, Sometimes they are a little slow. During an interview on 8/21/26, at approximately 12:58 p.m. when asked about call light response, Resident R4 stated, It all depends. You just have to cross your legs and hope. During an overheard conversation on 8/21/26, at approximately 1:00 p.m. in the nursing unit hallway, Nurse Aide (NA) Employee E1 asked NA Employee E2, Are you going to get him? NA Employee E2 responded, The one in the wheelchair, he can wait until I come back from break. During an interview on 8/21/26, at approximately 1:02 p.m. when asked about call light response, Resident R5 stated, It depends on how many people are here. Sometimes you might have to wait. But they will come in and turn it off (Resident R5 began laughing), they always turn it off. During an interview on 8/21/26, at approximately 1:05 p.m. when asked about call light response, Resident R6 stated, They don't show up. If I push it, they shut it off. I did this morning, she didn't come back. During an interview on 8/21/26, at approximately 1:06 p.m. when asked if call light response was prompt, Resident R7 stated, No, not really. Depends on what time. During an interview on 8/21/26, at approximately 1:08 p.m. when asked about call light response, Resident R8 stated, So, so. It varies. You can wait half a day. Observation at this time revealed Resident R8 to be eating his dinner, while in a brief visibly soiled with stool. During an interview on 8/21/26, at approximately 1:10 p.m. when asked if call light response was prompt, Resident R9 first began to laugh, then stated, When they have time. When Resident R9 was asked if he had ever soiled his clothing or had to wait an extended period to be changed, Resident R9 stated, Oh yes. During an interview and observation on 8/21/26, at approximately 1:12 p.m. the light above Resident R10 and R11's door was noted to be illuminated. Resident R10 stated that he had pushed the button for his roommate (Resident R11). Resident R11 stated that he was thirsty, and didn't have any water or anything else to drink. Resident R10 stated that he wanted water also. Observation at this time revealed that neither resident had water or other drinks available to them on the their tables or with their lunch trays. During an interview on 8/21/26, at approximately 2:05 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that necessary care and services were provided for ten of twelve residents. 28 Pa. Code: 211.10(a)(c)(d) Resident Care Policies28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Servic

Based on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, to treat and/or prevent pressure ulcers (PU/PI - injuries to the skin and underlying tissues resulting from prolonged pressure on the skin) for one of four residents (Resident R12).Findings include: Review of facility Pressure Ulcer / Pressure Injury Prevention and Management Policy dated January 2026, indicated, Residents with an identified pressure ulcer/pressure injury will receive appropriate assessment, treatment, monitoring, and care intended to promote healing, prevent infection, and reduce the risk of additional pressure injuries. Review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/26, indicated the diagnoses of Down syndrome (a genetic disorder causing developmental and intellectual delays), malnutrition (lack of sufficient nutrients in the body), and muscle wasting. Review of Section M: Skin Conditions revealed that Resident R12 one pressure ulcer, Stage 4 (full-thickness skin and tissue loss). Review of the plan of care initiated 2/12/26, for pressure ulcer to the left ischium (lower and back part of the hip bone) indicated for the facility to, Administer treatments as ordered. Review of a physician's order dated 6/11/26, indicated for the facility to provide wound care to the right buttock/coccyx and left upper posterior thigh twice daily. Review of Resident R12's treatment administration records for June, July, and August 2026 revealed the following dates failed to have wound care documented, without corresponding documentation as to why it was not completed.6/19/26 (evening shift wound care)6/24/26 (day shift wound care)7/03/26 (evening shift wound care)7/07/26 (evening shift wound care)7/15/26 (day shift wound care)7/19/26 (day shift wound care)7/24/26 (evening shift wound care)7/31/26 (evening shift wound care)8/01/26 (day shift wound care)8/04/26 (day shift wound care)8/08/26 (evening shift wound care)8/12/26 (evening shift wound care)8/17/26 (day shift wound care) Review of a physician's order dated 6/11/26, through 6/15/26, indicated for the facility to provide wound care to the left ischium twice daily. Review of Resident R12's treatment administration records for June 2026, revealed the following dates failed to have wound care documented, without corresponding documentation as to why it was not completed.6/13/26 (day shift wound care)6/15/26 (evening shift wound care) Review of a physician's orders dated 6/15/26, 6/23/26, 7/7/26, 7/28/26, indicated for the facility to provide wound care to the left ischium daily. Review of Resident R12's treatment administration records for June and July 2026, revealed the following dates failed to have wound care documented, without corresponding documentation as to why it was not completed.6/21/267/13/267/15/267/19/268/01/268/08/26 Review of Resident R12's progress notes and census information failed to reveal refusals of care on the above dates and confirmed the resident was in the facility on the above dates. Review of a wound nurse practitioner assessment dated [DATE], revealed photographs taken of Resident R12's left ischium wound to display measurement. The photograph was noted to have been taken during wound care, with the resident's brief visibly soiled with feces. During an electronic interview on 8/23/25, at 3:35 p.m. the Nursing Home Administrator confirmed the facility failed to make certain residents were provided necessary treatments and services, consistent with professional standards of practice, to treat and/or prevent pressure ulcers (PU/PI - injuries to the skin and underlying tissues resulting from prolonged pressure on the skin) for one of four residents 28 Pa. Code: 211.10(d) Resident Care Policies28 Pa. Code: 211.12(d)(5) Nursing services.

Based on review facility policies, clinical record review, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for a resident with a suspected urinary tract infection for one of four residents (Resident R1).Findings include: Review of the facility Urinary Tract Infection (UTI) last reviewed January 2026, indicated the facility Will provide appropriate assessment, prevention, identification, management, and monitoring of urinary tract infections. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/25/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section H: Bladder and Bowel, indicated Resident R1 was frequently incontinent of urine. Review of the plan of care for urinary incontinence initiated 1/10/24, indicated for staff to, Report S&S (signs and symptoms) of UTI such as flank pain, c/o burning/pain, fever, hematuria, change in mental status, etc. Review of a progress note dated 6/26/26, at 9:09 a.m. indicated, Resident is making delusional comments and stories. Seemed to be more confused. Refused to attend ice cream social yesterday and was in bed most of the day. Odd behavior for her. Reported to nursing Supervisors, discussed in clinical. Review of a physiatry progress note dated 6/30/26, at 12:21 p.m. indicated, Findings were discussed with the primary nurse practitioner, with recommendation for urinalysis and treatment of a urinary tract infection (UTI) if urinalysis is positive. Review of a physician's assistant progress note dated 7/1/26, at 10:41 a.m. indicated, Patient sates that she has noticed a foul smell from down below but is unsure where it is coming from. She states that she has been urinating more frequently. The note further stated a plan for, UA (urinalysis, a test that looks for signs of infection or inflammation) with reflex culture (a urine culture test to completed if the urinalysis is positive) to rule out infection. Review of the clinical record indicated that the order for the urinalysis was documented as completed on 7/2/26. Further review of the clinical record failed to reveal documentation that the urine was processed, received by the lab, or any results available from the documented urine test. Review of a change in condition progress note dated 7/4/26, at 7:37 p.m. indicated Resident R1 was demonstrating increased confusion, greater need for assistance with activities of daily living, and generalized weakness. Review of a progress note dated 7/5/26, at 10:15 p.m. indicated a urine specimen was collected. Review of a progress note dated 7/8/26, at 12:54 p.m. indicated that Resident R1 has E.coli (type of bacteria that lives in the intestines) present. [Resident R1] states that she continues to have foul smelling urine and intermittently pain with urination. Review of a physician's order dated 7/8/26, indicated, Fosfomycin Tromethamine (single-dose, oral antibiotic prescribed to treat uncomplicated urinary tract infections) Oral Packet 3 gram. Give 1 packet by mouth one time a day for UTI for 1 Day. Review of a progress note dated 7/8/26, at 10:07 p.m. indicated that the Fosfomycin was unavailable, awaiting pharmacy arrival. Review of a change in condition progress note dated 7/8/26, at 11:00 p.m. indicated Resident R1 was experiencing increased urinary incontinence. Review of a physician's note dated 7/10/26, at 8:33 a.m. indicated that Resident R1 had received her dose of fosfomycin and additionally received one liter of fluid, intravenously. Review of Resident R1's medication administration record (MAR) for July 2026 failed to reveal that Resident R1 received the medication or liter of fluid at the time of the progress note on 7/10/26, at 8:33 a.m. Review of a progress note dated 7/13/26, at 2:42 p.m. indicated that Resident R1 the administration of fosfomycin. During an interview on 8/21/26, at approximately 2:00 p.m. the Infection Preventionist confirmed the lack of treatment for Resident R1's urinary tract infection from the onset of symptoms (6/26/26) until medication administration on 7/13/26. During an interview on 8/21/26, at approximately 2:05 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that appropriate treatments and services were provided for a resident with a suspected urinary tract infection for one of four residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for medication administration for one of eight residents reviewed (Resident R1).Findings include: A review of the facility's policy, Medication Administration-Preparation and General Guidelines, dated 3/6/26 indicated that medications are administered as prescribed in accordance with good nursing principles and practices. A review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses that included, bipolar disorder, paranoid personality disorder, adjustment disorder, conduct disorder, and atopic neurodermatitis (severe itching of the skin). A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/2/25, indicated the diagnoses remained current and the resident is alert and oriented and independent with all activities of daily living (ADL's). A review of a physician order dated 3/23/26, indicated to apply Clindamycin Phos External gel 1% (a topical antibiotic) apply to armpit and groin topically every day and evening shift. A review of Resident R1's Medication Administration Record (MAR) dated March 2026, indicated the above medication was not administered on the evening shift of 3/27, 3/28. And 3/29/26. A review of the nurse progress notes indicated awaiting pharmacy. During an observation on 3/30/26 at 3:30 p.m., revealed the Clindamycin topical gel was available with a dispense date of 3/23/26 on the label. During an interview with the Director of Nursing on 3/30/26, at 3:30 p.m. confirmed that the facility failed to follow a physician order for medication administration for Resident R1.

