Every finding on record at Oak Hill Center for Rehabilitation and Nursing

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for daily weights for two of six residents reviewed (Residents 1 and 6).Findings include: Review of Resident 1's clinical record revealed diagnoses that included heart failure (a chronic condition where the heart cannot pump blood efficiently enough to meet the body's needs) and GERD (gastroesophageal reflux disease - a chronic condition where stomach acid frequently flows back into the esophagus, causing irritation, heartburn, and potential damage). Review of Resident 1's physician's orders revealed an active order to obtain weight daily, report 2-3 lb (pound) weight gain overnight or weight gain of 5 lb in one week, with a start date of March 10, 2026. Review of Resident 1's care plan revealed the Resident was at risk for nutrition/hydration problems related to anxiety, chronic heart failure/stage 3 chronic kidney disease with therapeutic diet, GERD, weight changes caused by fluid, fluid restriction, diuretics use, and elevated BMI (body mass index - a screening tool calculating a person's body fat using height and weight); with an intervention to monitor weight as ordered, initiated on March 11, 2026. Review of Resident 1's weights summary task failed to reveal a weight was obtained for the Resident on March 11, 13, 15, 21, and 22, 2026. Review of Resident 6's clinical record revealed diagnoses that included hypertension (high blood pressure) and major depressive disorder (MDD - a serious mental health condition characterized by persistent sadness, low energy, and loss of interest in activities lasting at least two weeks). Review of Resident 6's physician's orders revealed an order to weigh the Resident every morning for 6 weeks, with a start date of February 17, 2026. Review of Resident 6's care plan revealed the Resident was at risk for nutrition/hydration problems related to pain, hypertension, MDD, and overweight BMI; with an intervention to monitor weight as ordered, initiated on June 10, 2025. Review of Resident 6's weight summary task failed to reveal a weight was obtained for the Resident on March 15 and 22, 2026. During an interview conducted with the Nursing Home Administrator on April 7, 2026, at 10:37 AM, he confirmed the Residents were not weighed on the dates listed above and will do education with the weekend nurses to ensure they are completing resident weights as ordered. 42 CFR 483.25 Quality of care28 Pa. Code 211.12(d)(1)(3)(5)Nursing services.

Based on facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that PRN (as needed) psychotropic medication orders were limited to 14 days for one of five residents reviewed (Resident 1); failed to provide side effect monitoring for two of five residents reviewed (Residents 3 and 128); failed to inform resident representatives of initiating psychotropic medication for one of five residents reviewed (Resident 14); and failed to ensure that the resident was free from chemical restraints imposed for the purposes of convenience for one of five residents reviewed (Resident 128). Findings include: Review of facility provided policy, titled Policy for Psychotropic Use in Long-Term Care (LTC), with a last review date of August 18, 2025, revealed its purpose was to ensure the safe and appropriate use of psychotropic medications in residents of Long-Term Care (LTC) facilities, in compliance with regulatory standards and best practice guidelines, while promoting the well-being and rights of residents. Further review revealed that informed consent must be obtained from the resident or their legally authorized representative before initiating or changing any psychotropic medication and residents on psychotropic medications will be regularly monitored for efficacy and adverse effects. This includes periodic reassessment of the need for continued therapy. Review of facility provided policy, titled Antipsychotic Medication Use, with a last review date of August 18, 2025, revealed the following, 14. The need to continue PRN orders for psychotropic medication beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Review of Resident 1's clinical record revealed diagnoses that included major depressive disorder (a serious mental health condition marked by persistent sadness, hopelessness, and a loss of interest in activities that significantly impairs daily functioning) and dementia (progressive decline in cognitive function that interferes with daily life). Review of Resident 1's physician's orders revealed an order for ABH Gel (psychotropic medication) every eight hours as needed for agitation, with a start date of October 28, 2025. No end date was documented. Further review of Resident 1's physician's orders revealed an order for Seroquel (antipsychotic medication) every six hours as needed for agitation, with a start date of March 21, 2025. No end date or rational for continued use was documented. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), on December 3, 2025, at 2:19 PM, revealed that the NHA would expect PRN psychotropic medication orders to have a 14 day stop date documented and followed. Review of Resident 3's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) with agitation and depression.Review of Resident 3's physician orders revealed orders for Ativan oral tablet 0.5 milligrams (Lorazepam-medication used to treat anxiety and agitation) give one tablet by mouth once daily as needed for physical and escalated verbal aggression for 120 days, dated August 6, 2025; Seroquel (quetiapine-an antipsychotic medication used to treat psychosis and other mental health diagnoses) 25 milligrams give one tablet three times a day, dated August 11, 2025; Seroquel 25 milligrams give half a tablet (12.5 milligrams) once daily, dated July 25, 2025; Zoloft (sertraline-an antidepressant medication used to treat depression) 100 milligrams give one tablet once daily, dated March 12, 2022; and Zoloft 25 milligrams give one tablet once daily, dated March 17, 2022. Review of Resident 3's clinical record failed to reveal any documentation of monitoring for side effects of his aforementioned psychotropic medications. During a staff interview with the NHA and DON on December 4, 2025, at 9:10 AM, the NHA confirmed that side effect monitoring should have been in place for Resident 3's psychotropic medications. Review of Resident 14's clinical record revealed diagnoses that included anxiety disorder (excessive fear of or apprehension about real or perceived threats) and paranoid schizophrenia (psychiatric disorder characterized by distorted thinking and awareness). Review of Resident 14's physician orders reviewed an order for olanzapine (antipsychotic medication) twice daily. Further review of Resident 14's clinical record revealed a form titled psychoactive medication informed consent.Review of the form failed to reveal a signature from the Resident or Resident Representative consenting to the medication being used. During an interview with the NHA and DON on December 4, 2025, at 11:31 AM, the NHA revealed that it was the expectation of the facility that proper consent be obtained from either the resident or resident representative for psychotropic medication use. Review of Resident 128's medical record revealed diagnoses of major depressive disorder and anxiety disorder. Review of Resident 128's physician orders revealed an order for Lorazepam (anxiety medication) gel 1 mg/ml to be applied to Resident 128's arms or back at bedtime and every 6 hours as needed for anxiety and restlessness, with a start date of September 9, 2025. Further review of Resident 128's physician orders revealed that the Resident received all of their other medication in pill form. Review of Resident 128 Care plan revealed a focus are of, the Resident uses anti-anxiety medications, with a date initiated of August 12, 2025, an intervention to monitor and document signs and symptoms of anxiety, initiated on August 12, 2025, and another intervention of monitor/document/report adverse reactions to anti-anxiety therapy, initiated on August 12, 2025. Further review of Resident 128's care plan failed to reveal any plan of care regarding refusal of care or medications. Review of Resident 128's medical record failed to reveal any documented side effect monitoring regarding anxiety medication or behavior monitoring for symptoms of anxiety. Further review of Resident 128's medical record failed to review any refusal of medications or any nonpharmacological interventions used for Resident 128. Interview with the NHA on December 3, 2025, at 11:45 AM, revealed that Resident 128 was previously receiving Lorazepam in tablet form but Resident 128 began refusing the medication intermittently, so it was changed to Lorazepam gel. Another interview with the NHA on December 4, 2025, at 11:30 AM, revealed he would expect the behavior and side effect monitoring to be documented. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for four of 25 residents reviewed (Residents 3, 4, 9 and 14).Findings include: Review of the facility policy, titled Wound and Skin Care with a last review date of August 18, 2025, revealed, 3. For new admissions that do not have a pressure area/ulcer, the resident's skin will be monitored weekly through the nurses' skin assessments. Identified issues will be followed through skin program. Review of Resident 3's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) with agitation and depression. Review of Resident 3's clinical record revealed a laboratory order for complete blood count, comprehensive metabolic profile lipid panel, hemoglobin A1C, Phenytoin level, and Levetiracetam level every six months with a start date of April 14, 2025. Review of Resident 3's clinical record failed to reveal any of these laboratory test results for April 14, 2025. Email communication received from the Nursing Home Administrator (NHA) on December 4, 2025, at 9:48 AM, indicated he was unable to locate Resident 3's April 14, 2025, lab results. During a staff interview with the NHA on December 4, 2025, at 11:36 AM, he confirmed that Resident 3's labs were not obtained as ordered and indicated that he would expect physician orders to be followed. Review of Resident 4's clinical record revealed diagnoses that included dementia, hypertension (high blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 4's clinical record revealed a Consultant Pharmacist MRR (Medication Regimen Review) to Prescriber dated March 26, 2025, which indicated, Please consider adding the following recommended labs: Digoxin: drug level and basic metabolic profile and pulse daily. The document was signed by Resident 4's provider on March 26, 2025. Review of facility provided Nursing Recommendations completed by consultant pharmacist on May 28, 2025, for Resident 4 indicated Pulse should be monitored daily before digoxin is given. Digoxin dose is usually held if a pulse is less than 50. This document was not signed or dated as to when it was reviewed. Review of Resident 4's physician orders revealed an order for Digoxin oral tablet 125 micrograms give one tablet by mouth one time a day, hold for pulse less than 50, dated June 2, 2025; approximately nine weeks after the original recommendation was made by the pharmacist and signed by provider. Further review of Resident 4's clinical orders from March 26, 2025, through current failed to reveal any orders for a digoxin level to be obtained. During a staff interview with the NHA and Director of Nursing (DON) on December 4, 2025, at 11:26 AM, the DON confirmed that Resident 4's pulse monitoring and laboratory testing should have been implemented when the original recommendation was made and signed by provider on March 26, 2025. Review of Resident 9's clinical record revealed diagnoses that included cerebrovascular disease (conditions that impact the blood vessels in your brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 9's physicians' orders revealed an order for the Resident to have weekly skin checks every Saturday during the 3-11 shift, and to document weekly skin assessment in point click care (PCC - cloud-based electronic health record solution), with an active date of October 28, 2025. Review of Resident 9's care plan revealed a care plan with a focus area of, the Resident is at risk for skin breakdown due to decreased mobility, initiated on October 17, 2025; with an intervention for the Resident to have skin assessments completed weekly and as needed, initiated on October 17, 2025. Review of Resident 9's clinical record revealed the Resident had a skin assessment completed on October 25, 2025; November 4, 2025; and December 2, 2025. The facility was unable to provide any additional weekly skin assessments that were completed for Resident 9, which included three weeks of missing skin assessments. Interview conducted with the NHA on December 4, 2024, at 11:00 AM, revealed he would have expected Resident 9's weekly skin assessments to have been completed and documented in PCC as ordered by the physician. Review of Resident 14's clinical record revealed diagnoses that included type two diabetes mellitus (the body cannot use insulin properly and sugar builds up in the blood) and anxiety disorder (excessive fear of or apprehension about real or perceived threats).Review of Resident 14's physicians' orders revealed an order for blood glucose checks twice daily and to notify the physician if greater than 400 or less than 60.Review of Resident 14's Medication Administration Record (MAR) from August 2025 - December 2025 revealed Resident 14's blood glucose was documented as greater than 400 on the following dates: August 3 (430); November 3 (432); November 17 (406 in the AM); and November 18 (458). Further review of Resident 14's clinical record failed to reveal evidence that the physician was notified of Resident 14's blood glucose being over 400 on the aforementioned dates.An interview with the Nursing Home Administrator (NHA) and Director of Nursing on December 3, 2025, at 2:17 PM, revealed that the facility could not provide any documentation that the physician had been notified. The NHA stated that it was the expectation of the facility that physician orders be followed.28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to manage or prevent pain consistent with professional standards of practice and the resident's goals and preferences for one of one residents reviewed (Resident 69).Findings include: Review of facility policy, titled Pain Assessment and