Every finding on record at Park Lane Post Acute LLC

Based on staff and resident interview, observation, and clinical record review, it was determined that the facility failed to monitor a resident's skin after the application of an elastic wrap for one out of six residents reviewed (Resident 37).Findings include: A review of Resident 37's admission Minimum Data Set (MDS - a mandatory assessment of a resident's condition and care needs) dated April 20, 2026, revealed Resident 37 was moderately cognitively impaired and relied on staff for substantial assistance with personal care. Resident 37's diagnoses included pneumonia (a lung infection), acute respiratory failure (a condition where the lungs cannot provide enough oxygen to the blood), pulmonary hypertension (a type of high blood pressure affecting the blood vessels in the lungs and the right side of the heart), and cardiomyopathy (enlargement of the heart muscle). Resident 37 was receiving diuretic medication (removes excess fluid from the body), opioid medication (a narcotic pain medication), antiplatelet medication (medication to prevent blood clots), anticonvulsant medication (medication to control seizures), and continuous oxygen therapy.During resident interview and observation on May 4, 2026 at approximately 10:30 a.m., Resident 37 noted their left wrist had been x-rayed on May 3, 2026 because of pain. An elastic bandage was observed wrapped around the left wrist. Review of physician orders dated May 3, 2026, revealed an order for an x-ray of the left hand and wrist.Review of nursing progress notes dated May 4, 2026 revealed no fracture present.On May 6, 2026 at approximately 11:30 a.m. the elastic bandage was noted to be wrapped around Resident 37's wrist. When asked who placed the bandage, Resident 37 stated I don't know, someone who works here. This has been on for days now.Interview with Employee 4 on May 6, 2026 at approximately 12:45 p.m. revealed that they were aware that Resident 37 had an x-ray of the wrist, but they did not place a bandage on the wrist.Interview with the DON on May 6, 2026 at approximately 1:00 p.m. revealed that they were not aware that Resident 37 had an elastic bandage on the wrist and that there was no order to place the bandage or monitor the skin underneath the bandage. During observation at approximately 1:10 p.m., the DON removed the elastic bandage from the Resident 37's wrist to reveal a plastic identification bracelet on the left wrist that had been under the elastic bandage. The DON cut the plastic identification bracelet off Resident 37's wrist to reveal reddened, intact skin.The facility failed to ensure that Resident 37's skin was monitored after the placement of an elastic bandage over a plastic identification bracelet. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of facility policy, and clinical record review, it was determined that the facility failed to ensure physician orders for oxygen for one out of six residents reviewed (Resident 25).Findings include:Review of facility policy titled Oxygen Administration, undated, revealed the following: Oxygen is administered under orders of a provider, except in the case of an emergency where the resident [is] exhibiting signs and symptoms of respiratory distress.Review of Resident 25's admission Minimum Data Set (MDS - a mandatory assessment of a resident's condition and care needs) dated March 11, 2026 revealed Resident 25 was moderately cognitively impaired and totally dependent on staff to complete care needs. Resident 25's diagnoses included lung cancer and chronic respiratory failure (a condition where the lungs cannot deliver oxygen to the blood). Resident 25 was receiving antianxiety medication, hypnotic medication (medication for sleep), anticoagulant medication (medication to prevent blood clots), antibiotic medication (medication to treat infections), opioid medication (narcotic pain medication) and oxygen therapy.Observation of Resident 25 on May 4, 2026 at approximately 11:30 a.m. revealed the resident receiving 4 liters per minute (LPM) of oxygen via a nasal canula (N/C - tubing that delivers oxygen directly into the nostrils delivered by an oxygen concentrator (a machine that delivers supplemental oxygen). The oxygen tubing was labeled April 28, 2026.Review Resident 25's physician orders for March 2026 revealed an order dated March 31, 2026 to admit the resident to hospice but no orders for oxygen therapy.A nursing progress note dated March 6, 2026, at 4:28 a.m. revealed: oxygen on at 4.5L via N/C no distress noted.A nursing progress note dated March 19, 2026 at 02:14 a.m. revealed Oxygen increased to 5L via N/C.A nursing progress note dated April 3, 2026 at 3:06 a.m. revealed: Oxygen on at 2L via N/C.A nursing progress note dated April 21, 2026, at 3:08 a.m. revealed: Oxygen in place via N/C 4L sleeping at present time.A nursing progress note dated April 29, 2026, at 3:04 AM revealed: Oxygen on at 4L via N/CA nursing progress note dated May 1, 2026 at 1:04 a.m. revealed: Oxygen on at 4L via N/C and HOB (head of bed) elevated for comfort.Review of Resident 25's physician orders effective May 4, 2026 revealed no orders for oxygen.Review of nursing progress notes dated May 6, 2026 at 12:19 p.m. revealed: Received n/o (new orders) to titrate (adjust levels) oxygen as needed. Placed on 6L/min with good results.The facility failed to ensure a physician's order for oxygen was entered into the Medication Administration Record prior to administering continuous oxygen. 28 Pa. Code 211.5(f) Clinical Records Previously cited 5/16/2528 Pa. Code 211.12(d)(1)(3)(5) Nursing ServicesPreviously cited 5/16/2025