Based on observations, and resident and staff interviews, it was determined that the facility failed to provide a clean and comfortable environment in one of twelve resident rooms (Resident 100) and one of two unit lounges (second floor).Findings include:Review of facility policy Homelike Environment dated 6/20/25, indicated the residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. This includes a clean, sanitary, and orderly environment. Review of facility policy Bathrooms dated 6/20/25, revealed bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis.Review of facility policy Bedpan/Urinal, Offering/Removing dated 6/20/25, indicated after a resident uses the bedpan staff are to empty the bedpan into the commode. Flush the commode. Clean the bedpan. Wipe dry and clean with a paper towel. Store the bedpan per facility policy. Do not leave it in the bathroom or on the floor.During an observation on 3/3/26, at 9:15 a.m. Resident R100's bathroom contained a bedpan with feces in a clear bag on the floor.During an interview on 3/3/26, at 9:20 a.m. Registered Nurse (RN) Employee E1 confirmed the bedpan should not have been left soiled and on the floor.During an observation on 3/3/26, at 9:30 a.m. the second floor unit lounge contained the following:- A white blanket, and approximately two white towels were located on the floor beside a wheelchair, - Approximately three or four white towels were draped across the arm rests of the wheelchair,- A white blanket was loosely folded on top of a wooden stand, placed next to a lamp,- One white towel was spread across an end table, with another white towel draped across it,- One white towel spread across the seat of a visitor chair, and one white towel draped over the back of the couch.- A round wooden table with visible crumbs, two additional visitor chairs, a large resident scale, and a vending machine.During an interview on 3/3/26, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the second floor unit lounge should not be dirty, and dirty linens should not be left in the unit lounge.During an interview on 3/3/26, at 1:00 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility failed to provide a clean, comfortable, homelike environment for Resident R100 and the second floor unit Lounge.28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observations and staff interview it was determined that the facility failed to prominently display and maintain facility daily nurse staffing hours as required for eight of eight days 2/24/26 through 3/3/26)Findings include:During an observation on 3/3/26, at 8:30 a.m. the nursing hours posted in the front lobby was for 2/23/26. The previous nursing hours posted was 2/19/26.During an interview on 3/3/26, at 8:35 a.m. the Director of Nursing confirmed that the facility did not have the staffing hours updated and posted daily.28 Pa. Code: 201.14(a) Responsibility of Licensee.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of four medication carts (First Floor-South/East Hall, Second Floor-South/East Hall).Finding include:Review of facility policy Medication Storage in the Facility: Storage of Medications dated [DATE], [DATE], and [DATE], stated that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The policy further stated that multiple dose injectable vials and ophthalmics, once opened, require an expiration date shorter than the manufacturer ' s expiration date to insure medication purity and potency.During an observation of the first-floor medication cart on [DATE], at approximately 8:55 a.m. the following was observed:-(1) bottle of Pat-a-day eye drops, open and undated.-(1) bottle of Pat-a-day, dated as opened on [DATE] on the box with no date written on the bottle.-(1) bottle of Visine, dated as opened on box 11/25, no date written on bottle.-(1) bottle of Timoptic Opth. Solution, dated as opened on box 11/25, no date written on bottle.-(1) bottle of Brimonidine Tartrate Opth. Solution, dated on box as 11/25, no date written on bottle. -(1) bottle of Pepto-Bismol, opened and undated.-(2) bottles of Lactulose, opened and undated. During an observation of the second-floor medication cart on [DATE], at approximately 9:08 a.m. the following was observed:-(2) bottles of Pat-a-day eye drops were dated on box 11/25, with no date documented on bottle.-(1) bottle Timoptic Opth. Solution was dated [DATE], with no date documented on bottle.-(1) bottle Visine was dated [DATE], with no date documented on bottle.-(1) bottle Systane was dated 11/25, with no date documented on bottle.-(1) bottle Pepto-Bismol, opened and undated.-(2) bottles of Robitussin, opened and undated.Employee E1 confirmed that the above observation of medications being labeled with dates on boxes or no dates at all were noted on the multi-dose bottles that were in her cart when she started medication administration.During an interview on [DATE], at approximately 9:20 a.m. the Director of Nursing confirmed that the facility failed to make certain that our of date medications were properly stored and/or disposed of in two of four medication carts. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1)(e)(1) Management.28 Pa Code: 211.9 (a)(1) Pharmacy services.28 Pa Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed for hospitalization (Resident R6, R27, and R116).Findings include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were to change. The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed. Review of the clinical record indicated Resident R6 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/26/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of a progress note dated 10/19/25, at 10:29 p.m. indicated that Resident R6 was transported to the hospital for altered mental status. Review of a progress note dated 10/20/25, at 12:48 a.m. indicated Resident R6 was admitted to the hospital for low potassium. Further review of Resident R6's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the resident or resident representative upon transfer. Review of the clinical record indicated Resident R27 was initially admitted to the facility on [DATE], and he was readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and high blood pressure. Review of a progress note dated 10/27/25, at 1:30 p.m. indicated that Resident R27 was transported to the hospital for altered mental status and facial swelling. Further review of Resident R27's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the resident or resident representative upon transfer. Review of the clinical record indicated Resident R116 was initially admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure and muscle wasting. Review of a progress note dated 11/8/25, at 1:44 a.m. indicated that Resident R116 was transported to the hospital for fever and abnormal vital signs. Further review of Resident R116's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the resident or resident representative upon transfer. During an interview on 11/20/25, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed for hospitalization. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on a review facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered care plans for two of eight residents (Resident R11 and R27).Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 6/20/25, indicated, The interdisciplinary team (lDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan foreach resident. Review of facility census information revealed that Resident R11 and Resident R27 share a room. Review of the clinical record indicated Resident R11 was initially admitted to the facility on [DATE], and she was readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/26/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and end stage renal disease (ESRD, an inability of the kidneys to filter the blood). Review of the plan of care last reviewed 9/8/25, indicated in the Activities care plan, Resident has a significant other at facility. Further review of Resident R11's plan of care failed to reveal a plan of care developed for a personal relationship with a peer resident. Review of the clinical record indicated Resident R27 was initially admitted to the facility on [DATE], and he was readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and high blood pressure. Review of the plan of care last reviewed 11/11/25, indicated in the Activities care plan, Resident does have a significant other here at facility. Further review of Resident R11's plan of care failed to reveal a plan of care developed for a personal relationship with a peer resident. During an interview on 11/20/25, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop person-centered care plans for two of eight residents. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 14 of 20 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10. R11, R12, R13, and R14).Findings include: During an interview on 8/10/25, at 2:40 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R1 stated, No. Resident R1 stated that call light response takes a long time. During an interview on 8/10/25, at 2:42 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R2 stated, Could be better. During an interview on 8/10/25, at 2:43 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R3 stated, Not at all. Resident R2 further stated that call light response times can be long and he waits a long time for assistance to get out of bed. During an interview on 8/10/25, at 2:47 p.m., Resident R4, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated that sometimes she needs to wait a long time for call light response. During an interview on 8/10/25, at 2:50 p.m., Resident R5, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, No, I think they could use more help. Resident R5 further stated that call light response times can be long. During an interview on 8/10/25, at 2:56 p.m., Resident R6, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated that call light response time was sometimes good, sometimes bad. During an interview on 8/10/25, at 2:58 p.m., Resident R7, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, No. Too long to answer the call lights. I've been hollering help. Nobody came. During an interview on 8/10/25, at 4 14p.m., Resident R8, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, No. Resident R8 further stated that sometimes it takes an hour or more for call light response. Sometimes I'm in excruciating pain, and it takes an hour to get my pain meds. It's horrible. During an interview on 8/10/25, at 4 18 p.m., Resident R9, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, Hell no. When asked about call light response time, Resident R9 stated, Well it all depends on if it's close to quitting time. Can be 45 minutes to an hour. You push the button, the don't even answer. Resident R9 stated she would like more showers, I don't like the smell of myself. Observation at this time confirmed that Resident R9 was malodorous. During an interview on 8/10/25, at 4 23 p.m., Resident R10, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated, Not really and stated call light response time can be long. During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, the staff member stated, Absolutely not. We are running our asses off. Friday night there was one nurse up (second floor) and one nurse down (first floor), and one supervisor. We've had an increase in fall, increase in wounds, increase in not getting shit done. Review of a grievance filed on behalf of Resident R11, dated 5/28/25, revealed concerns documented for incontinence care, grooming, availability of fresh water, protective booties not applied, and call light availability. Review of a grievance generated from a resident council meeting dated 7/15/25, indicated Multiple residents reported wait time of 30 minutes for call lights to be answered. Review of a grievance filed on behalf of Resident R12, dated 7/25/25, indicated Resident R12 reported to a staff member, [Resident R12 has filed 3 grievances and no one has gotten back to her. Her roommate/husband [Resident R13] was tangled up in a phone cord, his urine bottle spilled and was all over the floor, and she and her husband both needed to be changed but the aide never came in to help them. The nurse told her to turn the aide in for not showing up. [Resident R12] tried calling the supervisor but only got a dial tone, so she called me instead. This all happened at 4:00 p.m. When I went up to the second floor to ask for help I saw [two staff members] were helping them. Review of a grievance filed on behalf of Resident R14, dated 7/30/25, revealed concerns documented for incontinence care and call light response times. During an electronic communication on 8/13/25, at approximately 1:00 p.m. the Nursing Home Administrator and confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 14 of 20 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of clinical record was determined that the facility failed to develop a person-centered care plan related to falls for one of five residents (Residents R15). This was identified as past non-compliance.Findings include: Review of the facility policy, Fall Risk Assessment dated 6/20/25, indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the facility policy, Care Plans, Comprehensive Person-Centered dated 6/20/25, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of the minimum data set (MDS, periodic assessment of resident care needs) dated 6/24/25, included diagnoses of anemia (too little iron in the body causing fatigue) , cancer, and multiple fractures. Review of Section V: Care Area Assessment revealed that Falls was triggered to review for care plan development. Review of a nurse practitioner's note created 6/18/25, at 9:27 a.m. indicated Resident R15 was admitted to the facility after hospitalization due to falls. Assessing this patient today due to risks of falls possibly leading to fracture or other significant injury, decreased participation in therapy with longer length of stay, aspiration and/or anorexia due to weakness and fatigue. All potentially leading to rehospitalization and/or death. Review of a Fall Risk Observation Assessment dated 6/18/25, indicated that Resident R15 was at high risk for falls. Review of a progress note dated 7/9/25, at 7:00 a.m. indicated, Called to assess resident post fall. Resident observed on floor next to bed. Resident has terminal restlessness and agitation. Call light was in reach, not activated. Resident was not incontinent. Resident has small skin tear to right elbow, cleansed with NS and optifoam (silicone faced foam dressing) applied. Resident assisted into bed per facility protocol. Fall mats applied. Hospice and family notified. Review of a change in condition note dated 7/10/25, at 10:32 a.m. indicated Resident R15 was experiencing Falls Pain (uncontrolled) Urinary incontinence (new or worsening) New or Worsening Pain. Review of Resident R15's care plan initiated on 6/18/25, and active on 7/9/25, indicated, Resident is at risk for falls with or without injury related to unsteady gait, history of falls with the intervention of Keep call light within reach. No other interventions to prevent falls were documented. Review of facility submitted information dated 7/17/25, indicated Family member called APS (Adult Protective Services) alleging neglect after her fall on 7.9.2025 for a lack of fall interventions. APS alerted facility on 7.17.2025 of this accusation. Review of fall care plan shows it was initiated on 6.18.2025. Fall mats added as an intervention post fall. No injuries noted and no further falls. Terminal agitation a factor. Multiple hospice and CRNP (certified nurse practitioner) visits and medication adjustments have been made. This incident will be taken to QA (Quality Assurance) for tracking and trending. **the original fall did not meet criteria as a reportable event. A more robust fall care plan for new admissions to be discussed.** *Resident rolled out of bed. Bed was in low position and call bell in reach but not activated. Fall mats put in place post fall. ** On 7/17/25, the facility initiated a plan of correction that included:-QAPI (Quality Assurance and Performance Improvement) performance improvement plan initiated on 7/17/25.-Education to nursing leadership regarding rounding related to fall care plans.-Audits of new admissions for fall care plan completion.-Staff meetings completed 8/7/25 on rounding and fall care plans. -Current plans of care were updated as appropriate. During an electronic communication on 8/13/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to develop a person-centered care plan related to falls for one of five residents. This was identified as past non-compliance.