Management, with a last review date of August 18, 2025, revealed, in part, Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Review of facility policy, titled Administering Pain Medications, with a last review date of August 18, 2025, revealed, in part, Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. Document the following in the resident's medical record: 5. Results of the medication (adverse or desired). Review of Resident 69's clinical record revealed diagnoses that included pain, osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints), and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves which disrupts communication between the brain and the body). During an interview with Resident 69 on December 1, 2025, at 10:19 AM, she indicated that she had ongoing pain management issues. Review of Resident 69's physician orders revealed the following orders: Acetaminophen (Tylenol) tablet 325 milligrams give two tablets by mouth every 4 hours prn (as needed) for pain, dated May 8, 2025; and Oxycodone hydrochloride oral tablet 5 milligrams give one tablet by mouth every 6 hours prn for breakthrough pain, dated May 8, 2025. Review of Resident 69's clinical record revealed that she had no comprehensive pain assessments completed between January 6, 2025, and September 19, 2025. Further review of Resident 69's comprehensive pain assessment completed on September 19, 2025, revealed she indicated that she had almost constant pain, but that it had not made it hard to sleep at night and it did not limit her day-to-day activities. She further identified that her pain goal was a 6. Review of Resident 69's September 2025 Medication Administration Record revealed the following:1) she received 34 doses of prn Tylenol for pain levels ranging from 2-8 (2=1; 5=1; 7=10; 8=22), with 2 doses documented as ineffective and 5 doses documented as effectiveness unknown;2) she received 25 doses of prn oxycodone for pain for pain levels ranging from 7-8 (7=10; 8=15), with 5 doses documented effectiveness unknown; and3) she received her prn Tylenol and her prn oxycodone at the same time on 19 occasions. Review of Resident 69's October 2025 Medication Administration Record revealed the following:1) she received 4 prn doses of Tylenol for a pain level of 0, with one dose documented as effectiveness unknown;2) she received 6 prn doses of Tylenol for fever (no parameter given as to when to administer) and the highest documented temperature was 97.4 and one dose documented as effectiveness unknown;3) she received 19 doses of prn Tylenol for pain levels ranging from 3-8 (3=1; 6=1; 7=9; 8=7), with 6 doses documented as effectiveness unknown;4) she received 1 dose of prn oxycodone for a pain level of 0;4) she received 29 doses of prn oxycodone for pain levels ranging from 4-8 (4=1; 6=4; 7=15; 8=9), with 8 doses documented as effectiveness unknown; and5) she received 19 doses of prn Tylenol and oxycodone at the same time. Review of Resident 69's November 2025 Medication Administration Record revealed the following:1) she received 3 prn doses of Tylenol for a fever and the highest temperature documented was 97.7, with one dose documented as effectiveness unknown;2) she received 6 prn doses of Tylenol for a pain level of 0, with 2 doses documented as effectiveness unknown;3) she received 14 prn doses of Tylenol for pain levels ranging from 7-8 (7=8; 8=6), with 2 doses documented as ineffective and 4 doses documented as effectiveness unknown;4) she received 3 doses of prn oxycodone for a pain level of 0; managemnet1; 7=8; 8=10), with 3 doses documented as ineffective and 6 doses documented as effectiveness unknown; and5) she received 13 prn doses of Tylenol and oxycodone at the same time. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 4, 2025, at 10:06 AM, the DON confirmed that there should have been parameters for Resident 69's prn pain medications and that the orders were revised after they were made aware of the concern. The DON also acknowledged that the two as needed pain medications should not have been given at the same time. The NHA indicated that they would follow-up with Resident 69 regarding her pain goal and the management of her pain. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two residents reviewed (Residents 42 and 53).Findings include:Review of facility policy, titled Hemodialysis, without implementation or review date, revealed, The facility will immediately contact and communicate with the attending physician, resident/ representative, and designated dialysis staff (i.e. nephrologist, registered nurse) any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan.Review of Resident 42's clinical record revealed diagnoses that included heart failure (when your heart muscle doesn't pump blood as well as it should) and end stage renal disease (when the kidneys no longer function normally).Review of Resident 42's physician's orders revealed an order for the Resident to receive dialysis on Tuesday, Thursday, and Saturday, starting on September 16, 2025.Review of Resident 42's care plan revealed a care plan with the focus area of, the Resident needs dialysis related to renal failure, with a revision date of September 5, 2025. Request for Resident 42's dialysis communication sheets (documented communication between the nursing facility and dialysis facility) on December 3, 2025, at 11:00 AM, failed to reveal any communications with the dialysis facility regarding Resident 42's care.Interview with the Nursing Home Administrator (NHA) on December 4, 2025, at 10:36 AM, revealed they were unable to locate Resident 42's dialysis binder with communication sheets and have created a new one. NHA revealed that they typically do not upload dialysis communication sheets to the resident's electronic health records and would expect the dialysis communication sheets be completed and available for review.Review of Resident 53's clinical record revealed diagnoses of chronic kidney disease (a gradual loss of kidney function where the kidneys become damaged and can't filter blood as well as they should) and calculus of kidney (kidney stones, hard objects made of minerals and salts in urine that form inside of the kidney).Review of Resident 53's physician's orders revealed an order for the Resident to receive dialysis on Monday, Wednesday, and Friday, starting on September 6, 2025. Review of Resident 53's care plan revealed a care plan with the focus area of, the Resident needs dialysis related to renal failure, with a revision date of August 5, 2025. Request for Resident 53's dialysis communication sheets (documented communication between the nursing facility and dialysis facility) on December 4, 2025, at 10:00 AM, failed to reveal any communications with the dialysis facility regarding Resident 53's care since November 12, 2025. During that time frame Resident 53 went for dialysis treatments nine times.Interview with the NHA on December 4, 2025, at 12:45 PM, revealed that he would expect the dialysis communication sheets be completed and available for review. 28 Pa Code 211.5(f) Clinical records28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of select facility personnel documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for five of five nurse aides reviewed (Employees 3, 4, 5, 6, and 7).Findings Include: Review of personnel information revealed that Employee 3's hire date was December 7, 2021; Employee 4's hire date was February 21, 2022; Employee 5's hire date was February 6, 2024; and Employee 6's hire date was October 11, 2022; and Employee 7's hire date was March 7, 2022. Further review of personnel information for Employees 3, 4, 5, 6, and 7, failed to reveal that annual performance reviews were completed. During an interview with the Nursing Home Administrator on December 4, at 12:00 PM, he acknowledged that he had no additional documentation to provide for the selected employees. He confirmed that he would expect annual performance reviews to be completed around an employee's date of hire.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.19(2) Personnel policies and procedures

Based on facility policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 25 residents reviewed (Residents 4 and 80). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last review date of August 18, 2025, read, in part, 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. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Review of facility policy, titled Pacemaker, Care of a Resident with, with a last review date of August 18, 2025, revealed, in part, Pacemakers are electronic devices that artificially stimulate the heart muscle with electrical impulses when the heart rhythm is too slow. The following devices or procedures may interfere with pacemaker functioning: a. Cell phones or MP-3 players (for example iPods); b. household appliances, such as microwave ovens; g. Magnetic Resonance Imaging (MRI) machines; and h. Radiation machines for treating cancer. Review of Resident 4's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), hypertension (high blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Observation of Resident 4 on December 1, 2025, at 11:28 AM, revealed she was lying in bed, and she had bilateral enabler bars on her bed. In addition, there was a Pacemaker Monitoring Unit (a bedside home monitor that is provided which performs remote pacemaker checks and then sends the information from the device to the physician). Review of Resident 4's clinical record revealed that the bilateral enabler bars were ordered to be placed on her bed on October 16, 2025. Facility provided documentation confirmed that the enablers were placed on Resident 4's bed on October 17, 2025. Further review of Resident 4's clinical record revealed that she has had a pacemaker since June 2018. Review of Resident 4's current care plan failed to reveal that her use of enablers or her pacemaker and appropriate safety precautions required were care planned. Review of her care plan revision history revealed that her enablers or her pacemaker and safety precautions had never been care planned. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on December 4, 2025, at 9:06 AM, the NNHA confirmed that Resident 4's pacemaker and appropriate safety precautions and her enablers should have been care planned. Review of Resident 80's clinical record documented diagnoses that included morbid obesity and spondylolisthesis lumbar region (condition where one of the vertebrae in the lower back slips out of its proper position causing lower back pain). Interview with Resident 80 on December 1, 2025, at 10:45 AM, revealed she utilized the bilateral enabler bars and trapeze on her bed for bed mobility and transfers. It was also revealed staff has completed safety checks on both the rails and trapeze. Review of Resident 80's physician orders included assist in bed mobility enabler bar both sides of bed, check every shift for functioning and placement, started September 3, 2025. The consent and risk benefit for use of bed rail was signed December 5, 2024. Review of Resident 80's care plan and Kardex failed to document use of the enabler bars or the trapeze. Per email communication with the NHA on December 2, 2025, at 1:20 PM, it was confirmed that use of the enabler bars and trapeze weren't documented on the care plan or the Kardex and they should have. 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.12(d)(2)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision and assistance devices to prevent accidents for one of five residents reviewed (Resident 4).Findings include: Review of facility policy, titled Falls and Fall Risk, Managing, with a last review date of August 18, 2025, revealed, in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of Resident 4's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and hypertension (high blood pressure). Review of Resident 4's care plan revealed a care plan focus for at risk for falls with a last revision date of January 4, 2024. Interventions included, but were not limited to, bilateral fall mats, with an initiated date of January 15, 2024. Observations of Resident 4 on December 1, 2025, at 11:28 AM; and December 3, 2025, at 12:58 PM, revealed that she was lying in bed and no fall mats were noted at the sides of her bed. In addition, no fall mats were noted to be in Resident 4's room. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on December 3, 2025, at 2:32 PM, the NHA confirmed that Resident 4's had no bilateral fall mats in her room and that they should have been in place as care planned. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 211.12(d)(2)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of two residents reviewed (Resident 15).Findings include: Review of facility policy, titled Catheter Care, Urinary, with a last review date of August 18, 2025, revealed, in part, Be sure the catheter tubing and bag are kept off the floor. The following information should be recorded in the resident's medical record: the date and time care was given and the name and title of the individual(s) giving the catheter care. Review of Resident 15's clinical record revealed diagnoses that included prostate cancer and Lewy Body dementia (a chronic disorder of mental processes caused by protein build-up in the brain, and marked by visual hallucinations, rigid muscles, slow movement, memory disorders, personality changes, and depression). Observation of Resident 15 on December 1, 2025, at 10:58 AM, revealed that he was lying in bed and his catheter bag was in direct contact with the floor. Observation of Resident 15 on December 3, 2025, at 11:25 AM, revealed that he was up in his chair and his catheter bag was in direct contact with the floor. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 3, 2025, at 2:34 PM, the NHA confirmed that Resident 15's catheter bag should not have been in contact with the floor. Further review of Resident 15's clinical record revealed that he was originally admitted to the facility on [DATE], with a foley catheter in place. Resident 15 was transferred to the hospital on November 15, 2025, and returned to the facility on November 21, 2025, with a foley catheter in place. Review of Resident 15's physician orders revealed an order for catheter every shift every day and as needed, dated December 1, 2025. Review of Resident 15's Treatment Administration Records for November 2025 and December 2025 failed to reveal any documentation of catheter care from November 21, 2025, through December 1, 2025. Further review revealed that catheter care was initiated on December 2, 2025, at 6:30 AM, but failed to reveal that catheter care was being administered every shift as ordered. The documentation box was noted to only populate for day shift. During a staff interview with the NHA and DON on December 3, 2025, at 2:34 PM, the NHA indicated that there were progress notes acknowledging that Resident 15 had a foley catheter between November 21, 2025, and December 1, 2025, but that the orders for Resident 15's catheter care were not re-populated until December 1, 2025. The DON confirmed that catheter care should be administered every shift. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, resident and staff interviews, and clinical record review, it was determined that the facility failed to provide routine and emergency dental services for one of one resident reviewed for dental services (Resident 81).Findings: Review of facility policy, titled Dental Services, revised December 2016, read, in part, selected dentists must be available to provide follow-up care. Social services representatives will assist residents with appointments. Review of resident 81's clinical record documented diagnoses that included Alzheimer's disease (progressive brain disorder that slowly damages nerve cells, causing a gradual loss of memory, thinking and language abilities), adjustment disorder with mixed anxiety (a feeling of worry, nervousness, or unease), and depression (feelings of severe despondency and dejection). Interview with Resident 81 on December 1, 2025, at 11:15 AM, revealed she hadn't seen a Dentist for two missing upper right teeth; they were to be replaced. Review of census documentation revealed Resident 81's payor source was Medicaid managed care health plan since June 21, 2024. Review of Resident 81's care plan and Kardex documented to assist with inserting/removing (upper and lower) dentures in AM and at bedtime, initiated February 23, 2023. Review of dental exam dated May 9, 2025, documented denture step 1 visit- impressions were taken of both maxillary (upper jaw) and mandibular (lower jaw) arches for fabrication of upper and lower dentures - continue oral care and remove dentures at night, denture step 3 scheduled May 30, 2025. Dental exam dated June 26, 2025, documented visit for annual exam and step 3 denture visit (a wax or temporary denture try-in appointment to evaluate the look, fit, and bite of future denture) revealed full upper and lower dentures worn with plaque, both ill fitting. Resident in the process of new denture fabrication, a bite registration (impression) was completed, and secondary impressions were obtained of both maxillary and mandibular arches. Recommend annual exam to monitor oral and tissue health, next visit for dentures step 4 (a wax denture try-in to evaluate bite, shape and appearance are correct before dentures are finalized). Dental consult dated July 28, 2025, documented the Resident was scheduled to be treated that day but that the Resident was unavailable; not in her room on 4 attempts during dental visit. Interview with the Nursing Home Administrator (NHA) on December 3, 2025, at 2:39 PM, revealed Resident 81 was scheduled to be seen the coming Friday, December 5th, 2025. It was also revealed that the Dentist comes to the facility about every six weeks, and that Resident 81 should've been see prior to December 5th, 2025, for her step 4 denture fitting. 28 Pa Code 211.15(a) Dental services

Based on clinical record review and staff interviews, it was determined that the facility failed to provide services consistent with professional standards of practice to ensure the resident's highest level of well-being, which resulted in harm as evidenced by a delay in sending the resident to the hospital following confirmation of a femur fracture, and by failure to provide appropriate pain assessment and management for the fracture, for one of three residents reviewed (Resident 1). Findings include:Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's Disease and Dementia (a progressive cognitive and mental decline that is severe enough to interfere with daily life, affecting memory, thinking, language, and judgment). Resident 1 resided on the locked memory care unit at the facility. Review of the clinical record revealed Resident 1 had a fall on August 26, 2025, at 4:45 PM. Resident 1 complained of pain in her right thigh and had an x-ray (an imaging test that uses a small amount of radiation to create images of internal body structures, such as bones, organs, and soft tissues) completed that same day on Resident 1's right hip, which came back negative for a fracture. Resident 1 was ordered Oxycodone hcl oral tablet (narcotic pain medication) 5 milligrams (mg) by mouth every 4 hours as needed for pain.Review of Resident 1's comprehensive care plan revealed a focus area for falls indicating the Resident is at risk for falls related to confusion, is unaware of safety needs, with an initiation and revision date of September 12, 2024, and an intervention to anticipate and meet the Resident's needs, initiated on September 12, 2024. Review of Resident 1's care plan also revealed a focus area that indicated the Resident has a communication problem related to impaired cognitive status, with an intervention to anticipate and meet needs, initiated and revised on August 21, 2025.Review of Resident 1's August 2025 Medication Administration Record (MAR) revealed an order to monitor for pain from a scale of 0-10, every shift. On August 26, 2025, during the night shift, it was documented that Resident 1 had a pain level of 8. On August 27, 2025, at 6:30 AM, Resident 1 was documented as having a pain level of 5. On August 27, 2025, during the night shift, Resident 1 was documented as having a pain level of 4. On August 28, 2025, at 6:30 AM, Resident 1 was documented as having a pain level of 4. From August 1 to August 25, the resident's pain score was zero. Further review of Resident 1's August 2025 MAR revealed an order for oxycodone hcl oral tablet 5 mg - give 5 mg by mouth every 4 hours as needed for pain. On August 27, 2025, at 2:08 AM, the Resident was documented as having a pain level of 8 and was administered the medication as ordered. On August 27, 2025, at 6:58 AM, the Resident was documented as having a pain level of 5 and was administered the medication as ordered. At 12:35PM, the Resident was documented as having a pain level of 6, and was administered the medication. Further review of Resident 1's August 2025 MAR revealed an order for oxycodone hcl oral tablet 5 mg - give 2.5 mg by mouth every 6 hours as needed for pain. On August 27, 2025, at 4:12 PM, the Resident was documented as having a level 8 pain, and was administered the medication as ordered. Review of Resident 1's clinical record revealed a nursing progress note on August 27, 2025, at 2:08 AM, that Resident 1 was yelling and moaning in pain on right hip area, and was administered 5 milligrams of oxycodone oral tablet. Further review of Resident 1's nursing progress notes revealed a note on August 27, 2025, at 6:58 AM, that the Resident was calling out, can't state her pain level, and was administered 5 milligrams of oxycodone oral tablet for pain. Further review of Resident 1's nursing progress notes revealed a note on August 27, 2025, at 12:35 PM, that the Resident was moaning and unable to walk, and received 5 milligrams of oxycodone oral tablet for pain.Review of Resident 1's clinical record revealed a physician note on August 27, 2025, at 4:06 PM, that read, in part, due to ongoing pain and difficulty ambulating, another x-ray will be ordered to check both right and left hip/femur/knee.On August 27, 2025, at 4:12 PM, there was a nursing progress note that Resident 1 was moaning in pain and was administered 5 milligrams of oxycodone oral tablet. At 7:11 PM, on August 27, 2025, a follow up nursing progress note was documented that the Resident still had a pain level of 4. There was no further documentation in Resident 1's clinical record to indicate any pain intervention or assessment was completed.Review of Resident 1's x-ray patient report dated August 27, 2025, at 11:26 PM, revealed the Resident had an acute fracture of the right sub capital femur.Review of Resident 1's clinical record revealed no documentation of the physician being notified of the Resident's fracture.Review of Resident 1's clinical record revealed no physician or nursing progress note after the notification of the fracture. There was no additional PRN (as needed) Oxycodone administered after the dose on August 27, 2025, at 4:12 PM.An interview conducted with the Director of Nursing (DON) on September 8, 2025, at approximately 1:30 PM, revealed x-ray results usually get faxed to the facility, unless it is an unusual finding then they will usually call to confirm it was received by the facility timely. The DON was unable to confirm if a call was received. The DON revealed she would have expected it to be documented on Resident 1's clinical record when the physician was notified of the positive fracture.Review of a written timeline provided by the DON on September 9, 2025, at 3:32 AM, revealed the provider was made aware of the x-ray results on August 28, 2025, at approximately 8:30 AM, assessed the Resident, and gave orders for the Resident to be sent to the hospital, which occurred at approximately 9:00 AM (Approximately 9.5 hours after the X-ray results came back positive for fracture).Review of Resident 1's clinical record failed to reveal any documentation of a time that EMS (Emergency Medical Services) was called or a time that the Resident was sent to the hospital. There was also no progress notes documented showing that Resident 1 was assessed for pain or discomfort throughout the evening and night shift.Review of the hospital records revealed Resident 1 was admitted to the hospital and required surgical intervention for the fracture. Resident 1 was administered IV (intravenous line) morphine for pain management until surgery. Review of the clinical record revealed Resident 1 was readmitted to the facility on [DATE], after having right hemiarthroplasty surgery (partial hip replacement surgery), with no postop complications.During an interview conducted with the Nursing Home Administrator (NHA) and DON on September 11, 2025, at 12:30 PM, revealed that he would have expected staff to monitor Resident 1 for pain and documenting if any pain assessments were completed prior to the Resident being transferred to the hospital. The facility failed to provide timely transfer to the hospital following confirmation of a femur fracture for Resident 1. The facility also failed to monitor and assess Resident 1 for pain and provide as needed pain medication prior to transfer to the hospital. 42 CFR 483.25 Quality of care28 Pa. Code 211.12(d)(1)(3)(5)Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of three residents reviewed (Resident 1).Findings Include:Review of Resident 1's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and muscle weakness (muscles aren't as strong as they should be).Review of Resident 1's June 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Ozempic subcutaneous solution (medication that mimics a hormone that lowers blood sugar) every Sunday for diabetes mellitus.Further review of the MAR revealed that nursing staff documented 9 other/see note on Sunday June 22, 2025, and Sunday June 29, 2025. Review of Resident 1's progress notes failed to reveal further documentation for the aforementioned dates. Further review of the clinical record revealed no evidence that the Ozempic was administered. An interview with the Director of Nursing on August 4, 2025, at approximately 2:00 PM, revealed that she had called the pharmacy on August 4, 2025, and the Ozempic had never been dispensed to the facility. The DON was unable to provide any additional information. Further review of Resident 1's clinical record failed to reveal documentation that any follow up regarding the facility not receiving the ordered medication had been done or that the physician had been notified the medication was not available.An interview with the Nursing Home Administrator on August 4, 2025, at approximately 2:15 PM, revealed he would expect staff to follow up with the pharmacy and physician when medications are not available. 