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that medications ordered by physicians were available for two of 19 residents reviewed (Residents 4 and 5).Findings Include: A review of Resident 4's readmission notes dated April 8, 2026, at 10:28 p.m., revealed the resident was readmitted with a left hip fracture, post ORIF (Open Reduction and Internal Fixation- A two-part surgical procedure used to treat severe, displaced bone fractures by realigning the bone and securing it with hardware) to the left hip. A review of Resident 4's physician's order dated April 8, 2026, revealed Heparin Sodium (anticoagulant) injection solution one ml (milliliter) subcutaneously (medication injected into the fatty tissue layer between the skin and muscle) every eight hours for DVT (Deep Vein Thrombosis- blood clot in the deep vein) prevention. A review of Resident 4's April 2026 Medication Administration Record (MAR) revealed Heparin was not administered on the following dates/times: April 27, 2026, at 6:00 a.m., 2:00 p.m., and 10:00 p.m., and on April 28, 2026, at 6:00 a.m. A review of Resident 4's nursing progress notes dated April 27, 2026, at 5:40 a.m., revealed: medication is not available in cart, reordered from pharmacy 4/26/26. A review of Resident 4's nursing progress notes dated April 27, 2026, at 3:08 p.m., revealed Resident missed the Heparin at 2 pm, notified [name of nurse practitioner], called pharmacy to send it stat (immediately), not available in Pyxis (automated medication storage). A review of the nursing progress notes dated April 28, 2026, at 5:37 a.m., revealed: Medication (Heparin) has not been received from pharmacy. A review of Resident 4's progress notes revealed that physicians were not notified of the missed Heparin doses on April 27, 2026, at 6:00 a.m. and 10:00 p.m., and April 28, 2026, at 6:00 a.m. An interview with the Director of Nursing, conducted on May 6, 2026, at 1:00 p.m., confirmed that Heparin medications were not administered to the resident due to the medication being unavailable from the pharmacy. The facility failed to ensure Resident 4's medication to prevent blood clots was available for administration. A review of Resident 5's physician orders dated March 23, 2026, at 9:00 p.m., revealed an active order for: Penicillin V Potassium Oral Tablet 500 MG (Penicillin V Potassium) Give 1 tablet by mouth two times a day for Osteomyelitis (a bone infection) for 6 Months. A review of Resident 5's April 2026 and May 2026 Medication Administration Record (MAR) revealed Penicillin V Potassium was not administered on the following dates/times: April 28, 2026, at 9:00 a.m., and 9:00 p.m., April 29, 2026, at 9:00 a.m., and 9:00 p.m., April 30, 2026, at 9:00 a.m., and 9:00 p.m., May 1, 2026, at 9:00 a.m., and 9:00 p.m., May 2, 2026, at 9:00 a.m., and 9:00 p.m., May 3, 2026, at 9:00 a.m., and 9:00 p.m., May 4, 2026, at 9:00 a.m. A review of Resident 5's nursing progress notes dated April 28, 2026, at 9:20 a.m., revealed: medication not available - awaiting delivery from pharm. supervisor made aware and at 8:22 p.m., awaiting delivery via pharm. A review of Resident 5's nursing progress notes dated April 29, 2026, at 9:55 a.m., revealed: waiting on pharm delivery and 9:03 p.m., Medication on order. A review of Resident 5's nursing progress notes dated April 30, 2026, at 12:11 p.m., revealed: not available in cart, notified pharmacy, stated that they need a new doctors order for a refill, notified supervisor who is contacting (Doctors name). A review of Resident 5's nursing progress notes dated May 1, 2026, at 10:26 a.m., revealed: awaiting refill from ordering physician and at 9:37 p.m., awaiting refill from Physician. A review of Resident 5's nursing progress notes dated May 2, 2026, at 11:36 a.m., revealed: medication not refilled and at 10:11 p.m., medication on order. A review of Resident 5's nursing progress notes dated May 3, 2026, at 9:57 a.m., revealed: medication on order. A review of Resident 5's nursing progress notes dated May 4, 2026, at 11:25 a.m., failed to reveal any notes stating why the medication was not administered at 9:00a.m. A further review of Resident 5's nursing progress notes dated May 3, 2026, at 4:40p.m., revealed: Called pharmacy to inquire about status of Penicillin script. Pharmacy stated they needed a new script. Note left for (Doctors name) requesting a new script for Penicillin. An interview with the Director of Nursing conducted on May 06, 2026, at 1:54 p.m., confirmed medication was not administered to the resident due to the medication being unavailable from the pharmacy. The facility failed to ensure Resident 5's medication to help treat osteomyelitis by killing the bacteria that are causing the bone infection was available for administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of the facility's policy, clinical records review, observations, and staff interviews, it was determined that the facility failed to practice infection control prevention and management for one of two residents reviewed (Resident 71).Findings:A review of the facility's policy titled Transmission-Based (Isolation) Precautions, revised on March 16, 2026, revealed that facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The same policy revealed, healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination). A review of Resident 71's hospital's Summary Report dated April 30, 2026, revealed resident had Sepsis (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage and death) from sacral pressure injury, and C. diff (Clostridium Difficile) colitis (Inflammation of the colon due to toxins released by the bacteria, leading to severe diarrhea, cramping and fever.) The same note revealed Post Hospital Care Requirement- Infection Control: Contact Isolation required due to C. diff and MDRO-GNR (Multi-Drug-Resistant Gram-Negative Rods- are bacteria resistant to multiple antibiotics, posing significant risk) status. A review of Resident 71's census revealed the resident was readmitted to the facility on [DATE]. A review of Resident 71's physician order dated May 4, 2026, revealed Contact precautions: r/t (related to) VRE (Vancomycin-resistant enterococci - are bacteria that have developed resistance