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a hematoma (pooling of blood under the skin) and a facial laceration that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 11/1/24, indicated that residents have the right to be free of neglect. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/7/25, included diagnoses of achondroplasia (a disorder of that prevents the changing of cartilage to bone), muscle weakness, and repeated falls. Review of the MDS dated [DATE], Section GG: Functional Abilities indicated Resident R1 utilized a wheelchair, had lower extremity impairment on both sides, and was dependent on staff for transferring into his wheelchair. Review of a progress note dated 2/11/25, at 7:33 p.m. indicated Resident R1 was found on the floor in front of his wheelchair facing down. Resident R1 had a hematoma on his forehead. Emergency services were called and Resident R1 was transferred to the hospital. Review of a progress note dated 2/12/25, at 6:55 a.m. indicated Resident R1 was returning to the facility, with all testing at the hospital negative for injuries. Review of a facility incident report dated 2/11/25, indicated, Was called to room where pt (patient) was on the floor in front of his wheelchair facing down. Pt denies pain, resident was seen approx. 1 hour prior when trays picked up and no needs were identified at that time. Review of a nurse practitioner note dated 2/14/25, at 11:57 a.m. indicated that after the fall, Resident R1 had been evaluated by occupational therapy, with staff being educated on positioning in the wheelchair, tilt and recline functions of the wheelchair, and the need for leg rests to be on. Review of Resident R1's plan of care for At risk for falls initiated on 6/19/18, included an intervention dated 2/12/25, that indicated, Foot rests on wheelchair when OOB (out of bed). Review of Resident R1's Kardex as of 2/12/25, included the instruction of OOB to personal chair with leg rests. Review of the document, Inservice for Positioning dated 2/13/25-2/20/25, provided by occupational therapy, revealed eight staff members educated on positioning in wheelchair, use of leg rests when in wheelchair, and how to tilt and recline in the wheelchair for Resident R1. Nurse Aide (NA) Employee E2 signed that she received this education. Review of facility provided education documents dated 3/7/25, revealed education provided to staff on the need to use the Kardex for appropriate assistance levels and individual resident safety needs. Nurse Aide (NA) Employee E2 signed that she received this education. Review of a progress note created on 3/19/25, at 4:06 p.m. indicated, Staff responded to a call to [Resident R1's] room because he was found on the floor in a pool of blood. I responded immediately and obtained 2 sets of vitals before EMS arrived. The resident, who sustained a head injury, did not provide details about the incident or his intended destination but repeatedly stated that he was fine. When EMS arrived, I assisted with holding his neck and head, as per their instructions. His head was bandaged and neck collar applied. His BP (blood pressure) was slightly elevated but other vitals stable, he has breathing easily on room air. Review of a nurse practitioner note dated 3/19/25, at 12:40 p.m. indicated, Pt was found on the floor by a PT (physical therapy) assistant. I was in the hallway and was able to see him immediately. He was found on the floor in a large pool of blood. He was laying on his right side of the most part with his R (right) shoulder pushed out from under him making his trunk face downward. Review of a nurse's note dated 3/19/25, at 9:24 p.m. indicated, Resident returned from [hospital] with sutures to forehead and a hematoma. Review of facility submitted information dated 3/19/25, indicated, On the morning of 3/19/2025 he [Resident R1] sustained a fall from his wheelchair and was transferred to the hospital. The last time the resident was seen was 20 minutes prior to the fall sitting in his wheelchair watching television. RN (registered nurse) and CRNP (certified registered nurse practitioner) assessed post fall. Upon return from the hospital, he will be evaluated for fall interventions. Review of emergency room documentation dated 3/19/25, at 3:30 p.m. indicated Resident R1 was treated for a fall with a head injury, with the laceration repaired by plastic surgery, and will need suture removal in the plastic surgery clinic in seven days. Review of a nurse practitioner note dated 3/20/25, at 9:52 a.m. indicated that at the hospital on 3/19/25, Resident R1 received five sutures to the laceration on his forehead and that the laceration measured 3.5 centimeters. Review of an update to the submitted information dated 3/25/25, indicated, On return from the hospital, resident was evaluated for seating. Upon investigation, it was noted by CNA (nurse aide) that she did not apply leg rests as indicated. Review of an undated employee statement written by NA Employee E2 indicated, When I got [Resident R1] put him in the chair and didn't put the leg rest on because they cause him pain. So I just sat him up straight and put him in front of the television. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 3/28/25, indicated that NA Employee E2 neglected to follow facility recommended safety measures, and was terminated from her employment. Attempts to call and interview NA Employee E2 were unsuccessful. During an interview on 5/7/25, at 11:00 a.m., NA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs. During an interview on 5/7/15, at 11:50 a.m., NA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs. During an interview on 5/7/25, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed NA Employee E2 had two separate educations on the need to use leg rests for Resident R1 and the need to use the Kardex for appropriate assistance levels and safety information, confirmed that NA Employee E2 did not appropriately position Resident R1 in his wheelchair, and confirmed that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma and a facial laceration that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma (pooling of blood under the skin) and a facial laceration that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Supporting Activities of Daily Living (ADL) dated 11/1/24, indicated Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/7/25, included diagnoses of achondroplasia (a disorder that prevents the changing of cartilage to bone), muscle weakness, and repeated falls. Review of the MDS dated [DATE], Section GG: Functional Abilities indicated Resident R1 utilized a wheelchair, had lower extremity impairment on both sides, and was dependent on staff for transferring into his wheelchair. Review of Resident R1's plan of care for Requires assistance / potential to restore function for MOBILITY dated 2/9/23, indicated the intervention of a high back w/c (wheelchair) with fitted leg rests and a foot buddy (a stable platform for the wheelchair user's feet). Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) as of 2/10/25, did not include information related to the use of a high back wheelchair or a foot buddy. Review of a progress note dated 2/11/25, at 7:33 p.m. indicated Resident R1 was found on the floor in front of his wheelchair facing down. Resident R1 had a hematoma on his forehead. Emergency services were called and Resident R1 was transferred to the hospital. Review of a progress note dated 2/12/25, at 6:55 a.m. indicated Resident R1 was returning to the facility, with all testing at the hospital negative for injuries. Review of a facility incident report dated 2/11/25, indicated, Was called to room where pt (patient) was on the floor in front of his wheelchair facing down. Pt denies pain, resident was seen approx. 1 hour prior when trays picked up and no needs were identified at that time. Review of Resident R1's plan of care for At risk for falls initiated on 6/19/18, included an intervention dated 2/12/25, that indicated, Foot rests on wheelchair when OOB (out of bed). Review of Resident R1's Kardex as of 2/12/25, included the instruction of OOB to personal chair with leg rests. Review of a nurse practitioner note dated 2/14/25, at 11:57 a.m. indicated that after the fall, Resident R1 had been evaluated by occupational therapy, with staff being educated on positioning in the wheelchair, tilt and recline functions of the wheelchair, and the need for leg rests to be on. Review of the document, Inservice for Positioning dated 2/13/25-2/20/25, provided by occupational therapy, revealed eight staff members educated on positioning in wheelchair, use of leg rests when in wheelchair, and how to tilt and recline in the wheelchair for Resident R1. During an interview on 5/7/25, at approximately 2:00 p.m. Director of Therapy Employee E1 confirmed that only eight staff were educated, with the expectation that those staff would disseminate the information to their coworkers. Review of a progress note created on 3/19/25, at 4:06 p.m. indicated, Staff responded to a call to [Resident R1's] room because he was found on the floor in a pool of blood. I responded immediately and obtained 2 sets of vitals before EMS arrived. The resident, who sustained a head injury, did not provide details about the incident or his intended destination but repeatedly stated that he was fine. When EMS arrived, I assisted with holding his neck and head, as per their instructions. His head was bandaged and neck collar applied. His BP (blood pressure) was slightly elevated but other vitals stable, he has breathing easily on room air. Review of a nurse practitioner note dated 3/19/25, at 12:40 p.m. indicated, Pt was found on the floor by a PT (physical therapy) assistant. I was in the hallway and was able to see him immediately. He was found on the floor in a large pool of blood. He was laying on his right side of the most part with his R (right) shoulder pushed out from under him making his trunk face downward. Review of a nurse's note dated 3/19/25, at 9:24 p.m. indicated, Resident returned from [hospital] with sutures to forehead and a hematoma. Review of facility submitted information dated 3/19/25, indicated, On the morning of 3/19/2025 he [Resident R1] sustained a fall from his wheelchair and was transferred to the hospital. The last time the resident was seen was 20 minutes prior to the fall sitting in his wheelchair watching television. RN (registered nurse) and CRNP (certified registered nurse practitioner) assessed post fall. Upon return from the hospital, he will be evaluated for fall interventions. Review of emergency room documentation dated 3/19/25, at 3:30 p.m. indicated Resident R1 was treated for a fall with a head injury, with the laceration repaired by plastic surgery, and will need suture removal in the plastic surgery clinic in seven days. Review of a nurse practitioner note dated 3/20/25, at 9:52 a.m. indicated that at the hospital on 3/19/25, Resident R1 received five sutures to the laceration on his forehead and that the laceration measured 3.5 centimeters. Review of an update to the submitted information dated 3/25/25, indicated, On return from the hospital, resident was evaluated for seating. Upon investigation, it was noted by CNA (nurse aide) that she did not apply leg rests as indicated. Review of an undated employee statement written by NA Employee E2 indicated, When I got [Resident R1] put him in the chair and didn't put the leg rest on because they cause him pain. So I just sat him up straight and put him in front of the television. Attempts to call and interview NA Employee E2 were unsuccessful. During an interview on 5/7/25, at 11:00 a.m., NA Employee E5 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs. During an interview on 5/7/15, at 11:50 a.m., MA Employee E10 confirmed the use of the Kardex when caring for residents to provide instruction for additional safety measures or any other needs. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 3/28/25, indicated that Nurse Aide Employee E2 neglected to follow facility recommended safety measures, and was terminated from her employment. During an interview on 5/7/25, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma and a facial laceration that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and facility provided documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a facial laceration requiring two sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Supporting Activities of Daily Living (ADL) dated 11/1/24, indicated Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 12/29/24, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), muscle weakness, and osteoarthritis (degeneration of the joint causing pain and stiffness). Review of Section GG - Functional Abilities indicated that Resident R1 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for rolling left and right. Review of Resident R1's physicians' orders did not reveal an order specifying an assistance level for bed mobility. Review of Resident R1's MDS assessment history revealed the following: 09/03/21: Assist 2 people for bed mobility. 11/10/21: Assist 2 people for bed mobility. 02/01/22: Assist 2 people for bed mobility. 05/02/22: Assist 2 people for bed mobility. 08/10/22: Assist 2 people for bed mobility, using extensive assist. 11/08/22: Assist 2 people for bed mobility, using extensive assist. 02/02/23: Assist 2 people for bed mobility, using extensive assist. 05/10/23: Assist 2 people for bed mobility, using extensive assist. 08/10/23: Assist 2 people for bed mobility, using extensive assist. 11/02/23: Assist 2 people for bed mobility, using extensive assist. 02/15/24: Assist: 2 people for bed mobility. using a sit to stand. 07/17/24: Assist: 2 people for bed mobility. using a sit to stand. 10/15/24: Assist: 2 people for bed mobility. using a sit to stand. 12/09/24: Assist: 2 people for bed mobility. using a sit to stand. Review of Resident R1's [NAME] (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) as of 2/3/25, indicated Resident R1 was ADL Assist:1- 2 people for bed mobility; 2 while using a sit to stand. During an electronic communication on 2/11/25, at 3:49 p.m. the Director of Nursing confirmed that wording sit to stand would be while using a lift for transfers, not for bed mobility. Review of a Physical Therapy Discharge Summary dated 1/7/25, indicated that for Rolling Resident R1 is maximum assistance. Review of a progress note written by Unit Manager Employee E1 dated 2/4/25, at 12:28 p.m. indicated, Upon entering the room resident was observed laying face down on right side of bed. Resident noted to have a laceration to left eyebrow area. Blood noted on her face and hair. Resident C/O (complained of) headache. Did not voice visual changes, or nausea. Able to move upper and lower extremities. CRNP (Certified Registered Nurse Practitioner) into assess resident and gave orders to send to [hospital] for evaluation and treatment. Review of a CRNP note dated 2/4/25, at 1:16 p.m. indicated, [Resident R1] is being seen emergently following a fall out of bed onto the floor. On exam she is laying on her back on the floor. she has a head laceration to her left eyebrow that is bleeding significantly. she has large amounts of blood in her hair but do not see a visible laceration. she does endorse neck pain on palpation. Per her report and nursing report at bedside she was receiving care and was rolled out of bed. She states that she did try to brace herself with her hands but didn't do a good job and hit her head off the floor. She denies any hand, wrist, back, hip or knee pain. Review of a progress note dated 2/4/25, at 7:11 p.m. indicated, resident returned from [hospital] with stated closed head injury with facial laceration. Review of a CRNP note dated 2/5/25, at 9:32 a.m. indicated, [Resident R1] evaluated today for a mechanical fall that occurred yesterday. The fall did result in injury. Pt (patient) sustained a laceration to her L (left) eyebrow. Bleeding was large in amount, pt was sent to [hospital] where she received wound cleanse and 2 sutures to the area. Imaging results not immediately available for review, however, pt verbalizes that her imaging was unremarkable. The pt states that she was leaning her head on her bedside table, but was stuck between the stable and another furniture object (?). A staff member came to help her get unstuck, but the table was pulled from underneath her, and she fell, hitting the left side of her body. Review of emergency room discharge paperwork dated 2/4/25, revealed Resident R1 was treated for a left eyebrow laceration that was repaired with sutures, and evaluated for a closed head injury, left knee pain, and left ankle pain. Review of facility submitted information dated 2/5/25, indicated, [Resident R1] was being washed by CNA (nurse aide) when she rolled out of bed and received a small laceration to her forehead. Resident was an assist of 1 for bed mobility and was receiving care per her care plan/orders. No suspected abuse. Resident was assessed by the RN and the CRNP and was sent to the ER for further precautionary eval. MD (doctor of medicine) and family were aware. Resident received 2 sutures, and all of the scans were negative for any further findings. Resident has since returned to facility and has been re-evaluated by the care plan team. resident is now an assist of 2 in bed during care to assist in prevention of future incidents. Review of an employee statement written by Nurse aide (NA) Employee E8 dated 2/4/25, indicated, I [NA Employee] was doing care on [Resident R1]. Her bed was waist level and she was a full bed change. I rolled her to the right and told her to hold on to the headboard. She said that other people told her not to do that. I told her to do it so she wouldn ' t't roll out of bed. I tried to catch her but it happened too fast. I saw blood coming from her head so I ran and got the nurse. During an interview on 2/8/25, at approximately 3:30 p.m. the Director of Nursing confirmed that the nurse aide requested Resident R1 to grasp the headboard to assist in maintaining her position in bed, which indicated the expectation of Resident R1 being able to assist in her care, contrary to her MDS level of Dependent. During interviews completed on 2/8/25, to confirm staff understood how to review bed mobility status, revealed the following: NA Employee E9 stated to review the [NAME]. NA Employee E10 stated to review the computer. NA Employee E11 stated to review the [NAME]. RN Employee E12 stated to review the [NAME]. RN Employee E13 stated she was familiar with her residents. Licensed Practical Nurse Employee E3 was not able to describe a process. During an interview on 2/8/25, at approximately 3:00 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a facial laceration requiring two sutures for one of three residents. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 PA. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility documents, and staff interviews it was determined that the facility failed to institute corrective actions and resolve resident grievances for seven of fifteen residents (Resident R2, R3, R4, R5, R6, R7, and R8). Findings include: Review of the facility policy Filing Grievances/Complaints dated 11/1/24, indicated the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. Review of facility grievances filed in January 2025, revealed the following: -On 1/15/24, Resident R2 had voiced a concern about not being assisted to shower and not receiving nail care. -On 1/15/24, Resident R3 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R4 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R5 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R6 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R7 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R8 had voiced a concern about not being assisted to shower. On each of the above grievances, the recommended corrective action was documented to be Staff Education. On each of the above grievances, the question, Was grievance/concern resolved? was checked Yes, and signed by the former Director of Nursing. On 2/7/25, the current Director of Nursing was asked to provide evidence of staff education related to the above grievances. During an interview on 2/8/25, at approximately 3:30 p.m. the current Director of Nursing confirmed the facility was unable to provide evidence that the above education occurred. During an interview on 2/10/24, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to institute corrective actions and resolve resident grievances for seven of fifteen residents. 28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.29(a) Resident's Rights.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate possible abuse and/or neglect for two of four residents. Findings include: Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 11/1/24, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R11 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/2/25, included diagnoses of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture) and autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). Review of Section C: Cognitive Patterns revealed Resident R11's BIMS score to be 00. Review of Resident R11's plan of care for behavior management initiated 7/10/24, did not include the mention of scratching or other self-inflicted behaviors until 1/21/25. Review of Resident R11's progress notes since admission related to scratches until 1/17/25. Review of physician's order dated 11/27/24, for behavior charting to be documented on the Medication Administration Record revealed that the nurse documented that he/she monitored for behaviors, but not if any behaviors occurred, or what they were. Review of a progress note dated 1/17/25, at 11:58 p.m. indicated Resident R11 was being seen for a cough and a fall. Per nursing the patient sustained a fall earlier today and was found laying on his fall mats beside his bed. He does not have any visible injuries but the fall was unwitnessed. He does not have any red marks or bruising but does have old scratch marks to his bilateral arms. Review of nurse aide charting on behaviors failed to indicate any behaviors documented. Review of a police report filed by [Police Officer A] in reference to a welfare check completed on Resident R11 on 1/19/25, at 5:26 p.m. indicated that a family member of Resident R11 requested a welfare check in regards to multiple scratches to both his forearms as well as the right inside and back of his neck. Resident R11's family member stated that through yes/no questioning, Resident R11 indicated Registered Nurse (RN) Employee E14 as the alleged perpetrator. In addition, the following interview dated 1/19/25, at 6:20 p.m. was documented with Resident R11: I [Police Officer B] asked Resident R11 if he knew how he received these injuries and he responded, Yes. I pointed to family member's husband and asked Resident R11 if he caused the injuries, Resident R11 replied No. I asked Resident R11 if family member caused the injuries to which he again replied, No. I showed Resident R11 a picture of an employee who family member reported as the actor to which he replied, Yes. [Police Officer A] and I later identified the employee as RN Employee E14. RN Employee E14 reported she is the registered nurse on duty and functions as the supervisor. I informed RN Employee E14 we were investigating an allegation as to an unknown employee leaving Resident R11 reclined in his chair to teach him a lesson. Family member reported that Resident R11's roommate had informed her that he overheard staff stating they were leaving Resident R11 in a reclined position to teach him a lesson. RN Employee E14 advised that she already notified the Director of Nursing of our presence and she would relay the purpose of our visit to her as well. Review of facility submitted information dated 1/20/25, indicated the facility was notified on 1/20/25, at 3:29 p.m., by an Adult Protective Services representative on the telephone, that resident, [Resident R11], his sister made allegations of scratches on resident. Resident is known to have self-inflicted scratches due to gait instability and behaviors, on BLE (bilateral lower extremities, both lower legs). Resident BIMS of 00. Resident is independent for bed mobility, an assist of 1 for transfers, and independent for wheelchair mobility. Investigation on-going. No AP (alleged perpetrator) identified at this time. Review of a progress note dated 1/21/25, at 10:34 a.m. indicated, Resident had a head-to-toe skin assessment completed by this writer after notification by APS (Adult Protective Services) that sister, had reported scratch marks on him. Resident does have scratches scattered across his body habitus, in various stages of healing. These are not new or acute findings as evidenced by provider documentation in recent history and behavior patterns observed that include wandering, restlessness, scratching, and agitation. Review of the clinical record indicated Resident R12 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and muscle weakness. Review of Section GG: Functional Abilities indicated Resident R12 required partial/moderate assistance for chair/bed to chair transfers, and for the ability to get on and off the toilet. Review of Section C: Cognitive Patterns indicated Resident R12 had a BIMS score of 15. Review of a change in condition note dated 1/12/25, at 3:06 p.m. indicated Resident R12 sustained a fall and a right knee x-ray was ordered. Review of a note in draft status dated 1/12/25, at 5:00 p.m. indicated, Resident noted on the right side of the bed s/p (status post, after) fall no injury while attempting to transfer from bed to wheelchair with sliding board. Review of a progress note dated 1/13/25, at 11:51 a.m. indicated Resident noted on right side of bed. S/P fall no injury while attempting to transfer from bed to wheelchair with sliding board. Review of a Nurse Practitioner follow-up note dated 1/14/25, at 11:56 a.m. indicated, Patient fell out of bed on 1/12- no injuries. She said she was trying to yell for staff but no one was coming and she slid out of bed on her bottom. Review of a facility provided incident report dated 1/12/25, indicated, Per progress note was being transferred with sliding board from bed to chair and slid to floor. No injury noted. Review of a facility provided Rehab - Status Post-Fall Screen dated 1/13/25, indicated, Per patient, she was attempting to get OOB (out of bed) into her wheelchair and did not use the slideboard. She reports that she had her call bell on and when no one came in for an extended period of time, she attempted to complete the transfer herself. She reports she slid to the floor. During an interview on 2/13/24, at approximately 2:00 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that Resident R11 had no mention of self-inflicted behaviors prior to the incident above, and confirmed that an alleged perpetrator was identified, but an investigation was not completed to rule out possible abuse. The NHA and the DON further confirmed that Resident R12 had made an allegation of neglect when she stated that she attempted to self-transfer after no response to her call light, that the progress notes and the incidents reports / Post-Fall Screen did not coincide, but no further investigation was completed to rule out neglect. 28 Pa Code: 201.14(a)(c)(e) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(e)(1) Management

Based on review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide necessary services to maintain grooming and personal hygiene for nine of 16 residents (Residents R2, R3, R4, R5, R6, R7, R8, R20, and R23). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the facility policy Supporting Activities of Daily Living (ADL) dated 11/1/24, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) b. mobility (transfer and ambulation, including walking) c. elimination (toileting). Review of facility grievances filed in January 2025, revealed the following: -On 1/15/24, Resident R2 had voiced a concern about not being assisted to shower and not receiving nail care. -On 1/15/24, Resident R3 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R4 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R5 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R6 had voiced a concern about not being assisted to shower. -On 1/15/24, Resident R7 had voiced a concern about not being assisted to shower. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/24/25, included diagnoses of weakness, gait abnormalities, and history of a stroke. Review of Section C: Cognitive Patterns revealed Resident R2 to have a BIMS score of 15. During an interview and observation on 2/7/25, at approximately 1:30 p.m. Resident R2 was noted to have long, dirty fingernails. When asked, Resident R2 stated he would like assistance in cleaning and clipping his fingernails. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of multiple sclerosis (a disease that affects central nervous system) and absence of both legs above the knee. Review of Section C: Cognitive Patterns revealed Resident R3 to have a BIMS score of 15. Review of Resident R3 ' s shower record for 1/9/25, through 2/7/25, revealed Resident R3 was scheduled to receive showers on Mondays and Thursdays. Resident R3 was documented as having received four showers, with no refusals documented. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of gait abnormalities, muscle weakness, and muscle wasting. Review of Section C: Cognitive Patterns revealed Resident R4 to have a BIMS score of 14. Review of Resident R4 ' s shower record for 1/9/25, through 2/7/25, revealed Resident R4 was scheduled to receive showers on Wednesday s and Saturdays. Resident R4 was documented as having received three showers, with no refusals documented. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), muscle wasting, and hemiplegia (paralysis on one side of the body) following a stroke. Review of Section C: Cognitive Patterns revealed Resident R5 to have a BIMS score of 15. Review of Resident R5 ' s shower record for 1/9/25, through 2/7/25, revealed Resident R5 was scheduled to receive showers on Mondays and Thursdays. Resident R5 was documented as having received two showers, with three refusals documented. During an interview on 2/7/25, at 1:36 p.m. Resident R5 stated she does not receive enough showers, and further stated that she has never refused a shower. Review of the clinical record indicated Resident R6 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes, glaucoma (a group of eye conditions that can cause blindness), and muscle weakness. Review of Section C: Cognitive Patterns revealed Resident R6 to have a BIMS score of 15. Review of Resident R6 ' s shower record for 1/9/25, through 2/7/25, revealed Resident R6 was scheduled to receive showers on Wednesday s and Saturdays. Resident R6 was documented as having received one shower, with one refusal documented. Review of the clinical record indicated Resident R7 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), muscle weakness, and hemiplegia following a stroke. Review of Section C: Cognitive Patterns revealed Resident R7 to have a BIMS score of 9. Review of Resident R7 ' s shower record for 1/9/25, through 2/7/25, revealed Resident R7 was scheduled to receive showers on Tuesdays and Fridays. Resident R7 was documented as having received two showers, with one refusal documented. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses dementia (a group of symptoms that affects memory, thinking and interferes with daily life), osteoporosis (condition when the bones become brittle and fragile), and muscle weakness. Section H: Bladder and Bowel indicated Resident R8 is frequently incontinent of both bladder and bowel. Review of Resident R8 ' s task care record for 2/7/25, indicated Resident R8 was incontinent of bladder, documented at 7:47 a.m. and incontinent of bowel, documented at 7:52 a.m. No further bladder or bowel movements were documented until 2/7/25, at 10:59 p.m. During an observation on 2/7/25, at 1:39 p.m. a soiled brief was observed on the floor by the door to Resident R8 ' s room. During an interview on 2/7/25, at 1:41 p.m. Registered Nurse (RN) Employee E16 confirmed the presence of the soiled brief on the floor of Resident R8 ' s room. During an observation on 2/7/25, at 2:05 p.m. the call light for Resident R20 and R23 ' s room was noted to be illuminated. An environmental service worker was observed passing the room, without entering. Licensed Practical Nurse (LPN) Employee E17 was observed entering the room next to Resident R20 and R23 ' s room. During an observation on 2/7/25, at 2:12 p.m. three staff members were observed at the nurses ' station (RN Employee E18 charting, RN Employee E4 working at a computer, and Nurse Aide Employee E19 using her personal phone). During an observation on 2/7/25, LPN Employee E17 was observed responding to Resident R20 and R23 ' s room. The three staff members at the nurses ' station were still engaged in their same activity. During an interview on 2/13/25, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to institute corrective actions and resolve resident grievances for seven of fifteen residents. 28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.29(a) Resident's Rights.

Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to accurately document meal consumption for two of two residents observed. (Residents R9 and R10). Findings include: Review of the facility policy, Meals - Feeding the Resident dated 11/1/24, indicated the percentage of the diet consumed is recorded. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/30/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anemia (too little iron in the body causing fatigue), and dysphagia (difficulty swallowing). Review of Resident R9's care plan for nutritional risk due to dementia and a mechanically altered diet initiated 6/20/24, included the intervention of Monitor intake at all meals. Review of Resident R9's ADL Care Record indicated that Amount Eaten was to be documented three times per day, (9:00 a.m., 1:00 p.m., and 6:00 p.m.). Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and dysphagia (difficulty swallowing). Review of Resident R10's care plan for nutritional risk due to diabetes and dysphagia initiated 10/12/22, and updated 4/18/24, included the intervention of PROVIDE 1:1 (one to one) ASSISTANCE WITH MEALS. Review of Resident R10's ADL Care Record indicated that Amount Eaten was to be documented three times per day, (9:00 a.m., 1:00 p.m., and 6:00 p.m.). During an observation on 2/7/25, at approximately 1:30 p.m. Resident R9 and Resident R10 were observed in the lounge across from the nurses' station. Resident R9 was seated in her wheelchair at the entrance to the lounge. Resident R10 was seated in her wheelchair at the first table upon entering the lounge. The meal trays were observed at the table behind the first table, with the lids removed. No food had been eaten from the trays. During an observation on 2/7/25, at 1:51 p.m. the surveyor entered the lounge, and residents and meal trays were in the same position, no food had been removed from the trays. Licensed Practical Nurse (LPN) Employee E3 was seated in a chair in the corner of the room. The surveyor seated themselves in the lounge for observation. During an observation 2/7/25, at 1:58 p.m. LPN Employee E3 exited the lounge. During an observation on 2/7/25, at 1:59 p.m. Registered Nurse (RN) Employee E5 entered the lounge, greeted the residents, and picked up the meal trays. Review of Resident R9's Task List history indicated that on 2/7/25, at 12:24 p.m. NA Employee E6 documented Resident R9's meal consumption was 51-75%. Review of Resident R10's Task List history indicated that on 2/7/25, at 1:05 p.m. NA Employee E7 documented Resident R10's meal consumption was 51-75%. During an interview on 2/7/25, at approximately 2:30 p.m. NA Employee E7 was asked why she documented 51-75% of meal consumption when Resident R10 did not consume any of her meal, almost an hour prior to Resident R10's meal tray picked up. NA Employee E7 stated, That's how much she normally consumes when she is in my presence. Ten additional residents were reviewed that NA Employee E6 charted meal consumption for on 2/7/25, revealed the following: Resident R13, Breakfast 51-75%, Lunch 51-75%: Resident R14, Breakfast 51-75%, Lunch 51-75%: Resident R15, Breakfast 51-75%, Lunch 51-75%: Resident R16, Breakfast 51-75%, Lunch 51-75%: Resident R17, Breakfast 51-75%, Lunch 51-75%: Resident R18, Breakfast 51-75%, Lunch 51-75%: Resident R19, Breakfast 51-75%, Lunch 51-75%: Resident R2, Breakfast 51-75%, Lunch 51-75%: Resident R21, Breakfast 51-75%, Lunch 51-75%: Resident R22, Breakfast 51-75%, Lunch 76-100%: During an interview on 2/7/25 at approximately 3:00 p.m., the Director of Nursing confirmed that the facility failed to accurately document meal consumption for two of two residents observed. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of neglect for one of four residents (Resident R122). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 11/1/24, indicated the facility will investigate and report any allegations withing timeframes required by federal requirements. Review of abuse education provided to facility staff defined abuse as willful mistreatment that can be verbal, sexual, physical, or mental. The education further stated that employees of nursing homes are mandated to immediately report any suspected abuse of a recipient of care, and provided a toll-free hot, elder abuse hot line to report abuse. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R12 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/27/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and muscle weakness. Review of Section GG: Functional Abilities indicated Resident R12 required partial/moderate assistance for chair/bed to chair transfers, and for the ability to get on and off the toilet. Review of Section C: Cognitive Patterns indicated Resident R12 had a BIMS score of 15. Review of a change in condition note dated 1/12/25, at 3:06 p.m. indicated Resident R12 sustained a fall and a right knee x-ray was ordered. Review of a note in draft status dated 1/12/25, at 5:00 p.m. indicated, Resident noted on the right side of the bed s/p (status post, after) fall no injury while attempting to transfer from bed to wheelchair with sliding board. Review of a progress note dated 1/13/25, at 11:51 a.m. indicated Resident noted on right side of bed. S/P fall no injury while attempting to transfer from bed to wheelchair with sliding board. Review of a Nurse Practitioner follow-up note dated 1/14/25, at 11:56 a.m. indicated, Patient fell out of bed on 1/12- no injuries. She said she was trying to yell for staff but no one was coming and she slid out of bed on her bottom. Review of a facility provided incident report dated 1/12/25, indicated, Per progress note was being transferred with sliding board from bed to chair and slid to floor. No injury noted. Review of a facility provided Rehab - Status Post-Fall Screen dated 1/13/25, indicated, Per patient, she was attempting to get OOB (out of bed) into her wheelchair and did not use the slideboard. She reports that she had her call bell on and when no one came in for an extended period of time, she attempted to complete the transfer herself. She reports she slid to the floor. Review of facility submitted events to the state survey agency failed to include the report of an allegation of neglect. During an interview on 2/13/23, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that facility failed to implement policies and procedures to report allegations of neglect for one of four residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of facility policy, clinical record, and staff and family interviews, it was determined that the facility failed to provide medically-related social services related to a resident transfer for one of three residents (Resident R11). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the facility policy, Social Services dated 11/1/24, indicated the facility provides medically-related social services to assure each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The social worker / social services staff are responsible for helping residents with transitions of care services (for example, community placement options, home care services, transfer arrangements, etc.). Review of the clinical record revealed that Resident R11 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/2/25, included diagnoses of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), and a seizure disorder. Review of Section C: Cognitive Patterns revealed Resident R11's BIMS score to be 00. Review of Resident R11's plan of care for Discharge/Transfer Preference initiated on 1/7/25, indicated that Resident R11's responsible party / family member indicated a preference to discharge to an assisted living facility. During an interview on 2/7/25, at 9:32 a.m. Social Services (SS) Employee E15 confirmed that the first set of documents were completed by the physician on 11/1/24, and sent to the assisted living facility on 11/6/24. Review of facility provided documentation dated 11/1/24, revealed the following: -Annual Physical Examination was missing documentation in the following sections: the date of birth , age, exam date, address, allergies to medications, height, weight, pulse, respirations, blood pressure, medications and treatments, visual screening, hearing screening, review of previous medical history, recommended diet, medical information pertinent to diagnosis and treatment in case of emergency, whether a walker or helmet was required, reason why the prostate exam was not completed, date of last diphtheria/tetanus (DTaP) vaccination, date of last Mantoux (tuberculosis screening test), the Seizure Procedure Verification Form indicated No Seizures, the audiometric (hearing) examination form was blank, the Abnormal Involuntary Movement Scale (AIMS) evaluation form was blank, the Vision and Eye Health Evaluation form was blank, the Dental Exam form was blank, and the Verification of Disability form was blank and unsigned. Review of information submitted by Resident R11's Autism Advocate dated 1/6/25, stated [Resident R11] client with autism and other developmental and mental health disabilities. The [ALF] has had a bed available in a community residential group home ready for him since about the end of October, 2024. Here we are two months later with simple paperwork left undone despite advocacy by family, supports coordination, Autism Connection of PA, and ALF. Here is a list of what remains outstanding which I received today from [Resident R11's] supports coordinator. I visited [Resident R11] to have him read and sign a release of his health records to his sister specifically so she could assure things were completed correctly. Every day [Resident R11] is kept in this inappropriate institutional setting harms his mental health. Please help [Resident R11] and his team correctly execute this simple paperwork and evaluation issues so he can access a least restrictive, community-based and age appropriate setting as soon as possible. During an interview on 2/12/25, at 12:15 p.m. the Vice-President of Corporate Compliance for the Assisted Living Facility (ALF) stated that an open bed became available for Resident R11 in October of 2024, and the resident/family accepted the vacancy on 10/22/24. A preadmission packet was provided to the facility on [DATE]. Per the ALF, no additional information was received from the facility until 12/20/24, at which time 10 of the required items were provided to the ALF. Additionally, one item was provided on 1/6/25, one on 1/8/25, three on 1/13/25, two corrected items received on 1/15/25, and two corrected items on 1/22/25, which allowed the Resident R11 to transfer to the facility on 1/23/25. During an interview on 2/13/25, at approximately 11:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide medically-related social services related to a resident transfer for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1))(3)(e)(1) Management. 28 Pa. Code 201.29 (a)(j) Resident rights. 28 Pa. Code 211.2 (a) Physician services. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function that resulted in actual harm of a severe fecal impaction and required hospitalization for one of three residents, (Resident R34), notify the physician in a timely manner of a resident's change in medical condition for two of six residents (Resident R6, and R50). Findings include: During an interview on 4/18/23, at 11:00 a.m., the Director of Nursing (DON) indicated that the facility did not have a policy relating to a bowel protocol and that bowel monitoring was individualized to each resident's needs through the care plan. Review of the Cleveland Clinic's (a non-profit academic medical center) definition of symptoms for severe fecal impaction (hardened stool in the rectum or colon that is not moving) indicated nausea, dehydration, increased confusion and diarrhea (patient may pass watery stool around hardened feces that the patient cannot pass), and bleeding. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. those changes early and getting the resident to a higher level of care faster may prevent damage for a better outcome. A review of the facility Diabetes Protocol last reviewed 9/9/22 and 2/6/23, indicated the management of residents with diabetes should be patient-centered, determine and document blood glucose, determine frequency of hyperglycemic episodes, review current interventions for effectiveness, and manage the diabetes appropriately with diet and medication, as indicated, following relevant guidelines and protocols. Review of the admission record indicated that Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's Minimum Data Set (MDS - periodic assessment of care needs) dated 3/27/23, indicated diagnoses of high blood pressure, cerebral palsy (a congenital disorder of movement, muscle tone, or posture caused by abnormal brain development), and pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid). Section H Bladder and Bowel, Question H0400 Bowel Incontinence indicated that Resident R34 was always incontinent of bowel. A review of physician orders for March 2023, indicated the following: -Diet - Nothing by mouth (NPO) -Jevity 1.2 ( liquid nutrition provided via a tube, when one cannot eat orally) at 60ml/hr (milliliters/hour) continuously through a Percutaneous Endoscopic Gastrostomy (PEG tube -the creation of an artificial external opening into the stomach for nutritional support) and an infusion pump due to the inability to swallow properly. -Ordered 10/29/22 through current, medication of Polyethylene Glycol 3350 give 17 grams via PEG tube every 24 hours as needed for constipation. A review of Resident R34's care plan on 4/18/23, at 12:00 p.m., failed to include any problems, goals, or interventions for bowel monitoring. A review of Resident R34's bowel record on the Documentation Survey Report v2 with Registered Nurse Assessment Coordinator (RNAC) Employee E4 indicated: -3/1/23, through 3/16/23, Resident R34 had 30 of 48 shifts (10 days) without a bowel movement. -More specifically 3/11/23 -3/16/23 resident had 13 of 18 shifts (four days and one shift) without a bowel movement and five soft movements. The March 2023, medication administration record indicated the order for Polyethylene Glycol 3350 give 17 grams via PEG tube every 24 hours as needed for constipation was not documented as administered. A review of the Physician note dated 3/7/23, at 5:53 p.m., indicated Resident R34's bowel movements have been inconsistent and has been somewhat constipated the past few days. The physician made reference to a CT scan (an x-ray that takes images from different angles around your body and uses the computer to create cross sectional images of bones, blood vessels and soft tissues inside the body) of the abdomen and pelvis that indicated that it was notable for rectal fecal impaction, date of this CT scan is unknown, and there were not any new physician orders in relation to this notation by the physician. A review of a progress note dated 3/17/23, at 7:49 a.m. indicated Resident R34 currently having projectile vomiting, blood pressure 145/104, bilateral wheezing in upper lungs and was being sent to the emergency room . A review of progress notes dated 3/1/23, through 3/17/23, (with the exception of the physician note above) failed to indicate any progress notes related to Resident R34's lack of a bowel movements or loose bowel movements. A review of CT abdomen and pelvis results dated 3/17/23 indicated: heavy colonic (colon) and rectal stool burden with rectal wall thickening and mild perirectal edema (swelling around rectum). Without intervention patient may be at increased risk for pressure necrosis (severe damage from pressure that causes tissue to die), ischemia (inadequate blood supply to an organ or part of the body), and perforation (pierce and make a hole or multiple holes). Clinical correlation is advised for constipation/fecal impaction. A review of hospital paperwork, Gastroenterology Physician note dated 3/20/23, at 7:31 a.m., indicated, Assessment: Resident R34 admitted to the hospital with an episode of nausea and vomiting which appears to have resolved. Resident R34 had severe fecal impaction for which treatment was received. Resident R34 was hospitalized from 3/17/23 - 3/20/23 to resolve the impaction. During an interview on 4/18/23, at 8:57 a.m., Registered Nurse (RN) Employee E10 indicated the bowel protocol was three days, the system alerts in the computer, it goes off the Nursing Assistant's charting, also we ask the residents