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, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm as evidenced by bilateral lobe pneumonia with small left-sided effusion (a collection of fluid around the lungs) for one of 10 residents reviewed (Resident 1). Findings include: Review of the current facility policy, titled Pre-Thickened Liquids Policy, read in part, Pre-thickened liquids will be provided at bedside in individual packaged containers per physician orders. Pre-thickened liquids will be offered between meals per physician orders. Review of facility's Guidelines for Volunteers, revealed instructions that the facility volunteers Do not give a resident food or drink, whether or not they ask for something specific, without asking the resident's nurse first. Review of facility policy, titled Abuse and Neglect-Clinical Protocol, dated July 2017, revealed 'Neglect', as defined at §483.5, means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.' Review of Resident 1's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 1's physician orders revealed an order for Regular diet, Mechanical Soft texture, Nectar Thickened Fluids consistency, with a start date of February 9, 2024. Review of Resident 1's clinical record revealed a nursing note on May 22, 2025, at 2:35 PM, that read [Resident 1] was in activity room and received thin liquids, began coughing. Diet order for nectar thick [liquids]. Nurse Practitioner notified. Activities aware not to let [Resident 1] have thin liquids now. Further review of Resident 1's clinical record revealed that a chest X-ray (CXR) was done on May 23, 2025. Review of Resident 1's CXR results revealed bilateral lobe atypical pneumonia (a type of lung infection caused by bacteria that are not typically associated with typical pneumonia) with small left-sided effusion. Review of Resident 1's physician orders revealed an order dated May 23, 2025, for Amoxicillin (antibiotic) 500 mg (milligrams), give one capsule three times a day for infection, for 10 days. Review of facility incident report revealed that On May 22, 2025, at approximately 2:30 PM, while in activities, a volunteer [Employee 1] was offering drinks and [Resident 1] was given a thin liquid drink. [Resident 1] took a sip and began coughing. It was noted the drink was thin liquids and [Resident 1] is nectar thick. The drink was removed, and Registered Nurse and provider were notified. Chest x-ray was ordered. X-ray performed on May 23, 2025, and results received on May 23, 2025, at 12:08 PM and showed bilateral lobe pneumonia with small left-sided effusion. Provider notified at 12:34 PM, and order given for [antibiotic] three times a day for 10 days. Description of follow-up action: Resident placed on alert charting and activities volunteer program suspended pending review. Volunteer no longer allowed in facility due to substantiated neglect. Review of facility investigation revealed that the Nursing Home Administrator (NHA) spoke with Employee 1 on May 23, 2025. Review of the interview revealed [Employee 1] stated that she holds cook club on a monthly basis- She failed to check with the activities team/staff regarding [Resident 1's] liquid status. States she knows he is on thickened liquids and had forgotten to have staff thicken the liquid that was provided to him. Apologized for the error. NHA reiterating that her as well as the entire volunteer program is currently suspended pending review. [Employee 1] understood. Further review of the facility investigation revealed an email correspondence from Employee 1 to the NHA on May 27, 2025, at 4:37 PM that read, in part, On May 22, 2025, at 2:00 PM, I was hosting a cook club. Sometimes I give drinks, and that day I did. I was asked if I gave a drink to [Resident 1] from nursing staff, or physical therapy without thickening it first, I said I did. I said yes, I did that and apologized 15 times. During an interview with the NHA on June 4, 2025, at 9:11 AM, he revealed Employee 1 should not have been handing out beverages to residents, and that the volunteer program is suspended at this time as a result of the substantiated neglect. During a follow-up interview with the NHA on June 4, 2025, at 1:23 PM, he revealed his expectation that volunteers should not pass drinks to residents, physician orders are followed, and diets and fluids are provided at the proper consistency. The facility failed to ensure that Resident 1 was free from neglect when Employee 1 provided a drink to Resident 1, without first asking Resident 1's nurse. Employee 1 provided Resident 1 with the wrong liquid consistency, resulting in Resident 1 experiencing bilateral lobe pneumonia with small left-sided effusion. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights

Based on facility policy review, clinical record review, review of facility incident report, observations, and staff interviews, it was determined that the facility failed to ensure each resident receives, and the facility provides, drinks prepared in a form designed to meet individual needs for two of 10 residents reviewed (Residents 1 and 2), which resulted in actual harm to Resident 1, experiencing bilateral lobe pneumonia (an infection that inflames the lungs' air sacs) with small left-sided effusion (a collection of fluid around the lungs). Findings include: Review of facility policy, titled Pre-Thickened Liquids Policy, read in part, Pre-thickened liquids will be provided at bedside in individual packaged containers per physician orders. Pre-thickened liquids will be offered between meals per physician orders. Review of facility's Guidelines for Volunteers, revealed instructions that the facility volunteers Do not give a resident food or drink, whether or not they ask for something specific, without asking the resident's nurse first. Review of Resident 1's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 1's current physician orders revealed an order for Regular diet Pureed texture, Nectar Thickened Fluids consistency, pureed diet with added gravy, with a start date of June 3, 2025. Further review of Resident 1's physician orders revealed an order for Regular diet, Mechanical Soft texture, Nectar Thickened Fluids consistency, with a start date of February 9, 2024, and an end date of June 3, 2025. Review of Resident 1's clinical record revealed a nursing note on May 22, 2025, at 2:35 PM, that read [Resident 1] was in activity room and received thin liquids, began coughing. Diet order for nectar thick [liquids]. Nurse Practitioner notified. Activities aware not to let [Resident 1] have thin liquids now. Review of select facility incident report provided revealed an email correspondence from Employee 1 (Volunteer) to the Nursing Home Administrator (NHA) on May 27, 2025, at 4:37 PM that read, in part, On May 22, 2025, at 2:00 PM, I was hosting a cook club. Sometimes I give drinks, and that day I did. I was asked if I gave a drink to [Resident 1] from nursing staff, or physical therapy without thickening it first, I said I did. I said yes, I did that and apologized 15 times. Further review of select facility incident report provided, revealed Factual Description: On May 22, 2025, at approximately 2:30 PM, while in activities, a volunteer was offering drinks and [Resident 1] was given a thin liquid drink. [Resident 1] took a sip and began coughing. It was noted the drink was thin liquids and [Resident 1] is nectar thick. The drink was removed, and Registered Nurse and provider were notified. Chest x-ray was ordered. X-ray performed on May 23, 2025, and results received on May 23, 2025, at 12:08 PM and showed bilateral lobe pneumonia with small left-sided effusion. Provider notified at 12:34 PM, and order given for [antibiotic] three times a day for 10 days. Description of follow-up action: Resident placed on alert charting and activities volunteer program suspended pending review. Volunteer no longer allowed in facility due to substantiated neglect. During an interview with the NHA on June 4, 2025, at 1:23 PM, he revealed his expectation that volunteers should not pass drinks to residents, physician orders are followed, and diets and fluids are provided at the proper consistency. The facility failed to ensure a proper drink texture was provided, resulting in Resident 1 experiencing bilateral lobe pneumonia with small left-sided effusion. Review of Resident 2's clinical record revealed diagnoses that included dysphagia, dementia, and muscle weakness. Review of Resident 2's physician orders revealed a diet order for Regular diet, Pureed texture, Nectar Thickened Fluids consistency, no straws, with a start date of May 28, 2025. Further review of Resident 2's physician orders revealed the fluid texture of her diet order changed from thin liquids to nectar thickened liquids on May 28, 2025. Review of Resident 2's care plan revealed a focus area at risk for nutrition/hydration problems related to dysphagia with interventions for honor food/fluid preferences within diet regimen, and provide, serve diet as ordered. Review of Resident 2's nurse aide tasks revealed a task for fluids offered and that Resident 2 is dependent on staff for eating and drinking. Observation in Resident 2's room on June 4, 2025, at 11:18 AM, revealed she was sleeping in her bed, and she had a Styrofoam cup at her bedside with a straw in the lid. Observation of the Styrofoam cup from Resident 2's bedside, revealed it contained clear thin liquid consistent with plain water. Interview with Employee 4 (Nurse Aide) on June 4, 2025, at 11:18 AM, revealed she passed the water on Resident 2's bedside earlier that day. She further revealed she was unaware that Resident 2 was ordered thickened liquids, as she normally works at night. It was confirmed that Resident 2 is dependent on staff for drinking. Interview with Employee 6 (Speech Language Pathologist) on June 4, 2025, at 11:32 AM, revealed Resident 2 is currently receiving speech therapy services for dysphagia, and she should be receiving nectar thickened liquids per her physician order. Interview with the NHA on June 4, 2025, at 1:19 PM, revealed his expectation that physician orders are followed, and diets and fluids are provided to residents at the proper consistency. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, facility dietary manual review, observations, and staff interviews, it was determined that the facility failed to provide a meal that was designed to meet the needs of residents requiring a mechanical soft meal, and failed to provide a pureed meal for one of three residents reviewed (Resident 1). Findings include: Review of the facility's dietary manual, section titled, Menus, revealed the facility's policy stated, .Menus are implemented by the Dietary Manager in conjunction with the Dietician . Further, review of subsection titled, Mechanical Soft Diet, stated, Purpose: The mechanical diet is modified in consistency to reduce the amount of chewing required to consume food. Review of the planned menu for April 22, 2025, lunch meal, revealed the mechanical soft lunch was to include ground chicken enchilada casserole and ground black beans. Review of the recipe for the chicken enchilada casserole revealed it included the instructions of, Mechanical Soft Steps: Remove desired number of servings to chop for the mechanical soft diets. Use a knife/fork or processor to chop foods to the desired consistency. Observation of the lunch meal service on April 22, 2025, revealed mechanical soft meals were served a chicken enchilada with chopped meat inside of a flour tortilla. The flour tortilla was served whole; not cut or chopped. Observations of the black beans served revealed they were served whole, not ground. During a staff interview on April 24, 2025, at approximately 2:30 PM, the Nursing Home Administrator (NHA) confirmed that the planned menu textures should have been followed as identified on the menu. Review of Resident 1's clinical record revealed diagnoses that included diabetes type II (decreased ability of the body to produce and utilize insulin) and essential hypertension (elevated/high blood pressure). Review of Resident 1's interdisciplinary progress notes revealed a note dated April 22, 2025, at 1:01 PM, by Employee 1 (Social Services), that stated, .[Resident 1] has been downgraded to puree texture [sic] [due to] difficulty swallowing pills . Review of Resident 1's physician orders revealed a diet order entered by Employee 4 (Registered Nurse) on April 22, 2025 at 8:01, for Liberalized Renal diet, Puree texture, Thin Liquids consistency. Review of meal tickets (paper utilized by dietary staff to identify a residents' dietary needs, ordered texture, likes, dislikes, and other dietary requests) provided by Employee 2 (Director of Food Services) revealed the meal tickets were printed on April 22, 2025. Review of Resident 1's meal ticket revealed it identified Resident 1's diet as Pureed, Liberalized Renal. Observation of lunch meal tray-line service on April 22, 2025, at approximately 11:30 AM, revealed the dietary slip for Resident 1 was dated (printed) on April 19, 2025. Observation of the dietary slip revealed it had Resident 1's diet listed as Regular, which was crossed out with, MS (mechanical soft) written above. Subsequent observation of tray-line service revealed that the tray prepared for Resident 1 was a mechanical-soft texture diet. Observation of meal tray delivery on April 22, 2025, at approximately 12:00 PM, revealed Resident 1 was served the mechanical soft diet in the presence of Employee 3 (Speech Therapist). During a staff interview at approximately 12:05 PM, Employee 3 revealed that Resident 1 was being observed by Employee 3 for the lunch meal to observe how Resident 1 tolerated consuming the puree diet. During the interview, Employee 3 revealed she was the staff that initiated the change to Resident 1's diet texture due to Resident 1 having difficulty swallowing food and Resident 1 not fully clearing food from her mouth as she was eating. Employee 3 stated that Resident 1 should have received a puree diet. At approximately 12:20 PM, Resident 1's meal tray was replaced with a puree texture meal tray. During a staff interview at that time, Employee 3 stated that, based on her professional judgement, Resident 1 was not able to safely consume the mechanical-soft texture meal. During the staff interview, Employee 3 stated that once the change to Resident 1's dietary order was made, a Dietary Communication Form, was completed and copies were provided to the unit licensed nurse, the dietary department, and the Director of Rehabilitation. During a staff interview on April 22, 2025, at approximately 1:15 PM, Employee 2 stated that the meal tickets are typically printed at the beginning of the week and used for duration of the week. During the interview, Employee 2 stated that changes to diets are typically made on the meal tickets as they are received by dietary. During a staff interview on April 22, 2025, at approximately 2:30 PM, the NHA confirmed that Resident 1 should have received a puree textured. 28 Pa code 201.18(b)(1)(3) Management 28 Pa code 211.6(a) Dietary services

Based on resident and staff interviews, clinical record review, and document review, it was determined that the facility failed to ensure each resident is included and provided the right to participate in the person-centered care planning process for two of 32 residents reviewed (Residents 25 and 31). Findings Include: Review of the facility's New Admission Introduction & Handbook, provided to each resident and/or his representative at admission read, in part, Care plans are created for each resident on admission, reviewed quarterly . You should expect to be invited to participate in Care Plan Meetings routinely. A review of Resident 25's physician's orders revealed diagnoses that included muscle weakness and chronic kidney disease (a long-term condition that occurs when the kidneys are damaged and can't filter blood properly). An interview with Resident 25, on November 18, 2024, at 11:02 AM, revealed he did not recall being invited to his recent quarterly care plan meeting. A review of Resident 25's clinical record failed to reveal any documentation of the Resident's recent invitation and participation in his care plan meetings. A review of Resident 31's physician's orders revealed diagnoses that included anemia (a condition in which the body doesn't have enough healthy red blood cells or the red blood cells don't function properly) and pain. An interview with Resident 31, on November 18, 2024, at 9:47 AM, revealed she did not recall being invited to her recent quarterly care plan meeting. A review of Resident 31's clinical record failed to reveal any documentation of the Resident's recent invitation to and participation in her care plan meetings. An interview with the Director of Social Services (Employee 2) on November 20, 2024, at 9:54 AM, revealed she had no process in place to ensure the invitation of residents to participate in their care plan meetings and confirmed all residents, who can participate, should be invited to attend their care plan meetings. 28 Pa. Code 201.24 Responsibility of licensee

