Every finding on record at Nottingham Village

Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service safety and store food in a sanitary manner in the facility's main kitchen and on two of three nursing units (Station 2 and Station 3). Findings include:An observation of the facility's main kitchen on November 12, 2025, at 9:30 AM with Employee 1, dietary manager, revealed the following: Debris and multiple dried brown liquid spots on the flooring underneath the coffee station area. The wall beside the area was covered in dried liquid splatter, with the broken pieces of drywall on the corner of the wall. A metal utensil rack hanging from the ceiling over the top of a food preparation table had multiple cooking utensils stored hanging from the rack such as spoon, ladles, whisks, and pans uncovered with food contact surfaces exposed to the potential for airborne particles such as dust and potential contamination and food preparation splatter from the table below it. A metal sheet tray located on a shelf under the steamer had grill cleaning utensils stored on it. The tray contained dried debris and dried brown spills. A large white plastic storage bin on wheels located under a preparation table contained a significant amount dried food on the top and exterior sides of the container. A cardboard dispenser box of plastic film covering was observed on the preparation table with dried food and liquid staining on the carboard. The lower shelves of the dry supply storage room contained dust and debris on the shelf liners. Observation of the Station 2 food service room on November 13, 2025, at 12:54 PM revealed the following:The interior of the microwave was covered in dried food splatter and portions of the interior of the microwave had peeled away in multiple areas exposing rust-colored areas. The interior base of a cabinet located under the sink contained multiple dried liquid spots with a glass jar and vase stored in the cabinet. Observation of the Station 3 refreshment room on November 13, 2025, at 1:05 PM revealed the following:The interior of the freezer above the refrigerator was soiled with debris and frozen spills. The interior base of the cabinet located under the sink area had black debris scattered throughout it with dried brown liquid stains. The above information was reviewed with the Nursing Home Administrator on November 13, 2025, at 1:22 PM. 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 1/30/2528 Pa. Code 201.14 (a) Responsibility of Licensee

Based on clinical record review and staff interview, it was determined that the facility failed to implement an individualized plan of care related to a resident's history of trauma to eliminate or mitigate re-traumatization for two of two residents reviewed for behavior and emotional status (Residents 95 and 101). Findings include:Clinical record review for Resident 95 revealed a revealed a Social History Assessment dated November 11, 2025, for the resident who was admitted on [DATE]. The assessment indicated the resident had a traumatic life event involving the death of his son who was murdered. A review of Resident 95's plan of care revealed a focus area for the resident's trauma indicating the Resident has encountered a trauma that has resulted in physical, social, or emotional harm or life-threatening situation. This trauma has continued to have adverse effects on the residents individual functioning and mental, physical, social, emotional and spiritual well-being: he reports his son was murdered. The plan of care noted a goal that the resident would not have any adverse effects from the trauma, such as behavioral outbursts, mood swings, or physical aggression to oneself or others.A review of interventions/tasks staff should utilize to help Resident 95 meet his trauma goal included continued communication between staff and the resident by showing compassion, develop a rapport with the resident to develop a relationship showing mutual respect and security, encourage family and friends, as appropriate, visits and participation, engage the resident to pursue strengths, choices and a sense of autonomy, offer emotional support and reassurance, and to provide safety to the resident. There were no specific individualized interventions related to the trauma that Resident 95 had indicating how staff are to eliminate triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring) or mitigate re-traumatization for the resident. Clinical record review for Resident 101 revealed a Social History Assessment dated October 17, 2025, for the resident who was admitted on [DATE]. The assessment indicated the resident had traumatic life events of losing three children, one of which was stillborn (not born alive), and two miscarriages. Review of Resident 101's plan of care revealed a focus area for the resident's trauma indicating the Resident has encountered a trauma that has resulted in physical, social, or emotional harm or life-threatening situation. This trauma has continued adverse effects on the residents individual functioning and mental, physical, social, emotional and spiritual well-being: history of losing children/miscarriages. The plan of care noted a goal that the resident would not have any adverse effects from the trauma, such as behavioral outbursts, mood swings, or physical aggression to oneself or others. A review of interventions/tasks staff are to utilized to help Resident 101 meet the goal noted above included continued communication between staff and resident by showing compassion, develop a rapport with the resident to develop a relationship showing mutual respect and security, encourage family and friends, as appropriate, visits and participation, engage the resident to pursue strengths, choices and a sense of autonomy, and offer emotional support and reassurance. There were no specific individualized interventions related to Resident 101's trauma indicating how staff are to eliminate triggers or mitigate re-traumatization for the resident. Resident 95 and 101's plan of care regarding a history of trauma reflected the same goals and interventions without identifying individualized information as to what staff are to do or not to do for each resident to prevent triggers for each of the resident's trauma. The above information regarding Resident 95 and 101's plan of care regarding trauma related care was reviewed with the Nursing Home Administrator on November 14, 2025, at 9:00 AM. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on review of select facility policies and procedures, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 66 and 112).Findings include: The facility's medication error rate was five percent based on 34 medication opportunities with two medication errors. The policy entitled, Administration Procedures for All Medications, last reviewed without changes on July 18, 2025, revealed procedural steps that included to check the MAR (Medication Administration Record, an electronic system used by licensed staff to document the administration of medications) for the physician's order and if unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. Observation of a medication administration pass on November 13, 2025, at 8:55 AM revealed Employee 2 (licensed practical nurse) administered Omeprazole (medication that reduces acid in the stomach and relieves symptoms such as heartburn) 40 mg (milligram) delayed release oral capsule to Resident 66. Interview with Resident 66 on the date and time of the medication administration confirmed that she finished her breakfast meal. Review of the Medication Guide section of the package insert for the Omeprazole medication revealed instructions how to take Omeprazole that included to take the medication at least one hour before a meal. Interview with Employee 2 on November 13, 2025, at 9:11 AM confirmed that she administered the Omeprazole medication to Resident 66 as scheduled after her breakfast meal. Employee 2 confirmed that Drugs.com would be a medication reference used when unfamiliar with a medication and confirmed with the surveyor that the instructions for the Omeprazole medication on Drugs.com note that it is best to take Omeprazole one hour before meals. When Omeprazole is taken with food, it reduces the amount of Omeprazole that reaches the bloodstream. Employee 2 confirmed that there was no individualized physician ordered parameter to give the Omeprazole medication outside manufacturer's instructions. The surveyor reviewed the above medication error for Resident 66 during an interview with the Nursing Home Administrator and the Director of Nursing on November 14, 2025, at 10:44 AM. Observation of a medication administration pass on November 14, 2025, at 8:22 AM revealed Employee 4, licensed practical nurse, administered an Ondansetron 8 mg tablet (a prescription medication used to prevent and treat nausea and vomiting), and three Imatinib Mesylate 100 mg tablets (a prescription cancer treatment medication). Clinical record review of resident 112's medication administration record revealed Special Instructions for the administration of Ondansetron reading Give 1 tablet by mouth in the morning for pre-chemo treatment of nausea. Give one hour prior to administration of Imatinib. Further review revealed that the Ondansetron was prescribed with an administration time of 8:00AM, while the Imatinib Mesylate had an administration time of 9:00 AM. The surveyor reviewed the above medication error for Resident 112 during an interview with the Nursing Home Administrator and the Director of Nursing on November 14, 2025, at 10:45 AM. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 23 residents reviewed (Resident 45).Findings include: Clinical record review for Resident 45 revealed a PASRR (Preadmission Screening and Resident Review, assessment required to ensure individuals are not inappropriately placed in nursing facilities and/or receive necessary services in those settings) dated November 2, 2023, that assessed her as having met the criteria for further mental health review by the Department of Human Services (DHS). A letter from DHS dated November 7, 2023, confirmed that Resident 45 met the criteria to require that she receive ongoing mental health services for a serious mental illness that would be arranged by the facility (PASRR II). An annual MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 24, 2025, incorrectly assessed that Resident 45 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Interview with the Director of Nursing on November 13, 2025, at 12:54 PM confirmed the above MDS error for Resident 45. 483.20(g) Accuracy of AssessmentsPreviously cited 12/06/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure an eligible resident received a pneumococcal vaccine for one of five residents reviewed for immunization concerns (Resident 45). Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed without changes on July 18, 2025, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Current CDC recommendations for the pneumococcal vaccinations note that the United States uses two types of pneumococcal vaccines. Each individual vaccine helps protect against different serotypes of pneumococcal bacteria. The pneumococcal conjugate vaccines (PCVs: PCV15, PCV20, and PCV21) and the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23). Based on shared clinical decision-making, adults 65 years or older have the option to get the PCV20 or PCV21, if they have received both the PCV13 (but not PCV15, PCV20, or PCV21) at any age and the PPSV23 at or after the age of [AGE] years old at least five years after the last pneumococcal vaccine dose. Clinical record review for Resident 45 revealed an immunization form dated November 9, 2023, that indicated Resident 45's responsible party consented to the administration of the Prevnar 20 (PCV20) pneumococcal vaccine. Review of Resident 45's immunization record revealed that she received the following pneumococcal immunizations:Pneumovax (PPSV23) administered March 20, 2007 (before her admission to the facility, at [AGE] years old)Prevnar 13 administered February 23, 2018 (before her admission to the facility, at [AGE] years old)Pneumovax (PPSV23) administered March 22, 2019 (before her admission to the facility, at [AGE] years old) Resident 45 would be eligible for the PCV20 vaccine five years after her last pneumococcal vaccine dose (which would be March 22, 2024). Interview with Employee 3 (registered nurse/infection preventionist) on November 14, 2025, at 9:23 AM confirmed that Resident 45 did not receive the PCV20 immunization that she was eligible for and consented to receive. The surveyor reviewed the above concerns regarding Resident 45's pneumococcal vaccinations during an interview with the Nursing Home Administrator and the Director of Nursing on November 14, 2025, at 10:35 AM. 483.80(d)1)(2) Influenza and Pneumococcal ImmunizationsPreviously cited deficiency 12/06/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to appropriately assess the use of enabler bars for one of seven residents reviewed for accident hazards (Resident 10).Findings include: The facility policy titled, Bed Safety, last reviewed without changes on July 18, 2025, revealed the facility will try to prevent deaths and injuries from the beds and related equipment including the frame, mattress, side rails, headboard, footboard, and bed accessories. Approaches to this included, in part, inspection by maintenance staff of all beds and related equipment as part of the regular bed safety program to identify risks and problems including potential entrapment risks; and review the gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA). The policy provided by the facility did not further define the gaps. Clinical record review for Resident 10 revealed a diagnosis list that included multiple sclerosis (a breakdown of the protective covering of the nerve causing functional limitations) and generalized muscle weakness. A Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 11, 2025, revealed that facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment. Current physician orders for Resident 10 revealed an order dated August 5, 2025, for a right bed enabler for resident use for positioning. The current care plan for Resident 10 revealed the resident requires assistance with activities of daily living (ADLs) and mobility due to physical limitations. An intervention included a right bed enabler for positioning. An interview with Resident 10 on November 12, 2025, at 11:20 AM revealed the resident was in bed. The resident's bed had bilateral enabler bars attached (the physician order and care plan only indicated a right enabler bar). The resident reported using the enabler bars to help with rolling and repositioning while in the bed. Review of the Side Rail Consent Form revealed that it was signed by the resident and a facility representative and dated October 3, 2025. The form noted the benefits and risks for the use of side