if they are alert and the nursing assistants will also report to the nurses. During an interview on 4/18/23, at 8:58 a.m., Licensed Practical Nurse (LPN) Employee E6 indicated after three days we take action (if the resident has not moved their bowels), for me after two days I give prune juice, push fluids and give as needed meds if they have them. If they don't have medication we have to call for an order. We are told through report who has not gone to the bathroom. During an interview on 4/18/23, at 9:00 a.m., RN Employee E11 indicated we have to contact the doctor for orders, there's not a standard protocol for every resident, the system generates an alert, which was demonstrated, and it goes off what the Nursing Assistants document. After three days we start something. During an interview on 4/18/23, at 9:01 a.m., Nurse Aide (NA) Employee E12 indicated we report to nurse if no bowel movement in three days, aides are able to go back and look at previous charting. During an interview on 4/18/23, at 9:03 a.m., LPN Employee E13 indicated if no bowel movement in three days then protocol starts, usually begins with Milk of Magnesia (MOM - a laxative), the system doesn't alert, usually hear about it from the RNAC, Unit Manager, or Director of Nursing from morning meeting. The night shift supervisor makes a list. The aides will tell us and we ask the residents if they are alert. The nurses are able to look back in the aides charting, but the aides are not able to. During an interview on 4/18/23, at 9:04 a.m., NA Employee E7 indicated we chart in the computer if they have a small, medium, or large and the nurses track it that way. We don't have to verbally tell the nurse because they review our charting. During an interview on 4/18/23, at 9:05 a.m., NA Employee E8 indicated they (the nurses) start doing stuff if they (the residents) don't go for three days. The RNAC or nurses make a list. During an interview on 4/18/23, at 9:06 a.m., RN Employee E14 indicated the protocol starts after three days with no bowel movement with MOM, then Senna (a laxative) or something a bit stronger, the enema (liquid medication inserted into the rectum to help stimulate bowel movement). The system alerts for everyone on the floor. I ask the residents if they are alert to make sure. A nurse alert assessment is completed if not. The aides do pass off the information also. During an interview on 4/18/23, at 9:08 a.m., LPN Employee E9 indicated everyone has something different, we don't really have a protocol. There is not an alert created in the computer that I'm aware of, I have gotten a list in the past of residents who have not moved their bowels for three or more days. Some of them are already on something daily to prevent constipation. During an interview on 4/18/23, at 9:10a.m., NA Employee E15 indicated the aides chart the bowel movement, if no movement charted in three days it's reported in the morning meeting. Unit Manager pulls it every day and they start protocol. The aides aren't able to go back in the charting to check, they get report from the previous shift. During an interview on 4/18/23, at 9:21 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E4 indicated the facility doesn't have a standard bowel protocol, alerts show up on dashboard if it's nine shifts or greater, I believe a small counts as going. We go over it at morning meeting and give it to the unit managers who then take it to the floors. If they have no order for medication management the floors' have to call and get one. During an interview on 4/18/23, at 10:20 a.m., DON indicated she wasn't aware if the nine shift alert in the computer included or excluded small in the count and confirmed the facility did not have a standard bowel protocol that was individualized for each resident through their plan of care. Review of the clinical record for Resident R6 revealed that the resident was admitted to the facility on [DATE], with diagnoses including anxiety, depression, and diabetes. A review of the Minimum Data Set ((MDS - periodic assessment of care needs) dated 2/22/23, indicated the diagnoses remain current. A review of a physician order dated 2/15/23, indicated for staff to give Lispro (rapid-acting insulin) insulin and notify the doctor for blood glucose levels over 400. A review of the Medication Administration Record (MAR) indicated the following fingerstick (FS) blood glucose results: On 4/13/23, at 4:32 p.m. FS was 462. On 4/13/23, at 8:53 p.m. FS was 443. On 4/14/23, at 3:54 p.m. FS was 474. A review of the care plan dated 3/1/23, indicated for staff to give diabetes medication as ordered by the doctor, educate resident/family/caregiver as to the correct protocol for glucose monitoring, and monitor/report to the doctor signs and symptoms of hyperglycemia. A review of the progress notes failed to reveal the physician was notified of fingerstick blood glucose over 400. Review of the clinical record for Resident R50 revealed that the resident was admitted to the facility on [DATE], with diagnoses including obesity, high blood pressure, and diabetes. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 3/24/23, indicated the diagnoses remain current. A review of a physician order dated 3/27/23, indicated for staff to give Humalog (rapid-acting insulin) insulin and notify the doctor for blood glucose levels over 401. A review of the Medication Administration Record (MAR) indicated the following fingerstick (FS) blood glucose results: On 4/7/23, at 8:00 p.m. FS was 436. On 4/13/23, at 8:00 p.m. FS was 440. A review of the care plan dated 12/9/22, indicated for staff to give diabetes medication as ordered by the doctor, educate resident/family/caregiver as to the correct protocol for glucose monitoring, and monitor/report to the doctor signs and symptoms of hyperglycemia. Further review of the care plan dated 11/8/22, indicated for staff to obtain glucometer readings and report abnormalities as ordered. A review of the progress notes failed to reveal the physician was notified of fingerstick blood glucose over 401. During an interview on 4/19/23, at 11:30 a.m. Registered Nurse (RN) Employee E10 stated for a fingerstick blood glucose reading over 400, he would check the orders and follow the doctor ' s protocol and chart the notification in the progress notes. During an interview on 4/19/23, at 11:35 a.m. RN Employee E11 stated he would check the physician order for protocol for blood glucose over 400, he would notify the doctor, chart any new order received, and chart the notification in the progress notes. During an interview on 4/19/23, at 11:37 a.m. Licensed Practical Nurse Employee E13 stated she had a resident with a blood glucose over 400 she would check the orders for protocol, notify the doctor, and chart the incident in the progress notes. During an interview on 4/19/23, at 12:58 p.m. the Director of Nursing confirmed the facility failed to notify the providers of fingerstick blood glucose levels as ordered for Resident R6, and R50. During an interview on 4/20/23, at 11:00 a.m. the DON confirmed that the facility failed to make certain that appropriate treatment and services were provided to maintain bowel function for Resident R34 that resulted in actual harm of a severe fecal impaction and required hospitalization 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code: 211.2(a) Physician services

Based on review of facility policy, documents, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for two of sixteen residents (Resident R1 and R2), which caused an organ transplant anti-rejection medication not to be administered. This failure resulted in an Immediate Jeopardy situation for one of sixteen residents (Resident R1). Findings include: Review of facility policy Medication and Treatment Administration Guidelines, Long-Term Care [DATE], indicated staff will ensure that all medications and biological orders are written, dated and signed by the person lawfully authorized to give such an order. Review of facility policy Prescriber Authorization and Communication of Orders [DATE], reconcile transfer/transition and admission orders and verify orders with the resident's prescriber. Review of the facility provided 24 Hour Chart Check procedure, dated [DATE], indicated for staff to: 1. Run/Print the Order Listing Report for all patients on the unit for the past 24 hours - previous day. 2. Access Orders to Review Clinical Care Management Orders. 3. Review each patient's orders received over the last 24 hours for accuracy and appropriateness. 4. Review the Order Tab in the hard chart to determine if Prescriber Written orders are displayed on the Order Listing Report. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated [DATE], indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cutaneous abscess (localized collection of pus in the skin) of the chest wall, and history of a heart transplant. Review of the admission evaluation completed by Registered Nurse Employee E1 on [DATE], at 5:51 p.m. indicated Resident R1 had received a heart transplant on [DATE]. Review of hospital discharge paperwork dated [DATE], indicated an order for Resident R1 to receive Tacrolimus (Prograf, a medication used to prevent organ rejection) 2.5 milligrams twice per day, and to receive eight units of insulin glargine (long-acting medication to lower blood sugar levels). Review of the plan of care initiated on [DATE], indicated that Resident R1 had altered cardiovascular status. No goals or interventions were developed related to Resident R1's transplant status. Review of Resident R1's After Visit Summary (discharge information provided after the consultation appointment) and the medication list provided with it dated [DATE], indicated to increase the dose of Tacrolimus from 2.5 milligrams twice daily, to 3 milligrams twice daily. Additionally, the medication list indicated to discontinue the insulin glargine, and to continue Metformin (a medication used to help control the amount of sugar in the blood) 500 milligrams twice daily. Review of a physician's note on [DATE], at 8:17 p.m. indicated an increase in the Tacrolimus dosage to 3 milligrams, twice daily. The progress note further stated, status post cardiac transplant, continue immunosuppressants and medication adjustment as above. Status post cardiac biopsy. Follow up progress notes written by physician on [DATE], [DATE], and [DATE], confirmed the dosage of Tacrolimus 3 mg, twice daily, and the continuation of the medication adjustment ordered on [DATE]. Review of the physician's order entered by Licensed Practical Nurse (LPN) Employee E1 on [DATE], at 5:35 p.m. indicated Tacrolimus 3 mg, twice daily. The start date for the order was [DATE]. Review of the electronic medical record audit details sections indicated entry fields for: Created by: Created date: Confirmed by: Confirmed date: Revised by: Revised date: Signed by: Signed date: Signed method: Review of the physician's order audit details failed to indicate that a nurse confirmed the order for Tacrolimus 3 mg, twice daily, nor that a physician signed the order. Review of the [DATE], MAR (medication administration record) revealed: -No doses of Tacrolimus were provided to Resident R1, from [DATE], through [DATE], (22 missed doses). -Insulin glargine was not discontinued, with injections given ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE], (10 doses given that should not have been). -No doses of Metformin were given. (Unknown number of doses, as original order was not written). During an interview on [DATE], at 11:45 a.m. the Director of Nursing confirmed that the order for Tacrolimus had a start date entered of [DATE], that should have been [DATE], that Resident R1 should not have received insulin glargine after [DATE], and that an order for Metformin continuation was never written. The Director of Nursing further confirmed that the orders received from the outside consultation were not verified. Review of a nurse practitioner note dated [DATE], at 5:47 p.m. indicated Pt (patient) seen today due to multiple chronic medical conditions leading to significant risk for increased discomfort, recurrent falls, poor progression in therapy, worsening condition, and rehospitalization . Review of a progress note dated [DATE], at 7:34 p.m. indicated the transplant physician was made aware of a temperature of 102.3, heart rate 115, bp ,d+[DATE]. This physician ordered stat (at once) lab draw. Resident documented that he feels chilly. Review of a progress note [DATE], at 9:43 p.m. indicated for Resident R1 to be transferred to hospital via direct admit, not through the emergency department. Review of a progress note dated [DATE], at 4:48 a.m. indicated the lack of availability of a bed at the hospital. Resident R1 is noted to be complaining of being cold, shivering, having increased respirations, and an elevated blood pressure of ,d+[DATE]. Review of a progress note dated [DATE], at 8:37 a.m. indicated Resident R1 ceased to breathe in the facility at 8:16 a.m. Review of the Medical Certification Worksheet (death certificate) signed [DATE], indicated the cause of death to be abscess sternum, cardiac transplant. During interviews of licensed nurses, who are documented to have provided care to Resident R1 during the period of [DATE], through [DATE], the following was stated: On [DATE], at 3:29 p.m. LPN Employee E4 stated they are aware that anti-rejection medications must be taken daily, for the lifetime of the patient. Confirmed that they are knowledgeable of the 24-hour chart check procedure. On [DATE], at 3:34 p.m. RN Employee E5 stated they are aware that anti-rejection medications must be taken daily, for the lifetime of the patient. Confirmed that after Resident R1 had ceased to breathe, they realized the medication error occurred, when reviewing the progress notes. On [DATE], at 3:48 p.m. LPN Employee E6 stated they are aware that anti-rejection medications must be taken daily, for the lifetime of the patient. Confirmed that they are knowledgeable of the 24-hour chart check procedure. LPN Employee E6 stated, He never should have died . On [DATE], at 3:29 p.m. LPN Employee E7 stated they are aware that anti-rejection medications must be taken daily, for the lifetime of the patient. Confirmed that they are knowledgeable of the 24-hour chart check procedure. Review of Resident R2's admission record indicated she was admitted to the facility on [DATE], with diagnoses of ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract), alcohol abuse, and depression. Review of hospital discharge paperwork dated [DATE], indicated an order for Resident R2 to receive Fluoxetine (Prozac, a medication to treat depression) 60 milligrams daily, and to receive vancomycin (medication used to treat infections caused by bacteria) 125 milligrams every six hours for two days. Review completed on [DATE], of Resident R2's physician's orders entered by RN Employee E8 on [DATE], revealed that the Fluoxetine order indicated a dosage of 20 milligrams daily. The vancomycin order indicated a dosage of 250 milligrams every six hours for two days. Review of Resident R2's September MAR revealed that she received Fluoxetine 20 milligrams daily on [DATE], [DATE], [DATE], and [DATE]. Resident R2 received Vancomycin 250 milligrams on [DATE] (6:00 p.m.), [DATE] (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.) and [DATE] p.m. (12:00 a.m., 6:00 a.m., and 12:00 p.m.). During an interview on [DATE], at 9:25 a.m. Certified Registered Nurse Practitioner (CRNP) Employee E3 confirmed the dosages for Fluoxetine and vancomycin were entered incorrectly for Resident R2. On [DATE], at 11:52 a.m. the Director of Nursing and Corporate Compliance were made aware that Immediate Jeopardy existed for one of 16 residents in the facility. The Immediate Jeopardy template was provided to facility administration and a corrective action plan was requested. On [DATE], at 4:50 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Actions: -Resident no longer resides in the center. -Staff nurse no longer works in the center. -Medical director reviewed resident's closed chart. -Incident report and investigation were initiated upon findings of medical director's review of closed chart -Licensed nursing staff, registered nurses and licensed practical nurses, had education of Medication and Treatment Administration Guidelines including order transcription initiated immediately and Laboratory Guidelines including reporting abnormal results. -The Director of Nursing, Assistant Nursing Home Administrator, and the Staff Development. nurse were reeducated on the Medication and Treatment Administration Guidelines including order transcription, and educated on the Interdisciplinary Care Transition Checklist- Transition from Acute Care to Skilled Nursing Facility, and the 24-Hour Chart Check guide by the Quality Assurance Consultant. On [DATE], at 09:15 a.m. -Licensed Nurse education including registered nurses and licensed practical nurses was initiated at 10:00 a.m. on [DATE]. -An ad hoc Quality Assurance (QA) committee meeting was conducted with the Medical Director on [DATE], at 1:30 p.m. -Identified Resident R2 was reviewed by the provider and Fluoxetine order updated. Vancomycin was completed at the time of the review. Like Residents: -A comprehensive review of newly admitted residents from [DATE], through [DATE], was initiated at 9:00 a.m. on [DATE], and is completed. Current residents who still reside in the facility will have current medication regimen reviewed by the medical provider to validate accuracy. -Residents who admitted from [DATE] through present who have already discharged from the facility were reviewed with the facility QA committee if transcription error was identified. System Correction: -Education of licensed nurses including registered nurses and licensed practical nurses on Medication and Treatment Administration Guidelines including order transcription, Interdisciplinary Care Transition Checklist- Transition from Acute Care to Skilled Nursing Facility, and 24-Hour Chart Check Guide initiated on [DATE] at 10:00 a.m. by the Director of Nursing/ designee. -Including transcription of orders. -Including reviewing transfer paperwork from acute care, and verification of orders on Admission. -Including completion of 24-hour chart check with addendum added. -Education will be completed by 7:00 a.m. on [DATE]. Current licensed nurses who have not completed the education by this time will not be permitted to work until they have received the education.