Based on document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to two of three residents to inform those residents of items and services no longer deemed eligible for coverage under Medicare A (Residents 2 and 108). Findings Include: A review of Resident 2's clinical record revealed the last covered day of Medicare A services dated September 1, 2024. Review of the facility's provided notice, revealed the facility did not offer the Resident the SNF-ABN form as Resident 2 was planning to remain in the skilled nursing facility and receive skilled services. A review of Resident 108's clinical record revealed the last covered day of Medicare A services dated August 9, 2024. Review of the facility's provided notice, revealed the facility did not offer the Resident the SNF-ABN form as Resident 108 planned to remain in the skilled nursing facility and receive skilled services. An interview with the Nursing Home Administrator on November 19, 2024, at 1:52 PM, revealed an acknowledgment of the facility providing the incorrect document, which will be corrected going forward. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 32 residents reviewed (Residents 33, 37, 46 and 67). Findings include: Review of Resident 33's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and moderate protein-calorie malnutrition (insufficient protein intake or protein deficiency). Review of Resident 33's recorded weights revealed that she weighed 100.8 pounds on February 13, 2024, and 89.4 pounds on August 18, 2024, which represented a significant weight loss of 11.31% in this approximately six month period. Review of Resident 33's August 24, 2024, 5 day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that a weight of 89 pounds was recorded on this assessment. Further review revealed that the assessment was not coded to indicate that Resident 33 experienced a significant weight loss of greater than 10% in the preceding 6 months. Review of Resident 33's recorded weights revealed that she weighed 84.2 pounds on October 2, 2024, and 79.2 pounds on October 24, 2024, which represented a 5.94% weight loss in this period of time. Review of Resident 33's November 8, 2024, quarterly MDS assessment revealed that a weight of 79 pounds was recorded on this assessment. Further review revealed that the assessment was not coded to indicate that Resident 33 experienced a significant weight loss of greater than 5% in the preceding month. During an interview with Employee 8 (Registered Dietician) on November 21, 2024, at 11:25 AM, she confirmed that Resident 33's August 24, 2024, and November 8, 2024, MDS assessments should have been coded for significant weight loss. During an interview with the Nursing Home Administrator (NHA) on November 21, 2024, at 12:07 PM, he acknowledged that the aforementioned MDS assessments were coded incorrectly. Review of Resident 37's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and anxiety disorder (a persistent of feeling of worry, nervousness, or unease). Review of Resident 37's clinical record revealed a nursing progress note on November 1, 2024, at 1:49 PM, that stated, Resident seen by Vital Health Solution Services on October 17, 2024. GDR (Gradual dose reduction- tapering of psychotropic medication) clinically advisable. Recommend discontinuing Quetiapine 12.5mg PO daily. After visit summary reviewed by Employee 9 (Nurse Practitioner). No GDR. Recently started and has been stable, reassess next month. Review of Resident 37's MDS with assessment reference date (ARD- last day of the assessment period) of November 2, 2024, it was marked no for Physician documented GDR as clinically contraindicated. During an interview with the NHA on November 21, 2024, at 10:08 AM, he revealed that the Registered Nurse Assessment Coordinator coded the MDS assessment inaccurately as the consult was scanned into the electronic health record later in the month of November 2024. The surveyor discussed the aforementioned notation in the electronic medical record from November 1, 2024, that was available for the assessment. No further information was provided. Review of Resident 46's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders) and anxiety disorder (a persistent of feeling of worry, nervousness, or unease). Review of Resident 46's physician orders revealed an order for Seroquel 25 milligrams (mg) at bedtime for dementia. Review of Resident 46's monthly medication regimen reviews revealed a consultant pharmacist recommendation to Resident 46's physician dated July 26, 2024, that recommended a GDR of Seroquel. Resident 46's physician agreed and signed the form August 5, 2024, with an order to decrease Seroquel to 12.5 mg at bedtime. Review of Resident 46's quarterly minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) dated October 8, 2024, failed to reveal a GDR had been attempted. During an interview with the NHA on November 20, 2024, at 11:10 AM, it was revealed that the MDS assessment was incorrect and would be corrected. The NHA stated it was the facility's expectation that MDS assessments be coded correctly. Review of Resident 67's clinical record revealed diagnoses that included dementia, hypertension (elevated/high blood pressure), and dysphagia (difficulty swallowing). Review of Resident 67's clinical record revealed a nutrition note from August 6, 2024, that detailed Resident 67 qualified for severe protein calorie malnutrition (PCM) based on weight loss and muscle/fat loss. Review of Resident 67's MDS with ARD of September 23, 2024, it was marked no for Malnutrition (protein, calorie), risk of malnutrition. Review of Resident 67's care plan revealed a focus area Resident 67 is at risk for malnutrition and dehydration, last revised on November 8, 2024. During an interview with Employee 1 (Regional Director of Clinical Services) on November 20, 2024, at 11:08 AM, revealed at the point of the MDS assessment with ARD of September 23, 2024, Resident 67 was assessed to be at risk of PCM. The surveyor revealed the concern that the question should also be marked yes if a resident were at risk of malnutrition. Follow-up interview with the NHA on November 21, 2024, at 10:06 AM, he revealed the aforementioned MDS assessment should have been marked yes to indicate Resident 67 was at risk of malnutrition. 28 Pa. Code 211.5(f) Medical records 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for two of three residents reviewed for pressure ulcers (Resident 64 and 84). Findings include: Review of facility policy, titled Wound Care, last reviewed September 25, 2024, read, in part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing, Verify that there is a physician's order for this procedure. The policy also states to wash and dry your hands thoroughly prior to the start of the procedure, after removing the soiled dressing, and at the end of the procedure. [NAME] tape with initials, time, date and apply to dressing. Review of Resident 64's clinical record revealed diagnoses that included unspecified severe protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and pressure ulcer stage 4, reoccurring (wound that occurs when the skin and tissue are damaged by prolonged pressure). Review of Resident 64's clinical record revealed the following physician orders: Wound Care: Sacrum 1) Cleanse w/ wound cleanser or normal saline 2) Pat dry & skin prep peri wound 3) place collagen sheet inside wound 4) Apply TRIAD paste then cover w/ optifoam daily every day shift for Wound Care and as needed for Wound Care if soiled or dislodged, with a start date of September 27, 2024, and discontinued on October 18, 2024. Wound Care: Sacrum 1) Cleanse w/ wound cleanser or normal saline 2) Pat dry & skin prep peri wound 3) place moisten collagen sheet over wound bed & cover w/ optifoam daily every day shift for wound care and as needed for wound care if soiled or dislodged, with a start date of October 18, 2024. Review of Resident 64's wound care consult from October 11, 2024, revealed under new order yes with cleanser of normal saline, primary treatment of collagen +Ag (silver), and secondary treatment of bordered foam dressing. Review of Resident 64's wound care consult from October 18, 2024, revealed the same aforementioned recommendation for a new order. During an interview with the Director of Nursing (DON) on November 21, 2024, at 12:19 PM, she revealed the new order recommendation from October 11, 2024, should have been updated no later than the morning of October 12, 2024, and that when the order was transcribed, the nurse forgot to add the +Ag to the order. No further information was provided. Review of Resident 84's clinical record revealed diagnoses that included paraplegia (paralysis that affects all or parts of the trunk, legs, and pelvic organs) and sacral (base of spine) pressure ulcer stage 4, recurring (ulcer involving loss of skin layers, exposing muscle and bone). A review of the Resident 84's physician orders on November 20, 2024, at 9:30 AM, revealed orders to cleanse wound with normal saline solution then lightly pack wound with 1/2 strength Dakin's solution soaked gauze BID, cover with ABD pad every day and evening shift. On November 20, 2024, at 10:00 AM, the surveyor followed wound nurse to Resident 84's room, the wound nurse informed the surveyor that orders were changed and a wound vac would be applied today. Physician order dated November 20, 2024, at 9:49 AM, NPWT (negative pressure wound therapy- a common treatment that helps wounds heal by reducing air pressure over the wound) stated cleanse area with normal saline solution or wound cleanser and pat dry, skin prep to periwound, cut sponge to fit into wound bed and all undermining areas, then complete wound vac application, ensure that wound vac is suctioning at 125 mm/hg (millimeters/mercury). Observation of wound care on Resident 84 on November 20, 2024, at 10:20 AM, revealed the following: No hand hygiene was performed before, during, or after the procedure. Resident was on enhanced barrier precautions and no gown was worn during the procedure. The soiled dressing that was removed was not dated. Collagen with silver (a wound care product that contains collagen, silver chloride, and other ingredients that help wounds heal) was placed in the wound bed prior to wound vac sponge placement and there was no order for the collagen with silver. During an interview with the Nursing Home Administrator (NHA) on November 20, 2024, at 1:45 PM, the NHA confirmed that hand hygiene should have been performed, a gown should have been utilized during the procedure, and the soiled dressing that was removed should have been initialed, timed, and dated. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of five residents reviewed for mobility (Residents 37 and 55). Findings Include: Review of facility policy, titled Restorative Nursing Services, last reviewed September 25, 2024, read, in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Review of Resident 37's clinical record revealed diagnoses that included contracture of left hand (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) and dependence on wheelchair. Review of Resident 37's physician orders revealed an order for Splint- patient to have palm guard/carrot in left hand donned during first shift, one time a day for contractures, with a start date of March 8, 2024. Review of Resident 37's nurse aid tasks revealed the following: Maintenance Nursing: Active ROM (range of motion) Left hand staff to assist, last revised April 12, 2022. Maintenance Nursing: Assistance with Splint/Brace Left hand. Wear 4-6 hours a day, last revised April 12, 2022. Review of Resident 37's June 2024 nurse aid task documentation revealed her Active ROM maintenance nursing program was marked not applicable or left blank 25 of 30 days. Further review of Resident 37's June 2024 nurse aid task documentation revealed her splint assistance maintenance nursing program was marked not applicable or left blank 26 of 30 days. Review of Resident 37's July 2024 nurse aid task documentation revealed her Active ROM maintenance nursing program was marked not applicable or left blank 25 of 31 days. Further review of Resident 37's July 2024 nurse aid task documentation revealed her splint assistance maintenance nursing program was marked not applicable or left blank 29 of 31 days. Review of Resident 37's August 2024 nurse aid task documentation revealed her Active ROM maintenance nursing program was marked not applicable or left blank 29 of 31 days. Further review of Resident 37's August 2024 nurse aid task documentation revealed her splint assistance maintenance nursing program was marked not applicable or left blank 30 of 31 days. Review of Resident 37's September 2024 nurse aid task documentation revealed her Active ROM maintenance nursing program was marked not applicable or left blank 30 of 30 days. Further review of Resident 37's September 2024 nurse aid task documentation revealed her splint assistance maintenance nursing program was marked not applicable or left blank 30 of 30 days. Review of Resident 37's October 2024 nurse aid task documentation revealed her Active ROM maintenance nursing program was marked not applicable or left blank 25 of 31 days. Further review of Resident 37's October 2024 nurse aid task documentation revealed her splint assistance maintenance nursing program was marked not applicable or left blank 25 of 31 days. Review of Resident 37's November 2024 nurse aid task documentation revealed her Active ROM maintenance nursing program was marked not applicable or left blank November 1-14 and 16, 2024. Further review of Resident 37's September 2024 nurse aid task documentation revealed her splint assistance maintenance nursing program was marked not applicable or left blank November 1-14 and 16, 2024. During an interview with the Nursing Home Administrator (NHA) on November 21, 2024, revealed he would expect nurses to be documenting that the Resident refused rather than marking not applicable for the program if the Resident refused, and consistent refusals