rails. There was an X marked next to, I DO CONSENT to the use of side rails. The form did not specify installation parameters of only a right side rail or bilateral side rails. Review of the Side Rail Assessment Form revealed that it was signed by the resident and a facility representative and dated October 3, 2025. The recommendation marked with an X indicated that side rails are indicated and serve as an enabler to promote independence. The form did not specify installation parameters of only a right side rail or bilateral side rails. Review of facility documentation for Resident 10 titled, Bed System Measurement Device Test Results Worksheet, dated October 15, 2025. The form indicated a pass or fail of the entrapment zones measured by facility staff. The form documented bilateral head rails and zones one through four had a circled P which indicated pass. Further review of this documentation revealed documentation of assessment of bilateral foot rails. The form documented bilateral foot rails and zones one through four had a circled P which indicated pass. Resident 10's bed did not have bilateral foot rails at the time of observation, and the facility provided no documentation to indicate that the resident's bed ever had foot rails. There was no measurement recorded on the form for zones five through seven or indication that these zones were assessed as not applicable at the time of the assessment. Zones five through seven were not listed as part of the worksheet. The above information was reviewed in a meeting with the Nursing Home Administrator (NHA) on November 14, 2025, at 11:38 AM. The NHA indicated it was unclear why facility staff assessed the bed as having foot rails and no further documentation was provided by the facility regarding Resident 10's enabler bars. 483.25(n)(1)-(4) Bed RailsPreviously cited deficiency 12/6/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide resident bathing per preference for one of 32 residents reviewed (Resident 101). Findings include: In an interview with Resident 101 on November 12, 2025, at 11:48 AM the resident stated she is supposed to be getting a shower on Tuesdays and Fridays but does not get them. Resident 101 stated it happened again the day prior on Tuesday, November 11, 2025. Resident 101 stated staff come in early and just wash her up a little in bed and get her dressed but don't take her to the shower. Resident 101 stated her family member had discussed this with facility staff prior, but she still does not get them. Resident 101 stated I was one time a week showers during the day, then it changed to the night, then we got it changed to twice a week like I like it, and I still only get one a week.Clinical record review of Resident 101's bathing task revealed Resident 101 was scheduled upon admission October 14, 2025, to receive a shower on Tuesdays during the day shift. The task was changed to Thursdays on the evening shift on October 16, 2025, back to Tuesday's evening shift on October 21, 2025, and was changed to Tuesdays and Fridays day shift noting per family on October 22, 2025, just as the resident indicated. A review of Resident 101's bathing record revealed the resident received showers on Fridays, October 24, 21, and November 7, but did not receive showers per her preference on Tuesdays, October 28 (bed bath instead of shower), November 4, or November 11, 2025. There was no evidence to indicate Resident 101 refused to be showered. Review of Resident 101's admission MDS (Minimum Data Set - a resident assessment completed at periodic intervals of time to determine resident care needs), dated October 20, 2025, revealed facility staff assessed the resident as being dependent on staff to transfer from bed to chair, or sit to stand, and needing assistance for bathing. Resident 101's missed showers were reviewed with the Director of Nursing (DON) on November 14, 2025, at 10:40 AM. The DON indicated due to the resident being dressed by night shift in the morning the day shift nurse aides thought the resident showers were already completed. 483.10(e)(3) Reasonable Accommodations Needs/PreferencesPreviously cited 1/30/2528 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies, and resident and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of three residents reviewed (Resident 1). Findings include: Review of the current facility policy entitled Pain Assessment/Management, revealed at the time of a pain interview, if it is determined that the resident is having pain on a scale of 7 to10, or severe pain (regardless of frequency), or is having frequent or constant pain (that the resident does not feel is tolerable), the resident will be placed on a pain management program, unless otherwise documented on the pain assessment. The pain management program consists of assessing/observing for pain at least every shift and updating the physician if pain is not being managed effectively. Pain management will be documented on the Medication Administration Record (MAR, a form utilized to document the administration of medications) by licensed staff. The charge nurse will update the physician if the resident's pain is not being managed effectively. Clinical record review revealed the facility admitted Resident 1 on June 26, 2024, with diagnosis including displaced bimalleolar fracture of right lower leg (a severe injury to the ankle joint and bones of the lower leg) and displaced osteochondral fracture of her right patella (a break in the cartilage and bone of the kneecap). Nursing documentation dated January 19, 2025, at 6:15 AM revealed the registered nurse found Resident 1 on the floor and upon assessment she was found with complaints of pain rating five out of 10 in her right knee. Documentation noted Resident 1's right outer canthus (the outer or inner part of the eye where the upper and lower lids meet) with a 2.5 centimeter (cm) by 3 cm ecchymotic contusion (bruising. Documentation revealed Resident 1 was assisted from the floor with a maxi lift and three staff. Resident 1 was noted to be yelling out in pain during the entire process. The registered nurse noted Resident 1's verbalization of pain did not match her cathartic reaction. The registered nurse noted as needed Tylenol and an ice pack were provided for pain relief. Nursing documentation dated January 19, 2025, at 6:15 AM revealed the licensed practical nurse found Resident 1 lying on the floor in her bathroom doorway complaining of severe pain. Review of Resident 1's neurological checklist dated January 19, 2025, noted staff assessed Resident 1's pain as a seven out of 10, noting she grimaced and showed nonverbal signs of pain. Review of Resident 1's MAR dated January 2025, noted an order dated June 28, 2024, for nursing staff to administer Resident 1 Tylenol 325 milligrams (mg), two tablets every four hours as needed for pain rated one to three. Review of Resident 1's January 2025, MAR revealed nursing staff did not administer Resident 1 any as needed Tylenol on January 19, 2025. Further review of Resident 1's MAR revealed an order for pain monitoring every shift for routine pain dated June 26, 2024. Nursing staff assessed Resident 1's pain on the first shift on January 19, 2025, noting pain rated a five out of 10. There were no further assessments of Resident 1's pain noted. During an interview with Resident 1 on January 11, 2025, at 11:40 AM she confirmed that she was in a lot of pain after her fall on January 19, 2025. There was no documentation that the facility implemented the pain assessment program or addressed Resident 1's complaints of severe pain. Interview with the Director of Nursing on February 11, 2025, at 1:25 PM confirmed these findings. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services