to the antibiotic vancomycin) in wound / C-Diff (+) . An observation conducted on May 4, 2026, at 1:00 p.m., revealed a PPE supply outside the resident's room and a sign on the door indicating STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry, Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. An observation conducted on May 7, 2026, at 9:00 a.m., revealed Employee E5 and E6 were both in the resident's room, the following were observed: Employee E6 standing at resident's bedside, talking and examining the resident. Employee E6 was observed only wearing a surgical mask. Further observations revealed Employee E5, who was only wearing gloves, was observed taking garbage from the resident's room, leaving the room without taking off their gloves or washing their hands, pushing a cart in the hallway with clean linens on top, with the left hand still carrying the plastic with garbage taken from the resident's room, then entered the soiled room. An interview was conducted with Employee E5 on May 7, 2026, at 9:05 a.m. Employee E5 reported that they don't need to wear a gown since they only repositioned the residents in bed and removed the trash. Employee E5 also reported that there were no signs indicating that gowns needed to be worn when entering the room. The surveyor showed the sign (contact precaution) posted on the resident's door to Employee E5. After the interview, Employee E5 was observed entering the resident's room without wearing PPE when the Assistant Director of Nursing, Employee E3, stopped and talked to the employee. Employee 5 was observed putting on gowns and gloves after conversing with Employee E3. Additional observations revealed Employee E6 left the room without washing hands, used the wall hand sanitizer across the resident's room to clean their hands, then walked in the hallway. An interview with Employee E6 on May 7, 2026, at 9:15: a.m., was conducted. Employee E6 reported cleaning their hands with alcohol-based sanitizer located across the resident's room, then washing their hands afterwards. Employee E6 confirmed that they did not wash their hands before leaving the resident's room. The above information was conveyed to the Director of Nursing (DON) on May 7, 2026, at 9:30 a.m. The facility failed to ensure infection control prevention and management were implemented for a resident on contact precaution for positive C-diff.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of clinical and pharmacy records and staff interviews, it was determined that the facility failed to ensure medications were made available for one of the two residents reviewed (Resident CL1).Findings include: Clinical records review revealed Resident CL1 was admitted to the facility on [DATE], with a diagnosis of T11-T12 compression fracture. A review of the Physician's order (POS) dated November 26, 2025, revealed Lyrica (A medication used to treat nerve pain and seizures) 25 mg one capsule by mouth three times daily. The medication was scheduled at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the November 2025 Medication Administration Record (MAR) revealed that Resident CL1 was not administered Lyrica on November 27, 2025, at 9:00 a.m., 1:00 p.m., and 9:00 p.m. A review of the nursing progress notes dated November 27, 2025, at 10:39 a.m., revealed Lyrica medication not yet in from pharmacy. A review of the nursing progress notes dated November 27, 2025, at 12:12 p.m., revealed Lyrica medication Not here from pharmacy, not available in Pixis. (An automated medication dispensing system). A review of the nursing progress notes dated November 27, 2025, at 11:07 p.m., revealed Lyrica medication waiting for pharmacy to deliver. A review of the pharmacy records, delivery report revealed Lyrica medication was not delivered to the facility until November 28, 2025, which resulted in Resident CL1 missing three doses of the medication. Clinical records review failed to reveal that the physician was notified of the missed medications. A review of the POS dated November 25, 2025, revealed an order for Hydrocodone-Acetaminophen (A medication used to treat moderate to severe pain) 7.5-325mg, give one tablet every four hours for back pain. A review of December 2025, MAR revealed Hydrocodone-Acetaminophen was not administered to Resident CL1 on December 8, 2025, at 8:00 a.m. A review of the nursing progress notes dated December 8, 2025, 10:17 a.m., revealed medication administered approximately 11:15 a.m., delayed due to unavailability. An interview with the Director of Nursing on January 2, 2026, at 1:00 p.m., confirmed that the above medications were not administered to Resident CL1 due to unavailability from the pharmacy. The facility failed to ensure Resident CL1's pain medications were made available for the resident for administration. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders and adequately monitor significant weight changes for three of eight residents reviewed for nutrition (Residents 18, 36 and 37). Findings include: Review of facility policy, Weight and Weight Change Management, last revised date unknown, revealed: Resident weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Each resident will be weighed monthly or more frequently as deemed necessary by physician orders, Dietician, or IDT (interdisciplinary team) recommendation. Clinical records review revealed Resident 18 was admitted to the facility on [DATE], with diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Chronic Kidney Disease (CKD-Gradual loss of kidney functions which can result to renal failure), and right leg bimalleolar fracture (A serious ankle injury that involves breaks in both the medial and lateral malleolar bones). A review of Resident 18's physician's order dated April 24, 2025, revealed an order for a daily weight one time a day, ensuring wheelchair weight is subtracted before inputting the weight. A review of the weight and vitals revealed the