should be evaluated for lack of tolerance to the program to determine if it continues to be indicated. Review of Resident 55's clinical record revealed diagnoses that included hemiplegia and hemiparesis following cerebral infarction (inability to move, severe weakness, or rigid movement on either the right or left side of the body due to stroke) and lack of coordination. During an interview with Resident 55 on November 19, 2024, at 11:00 AM, she revealed that she is supposed to walk with her walker daily with the assistance of nursing staff, but that she has trouble getting anyone to help her with this. Review of Resident 55's Kardex (care guide for use by nursing staff) revealed Ambulation: The resident is to walk to and from dining room [ROOM NUMBER]x/day with walker and WC [wheelchair] follow. This was last revised September 27, 2024. Further review of Resident 55's clinical record failed to reveal any documented evidence that this ambulation program was occurring daily. During an interview with the NHA on November 20, 2024, at 11:33 AM, he revealed that when the task was entered it appeared on Resident 55's Kardex, but it was not entered so that it could be documented on. He revealed the expectation that nursing staff should be documenting when they are assisting Resident 55 with ambulation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record and hospital record review, policy review, and staff interviews, it was determined that the facility failed to implement treatment and care in accordance with professional standards of practice, which resulted in actual harm, evidenced by a urinary tract infection and septic shock for one of three residents reviewed (Resident 1), and failed to follow physician orders for one of three residents reviewed (Resident 1). Findings include: Review of the facility policy, titled Collecting a Urine Specimen from a Closed Drainage System, read, in part, The purpose of this procedure is to obtain an uncontaminated urine specimen from a resident with a catheter. The policy included steps in the specimen collection procedure to prevent specimen contamination. These steps included Wash your hands thoroughly before beginning the procedure, cleanse the speci-port with the alcohol swab, do not touch the inside of the specimen container, place the lid on the specimen container, do not touch the inside of the lid. Review of facility policy, titled Catheter Care, Urinary, last revised September 2014, read, in part, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The following information should be recorded in the resident's medical record: The date and time that the catheter care was given. The signature and title of the person recording the data. Review of Resident 1's clinical records revealed diagnoses that included history of urinary tract infections (UTI), pressure ulcer of sacral region, stage 4 (wound that occurs when the skin and tissue are damaged by prolonged pressure), hypertension (high blood pressure) and need for assistance with personal care. Resident 1 had an order for a foley catheter (a tube inserted into the bladder to drain urine). Resident 1 also had an order for foley catheter care every shift, with a start date of September 26, 2024. Review of Resident 1's September 2024 and October 2024 TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored), failed to reveal catheter care was completed on September 28, 2024, in the AM; October 3, 2024, in the AM; and October 17, 2024, in the PM. Further review of the clinical record revealed lab results from October 14, 2024, which noted an elevated white blood cell (WBC - blood cells that fight infection) of 18.1 (normal is 4.5-11) Review of Physician orders revealed an order dated October 14, 2024, for Doxycycline Hyclate Tablet (antibiotic) 100 MG. Give one tablet by mouth two times a day for infection for 7 Days, with a start date of October 14, 2024, and discontinued on October 21, 2024. Resident 1's physician orders revealed an order dated October 14, 2024, for a Urinalysis culture and sensitivity (lab test that checks for bacteria in urine and determines what kind of antibiotic can treat it) ordered stat (immediately) related to fever unspecified. Resident 1's clinical record revealed no evidence of a fever. During an interview with the Director of Nursing (DON) on October 29, 2024, at 1:34 PM, she stated that the urine culture was ordered due to the elevated WBC's. Review of the Urinalysis report revealed that the urine specimen wasn't obtained until the following day, despite being ordered stat. Review of Resident 1's October 2024 MAR (Medication Administration Record) revealed her doxycycline antibiotic medication failed to be administered as ordered on October 14, 2024. Review of Resident 1's clinical record revealed a progress note on October 14, 2024, at 8:35 PM, stating the doxycycline was not given because it was not at the facility and unable to be pulled from their back up supply. Interview with the DON on October 29, 2024, at 1:37 PM, revealed their back up stock was out of the doxycycline so they had to wait until it came from pharmacy, and that it should be documented that the provider was notified of the missed dose of the antibiotic. She further revealed that the lab was likely not obtained that afternoon of the 14th because the provider ordered the urinalysis around 2:30 PM, and the last lab pick up of the day is at 3:00 PM and it was about to be nursing shift change. Review of Resident 1's urinalysis lab report revealed the results were available on October 15, 2024, at 9:57 AM, and were positive for bacterial species (infection) but indicated that the sample was likely contaminated, so it was not cultured. The urinalysis was not signed by the physician until October 17, 2024. Review of the clinical record revealed that no additional directions or orders were noted and no new urine sample was obtained. Interview with the DON on October 29, 2024, at 2:01 PM, revealed she would expect a response from the physician regarding the contaminated urine sample as to any new orders or new plan of care. She further revealed the physicians have access to lab reports as soon as they are resulted, and she would expect a timely physician response the same day. Review of a nursing progress note written by Employee 1 (Registered Nurse) on October 18, 2024 at 5:57 AM, stated that Employee 1 was called to Resident 1's room by the LPN for a change in condition. Upon assessment at 5:30 AM, Resident 1 would not turn head to look at the nurse and would not follow commands to assess neurological status. When her bilateral upper extremities were lifted, they fell to the bed before 5 seconds. Her lower extremities fell immediately. Her blood pressure was 111/64 (normal is 120/80) and her respiratory rate was 30 (normal 12-20). Per LPN, Resident 1 was responding appropriately at 4:15-4:30 AM. Further review of the clinical record revealed that LPN documented that Resident 1 would not take her medication at 1:34 AM. Further review of the nursing progress note dated October 18, 2024 at 5:47 AM, revealed a call was put in to on call provider, waiting to hear back. Nursing progress note written by Employee 1 on October 18, 2024, at 6:01 AM, revealed resident also has had decreased urine output. A follow up nursing progress note written by Employee 1 at 6:17 AM, stated MD called back will be sending resident out to hospital, family notified. Review of Resident 1's hospital records revealed that when she arrived to the ER her blood pressure was 93/63 (normal is 120/80), and heart rate was 110 (normal is 60-11). She was unable to complete words or follow commands. Upon assessment she was noted to appear unwell and toxic, and she was extremely dry. Her Glasgow Coma Scale (GCS) was a 7, which indicated that a severe brain injury and immediate medical attention is required. For this reason, the Resident was intubated (when a tube is inserted into the airway to allow air to flow into their lungs, the tube is connected to a machine that provides oxygen). The ER note stated that IV (intravenous) placement was unsuccessful because the Resident was very dry and her veins were very collapsible. A central line (a long tube inserted into a large vein near the heart) was placed. She was given IV fluids and IV Cefepime (antibiotic) and Vancomycin (antibiotic). The physician ordered labs and a urine analysis and urine cultures. The Resident 1's bloodwork showed a WBC count of 47.9 (counts above 11 are considered to be high and 50 is critical). The Resident had no urine output while in the ER. Her foley catheter was replaced and she had large volume of cloudy urine. Another ER note described her urine as frothy and concentrated. The Resident was admitted to the intensive care unit for septic shock (a widespread infection causing organ failure and dangerously low blood pressure). Further review of hospital records revealed Resident 1's blood cultures and urine culture were positive for Proteus mirabilis bacteremia from a UTI. The Resident was started on cefazolin (antibiotic used to treat serious infections), and was later switched to Zosyn and then to Bactrim (antibiotics). Review of the facility policy, titled Wound Care, read, in part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record: The type of wound care given. The signature and title of the person recording the data. Review of Resident 1's physician orders revealed the orders for wet to dry dressings two times a day. Review of Resident 1's October 2024 TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored), failed to reveal her wound treatments were completed on October 3, 2024, in AM, and October 17, 2024, in PM. Further review of Resident 1's orders revealed an order for Weight on admission and weekly x 4 weeks, every evening shift every Saturday, with a start date of September 26, 2024, and discontinued on October 21, 2024. Review of Resident 1's clinical record failed to reveal weekly weight measures were obtained during the weeks ending October 5 and 12, 2024. Interview with the Nursing Home Administrator (NHA) on October 29, 2024, at 1:07 PM, revealed the facility has identified an issue with weights being obtained per physician order and they are working on this process as an interdisciplinary team. During an interview with the NHA and DON on October 29, 2024, at 2:49 PM, the surveyor revealed the concern with Resident 1's overall quality of care regarding the missing documentation for wound treatments, catheter care, and weights; missed medication without documentation of physician notification; and delay in the physician's response to the urinalysis report. The NHA revealed he is aware of what processes the facility will need to fix in response to the concern. The facility failed to provide care and services to identify and treat a urinary tract infection for Resident 1. This failure resulted in further decline and hospitalization for septic shock. 28 Pa. Code 201.4(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1). Findings include: Review of facility policy, titled Abuse Prevention Program, dated January 1, 2022, revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness Signs of Actual Physical Neglect: 6. Inadequate provision of care. Review of facility's nurse aide job description revealed, Purpose of Your Job Position- To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Review of Employee 1's education revealed Employee 1 was most recently provided abuse training on November 15, 2023. Review of Resident 1's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hypertension (elevated blood pressure), and depression. Review of Resident 1's care plan revealed an intervention initiated on November 29, 2023, for BED MOBILITY: The resident requires (max assistance) by (2) staff to turn and reposition in bed. Review of Resident 1's nursing progress note dated March 31, 2024, revealed that at 3:50 PM, the Nurse was notified that Resident 1 rolled out of bed onto the floor. The note stated that Resident 1 was observed laying on the floor on her left side, parallel to her bed. Resident 1 was complaining of right knee and right ankle pain, and was not able to move her right leg due to pain. A hematoma (a collection of blood outside of blood vessels) was also noted on the left side of Resident 1's head. Resident 1 was assisted back to bed via a hoyer lift with the assist of five staff members. A new order was received to send Resident 1 to the emergency department for evaluation and treatment. Resident 1 left the facility for the hospital at 4:20 PM. Review of Resident 1's nursing progress note dated April 1, 2024, revealed that Resident 1 returned to the facility from the hospital at 2:30 PM, with an immobilizer in place to the right leg. Review of Resident 1's hospital discharge instructions dated April 1, 2024, revealed that Resident 1 was diagnosed with a right femur fracture after falling out of bed. Resident 1 was evaluated by orthopedic surgery, who recommended non-operative management and to follow-up as outpatient. Review of facility's investigation dated March 31, 2024, revealed that Employee 1 was providing Resident 1 with care. Resident 1 was on her left side in bed and, as Employee 1 was attempting to change Resident 1's sheets, Resident 1 rolled out of bed. Review of Employee 1's witness statement dated March 31, 2024, revealed that Employee 1 was providing care to Resident 1, as her bed, sheets, and clothes were wet. Employee 1 stated that as she turned Resident 1 to the other side and started fixing her sheets, Resident 1 fell on to the floor. Review of facility's investigation revealed that there were no additional witness statements obtained and no evidence that any other staff member was present when Resident 1 rolled out of bed. Review of the facility reported incident for the fall on March 31, 2024, revealed that Employee 1 was changing the bed linen and rolled Resident 1 away from her, slightly beyond the perimeter of the mattress, resulting in Resident 1 falling out of bed. Review of the facility reported incident revealed that Employee 1 was suspended, pending investigation, and Employee 1 was immediately educated regarding ensuring that Resident care plans are followed when providing care. Review of the facility's investigation revealed that a written warning was given to Employee 1 dated April 1, 2024, stating, On 3/31/2024 while providing care on a Resident she rolled out of the bed and sustained injury. Resident is care planned