Based on review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for three of three residents reviewed with a signed arbitration agreement (Residents 19, 62, and 68). Findings include: Review of an Agreement to Resolve Disputes by Voluntary Mediation and/or Mandatory Binding Arbitration, (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving the right to a trial) signed by Resident 19 on February 22, 2023, revealed that the document stipulated that, Subject to Section 6 of this Agreement, the Arbitration shall be administered by (name of arbitrator services company designated by the facility). In the event (name of arbitrator services company designated by the facility) is unable or unwilling to serve, then the request for Arbitration must be submitted to the Facility within thirty (30) days of receipt of notice of (name of arbitrator services company designated by the facility) unwillingness or inability to serve as a neutral arbitrator. The parties shall mutually select an alternative neutral arbitration service within thirty (30) days thereafter. The agreement afforded the facility the selection of the arbitrator (third-party decision-maker contracted to resolve a dispute) initially unless the facility-selected arbitrator could not provide the services. Resident 62 signed an arbitration agreement with the same verbiage on April 20, 2023. Resident 68 signed an arbitration agreement with the same verbiage on July 15, 2024. The surveyor reviewed the above concerns regarding the arbitration agreements signed by Residents 19, 62, and 68 during an interview with the Nursing Home Administrator and the Director of Nursing on December 4, 2024, at 2:00 PM. Interview with the Nursing Home Administrator on December 5, 2024, at 10:10 AM confirmed that the facility's current arbitration agreement did not stipulate that both parties would agree upon a neutral arbitrator unless the arbitrator that was selected by the facility was unable or unwilling to provide the services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a)(j) Resident rights

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on [DATE], between 7:55 AM and 9:00 AM revealed the following: The dry storage goods area revealed the following: A bag of elbow macaroni had a blank date sticker on it and contained no open or use by date. There was a hole in the bottom of the bag. A temperature control unit on the wall had a significant accumulation of a black substance on the vents. An open container of whole rosemary had an expired use date of [DATE]. An open container of blue food coloring had an unreadable use by sticker. The bottle was hand dated [DATE]. The walk-in freezer contained several cardboard boxes that held food items (snickerdoodle dough, whipped topping, and cherry turnovers) that were located under the internal circulation fans. The boxes had a large accumulation of ice on them. A walk-in cooler contained eight cardboard boxes that held orange juice containers. The boxes noted, store at 0 degrees Fahrenheit. Three boxes observed were stamped by the facility with a date of [DATE], and one box had a date of [DATE]. A concurrent interview with Employee 6, Dietary Manager, revealed the dates indicated when the items were pulled from the freezer to thaw for use. A review of the manufacturer's instructions for the items revealed the items come frozen, thaw before serving, mark each case with the date the product was thawed, once thawed the items are to be kept refrigerated, and once thawed they are to be used within 10 days of thawing. The orange juice was not used within 10 days of thawing. Further observation of the walk-in cooler revealed a low-fat cottage cheese with an expired use by date of ,d+[DATE], and two open bags of cubed cheese that had an expired facility use by date of [DATE]. Observation of a second walk-in cooler revealed the following: Several clear containers of pudding with expired facility use by dates of [DATE], and [DATE]. A thawed box of hot dogs with a facility use by date of [DATE]. A container of hot dog chili sauce with a manufacturer's use by/freeze by date of [DATE]. Two containers of baked lima beans with an expired use by date of [DATE]. A large bag of shredded lettuce with an expired use by date of [DATE]. Two coated wire storage racks of items located near the center of the kitchen, that Employee 6 identified as clean, had items stored on the bottom shelves (one rack had various baking pans; the other rack had large black colored storage tubs and plate lids). There was no protective covering to protect these clean items on the bottom shelf from mop splash during floor cleaning. A green colored plastic tray in the sink next to the dishwasher had an extensive build-up of a black colored substance on it. A temperature control unit located on the wall in the food prep area had visible dust on it and a black colored build-up on the vents. The tops of the commercial coffee machine and juice machine had an accumulation of dust. Observation revealed an employee at a food prep area with a beard and no facial hair restrainer (beard guard). The employee was identified by administrative staff as Employee 7, dietary staff, and revealed the employee should have a beard cover. The above findings were reviewed with Employee 6 at the time of the findings. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:50 PM. 483.60(i) Food Procure, Store/Prepare/Serve -Sanitary Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure routine prophylactic dental services for one of three residents reviewed for dental concerns (Resident 62). Findings include: Interview with Resident 62 on December 3, 2024, at 12:49 PM revealed that he had natural teeth, but the, hygienist has never been here. Resident 62 indicated that no dental professional had cleaned his teeth, and he brushes his teeth. Interview with the Director of Nursing on December 5, 2024, at 10:40 AM confirmed that there was no evidence that a hygienist or dental professional provided prophylactic (preventative) cleaning of Resident 62's teeth in the past year. Following the interview with the Director of Nursing, the facility provided one progress note from the facility's consulting dental provider dated September 17, 2024, that was noted as an annual exam by the dentist. The progress note indicated that there was heavy soft plaque/food debris buildup, light hard calculus (hard deposit when soft plaque becomes calcified) deposits, moderate gingival (gum) inflammation/swollen bleeding gums, and moderate risk for caries (cavities/decay). The recommended treatment plan was for prophy (preventative cleanings) every six months. The facility provided no clinical record evidence that Resident 62 received routine prophylactic dental cleanings in the past year. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to obtain consent for, assess the need for, and assess entrapment risks from bed assistive bars for two of two residents reviewed for accident hazards (Residents 19 and 108). Findings include: Observation of Resident 19 on December 4, 2024, at 11:52 AM revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Resident 19's bed was also equipped with a headboard and a footboard. The surveyor requested evidence of an assessment for need, an assessment for entrapment risks, and consent for the use of the bed assistive devices for Resident 19 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 8 (registered nurse/infection control prevention coordinator) on December 4, 2024, at 2:00 PM. Interview with the Nursing Home Administrator on December 5, 2024, at 10:10 AM indicated that the facility utilized a bed system measurement device to assess four zones of potential entrapment risks presented with the use of a bed rail. The interview indicated that the facility could not provide documentation of the assessment completed to determine Resident 19's need for the assistive device, the assessment of potential entrapment risks from the use of the device on Resident 19's bed, or a consent obtained prior to installation of the device for Resident 19. A new physician's order obtained on December 5, 2024, at 11:04 AM (following the surveyor's questioning), indicated that Resident 19 was to use a bed enabler rail to assist with bed mobility. A Side Rail Assessment Form dated December 5, 2024, indicated that occupational therapy staff recommended side rails as an enabler for Resident 19. A Side Rail Consent Form signed by Resident 19 on December 5, 2024, indicated a desire for the assistive device. A Bed System Measurement Device Test Results Worksheet dated December 5, 2024, indicated that maintenance staff assessed Resident 19's bed assistive device for entrapment risks. Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM, revealed that she has limited range of motion to her right side following her stroke. Observation of Resident 108 on December 3, 2024, at 11:26 AM and 1:14 PM, revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Observation of Resident 108 on December 4, 2024, at 11:17 AM revealed she was in bed with assist bars mounted bilaterally at the head of her bed. Observation of Resident 108 on December 5, 2024, at 11:01 AM revealed she was in bed, and the assist bars were removed bilaterally from the head of her bed. Interview with the Nursing Home Administrator on December 5, 2024, at 11:57 AM confirmed that Resident 108 was unable to use the bilateral assist bars mounted on her bed. He stated the facility had no documentation of the assessment completed to show the need for Resident 108's assist bars, the assessment of potential risks from the use of the device on Resident 108's bed, or consent obtained prior to the installation of the device for Resident 108. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 23 residents reviewed (Residents 108 and 112). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting her right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. Further review of Resident 108's clinical record revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 25, 2024, in which facility staff assessed Resident 108 as having no impairment of her upper extremities. Interview with the Director of Nursing on December 5, 2024, at 10:22 AM confirmed Resident 108's functional limitation in her range of motion was coded in error on the MDS dated [DATE]. Review of Resident 112's clinical record revealed an MDS dated [DATE], that indicated the facility assessed him as being discharged to a hospital setting. Nursing documentation dated September 21, 2024, at 10:35 AM revealed that the facility discharged Resident 112 to his home. Interview with the Director of Nursing on December 5, 2024, at 10:23 AM confirmed that Resident 112's September 21, 2024 MDS was coded in error regarding his discharge status. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure quality of care related to a cardiac pacemaker use for one of 23 residents reviewed (Resident 68). Findings include: Interview with Resident 68 on December 4, 2024, at 11:14 AM revealed that she had a history of heart disease, and that she had a cardiac pacemaker (medical device implanted in the chest with wires to the heart to deliver electrical signals to control a heart rate) placed. Resident 68 pointed to an electronic device on her bedside stand and stated that a representative from the pacemaker monitoring company calls the nurses' station when she begins to show signs that fluid is accumulating in her body. Resident 68 stated that her Lasix (diuretic medication, used to remove excess fluid from the body) is sometimes adjusted because of this symptom change. Clinical record review for Resident 68 revealed no physician orders or plan of care that indicated that Resident 68 had a cardiac pacemaker. Diagnoses listed in Resident 68's clinical record included the following: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (ongoing failure of the heart to pump effectively that results in fluid buildup in the body that can worsen suddenly requiring treatment) Paroxysmal atrial fibrillation (irregular heartbeat in the upper part of the heart that can be intermittent) An admission physician's progress note (history and physical) dated July 18, 2024, indicated that the facility admitted Resident 68 following a hospitalization for heart failure. The documentation noted a surgical history that included heart ablation (sections of the heart are surgically treated to stop abnormal electrical signals, Ablate Heart Dysrhythm Focus). The documentation indicated that Resident 68 had an, AICD (automatic implantable cardioverter defibrillator, battery-operated device that can provide electrical impulses to maintain a normal rhythm and provide electrical shocks to the heart to correct life-threatening fast rhythms) per her records. The surveyor reviewed the above concerns that Resident 68 had an internal cardiac pacemaker; however, her physician orders and plan for her care did not address the use of this device, during an interview with the Director of Nursing and the Nursing Home Administrator on December 5, 2024, at 2:00 PM. A physician's order (following the surveyor's questioning) dated December 5, 2024, at 4:37 PM noted that Resident 68 had an, ACID and HF Integration, completed for alerts and every 91 days as scheduled by a consulting cardiology provider. The cardiology provider monitors and would notify the facility of any issues. Interview with the Director of Nursing on December 6, 2024, at 10:07 AM confirmed that Resident 68's cardiac pacemaker device could identify a potential fluid accumulation around her heart for which the monitoring company would call the facility. The facility was unaware how this device communicates with the monitoring company (e.g., via satellite, internet, cell phone); or what emergency procedures (e.g., power supply) would be necessary to continue its functioning when the facility would experience an interruption in utilities. The interview also confirmed that the device was not addressed in Resident 68's plan of care. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to implement a restorative nursing program as recommended by therapy to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for one of three residents reviewed (Residents 108). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following a cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. She stated that she no longer receives physical therapy. Review of Resident 108's admission Minimum Data Set (MDS, an assessment completed at specific intervals to determine care needs) dated September 25, 2024, noted Resident 108 had impairment on one side of her lower extremity. Review of physical therapy documentation dated November 8, 2024, noted the discharge recommendations for Resident 108 was for staff to complete passive range of motion (PROM) and active range of motion (AROM) exercises to both Resident 108's lower extremities to maintain ability for clothing management and daily hygiene tasks. Therapy discharge documentation noted therapy established PROM/AROM exercises and trained staff. Further review of Resident 108's clinical record revealed no evidence that staff implemented PROM or AROM programs. Interview with Employee 5 (physical therapist) on December 6, 2024, at 10:30 AM confirmed that a range was motion program was never established for Resident 108, and nursing staff were not educated. The above findings for Resident 108 were reviewed with the Director of Nursing on December 6, 2024, at 1:12 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs related to call bell response time for two of 23 residents reviewed (Resident 19 and 52). Findings include: Interview with Resident 19 on December 4, 2024, at 11:34 AM revealed that when she rings her call bell, staff will come in and then say they will be back but never come back. Review of Resident 52's Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated November 11, 2024, indicated the facility assessed her as being cognitively intact and needing the extensive assistance of two staff members for toileting. Observation on December 3, 2024, at 9:54 AM revealed that Resident 52 rang her call bell. The call bell continued to ring until 10:26 AM, 32 minutes after Resident 52 initiated the call bell. At 10:26 AM, Employee 1, nurse aide, entered Resident 52's room, the call light went out, and Employee 1 immediately walked back out of Resident 52's room. Interview with Resident 52 on December 3, 2024, at 10:29 AM revealed that she needed to move her bowels and needed the bed pan but Employee 1 flew out of here. This surveyor instructed Resident 52 to ring the call bell again. After Employee 1 exited Resident 52's room, this surveyor observed her collecting breakfast trays. Employee 1 was not providing any other care to residents. Observation on December 3, 2024, at 10:29 AM revealed that Resident 52's call bell was answered a second time, 35 minutes after Resident 52's initial call for assistance. Review of Resident 52's clinical record revealed that she has a diagnosis of irritable bowel syndrome (a condition that affects the digestive system). Nursing documentation dated December 2, 2024, at 4:40 PM indicated that Resident 52 had not had a bowel movement for three days. Nursing staff administered Milk of Magnesia (a medication used to treat occasional constipation) on December 2, 2024, at 6:31 PM. Interview with the Administrator and Director of Nursing on December 5, 2024, at 2:00 PM acknowledged the above findings for Resident 52. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure adequate labeling and storage of medications and biologicals on one of three nursing units (Station III) and for one of 23 residents reviewed (Resident 29). Findings include: Observation of the Station III nursing unit on [DATE], at 10:41 AM revealed an unlocked medication cart. The medication cart was sitting in a heavily occupied area of the nursing station. The unlocked medication cart was accessible to non-licensed staff, visitors, and other residents. The unlocked medication cart remained unattended until 10:46 AM. Interview with Employee 3, licensed practical nurse, on [DATE], at 10:46 AM confirmed the above observations. During a medication administration observation on [DATE], at 9:00 AM revealed Employee 2, licensed practical nurse, administering medications to Resident 29. Employee 2 indicated that Resident 29 administers her own eye drops. Employee 2 prompted Resident 29 to find her eye drops and administer them during the medication administration observation. Resident 29 reached into a zippered pouch that contained other items such as writing implements and pulled out a bottle of eyedrops. The bottle of eyedrops had some small brown colored stains on it, and the label was rubbing off. The eyedrops were not labeled with the resident's name or administration details. This surveyor was unable to identify that actual name of the eyedrops, other than it was a saline eye drop. Resident 29 could not remove the lid to the eyedrops, as the lid appeared stuck. Employee 2 had to assist Resident 29 to remove the stuck lid. The bottle of eye drops had an expiration date of [DATE]. Resident 29 administered the eyedrops using the bottle of eyedrops she found in her zippered pouch. Employee 2 then told Resident 29 that those eyedrops were expired after the surveyor informed her of the expiration date. Interview with the Administrator and Director of Nursing on [DATE], at 2:03 PM acknowledged the above findings. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of an investigation of an unknown injury for one of one resident reviewed (Resident 28). Findings include: The policy entitled Abuse Prohibition last reviewed on July 18, 2024, indicates that the facility uses an incident reporting system to report, investigate, and track all unusual incidents. Incidents of unknown origin are investigated according to the facility's stand-up meeting/investigation of unusual incidents. Suspicious injuries, occurrences, trends, or patterns that may constitute abuse are identified and investigated. Review of Resident 28's clinical record revealed nursing documentation dated September 26, 2024, at 2:30 PM that indicated Resident 28 was complaining of right leg pain. Nursing staff administered Tylenol (for pain relief) that was ineffective and notified Resident 28's physician. Nursing documentation dated September 27, 2024, at 2:30 PM indicated that Resident 28 continued to complain of pain in her right lower extremity from her hip to ankle. Nursing staff obtained a physician order for an x-ray of her right knee. Review of Resident 28's x-ray report dated September 27, 2024, indicated that her right knee demonstrated irregularity suggesting a tibial plateau fracture (a break at the top of the tibia bone in the knee joint, typically due to impact trauma). Nursing documentation dated September 28, 2024, at 2:04 AM revealed that the facility obtained a physician's order to send Resident 28 to the emergency room for treatment of her injury. Review of the emergency room documentation dated September 28, 2024, at 3:07 AM confirmed Resident 28's right knee tibial plateau fracture and indicated that her diagnosis also included ligamentous knee injury (a tear or sprain in one of the knee's four major knee ligaments). Nursing documentation dated September 28, 2024, at 11:00 AM revealed that Resident 28 returned from the emergency room with a right leg immobilizer (a splint used to keep stabilize or restrict movement of the leg). There was no documented evidence or incidents noted in Resident 28's clinical record to indicate how this injury occurred. Interview with the Director of Nursing on December 5, 2024, at 9:08 AM confirmed that the facility did not complete an investigation into Resident 28's fractured tibial plateau fracture to rule out the potential for abuse and neglect. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for one of 23 residents reviewed (Resident 108). Findings include: Clinical record review for Resident 108 revealed the facility admitted her on September 19, 2024, with diagnosis including hemiparesis (a condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (a serious condition that occurs when brain tissue dies due to lack of blood flow to the brain) affecting the right dominant side. Interview with Resident 108 on December 3, 2024, at 11:23 AM revealed that she has limited range of motion to her right side following her stroke. Observation of Resident 108 on December 3, 2024, at 11:26 AM and 1:14 PM revealed Resident 108 was in bed with her call bell attached to the top of the assist bar rail at the head of her bed. Resident 108 was unable to reach her call bell. Observation of Resident 108 on December 4, 2024, at 11:17 AM revealed Resident 108 was again in bed with her call bell attached to the top of the assist bar rail at the head of her bed. Resident 108 was unable to reach her call bell. The above information for Resident 108 was reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on December 5, 2024, at 2:22 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement care to prevent potential complications from a dialysis access site for one of one resident reviewed for dialysis services (Resident 62). Findings include: Interview with Resident 62 on December 3, 2024, at 12:58 PM revealed that he required dialysis treatments (treatment for kidney failure; a machine filters extra fluid and waste products from the blood) three times a week, and that the treatment was administered through a fistula (surgical connection between an artery and a vein making a larger blood vessel for dialysis treatment) located in the area over his right bicep (upper arm) muscle. Resident 62 stated that staff obtain blood pressure assessments from his leg. Resident 62 stated, Once in a while a nurse will come in and think that she's going to take it in my arm, but I tell her to do it in my leg. Observation of Resident 62 and his room during the interview revealed no indicators that Resident 62 had right arm use restrictions. Clinical record review for Resident 62 revealed no physician's order or plan of care intervention that restricted staff use of his right arm for blood pressure assessments or blood draws. The surveyor reviewed the above concern that staff could utilize Resident 62's right arm inappropriately causing potential damage to his dialysis fistula during an interview with the Nursing Home Administrator and the Director of Nursing on December 4, 2024, at 2:00 PM. Interview with the Director of Nursing on December 5, 2024, at 10:40 AM confirmed that the right arm limb restriction was not included in Resident 62's plan of care until following the surveyor's questioning. Observation of Resident 62's room on December 6, 2024, at 9:15 AM revealed that Resident 62 was out of the facility for his dialysis treatment. A sign above the right side of his bed noted, No BP (blood pressure) right arm. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm with serious injuries, including diagnoses of traumatic subarachnoid hemorrhage (bleeding in the brain), right hip contusion, and scalp laceration for one of one resident reviewed for abuse (Resident 41). Findings include: The facility policy entitled Abuse Prohibition, last reviewed without changes on July 20, 2023, revealed it is the policy of the facility that every resident will be free from mistreatment, neglect, and misappropriation of property. The facility will do all that is within its control to prevent occurrences of abuse. This will be managed through a system of employee screening, staff training, resident and family awareness programs, procedures to identify abuse and contributing factors, procedures to report and investigate occurrences, and corrective actions to prevent occurrences of abuse. The supervision of staff to identify inappropriate behaviors, when such staff behaviors or unsafe techniques are identified, the staff member's supervisor must intervene and correct the inappropriate behavior or unsafe technique. The monitoring of the provision of care and services and supervising the delivery of care to ensure that neglect of care does not occur. Clinical record review for Resident 41 revealed nursing documentation dated December 24, 2023, at 11:20 AM noting the registered nurse entered Station One and heard yelling on the front hall. The registered nurse observed Resident 41 lying on the floor on the right side of the bed with a lift sling and lift at his feet. Blood was noted on the back of Resident 41's head. Nursing documentation dated December 24, 2023, at 6:39 PM noted Resident 41 was sent to the hospital at 12:05 PM, was admitted , and transferred to the trauma intensive care unit with diagnoses of subarachnoid hemorrhage, right hip contusion (bruise), and occipital scalp laceration. A review of the facility investigation dated December 24, 2023, at 11:20 AM revealed while Employee 8 (nurse aide) was transferring Resident 41 in the maxi lift, Resident 41 slid out from the sling and fell on to the floor. Resident 41 was noted with a hematoma forming on the back of his head, with a laceration on top of the hematoma. A statement from Employee 8 revealed she attached the lift, and at that time her hall partner returned from break and stopped in to say she would be down in a minute. Employee 8's statement revealed she began to lift Resident 41, while Resident 41's daughter was moving his wheelchair into the hall. Employee 8 noted she began to move Resident 41 into bed and without warning Resident 41 slid down through the sling, and his head hit the floor. Further review of Resident 41's clinical record revealed a physician's order dated September 12, 2023, that indicated Resident 41 transfers with two staff assist, using the maxi lift. A review of Resident 41's task history (where nurse aides document the care provided to residents) in point click care (electronic medical record) also noted Resident 41's transfer status was maxi lift with the assistance of two staff. A review of the PB22 (Provider Bulletin 22, form required from the facility to document an investigation of abuse and/or neglect) submitted to the Department of Health on December 28, 2023, revealed Employee 8 transferred Resident 41 from his wheelchair to his bed via the full mechanical lift. During the process, Resident 41 slid off the lift sling onto the floor causing a laceration to the back of his head. It was reported that another nurse aide stopped by the room and stated she would be back in a minute to help, but Employee 8 chose not to wait and proceeded on her own to lift and transfer Resident 41. The facility investigation concluded that Resident 41 was not safely secured for transfer, and a two-person assist was not present during the transfer, which was listed on Resident 41's task Kardex for transfers. A review of Employee 8's personnel file revealed that she received a verbal warning on January 8, 2019, due to transferring a resident with one assist when the resident was care planned two assist. There was no documentation of education. Employee 8 received a verbal warning again on March 18, 2019, for transferring a resident incorrectly who was ordered a maxi lift. The verbal warning noted this is the second resident Employee 8's supervisor had witnessed her transfer not according to the resident's plan of care. There was no documentation of education. Employee 8 received a written warning on January 2, 2020, for again not following a resident's plan of care regarding two assists with a maxi lift. The written warning noted Employee 8 admitted she did not follow the resident's plan of care. A review of the Personnel Policy