following weights: 204 pounds on April 25, 2025, 204.2 pounds on April 26, 2025, 203.4 pounds on April 27, 2025, 204.1 pounds on April 28, 2025, and 204.4 pounds on April 29, 2025, which revealed a stable weight from April 25 until April 29, 2025. On May 3, 2025, the resident's weight was 247.8 pounds. A reweigh was done which also revealed 247 pounds, a 43.4 (21.23%) significant weight gain in four days. A review of the dietitian's progress notes dated May 5, 2025, revealed the resident with a weight gain of 40 pounds, reweight also showing +40 pounds. The notes also revealed that RD (registered dietitian) checked wheelchair weight alone and it's 47.4 #. Weight gain x 1 (one) day most likely due to not subtracting wheelchair weight when inputting weights obtained. RD spoke to the nurse for the resident today and emphasized subtraction of wheelchair weight/clarification from CNA (certified nursing assistant) if the subtraction was completed or not before inputting into the system. Spoke to MD (physician) about weight gain and made aware of weight change most likely r/t (related to) wheelchair weight being included. An interview with the Dietitian, licensed Employee E3 conducted on May 15, 2025, at 11:30 a.m., confirmed that the significant weight gain was due to the wheelchair not subtracted before inputting the weight into the system. The dietitian reported that the current daily weights (240 + pounds) documented in the weights and vitals were all with a wheelchair. An interview with an Occupational therapist (A healthcare provider that helps people to improve their daily living tasks and activities), Employee E5 was conducted on May 16, 2025, at 11:00 a.m. Employee E5 reported providing treatment and rehabilitation services for Resident 18. Employee E5 reported that she/he took the resident's weight on May 16, 2025, and it was 244 pounds without a wheelchair. An interview was conducted with the Director of Nursing on May 16, 2025, at 1:00 p.m. The DON was unable to provide a valid explanation of the 40 + pounds significant weight change in four days. The facility failed to ensure Resident 18's weight was appropriately monitored and addressed. Review of Resident 36's face sheet revealed medical diagnoses that include, Progressive Bulbar Palsy (damage to cranial nerves responsible for controlling muscles for speech, swallowing and facial movement), Sever Protein Calorie Malnutrition (insufficient energy, fat protein and nutrients), Amyotrophic Lateral Sclerosis (ALS - loss of muscle control), Acute Respiratory Failure with Hypoxia (lack of oxygen in blood), Dysarthria (speech disorder) and Anarthria (loss of muscle control for speech). Review of Resident 36's clinical records revealed a care plan dated March 10, 2025, documenting Resident 36 is at nutritional/hydration risk secondary to need for Enteral (nutritional intake via tube) feeding and flushes to maintain nutritional status. Inability to meet established nutritional needs with PO (by mouth) diet, history of prior need for mechanical altered diet with thickened liquids, history of altered lab values, history of inadequate PO intake, and increased risk for clinical changes including weight, skin and lab changes. Review of Resident 36's physician orders revealed an order dated May 1, 2025, for weekly weights for four weeks with an end date of May 29, 2025. Per the physician orders Resident 36 should have been weighed on May 1, 2025, May 8, 2025, May 15, 2025, and May 22, 2025. Review of Resident 36's physician orders revealed an order dated April 24, 2025, for NPO (nothing by mouth) diet, NPO texture, NPO consistency. Further review of Resident 36's physician orders revealed an order dated May 2, 2025, for Enteral Feed four times per day via Bolus Feeding Tube (tube syringe used to provide nutrition). Nutren 2.0 (a nutrition formula), 220cc 4 times per day, every 6 hours, total volume 880cc per 24 hours, providing 1760 kcals, 74grams protein, 609cc free water, per 24 hours. Review of Resident 36's weights on May 15, 2025, at 12:35 p.m., revealed one weight dated May 1, 2025, at 1:29 p.m. where the resident was recorded as weighing 134.9 lbs. Further review of Resident 36's weights on May 16, 2025, at 11:15 a.m., revealed a recorded weight dated May 16, 2025, at 10:49 a.m., where the resident was recorded as weighing 137.4 lbs. Interview with Dietary staff Employee E3 on May 15, 2025, at 12:40 p.m., Employee E3 stated nursing staff is responsible for resident's weights. Employee E3 confirmed Resident 36 was not weighed on May 8, 2025, as ordered. Employee E3 stated he/she had no clarification why Resident 36 was not weighed. Employee E3 confirmed there was no documented explanation as to why Resident 36 was not weighed on May 8, 2025. Employee E3 stated the nursing supervisor was notified of Resident 36's missing weight the following day, May 9, 2025. Employee E3 confirmed Resident 36's next scheduled weighing was May 15, 2025. Interview with the DON on May 16, 2025, at 11:30 a.m., when the above was mentioned, the DON confirmed Resident 36's physician orders for weekly weights were not followed. Review of Resident 37's diagnosis list revealed diagnoses but not limited to dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), anxiety disorder (feelings of persistent anxiety), muscle weakness and depression. Review of Resident 37's physician orders revealed an order dated May 7, 2025, for weekly weight for four weeks with an end date of June 4, 2025. Review of Resident 37's clinical record revealed that weights were obtained as follows: April 30, 2025 - 113.2 pounds and May 14, 2025 - 101.0 pounds. Revealed a significant weight loss of 12.2 pounds. Further review of Resident 37's clinical record failed to reveal that any weights were obtained on May 7, 2025. The above-mentioned information was conveyed to the Director of Nursing on May 16, 2025, at approximately 1:00pm. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on clinical records facility policy review and staff interviews, it was determined that the facility failed to follow physician orders for oxygen for one of one residents reviewed. (Resident 317) Findings include: Review of Facility policy titled Tracheostomy Care, undated, revealed the following: The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. And tracheostomy care will be provided according to the physicians orders, comprehensive assessment and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. Review of resident 317's Diagnosis list revealed, chronic respiratory failure with hypoxia (Respiratory failure is a condition where there's not enough oxygen or too much carbon dioxide in your body. It can happen all at once (acute) or come on over time (chronic). Review of Resident 317's physician orders revealed Trach Collar (trach collar is a medical device used to deliver oxygen therapy to patients who have a tracheostomy tube in place.) 28% humidified oxygen. Concentrator (condenses room air into pure oxygen) set at 2L/min Observation of Resident 317 on May 15th, 2025, at 09:53 AM revealed the resident was not receiving physician ordered two liters of oxygen. Interview with Registered Nurse (RN) E-6 at 10:12 am, revealed the resident was last seen at 7:15 am. When asked if the trach setup was the same it was revealed to be the same. Upon request E-6 [NAME] order and recited it back. The facility failed to ensure Resident 317's tracheostomy collar with 28% humidified oxygen medication order was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to monitor behaviors and potential side effects for residents receiving anti-psychotic medications (psychiatric drugs used to treat symptoms of psychosis, like hallucinations and delusions) for two of five residents reviewed (Residents 18 and 25). Findings include: A review of the facility's policy titled Psychotropic Medications, with an effectivity date of January 14, 2025, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record. The medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Further review of the same policy revealed that residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS- A test used to assess and monitor involuntary movements) test performed per facility policy. A review of Resident 18's diagnosis list includes bipolar disorder (A disorder associated with mood swings ranging from depressive lows to manic highs) and Major Depression. A review of Resident 18's physician's order dated April 24, 2025, revealed an order of Abilify (An anti-psychotic medication) 10mg one tablet two times daily. Clinical records review failed to reveal behaviors and medication side effects monitoring were being done while the resident was taking Abilify from April 24, 2025, until May 16, 2025. A review of Resident 35's diagnosis list includes bipolar disorder and generalized anxiety disorder. A review of Resident 35's physician's order dated April 17, 2025, revealed an order of Chlorpromazine HCl 50 mg (An anti-psychotic medication) one tablet at HS (hours of sleep). Clinical records failed to reveal behaviors and medication side effects monitoring was being done while the resident was taking Chlorpromazine from April 17, 2025, until May 12, 2025. An interview conducted with the Director of Nursing on May 16, 2025, at 1:00 p.m., confirmed behavior and medication side effects monitoring were not done for Resident 18 and 35 while receiving an antipsychotic medication. The facility failed to ensure Residents 18 and 35 were monitored for behaviors and medication side effects while receiving an anti-psychotic medication. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/19/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 4/19/24

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to thoroughly investigate allegations of staff being rough to the resident while providing care for one of the 19 residents reviewed (Resident 62). Findings include: A review of the facility's policy titled Abuse, Neglect and Exploitation, implemented on March 17, 2025, revealed that an investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occurs. Written procedures for investigations include the following: Identifying staff responsible for investigation; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might know about the allegation; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and the cause; and Providing complete and thorough documentation of the investigation. A review of Resident 62's diagnosis list includes Spinal Stenosis (The narrowing of one or more spaces within your spinal canal that cause symptoms like back or neck pain), and lumbar disc degeneration (A condition of the discs between vertebrae with loss of cushioning, fragmentation and herniation related to aging). A review of Resident 62's Admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated May 1, 2025, revealed resident's cognition was intact. The same MDS revealed resident required partial/moderate assistance with rolling in bed and was dependent on transfers. A review of the facility documentation, Grievance Form dated May 1, 2025, revealed the following: Pt (patient) stated no medication given for upset stomach. On admission, pt stated 2 (two) CNA (certified nursing assistant) were rough when trying to take (his/her) weight and roll in bed. The same documents revealed that the concern was resolved on May 2, 2025, with a grievance official follow up EMAR (electronic medical record) printed to show medication was given to help with stomach pain. DON (Director of Nursing) and guest services present at the care conference to address concerns, Pt also paired care for care. A review of the clinical records and the facility's investigation revealed that the resident's concern for not receiving the medication was addressed, however, a resident report regarding two staff being rough during care was not thoroughly investigated. The investigation report failed to reveal a statement from the two alleged staff and other potential witnesses were taken to determine the presence of abuse. An interview conducted with the Nursing Home Administrator on May 16, 2025, at 9:07 a.m., confirmed statements were not taken from the two staff who were allegedly rough to the resident during care until May 15, 2025, after the surveyor asked for it. The facility failed to ensure allegation of staff being rough to the resident during care was thoroughly investigated. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/19/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 4/19/24