for 2 [person] assist for bed mobility. It is important to follow the care plan and to seek clarification if you are unsure. This is for the safety of the Residents. When rolling Residents they should be rolled toward you to prevent falls. During an interview with the Nursing Home Administrator on April 8, 2024, at 12:10 PM, she confirmed that Employee 1 rolled Resident 1 away from her in the bed and did not follow the care plan of two-person assist when Resident 1 rolled out of bed. The facility failed to ensure that Resident 1 was free from neglect when Employee 1 did not follow Resident 1's care planned interventions for two-person assist with bed mobility, resulting in Resident 1 rolling out of bed and sustaining a right femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in a fall and actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, undated, revealed 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: .b. Mobility (transfer and ambulation, including walking) . Review of facility's nurse aide job description revealed, Purpose of Your Job Position- To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Review of Resident 1's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hypertension (elevated blood pressure), and depression. Review of Resident 1's care plan revealed an intervention initiated on November 29, 2023, for BED MOBILITY: The resident requires (max assistance) by (2) staff to turn and reposition in bed. Review of Resident 1's nursing progress note dated March 31, 2024, revealed that at 3:50 PM, the nurse was notified that Resident 1 rolled out of bed onto the floor. The note stated that Resident 1 was observed laying on the floor on her left side, parallel to her bed. Resident 1 was complaining of right knee and right ankle pain, and was not able to move her right leg due to pain. A hematoma (a collection of blood outside of blood vessels) was also noted on the left side of Resident 1's head. Resident 1 was assisted back to bed via a hoyer lift with the assist of five staff members. A new order was received to send Resident 1 to the emergency department for evaluation and treatment. Resident 1 left the facility for the hospital at 4:20 PM. Review of Resident 1's nursing progress note dated April 1, 2024, revealed that Resident 1 returned to the facility from the hospital at 2:30 PM, with an immobilizer in place to the right leg. Review of Resident 1's hospital discharge instructions dated April 1, 2024, revealed that Resident 1 was diagnosed with a right femur fracture after falling out of bed. Resident 1 was evaluated by orthopedic surgery, who recommended non-operative management and to follow-up as outpatient. Review of facility's investigation dated March 31, 2024, revealed that Employee 1 (Nurse Aide) was assisting Resident 1 with care independently. Resident 1 was on her left side in bed and, as Employee 1 was attempting to change Resident 1's sheets, Resident 1 rolled out of bed. Review of Employee 1's witness statement dated March 31, 2024, revealed that Employee 1 was providing care to Resident 1, as her bed, sheets, and clothes were wet. Employee 1 stated that, as she turned Resident 1 to the other side and started fixing her sheets, Resident 1 fell on to the floor. Review of the facility reported incident for the fall on March 31, 2024, revealed that Employee 1 was changing the bed linen and rolled Resident 1 away from her and outside of the perimeter of the mattress. This resulted in Resident 1 falling off the side of the bed. Review of facility's investigation revealed that there were no additional witness statements obtained and no evidence that any other staff member was present when Resident 1 rolled out of bed. Further review of the facility's investigation revealed a written warning given to Employee 1 dated April 1, 2024, stating, On 3/31/2024 while providing care on a Resident she rolled out of the bed and sustained injury. Resident is care planned for 2 assist for bed mobility. It is important to follow the care plan and to seek clarification if you are unsure. This is for the safety of the Residents. When rolling Residents they should be rolled toward you to prevent falls. During an interview with the Nursing Home Administrator on April 8, 2024, at 12:10 PM, she confirmed that Employee 1 rolled Resident 1 away from her in the bed and did not follow the two-person assist when Resident 1 rolled out of bed. Employee 1 failed to provide the appropriate assistance and technique with bed mobility for Resident 1, resulting in Resident 1 falling out of bed and sustaining a right femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility failed to implement interventions to ensure resident safety during transport, which resulted in actual harm, evidenced by a fracture of the patella for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses including Alzheimer's dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and stage 3 chronic kidney disease (decreased ability of the kidneys to filter toxins from the blood). Review of Resident 1's pre-admission hospital paperwork revealed medical history of right knee replacement. Review of the physical therapy assessment on February 20, 2023, by Employee 1 (Physical Therapist) documented the following: Despite max encouragement, practice and verbal/tactile cueing, [Resident 1] avoided bending her [right] knee with all mobility and demonstrates little carryover with patient education to increase use of hands with transfer to improve safety as well as avoiding knee bending with transfers and gait. Further review of Resident 1's physical therapy notes revealed that Resident 1 attended physical therapy on February 21, 2023, again with Employee 1. Employee 1 documented in the physical therapy Summary of Skills comment section on February 21, 2023, at 11:47 AM, Patient perseverating over [right knee], inability to bed it, use it and pain, limiting her ability to correctly and safely stand with therapist this session. Required Max [assistance] for standing, but patient was unable to maintain [weight-bearing] in [right lower extremity] for attempts at gait this session. Review of Resident 1's interdisciplinary progress notes revealed that on February 21, 2023, at 6:12 PM, Employee 2 (Registered Nurse) documented a progress note that stated, Writer evaluated resident who seemed to be experiencing a lot of pain in the right knee and lower leg. There is bruising as noted earlier today. Resident is unable to stand even [with] assistance due to pain . A new order was entered for a STAT (immediate) X-ray. As a result of Resident 1's right knee injury identified on February 21, 2023, the facility initiated an investigation. Review of the investigation revealed a statement was obtained by the facility from Employee 2 in regards to Employee 2's interactions with Resident 1 on February 21, 2023. In a statement provided by Employee 2, dated February 24, 2023, Employee 2 stated, Writer called to assist resident from toilet. Resident stated she is unable to stand, her leg won't hold her. He [Employee 1 (Physical Therapist)] hurt my leg. It just dropped and then caught it under the chair. I yelled. Then he really pulled and bent it. Said I needed to get moving it more. We used gait belt with assistance of therapy tech [sic] and CNA [Certified Nursing Assistant]. We stood resident to pivot to [wheelchair]. Resident resisted putting weight on the right leg and very little on the left. She said she was unable to put weight on it before or only a little. Now so painful can't do it at all. [Right] knee appears more swollen and there is bruising in the shin area. We had placed the lift pad in the wheelchair and used hoyer to place resident in the bed. Review of interdisciplinary progress notes revealed Employee 3 (Licensed Practical Nurse) entered a note on February 21, 2023, at 10:01 PM, regarding Resident 1's scheduled shower. Employee 3 documented, No shower resident yelling out with slightest touch of leg. Performed bed bath as tolerated. As a result of Resident 1's right knee injury identified on February 21, 2023, a statement was obtained by the facility from Employee 3 in regards to Employee 3's interactions with Resident 1 on February 21, 2023. In a written witness statement provided by Employee 3, dated February 23, 2023, Employee 3 stated, Resident hollering more than usual upon transferring. Co[m]plaints of [right] knee/leg pain. Assessed leg. New bruising and swelling forming. Resident screams out in pain at slightest touch. RN supervisor notified and assessed. Notified MD. Obtained orders for x-ray and labs in [morning]. Review of Employee 1's witness statement dated February 22, 2023, revealed Employee 1 stated, I was rolling the patient back to her room following a [physical therapy] session. The patient was holding her [right] leg out straight because she refuses to bend it at the knee joint. This has been a consistent behavior of the patient that has been observed repeatedly by several staff members. While transferring her down the hallway, the patient relaxed her knee enough that her shoe caught the floor and caused her knee to bend beyond 90 [degree] angle. The patient immediately yelled, i corrected the position of her leg and returned the patient to her room. A leg rest was applied [to the wheelchair] and [right] leg was placed in a position of comfort. Ice was offered but patient declined, fearing pain. One final observation, I found [Resident 1] in the living room area at the start of our session without leg rests on her chair, seeing this, I assumed she had propelled herself out there. Review of the X-ray report revealed Resident 1 had sustained a fracture of the interior/anterior one third of the patella. On February 23, 2023, Resident 1 was seen by consultant orthopedic physician. Review of consultation report revealed the orthopedic physician's findings, Acute exacerbation quadriceps (muscle that extends from the front of the hip to the top of the knee) rupture. Recommendations for a specialized brace, weight bearing as tolerated, DVT prophylaxis, and no physical therapy to the right knee range of motion were made by the orthopedic physician. Review of the facility investigation revealed the result of an interview with Resident 1's orthopedic physician, the orthopedic physician concluded that the patellar fracture was the result of Resident 1's leg getting caught under her wheelchair during the transport by Employee 1. During an interview on March 8, 2023, at 12:15 PM, with the Nursing Home Administrator (NHA), she stated that it was the facility's expectation that footrests are applied to wheelchairs when facility employees are transporting residents in wheelchairs. During the interview, NHA revealed that, at the time of the aforementioned incident, the facility did not have a policy or protocol in place that stated resident wheelchairs should have footrests applied when being transported. On March 8, 2023, NHA provided a document titled No Pedal No Push. The document was distributed facility wide as a result of the incident with Resident 1. The document stated, If a resident's foot touches the ground, it could get stuck (stumped) and they could project forward causing injury (possibly bad head injury or death). We encourage our team members to operate by best practice- transport residents in wheelchairs safely by ensuring their feet are securely on foot pedals/rests before ambulation. THANK YOU! The facility failed to develop or implement policy or procedure for the use of footrests while transporting Residents in a wheelchair. During transportation, Resident 1's foot getting caught under the wheelchair, resulting in a fractured patella. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility policies and procedures, facility documentation and interviews with staff, 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 28 residents reviewed (Resident 108), resulting in harm of a skin tear with an transfer to the hospital and receiving of sutures. Findings include: Review of facility policy titled, Reporting Reasonable Suspicion of a Crime - Elder Justice Act, last reviewed (MONTH) (YEAR) revealed the facility standard was to, .protect each resident's (sic) right to be free from crimes caused by, for example, abuse, neglect . Review of section A, subsection 7 defined neglect as, .the failure of the facility, its employees or service providers to provide goods and service to a resident that are necessary to avoid physical harm, pain mental anguish, or emotional distress Review of Resident 108's clinical record on (MONTH) 9, (YEAR), at approximately 9:00 a.m. revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility documentation revealed that on (MONTH) 26, (YEAR), Licensed Practical Nurse (LPN) 4 transferred Resident 108 to bed from a shower chair, with no assistance from a second staff member. Review of the facility documentation revealed a written statement by LPN 4 dated (MONTH) 26, (YEAR), in which LPN 4 stated, (LPN 4) noted skin tear after putting the resident feet in bed, and noted blood on the side of the bed frame. Review of the clinical record revealed Resident 108 was subsequently sent to the hospital and received 12 sutures to close the skin tear on Resident 108's right leg. Review of facility documentation revealed that on (MONTH) 27, (YEAR), at 12:40 p.m. the Director of Nursing obtained a telephone statement from LPN 4 which revealed, that LPN 4 stated, Yes. I knew (Resident 108) was a 2 assist (for transfers). During an interview on (MONTH) 9, (YEAR), at approximately 2:30 p.m. the Director of Nursing revealed it was the facility's expectation that the staff follow the ordered transfer status when transferring residents. The facility neglected to provide the goods and services necessary to maintain a resident at the highest practicable physical well-being. This failure resulted in harm, transfer to the hospital and sutures to Resident 108's right leg. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/10/17, 5/12/16. 28 Pa. Code 201.14(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/27/17, 4/10/17, 10/14/16, 5/12/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/12/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/10/17. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/10/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/27/17, 6/16/17, 4/10/17, 10/14/16, 7/21/16, 5/12/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/16/17, 4/10/17, 10/14/16, 8/10/16, 7/21/16, 5/12/16.