-The vaccination matrix will be updated immediately and will stay updated with all current staff and agency staff members, vendors, providers, and CRNPs. -Identified transcription errors will be addressed through the medication error process. -The 24-hour chart check process was reviewed by the center QAPI committee including the medical director and was updated with an addendum to page 2 of 4 to include the review of consultations to validate transcription accuracy. Ongoing Monitoring: -Utilizing the Order Review audit tool, new admissions' orders will be reviewed to validate accuracy by the Director of Nursing/ designee for four weeks. -Utilizing the Order Review audit tool, five random current residents with new orders will be reviewed three times a week for three weeks. -The facility Quality Assurance and Performance Improvement (QAPI) committee through ad hoc or full QAPI shall monitor for 4 weeks to review any trends and findings, issues or concerns, and develop a plan of action for follow up and resolution. Facility observations on [DATE], from 2:00 p.m. through 4:00 p.m. confirmed that education was being provided to the day and evening shifts shift licensed nurses. Observation on [DATE], at 8:30 a.m. confirmed education was being provided to the remaining licensed nurses. During interviews on [DATE], from 9:00 a.m. through 10:00 a.m. seven of seven licensed nurses confirmed they had received education on transcribing orders, verification of accuracy of order transcription, the need to review consultation and appointment records, and the 24-hour chart reconciliation process. The Immediate Jeopardy was lifted on [DATE], at 10:44 a.m. when the action plan implementation was verified. During an interview on [DATE], at 11:00 a.m. the Nursing Home Administrator, the Director of Nursing, and the Quality Assurance Consultant confirmed that the facility failed to ensure that residents were free from significant medication errors for two of sixteen residents, which caused an organ transplant anti-rejection medication not to be administered. This failure resulted in an Immediate Jeopardy situation for one of sixteen residents. During a follow-up interview on [DATE], at 10:42 a.m. Nursing Home Administrator (NHA) confirmed there is not a specific procedure for 24-hour chart check, in reference to the consult sheet [DATE], it would be a nurse's responsibility. The NHA indicated he was unsure whether a chart check was completed that night, as there is no evidence of one being done. S483.45(f)(2) Residents are free of any significant medication errors. 28 Pa Code 201.14(a) Responsibility of licensee. Previously cited: [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited: [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.10(c) Resident care policies. Previously cited: [DATE], [DATE], [DATE], [DATE]. 28 Pa Code 211.12(d)(1)(5) Nursing Services. Previously cited: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa Code 211.12(d)(3) Nursing Services. Previously cited: [DATE].

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to update the interdisciplinary plan of care after a change in bed mobility status for one of three residents (Resident R13), which resulted in actual harm of a fractured shoulder bone and injury to the jugular vein for Resident R13. Findings include: The facility policy Interdisciplinary Care Planning dated 10/31/21, indicated the care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also defines the types and methods of care that the patient should receive. The care plan should describe the services that the facility is to provide. It should include initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of Resident R13's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 3/20/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R13's MDS assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, dated: 2/1/21, 5/4/21, 8/2/21, 8/29/21, 11/22/21, 12/28/21, and 3/20/22, all indicated that Resident R13 required extensive assistance of two or more staff members. Review of Resident R13's plan of care for ADL (activities of daily living) Self-care deficit related to physical limitations initiated 2/25/20, indicated Resident R13 required a limited assist of one staff member for bed mobility. Review of the plan of care revision history failed to indicate any updates to this portion of the plan of care. Review of the Therapy Communication document, dated 12/31/21, indicated that for bed mobility, Resident R13 was totally dependent, and required two or more staff members for moving to and from a lying position, moving side to side, and positioning while in bed. During an interview on 5/31/22, at 1:30 p.m. the Director of Therapy Services Employee E9 confirmed that Resident R13 was an assist of two persons, and that this information was communicated to nursing staff. Review of Resident R13's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 4/27/22, indicated that Resident R13 as Bed mobility - limited assist of 1. Review of Resident R13's April 2022 Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 4/1/22, through 4/26/22, Resident R13 had bed mobility documented on 71 times, with 34 of those times (approximately 48%) documented has having required two persons. During an interview on 5/31/22, at 3:30 p.m. the Director of Nursing confirmed that the facility failed to update the interdisciplinary plan of care after a change in bed mobility status for one of three residents, which resulted in actual harm of a fractured shoulder bone and injury to the jugular vein for Resident R13. Refer to F689 28 Pa. Code 211.11(e) Resident care plan.

Based on review of facility policies, faciltiy training documents, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for the bed mobility needs for one of three residents (Resident R13), which resulted in actual harm of a fractured shoulder bone and injury to the jugular vein for Resident R13. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of facility provided training document for staff education on activities of daily living indicated that bed mobility included turning side to side. Review of Resident R13's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 3/20/22, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), [CONDITION(S)] (a quivering or irregular heartbeat), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R13's MDS assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, dated 2/1/21, 5/4/21, 8/2/21, 8/29/21, 11/22/21, 12/28/21, and 3/20/22, all indicated that Resident R13 required extensive assistance of two or more staff members. Review of Resident R13's plan of care for ADL (activities of daily living) Self-care deficit related to physical limitations initiated 2/25/20, indicated Resident R13 required a limited assist of one staff member for bed mobility. Review of the plan of care revision history failed to indicate any updates to this portion of the plan of care. Review of Resident R13's plan of care for At risk for falls initiated 9/28/17, most recently revised on 3/23/21, indicated for staff to refer to the therapy plan of treatment in the medical record. Review of the Therapy Communication document, dated 12/31/21, indicated that for bed mobility, Resident R13 was totally dependent, and required two or more staff members for moving to and from a lying position, moving side to side, and positioning while in bed. During an interview on 5/31/22, at 1:30 p.m. the Director of Therapy Services Employee E9 confirmed that Resident R13 was an assist of two persons, and that this information was communicated to nursing staff. Review of Resident R13's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 4/27/22, indicated that Resident R13 as Bed mobility - limited assist of 1. Review of Resident R13's April 2022 Documentation Survey Report (monthly calendar grid for a patient, showing the patient's tasks/intervention description) indicated that from 4/1/22, through 4/26/22, Resident R13 had bed mobility documented on 71 times, with 34 of those times (approximately 48%) documented has having required two persons. Review of a progress note written by Registered Nurse (RN) Employee E10 dated 4/27/22, at 11:08 a.m. indicated Alerted by staff that resident was observed by staff rolling out of bed onto floor during ADL care. Entered room and observed resident laying supine on floor beside bed. Resident alert to self and situation, mumbled speech at baseline. Resident denied any significant pain however stated she did strike head on floor. Resident denied change in vision, denied headache, no observed bleeding and no immediate bruises or swelling noted. Resident ROM (range of motion) intact to extremities with no deformations or pain on movement. CRNP (Certified Registered Nurse Practitioner) notified and assessed. Order to send to UPMC East for evaluation. Resident in agreement with plan of care, small bump noted to develop during assessment to left lateral head region. Review of a progress note written by CRNP Employee E11 dated 4/27/22, at 3:19 p.m. indicated Patient's aide was in the middle of performing AM care when the patient rolled out of bed. It was able to brace her fall, but she did fall from waist level onto the floor. Patient states she had the back of her head on the dresser. She has a small developing lump on the right side of the back of the head. She states that she does have pain there. She states that overall she feels fine and that she doesn't have pain in any other area of her body. She is on the ground when I see her and seems to be sort of resting on her right-hand side. This patient has history of falls, poor safety awareness, unsteady gait, generalized weakness and dementia. per nursing report pt has been more fatigued than usual. Review of a progress note dated 4/27/22, at 8:42 p.m. indicated that Resident R13 returned to the facility. Resident R13 had her left shoulder/arm in a sling, and bruising noted. Review of hospital discharge paperwork dated 4/27/22, at 6:28 p.m. indicated that Resident R13's main medical problem identified in the emergency room was a clavicle (shoulder bone) fracture, external jugular vein (vein in the neck that drains blood flow down from the head and face) injury, fall, and a hematoma (pooling of blood outside of the blood vessel). Review of a progress note written by CRNP Employee E12 dated 4/28/22, at 12:33 p.m. indicated there was a complicated fracture of the left clavicle with possible venous injury. CT scan with contrast reveals an acute displaced and angulated fractures of the medial left clavicle with moderate to large associated surrounding hematoma with concerns for possible injury to the left external jugular vein. There was also findings to suggest an intramuscular hematoma of the left SCM with a moderate left-sided pleural effusion. lengthy discussion with the patient as well as the power of attorney at bedside who advised me that this could be a life-threatening situation being the fact that she is on [MEDICATION(S)] and has concerns for vessel injury. She is advised that she could continue to bleed, hemorrhage and possibly even die. Aside from the worst-case scenario she could have chronic immobility, chronic pain, paralysis or further injury to cardiopulmonary structures and vessels. Patient did not want any sort of surgery or further work-up for this. She agrees and understands all the risks and benefits. Power of attorney also agrees and understands. Review of a progress note written by CRNP Employee E12 dated 4/29/22, at 7:01 a.m. indicated that she was seen for increased pain. The note further indicated that since patient does not want any medical intervention it would be appropriate to discuss hospice with patient and POA (power of attorney). Review of a progress note dated 4/29/22, at 2:35 p.m. indicated that Resident R13 required her order for [MEDICATION(S)] (narcotic used to treat moderate to severe pain) frequency increased pain. Review of a progress note written by CRNP Employee E12 dated 5/3/22, at 4:58 p.m. indicated a new order for [MEDICATION(S)] (narcotic used to treat severe pain) 12 micrograms every three days. Review of a physician order dated 5/6/22, indicated that Resident R13 was admitted to hospice. Review of a progress note dated 5/7/22, at 5:04 a.m. indicated that Resident R13 was experiencing [NAME]-Stokes breathing (breathing slows down and becomes irregular), was cold and clammy, and unresponsive. Review of a progress note dated 5/7/22, at 6:41 a.m. indicated that Resident R13 ceased to breathe at 6:15 a.m. During an interview and observation on 5/31/22, at 2:13 p.m. Nurse Aide (NA) Employee E14 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E14 demonstrated entering the electronic point of care charting portal, and opening the resident's Kardex to see the assistance level. During an interview and observation on 5/31/22, at 2:20 p.m. Nurse Aide (NA) Employee E15 was asked how she knows what level of staff assistance for bed mobility is appropriate for a resident. NA Employee E15 demonstrated entering the electronic point of care charting portal, and opening the resident's Kardex to see the assistance level. During an interview on 5/31/22, at 3:00 p.m. NA Employee E13 stated that while providing incontinence care to Resident R13, her upper body (which NA Employee E13 described as being disproportionately heavier than her lower body) rolled off the bed and she was unable to catch her. NA Employee E13 stated that no other staff were assisting her, and she thought Resident R13 was a staff assistance of one person. During an interview on 5/31/22, at 3:30 p.m. the Director of Nursing confirmed that the facility failed to provide adequate supervision for the bed mobility needs for one of three residents (Resident R13), that resulted in actual harm of a fractured shoulder bone and injury to the jugular vein for Resident R13. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 11/5/20, 3/12/21, 4/29/22. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 11/5/20, 3/12/21, 4/29/22. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 3/12/21, 4/29/22. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited: 3/12/21, 4/29/22. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 28 Pa Code 211.12(d)(1)(5) Nursing services. Previously cited: 11/5/20, 3/12/21, 4/29/22. 28 Pa Code 211.12(d)(2) Nursing services. Previously cited: 3/12/21, 4/29/22.