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure skin impairment identified from admission was thoroughly assessed and wound care recommendations from the wound physician were followed for one of four residents reviewed (Resident 59). Findings include: A review of the facility's policy titled Pressure Injury Prevention and Management, implemented on January 14, 2025, revealed that the facility should establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Clinical records review revealed Resident 59 was admitted to the facility on [DATE], with a diagnosis of progressive supranuclear ophthalmoplegia (A late-onset neurodegenerative disease involving the gradual deterioration and death of specific volumes of the brain), generalized weakness, and urinary tract infection. A review of the admission skin assessment dated [DATE], revealed Right heel pressure. The skin assessment failed to reveal the wound stage, size, appearance, drainage, odor, and condition of the surrounding area of the skin. A review of the physician's order dated April 23, 2025, revealed an order to cleanse the right heel wound with normal saline, apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) and cover with dressing every other day. An interview with the Assistant Director of Nursing (ADON), licensed Employee E4 was conducted on May 15, 2025, at 1:30 p.m. Employee E4 reported that the admitting nurse is responsible for the wound assessment. The ADON reported that assessment should include the wound's stage, measurements, appearance, and drainage and documented on the resident's medical records. Employee E4 confirmed that Resident 59's right heel wound identified on admission was not comprehensively assessed until seen by the wound physician for a consult on April 25, 2025, two days after admission. A review of the wound physician's consult dated April 25, 2025, revealed right heel wound was identified as an Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) measuring 2.4 x 2.0 x 0.1 cm. (centimeters) with 50% slough (Is a non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). A treatment to cleanse the wound with saline, apply medical grade honey, and cover with foam dressing daily and as needed was ordered by the wound physician. A review of the May 2025, Treatment Administration Record (TAR) revealed Resident 59's right heel unstageable wound treatment was not done on April 26, and 27, 2025, despite the wound physician's order to do the treatment daily and as needed. An interview with the ADON on May 16, 2025, at 10:00 a.m., revealed facility follows the wound physician's recommendations for wound treatment and puts it as an order. The ADON confirmed that the wound physician's recommendation made on April 25, 2025, to change the treatment daily and as needed instead of every other day was not followed missing two days of wound treatment to the right heel unstageable wound. The facility failed to ensure Resident 59's right heel wound was comprehensively assessed, and the recommendation of the wound physician was followed. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/19/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 4/19/24

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of nutrition for one of two residents reviewed (Resident 317). Findings include: Review of Resident 317's Medical Diagnosis revealed, unspecified protein-calorie malnutrition and chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels or high carbon dioxide levels). Clinical record review that patient was admitted to facility on May 8, 2025 with a tracheostomy (a surgical procedure where an opening (stoma) is created in the neck to access the trachea (windpipe), allowing for easier breathing) and PEG tube (a thin, flexible tube inserted directly into the stomach through the abdominal wall). Review of Resident 317's physicians order revealed an order dated May 8, 2025 for Enteral Feed Order one time a day Continuous Tube Feeding: Product: Nutren 1.5 At 60 ML/ Hour via PEG tube x 20hours/day Total Volume: 1200 mL (milliliter) Up at 4 pm Down when total volume has been infused. Review of resident 317's medication administration record (MAR) for May 2025 revealed Resident 317 received a total Nutren 1.5 volume on May 9, 2025 of 60 ml, on May 10, 2025 of 1320 ml, on May 11, 2025 of 3405 ml and on May 12, 2025 of 565ml. Interview with licensed nurse Employee E4 confirmed that tube feeding order was not being documented correctly. The facility failed to ensure Resident 317's physician order regarding continuous tube feeding for the total volume of 1200 ml was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medications were made available for one of the 19 residents reviewed (Resident 18). Findings include: A review of Resident 18's diagnosis list includes bipolar disorder (A disorder associated with mood swings ranging from depressive lows to manic highs), Major Depression, and Sleep Apnea (A potentially serious disorder in which breathing repeatedly stops and starts). A review of Resident 18's physician's order dated April 23, 2025, revealed an order of Armodafinil 250 mg (A medication that treats sleepiness from narcolepsy, sleep apnea, or night shift work) one tablet one time a day for sleep disorder. A review