Based on clinical record review and staff interview, it was determined that the facility failed to provide residents with supervision and to provide a safe environment to prevent accidents for two of 28 residents reviewed (Resident 108 and 95) resulting in harm of a skin tear, transfer to the hospital and receiving sutures to Resident 108. Findings include: Review of Resident 108's clinical record on (MONTH) 9, (YEAR), at approximately 9:00 a.m. revealed [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of facility documentation revealed that on (MONTH) 26, (YEAR), Licensed Practical Nurse (LPN) 4 transferred Resident 108 to bed from a shower chair, with no assistance from a second staff member. LPN 4 did not follow the physician's orders [REDACTED]. Review of facility documentation revealed a written statement by LPN 4, dated (MONTH) 26, (YEAR), in which, LPN 4 stated, (LPN 4) noted skin tear after putting the resident feet in bed, and noted blood on the side of the bed frame. Review of Resident 108's clinical record revealed Resident 108 was subsequently sent to the hospital and received 12 sutures to close the skin tear on the right leg. Review of facility documentation revealed that on (MONTH) 27, (YEAR), at 12:40 the Director of Nursing obtained a telephone statement from LPN 4 which revealed that LPN 4 stated, Yes. I knew (Resident 108) was a 2 assist (for transfers). During a staff interview on (MONTH) 9, (YEAR), at approximately 2:30 p.m. the Director of Nursing revealed it was the facility's expectation that the staff would follow the ordered transfer status when transferring residents. Review of Resident 95's clinical record on (MONTH) 8, (YEAR), at approximately 12:45 p.m. revealed [DIAGNOSES REDACTED]. An observation of Resident 95 from the unit hallway on (MONTH) 9, (YEAR), at approximately 9:30 a.m. revealed Resident 95 was lying in bed and Nurse Aide (NA) 2 was at the bed side. NA 2 was observed leaving Resident 95's room at approximately 9:33 a.m. Observation of Resident 95 at approximately 9:34 a.m. revealed that there was a clear plastic cup resting on it's side on Resident 95's personal blanket near the foot of the bed. Observation revealed a spilled liquid from the cup was left on Resident 95's blanket. Observation of Resident 95's room revealed spilled thicken liquid under Resident 95's bed and oxygen concentrator, which had accumulated in a puddle. At approximately 9:40 a.m. NA 2 entered the room and was observed shortly afterward exiting with a clear plastic cup. Observation at approximately 9:41 a.m. revealed the thickened liquid remained on Resident 95's blanket and floor. Observation on (MONTH) 9, (YEAR), at approximately 10:21 a.m. revealed the Director of Environmental Services entered Resident 95's room. During a staff interview on (MONTH) 9, (YEAR), at approximately 10:22 a.m. the Director of Environmental Services was not aware of the liquid that was on Resident 95's blanket and floor. During the interview, Director of Environmental Services confirmed the presence of the liquid on Resident 95's blanket and floor. During the staff interview, the Director of Environmental Services revealed that if nursing staff find something spilled on the floor they notify him and he instructs the housekeeping staff to address the area. During the staff interview, the Director of Environmental Services revealed he was not notified of any spills in Resident 95's room. During a staff interview on (MONTH) 9, (YEAR), at approximately 12:45 p.m. the DON revealed the spilled liquid should have been cleaned up when identified. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 4/10/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/10/17, 5/12/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/27/17, 4/10/17, 10/14/16, 5/12/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/12/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/10/17. 28 Pa. Code 201.29(j) Resident rights. Previously cited 4/10/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/16/17, 4/10/17, 10/14/16, 8/10/16, 7/21/16, 5/12/16.

Based on clinical record review, a review of facility documentation, review of FDA guidelines, observations and staff interviews, it was determined that the facility failed to ensure that the residents were protected from the potential for harm regarding the use of bed side rails without assessments for safety to prevent entrapment and harm to the residents. This occurrence created an Immediate Jeopardy situation to resident health and safety for 55 of 127 residents reviewed with gaps exceeding 2 3/8 inches (Residents 1, 2, 3, 4, 5, 7, 9, 11, 12, 17, 19, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69). Findings include: Review of the Food and Drug Administration (FDA) guidelines, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment revealed that the dimensional limit recommendations for Zone 4, defined as under the rail, at the ends of the rail (the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of the rail) is less than 2 3/8 inches. During an observation on April 4, 2017, at 9:40 a.m. it was revealed that Resident 8 was lying in bed with the bilateral (both sides) bed side rails (bars of approximately 20 inches in length, 12 inches in height, made of metal attached to both sides of the head end of the bed that protrude up above the mattress) in the affixed-up position. During an observation on April 4, 2017, at 10:30 a.m. it was revealed that Resident 6 was in bed with the bilateral bed side rails in the up position. During an observation on April 4, 2017, at 11:55 a.m. revealed that Resident 1 was in bed with bilateral bed rails in the up position. During an interview with the Nursing Home Administrator (NHA) on April 6, 2017, at 11:47 a.m. it was revealed that the facility does not have a policy related to the use of side rails. During an interview on April 6, 2017, at approximately 2:30 p.m. the NHA revealed that there were no entrapment assessments completed including measurements, no risk/benefits form signed by the residents' or their responsible party, no physician's order and no care plans for the use of bed side rails for any of the residents. On April 6, 2017, at approximately 3:00 p.m. observations of all of the residents' rooms revealed that all of the residents' beds had bed side rails installed. Further review revealed that the bed side rails were in the upright position on all the beds except for eight of the 127 resident beds in the facility. On April 7, 2017, at approximately 5:20 p.m. the NHA was notified that the facility was placed in Immediate Jeopardy status related to the application of bed side rails to the residents' bed frames without assessments, physician's orders, care plans and consents to the risk and benefits of bed rails prior to identification by the State surveyors on April 6, 2017, and must immediately provide a Corrective Action Plan (indicating how they are going to protect all of the residents) for review and approval. On April 7, 2017, at 7:03 p.m. the Corrective Action Plan was approved. The Corrective Action Plan included that all residents were assessed and those who were not appropriate for bed side rails had them removed. The bed side rails (enabler bars - used to allow a resident to reposition themselves in bed) were removed from the beds of the residents who did not want them, consents (risk/benefits) were obtained from the residents who did want the bed side rails, physician's orders were obtained for the residents utilizing bed side rails, resident care plans were updated for the use of bed side rails as enablers and 15 minute safety checks were performed on the four residents with pending consent forms (the risk/benefits form had not yet been signed by the residents' responsible party) for the use of bed side rails. On April 8, 2017, at 1:00 p.m. observations of the mattress measurements from the end of the side rail closest to the foot of the bed, to the mattress, were obtained by Employee MNT1, the Maintenance Director. The measurements revealed that 55 residents had greater than the minimum gap space of 2 3/8 inches, as recommended by the Federal Drug Administration (FDA), from the bottom of the bed side rail to the mattress. On April 8, 2017, at 1:30 p.m. the facility provided an amended Corrective Action Plan which included that a bolster (a firm foam pad that attaches to the bed with Velcro straps) would be placed between the mattress and the bed side rails on all of the beds with a gap greater than 2 3/8 inches in measurement and that 1:1 continuous safety checks would be instituted for the three residents with pending consent for the use of bed side rails. On April 8, 2017, at 2:00 p.m. the amended Corrective Action Plan was accepted. On April 9, 2017, at 8:15 a.m. observations were made to determine that the Corrective Action Plan was implemented, which included the review of every resident to ensure assessments for mattress measurements, to the end of the bed side rail, were completed and that the bolster were placed between the mattress and the side bed rail, risk/benefits forms were explained and signed by the residents' or their responsible party, and that physician's orders were obtained for the use of bed side rails. On April 9, 2017, at 10:00 a.m. the facility was notified that the Immediate Jeopardy was lifted. The facility failed to ensure that residents were protected from the potential for harm regarding the use of bed side rails, without assessments for safety, to prevent entrapment and harm to the resident and without a review of the risks and benefits of bed rails with the resident or resident representative, and failed to obtain informed consent prior to installation of the bed side rails. The facility failed to ensure that gaps, between the end of the bed side rail and the mattress, greater than 2 3/8 inches were not present on any resident beds. This occurrence created an Immediate Jeopardy situation to resident health and safety. 42 CFR 483.25 (n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 4/16/15. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/12/16. 28 Pa. Code 211.8(d)(e) Use of restraints.

Based on a review of clinical records, facility documentation, facility policy and interviews with facility staff, it was determined that the facility failed to provide adequate supervision and monitoring to prevent accidents for four of 24 residents reviewed (Residents 2, 5, 6, 9). Findings include: Review of the facility's Fall Management policy, reviewed June, 2013 indicates that a post fall investigation form will be completed, causes of the fall will be removed and preventive measures to prevent re-occurrence will be implemented. Review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her care plan was initiated on November 6, 2012 and she was identified as at risk for falls. A fall care plan was developed at that time, updated on June 14, 2013 and which continues, included to transfer with a Sara lift (a device designed to transfer a patient between two seating surfaces). The nurse aide care instruction sheet (used by aides as a reference for care provided to residents) indicates Resident 2 is to be transferred with two persons and a Sara lift. Review of the facility's incident report dated April 13, 2014, revealed Resident 2 was being transferred with a stand-pivot approach when she began to lean to the side and had to be lowered to the floor; she sustained no injury. There were no new interventions put into place and no note as to the transfer method used. A second incident report, dated April 30, 2014 indicates Resident 2 was being transferred into chair when her knees started to give out and she was lowered to the floor with the assist of one staff person; she sustained no injury. In both instances, the resident was not transferred with the Sara lift or the assist of two staff as per the care plan. During an interview on May 15, 2014 at 10:15 a.m. with the Director of Nursing, she confirmed that Resident 2 should have been transferred as per the care plan. Review of the clinical record for Resident 5 revealed she had 11 falls between June 28, 2013 and March 15, 2014. Review of the fall investigations dated July 7, 2013, September 11, 2013 and January 15, 2014 revealed the plan was to continue all current interventions. Review of the care plan revealed interventions dated January 16, 2013 to toilet at beginning of evening shift, before and after supper, bedtime and as needed with checks every two hours on night and day shift. Review of the fall investigation dated July 19, 2013 revealed the resident was not checked every two hours for toileting needs. Review of Resident 9 ' s clinical records on May 12, 2014 revealed [DIAGNOSES REDACTED]. Review of the record revealed that on December 2, 2013 Resident 9 had a fall with fracture. A Resident/Visitor Incident Report was completed. On December 2, 2013, Resident 9 was assessed to have a BIMS of 14 and required assist of 2 for transfer. Review of the fall report reveals that the fall occurred as Resident 9 slid out of wheelchair due to not being positioned properly in the chair. As per the facility investigation, the beautician in the beauty salon had tried to reposition Resident 9 alone in the beauty salon as Resident 9 had complained that her foot had got stuck and was in pain when she was placed under the dryer. The beautician transported Resident 9 back to dining room and it was observed by 2 witnesses that Resident 9 was sliding out of wheelchair. An interview with Nursing Home Administrator on May 14, 2014 at 3:05 pm revealed that it is a required job task for beauticians ' to be able to transport residents and that the orientation for beauticians does not include training on transporting. A document was received from facility on May 15, 2014, indicating documentation that on December 4, 2013, Beauty Salon employee, BS 1 , indicated that beauty salon employees are to ask for assistance if a resident needs repositioning or if there is a problem in the salon or if a resident needs lifting. Review of Resident 6 ' s clinical record on May 12, 2014 revealed [DIAGNOSES REDACTED]. Review of Resident 6 ' s Resident/Visitor Incident Reports reveals a total of 7 falls from May 6, 2013 to May 1, 2014. Report of May 6, 2013 indicates " New Intervention " as " not to help roommate " (she fell due to helping her roommate with a task). Report of May 15, 2013 indicates " New Intervention " as ambulate with RN, bed alarm, enabler R rail, hide alarm box, toilet program, use call bell " . Report of June 25, 2013 indicates " New Intervention " of " bed alarm, wanderguard " . Report of September 27, 2013 indicates " New Intervention " of " remind to use call bell and walker, not to turn off alarm, place bed alarm out of reach " . Report of December 9, 2013 indicates " New Intervention of " bed alarm, move to less accessible place " . Report of April 30, 2014 indicates " New Intervention " of bed alarm at bedtime, enable bar (R) side, ambulatory with p/w and supervision. Continue current interventions. Report of May 1, 2014 indicates " New Intervention of " bed alarm at bedtime, enable bar, toileting, RNP, falling Star. Interventions and progression of interventions do not support effectiveness in modifying interventions when necessary. Review of TARs for wandergard checks revealed this was not done for 1 shift in November 2013, 4 shifts in December 2013, 1 shift in March 2014, and 4 shifts in April 2014. An interview with LPN 2 on May 13, 2014 at 11:50 am on Lincoln unit did not reveal any rationale for checks not having been documented. During an interview on May 15, 2014 at 10:00 a.m., the DON stated that new interventions were not always initiated following an fall because all interventions were already in place. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previsouly cited 4/18/13 28 Pa. Code: 211.11(a)(c) Resident care plan. Previsouly cited 4/18/13 28 Pa. Code: 211.12(d)(1) Nursing services. Previsouly cited 4/18/13 28 Pa. Code: 211.12(d)(5) Nursing services. Previsouly cited 4/18/13 and 4/24/14