Based on review of clinical records, facility documents and staff interviews, it was determined that the facility failed to provide care and services after an unwitnessed fall, and the facility failed to give the physician an accurate physical assessment to include description of the fall and that the resident was on anticoagulant medication (blood thinner). This failure placed the resident in an Immediate Jeopardy situation for one of four residents reviewed (Closed Record Resident CR1). Findings include: Review of facility policy dated [DATE], Clinical Services Post Fall Evaluation FYI, indicated that, a comprehensive clinical assessment is completed by a nurse supervisor, is important to determine extent of the injury and the need for additional intervention. Clinical system area of focus for a post fall evaluation may include: Compare vital signs to baseline readings, change in mental status may be indicative of acute neurological or cardiovascular change. Compare to baseline. Patients with suspected head injury or neck injury should not be moved until evaluated by emergency personnel. Completion of neurological status may indicate acute change in status. Compare to baseline. Acute head and neck injuries require additional evaluation. Anti-coagulant therapy combined with a head injury increases the risk for intracranial bleeding. Neurological (functions of the nerves and nervous system) evaluation (neurocheck - an assessment of sensory neuron and motor responses to include at a minimum pulse, respiration, and blood pressure; assessment of pupil size and reactivity and equality of hand grip strength) is completed following an un-witnessed fall when a head injury may be suspected. The licensed nurse's evaluation is of a patient condition after a fall, identification changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes to the attending physician whenever any symptom, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Review of facility policy, Neurological: Neurological Evaluation, dated [DATE], indicated that the, Purpose: A neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. Following an unwitnessed fall (when a head injury is suspected). Notify physician of specific patient event, initial findings, and baseline neurological evaluation. Review of the clinical record, Admission Record Report, revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record, progress notes - general progress notes, dated [DATE], indicated that at 6:00 p.m. RN (Registered Nurse) Employee E1, found Resident CR1 on the floor at the foot of the bed in Resident CR1 bedroom. Resident CR1 stated that I fell and hit my head. Neurochecks started. Additional findings, include that the physician was contacted and the facility was awaiting instructions from the physician. Review of the clinical record, neurological evaluation flow sheet dated [DATE], revealed neurochecks started on [DATE], at 7:08 p.m. and ended on [DATE], at 8:38 p.m. with the next check due at 9:08 p.m. left blank and no other neurochecks being completed. Review of clinical record, progress notes- general progress notes, dated [DATE], indicated that at 3:30 a.m. Resident CR1 was observed prone (laying face up) on the floor, noted that head was against the wall/ Unable to move body due to body proneness and stiffness. Notified physician and Resident CR1 was transferred to the hospital. Review of the resident's care plan dated [DATE], revealed that the resident was a one person guidance and physical assist for transfer. During an interview on [DATE], at 10:30 a.m. the Director of Nursing (DON) confirmed that neurochecks were not completed and the next documentation regarding Resident CR1 status was the clinical progress note when the resident was found prone on the floor. During an interview on [DATE], at 12:00 p.m. Licensed Practical Nurse (LPN) Employee E2, stated that on the evening of [DATE], she was informed by RN Employee E1 that, Resident CR1 had a fall, I assessed her and she's o.k. LPN Employee E2, then indicated that he/she went to room and found Resident CR1 in a different condition then stated. Resident CR1 had three hematomas (a bruise) versus the one identified by RN Employee E1. One of the hematomas was bleeding. LPN Employee E2, was told by RN Employee E1 that he/she notified the Physician. LPN Employee E2 started neurological checks, and left for the evening at 9:00 p.m. and RN Employee E1 took my cart and was aware of Resident CR1's status. Review of a nursing progress note dated [DATE], at 7:15 p.m. called physician's service, no call back, no orders. During an interview on [DATE], at 12:30 p.m. Physician Employee E3, revealed, that he/she does not recall a phone call on [DATE], if he/she got a phone call the protocol is for staff to give the information i.e. name, diagnosis, medication status of resident. When Physician Employee E3, was asked if he/she was called about a resident who had a fall, was on an anticoagulant medication and was bleeding from the head with a few lumps, Physician Employee E3 stated they would be sent out to hospital. During a second interview on [DATE], at 12:41 p.m. Physician Employee E3 stated that the message from RN Employee E1, was retrieved from the answering services and stated the following, Resident CR1 bumped head no call needed. During the interview Physician Employee E3, confirmed that RN Employee E1, was the staff that made this phone call. A telephone interview with RN Employee E1, on [DATE], at 2:00 p.m. revealed that she had called the physician on [DATE], following Resident CR1's fall at 6:00 p.m. and informed him that the resident had a fall with no injuries, and that the physician had said to watch the resident. Review of hospital records, History and Physical, indicated that Resident CR1 was seen on [DATE], originally presented to an outside Emergency Department after a fall early in the morning and was later transferred to a level 1 trauma unit after CT scan (a type of X-Ray) showed evidence of extensive intraventricular hemorrhage (bleeding in or around the brain cavity). Additionally, the record indicated that Resident CR1 had a fall on [DATE], around 6:00 pm and had a second fall on [DATE], around 3:30 a.m. On presentation she was not able to give any history due to deceased responsiveness. A head CT was obtained and was notable for right lateral (side) bleed with extension into the third and fourth ventricle (fluid fill cavity in the center of the brain) and developing [CONDITION(S)] (build-up of fluid in the cavities deep within the brain). Review of hospital record, Final Report, revealed, Critically Ill with coma following hospital admission with post traumatic intraventricular hemorrhage while anticoagulated. Further review of the hospital record, Final Report, revealed Resident CR1 ceased to breathe. The facility failed to give the physician an accurate physical assessment of the resident, failed to include the description of the fall and that the resident was on anticoagulant medication. There were no interventions put into place after the first fall and the resident did not receive medical treatment until after the second fall which occurred several hours later. Staff failed to ensure neurological checks were completed which placed Resident CR1 in an immediate jeopardy situation. Immediate Jeopardy was identified on [DATE], at 6:22 p.m. for the facility's failure to notify the physician, continue neurological checks and receive medical treatment. The IJ template was provided at that time and an Immediate Action plan was requested to immediately put systems into place to ensure that physicians are provided with accurate physical assessments of residents following falls. The facility submitted an action plan which included training for employees on falls practice flow chart guide, change in condition, SBAR (an acronym for Situation, Background, Assessment, Recommendation which is a technique that can be used to facilitate prompt and appropriate communication), Interdisciplinary care plan, neurological evaluations, transfer screening, FYI #34 (a facility flowchart of action post fall), past fall evaluation, and DRR - Drug Regime Review. The facility submitted audits completed on all residents who receive anticoagulant therapy and audits for residents who had previous fall concerns. The facility completed an anticoagulant and aspirin use review of each resident. The facility trained 100% of the LPN's and The facility trained 100% of the LPN's and 91% of the RN's on the above topics. Immediate Jeopardy was removed on [DATE], at 4:10 p.m. following confirmation through review of facility documents, observations and interviews that the Immediate Action plan had been implemented. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1)Management.

Based on review of facility policy, facility documents, clinical record review and staff interview, it was determined that the facility neglected to provide goods and services necessary to maintain a resident at the highest practicable physical well-being for one of four residents reviewed (Resident R2) resulting in harm with a fracture during transfer requiring admission to the hospital and surgery. Findings include: Review of facility policy, Abuse, Neglect, Exploitation, Mistreatment, & Misappropriation Prevention, dated 10/8/20, revealed that no one should be subjected to neglectful behavior. Neglect is 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. Review of Resident R2's clinical record, Admission Record Report, indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan with a date of 4/20/19, revealed an ongoing intervention that the resident required an assist of two with a mechanical lift. Review of facility documentation, NP (Nurse Practitioner) Progress Notes dated 2/17/21, indicated Resident R2 was being assisted to transfer from the wheelchair to the bed when he/she slipped. Resident R2 did not fall to the ground and was able to be slid on to the side of the bed. Resident R2 had immediate pain in the RLE (right lower extremity) with deformity to the lateral aspect of the right thigh just above the knee, with noted gross deformity of the right leg with protrusion above the right knee. Review of facility documentation, General Progress Note, dated 2/17/21, at 3:01 p.m. indicated the resident was transferring from the wheelchair to the bed when their leg started to slip. NA (Nurse Aide) Employee E4, rolled Resident R2 onto the bed. Resident R2 was sent to the ER (emergency room ) for evaluation/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation, Witness Statement, dated 2/18/21, revealed NA Employee E4, was assigned to Resident R2. The witness statement dated 2/18/21, revealed Resident R2 requested to go back to bed, NA Employee E4, stood Resident R2 up out of the wheelchair and Resident R2's feet began to slide out from underneath him/her, NA Employee E4, rolled Resident R2 over on the bed positioned him/her in the bed and went to get a nurse. Review of the facility's documentation witness statement, revealed Resident R2 was to be transferred with a two person assist. Review of Resident R2's clinical record care plans states, Requires assistance/potential to restore function for transferring from one position to another as evidenced by assist x2 staff with mechanical lift related to physical limitations. Review of facility documentation provided to agency staff prior to their initial day revealed that NA Employee E4, had been informed how to located the transfer status of the residents and had received training on abuse and neglect. Review of hospital record dated 2/18/21, indicated Resident R2 was admitted to the hospital 2/17/21, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/8/21, at 9:15 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that Resident R2's transfer status was for a two person assist and on 2/17/21, Resident R2 was transferred by one person, admitted to the hospital and diagnosed with a right femur fracture, and had surgery due to the fracture. The facility neglected to provide goods and service necessary to maintain a resident at the highest practicable physical well-being resulting in harm with a fracture during transfer requiring Resident R2 to be evaluated at the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.