of the April 2025, Medication Administration Record revealed Armodafinil medication was not administered to Resident 18 on April 24, 25, 26, 27, and 28, 2025. A review of the nursing progress notes dated April 25, 2025, at 8:52 a.m., revealed Armodafinil medication was still on order from the pharmacy, the physician was notified. A review of the nursing progress notes dated April 26, 2025, at 9:25 a.m., revealed Armodafinil medication was on order from pharmacy. A review of the nursing progress notes dated April 27, 2025, at 10:44 a.m., revealed Armodafinil medication was not available. A clinical records review revealed that the physician was not notified of the missed medication on April 26, 27, and 28. An interview conducted with the Director of Nursing on May 16, 2025, at 1:00 p.m., confirmed Armodafinil medication was not administered to Resident 18 on the above-mentioned dates due to unavailability of the medication from the pharmacy. The facility failed to ensure Resident 18's Armodafinil medication was made available timely for the resident. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/19/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 4/19/24

Based on observations and staff interviews, it was determined that the facility failed to store food in a sanitary manner. Findings include: Observations in the walk-in freezer on March 15, 2025, revealed that there was a large accumulation of ice on the fans and ceiling extending down to the food boxes on the top shelf. Interview with the Dietary Director on March 15, 2025, at 11:40am confirmed the ice buildup and stated, it is cleaned up after lunch. Observation in the walk freezer on March 16, 2025, at 9:08am revealed accumulation of ice on the fan still present ice on the fans and on ceiling. Interview with the Nursing Home Administrator on March 16, 2025, at 1:15 confirmed the above statement. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on review of clinical records and Minimum Data Set (MDS-mandated assessments of a resident's abilities and care needs) assessments, and a staff interview, it was determined that the facility failed to timely certify the completion of the MDS assessments for nine of nine sampled residents (Residents 6, 40, 42, 50, 57, 65, 76, 77, and Resident 99). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated [DATE], indicated that the MDS Completion Date must be no later than 14 days after the Assessment Reference Date. Review of Resident 6's progress note of [DATE], revealed that resident was discharged to home. Review of Resident 6's clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of progress note of [DATE], revealed that orders were received to discharge the resident home. Further review of the clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of Resident 40's progress note of [DATE], revealed that resident was discharged . Review of the clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of Resident 42's progress note of [DATE], revealed that the resident was discharged home. Review of the clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of Resident 50's progress note of [DATE], revealed that the resident was admitted to the hospital. Further review of the clinical record revealed that a discharge MDS assessment was not completed. Review of Resident 57's progress note of [DATE], revealed that resident was discharged home. Review of the clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of Resident 65's clinical record revealed Resident 65 was discharged to the community on February 1, 2024. Review of Resident 65's clinical record revealed Resident 65's discharge MDS was listed as in progress. Review of Resident 76's progress note of [DATE], revealed resident was admitted to the hospital. Further review of the clinical record failed to reveal evidence that a discharge MDS assessment was completed. Review of Resident 77's progress note of [DATE], revealed that the resident was discharged home. Review of the clinical record revealed that a discharge MDS assessment dated [DATE], was not completed and was listed as in progress. Review of Resident 99's progress note dated February 14, 2024 revealed Resident 99 expired in the facility. Review of Resident 99's clinical record revealed Resident 99's Death in Facility MDS was listed as in progress. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited [DATE]

Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for three of three reviewed (Residents 50, 212, and 213). Findings include: Review of facility policy and procedure titled Enhanced Barrier Precautions, revised March 26, 2024, revealed Enhanced Barrier Precautions (EBP) expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of multidrug resistant organism (MDROs) to staff hands and clothing. Further review of facility policy and procedure revealed EBP are indicated for residents with any of the following and should be used: infection or colonization with a CDC-targeted MDRO when Contact Precautions do otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; wounds in this policy refer generally to chronic wounds, not shorter lasting wounds such as skin breaks or tears covered with adhesive bandage or similar dressing. Examples of chronic wounds include but are not limited to pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; indwelling medical device examples include central lines, urinary catheters, feeding tubes and tracheotomies. A peripheral intravenous line (not a peripherally inserted central catheter/PICC) is not considered an indwelling medical device for this policy. Further review of this policy revealed Examples of high contact resident care activities requiring gown and gloves for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing liens, changing briefs or assisting with toileting, device care or use, wound care - any skin opening requiring a dressing, contact during therapy in gyms, and