handbook provided by Employee 3 (human resources) revealed any employee may be discharged without warning for one of the following, including abusive and inconsiderate treatment of residents, and negligence in the performance of duties directly related to care of a resident. An interview with Employee 3 on January 4, 2024, at 12:32 PM confirmed Employee 8 had three previous violations for not transferring residents appropriately. She stated the facility does not have a specific protocol for progressive discipline, indicating it would be on a case-by-case basis. The facility failed to ensure that a resident remained free from neglect, which resulted in actual harm. These findings were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on January 4, 2023, at 1:22 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to implement measures to prevent a resident accident with serious injury (ankle and nose fracture) resulting in harm for one of three residents reviewed for falls (Resident 27). Findings include: Clinical record review for Resident 27 revealed a plan of care developed by the facility to address her required assistance with activities of daily living due to physical limitations. Interventions included in that plan of care instructed staff to complete transfers as ordered (by the physician). Review of physician orders for Resident 27 revealed that on June 18, 2020, staff received a physician's order that Resident 27 could be out of bed to a bedside chair or wheelchair with bilateral elevating leg rests. The order instructed staff to apply nonskid matting (material used to prevent sliding or slipping from a surface) above and below a mosaic cushion (removable seating cushion designed with individual pockets of air for skin breakdown prevention). Review of task documentation (instructions available to nurse aide staff regarding resident care needs) revealed that instructions pertaining to Resident 27's transfer needs included the use of a mechanical lift to the bedside chair or wheelchair with bilateral elevating leg rests and nonskid matting above and below a mosaic cushion as of June 23, 2020. Nursing progress note documentation dated July 26, 2020, at 8:22 AM revealed that staff observed Resident 27 face down on the floor in front of her recliner with a pool of blood (approximately the size of a dinner plate) on the floor. Resident 27 sustained a, large gaping laceration, to her forehead, above her nose. Resident 27 also reported pain to her nose and presented with early swelling and pain in her left cheek/jaw area. Resident 27 stated that she felt herself start to slide from her recliner chair; however, she could not stop herself. Staff notified the physician who provided a new order to send Resident 27 to the emergency room for evaluation. Nursing progress note documentation dated July 26, 2020, at 1:46 PM revealed that Resident 27 arrived back to the facility via ambulance from the hospital. Staff received report from hospital staff that Resident 27 received eight stitches (to her head laceration) and was diagnosed with a fracture under her nose and a small, nondisplaced, fracture in her left ankle. Hospital documentation dated July 26, 2020, confirmed that Resident 27 sustained a nondisplaced maxilla (upper jaw) fracture and a nondisplaced left ankle fracture (treated with an ace wrap, an elastic bandage used to support a joint). Review of the facility's investigation dated July 26, 2020, at 6:50 AM revealed that prior to the above incident, Resident 27 was sitting in her chair. Staff ensured the placement of the mosaic cushion on the recliner; however, did not ensure the application of the non-slip matting above or below the cushion (per the physician's order). The facility provided the staff with verbal education and suspended the staff from work. A physician's order dated July 26, 2020, instructed staff to ensure Resident 27 did not bear weight on her left ankle. Interview with the Nursing Home Administrator on September 11, 2020, at 10:00 AM confirmed that the facility's investigation of Resident 27's fall on July 26, 2020, concluded that staff failed to ensure the application of the non-skid material above and below the mosaic cushion when she slid from her recliner chair and sustained facial and left ankle injuries. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited 7/25/19 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/25/19, 9/14/18

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to prevent resident neglect that resulted in a fall with serious injury for one of 23 residents who sustained a fall resulting in a fractured left hip. This deficiency is cited as past non-compliance (Resident 38). Findings include: Clinical record review for Resident 38 revealed an annual Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine resident care needs) dated June 6, 2017, that indicated she required extensive assistance of two staff for weight-bearing support. It further indicated that she was not steady and only able to stabilize with staff assistance. Resident 38's plan of care indicated that she transfers with the assistance of two staff and a pyramid cane (cane with four legs). Review of an incident investigation dated June 12, 2017, revealed a nurse aide was preparing to shower Resident 38. The nurse aide attempted to have the resident grab the handicap bar and stand from the wheelchair. The nurse aide was attempting to lower the resident's pants when Resident 38 lost her balance and fell to the floor. Resident 38 complained of back pain that radiated to her left hip. Nursing staff notified her physician and received orders to send her to the emergency room where she was diagnosed with [REDACTED]. The incident investigation revealed that the nurse aide asked the resident how she transferred and the resident stated that she holds onto the bar. Facility interview with the resident indicated that she, knew the girl might need help, but I didn't want to say anything. An interview with Resident 38 on August 27, 2017, at 9:05 AM revealed that she fell when she was transferring from the wheelchair to the shower chair. She stated that she grabbed onto the bar in the shower room. The bar was wet, her hands slipped, and she fell to the floor breaking her hip. She confirmed there was only one nurse aide assisting her. An interview with the Director of Nursing on August 29, 2017, at 10:15 AM confirmed the above. The facility failed to provide the assessed assistance needed for Resident 38 resulting in a fall with a fracture requiring surgery. This deficiency involving Resident 38 is cited as past non-compliance. The facility's action plan included the Director of Nursing reviewing the incident with the nurse aide involved. The Director of Nursing then re-educated the nurse aide on the types of abuse and intent, not to rely on the residents for information regarding transfer orders, verify transfer orders with the plan of care, Kardexes are to be updated and kept in residents' closets, and to check the 24 hour nurse aide report for new orders. All of this information was verified during the onsite survey and a hard copy of all the documentation was provided to the survey team. 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 2/3/17, 7/29/16, 5/11/16, 5/4/16, 8/14/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 2/3/17, 12/14/16, 7/29/16, 5/4/16, 8/14/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 2/3/17, 12/14/16, 7/29/16, 5/11/16, 5/4/16, 8/14/15