transfers in shower rooms/bathing areas. Further review of this policy revealed Post EBP signage to communicate with associates the need for gown and gloves as applicable. Review of Resident 50's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated December 25, 2023, revealed that the resident had an in-dwelling catheter (a flexible tube inserted into the bladder for removing fluid). Observations of Resident 50's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 212's admission diagnosis list revealed a diagnosis of osteomyelitis of the left foot with MRSA (an MDRO). Observation of Resident 212's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 213's admission diagnosis list indicated Resident 213 had a colostomy. Observation of Resident 213's room on the first three days of the survey failed to reveal evidence of EBP signage and failed to reveal evidence of PPE. Observation of the First-Floor nursing unit on the first three day of the survey failed to reveal evidence of any EBP signage on any resident room that required same. No PPE was present in resident rooms or hallways. Multiple observations of staff entering and exiting rooms requiring EBP failed to reveal evidence of any PPE in use. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/23/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 6/23/23

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for four of 12 residents reviewed (Residentsv 5, 22, 50, and 211 ). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2019, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date. Review of Resident 5's clinical record revealed a quarterly assessment with an ARD (assessment reference date - last day of the assessment's look back period) of March 15, 2024. The assessment was not completed and is listed as in progress. Review of Resident 22's clinical record revealed a quarterly assessment with an ARD of March 6, 2024. The assessment was not completed. Review of Resident 50's clinical record revealed a quarterly assessment with an ARD of March 22, 2024. The assessment was not completed and is listed as in progress. Review of Resident 211's clinical record revealed a quarterly assessment with an ARD of November 14, 2023 was not completed and is listed as in progress. 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 6/23/23

Based on review of the Resident Assessment Instrument User's Manual, clinical record review and staff interview, it was determined that the facility failed to ensure that the comprehensive Minimum Data Set assessments were completed in the required time frame for five of 12 residents reviewed (Residents 27, 166, 212, 214, 262) Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a comprehensive admission MDS assessment was to be completed no later than 14 days following admission and an annual assessment not less than once every 12 months. Review of Resident 27's clinical record revealed that an admission MDS assessment with an ARD (assessment reference date - last day of the assessment's look-back period) of April 17, 2023. The MDS is not completed and is listed as in progress. Review of Resident 166's clinical record revealed an admission MDS assessment dated [DATE], was not completed and was listed as in progress. Review of Resident 212's clinical record revealed an admission MDS assessment with an ARD of April 11, 2024 was not initiated or submitted. Review of Resident 214's clinical record revealed an admission MDS assessment with an ARD of April 16, 2024 was not completed and was listed as in progress. Review of Resident 262's clinical records revealed that an annual assessment with an ARD of November 3, 2023, was not completed and was listed as in progress. 28 Pa Code 201.18(b)(1) Management Previously cited 6/23/23 28 Pa. Code 211.5(f) Clinical records. Previously cited 6/23/23

Based upon review of clinical records, it was determined the facility failed to ensure baseline care plans were completed upon admission for three of 18 residents reviewed (Residents 93, 212 and 213). Findings include: Clinical records review revealed Resident 93 was admitted to the facility on [DATE], with a PICC (Peripherally Inserted Central Catheter) line to the right upper arm. Review of Resident 93's physician order dated April 12, 2024, revealed an order for Micafungin Sodium (Anti-fungal medication) Intravenous Solution 100mg one time a day for post abdominal surgery for ten days. Review of Resident 93's current care plan revealed that a care plan for the Resident's presence of PICC line and IV Anti-Fungal medication administration was not developed. Interview with the Director of Nursing on April 19, 2024, at 1:00 p.m., confirmed a baseline care plan for the presence of PICC line and IV anti-fungal medication was not developed for Resident 93. Review of Resident 212's clinical record revealed Resident 212 was admitted with a diagnosis of MRSA [methicillin resistant staph aureus - multi-drug resistant organism] of the left foot. Review of Resident 212's baseline care plan failed to reveal evidence that the MRSA of the left foot was included in the baseline care plan. Review of Resident 213's clinical record revealed Resident 213 was admitted to the facility on [DATE], with a colostomy. Review of Resident 213's baseline care plan failed to reveal evidence of the presence of a colostomy on admission. Interview with the Nursing Home Administrator and Director of Nursing on April 19, 2024, at 1:45 p.m. confirmed there was no baseline care plans initiated for Resident 212's MRSA and Resident 213's colostomy. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/23/23 28 Pa. Code 211.11(a)(d) Resident care plans 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 6/23/23

Based on clinical record review and staff interview, it was determined that the facility failed to ensure MDS assessments accurately reflected the resident's status for two of 12 residents reviewed (Residents 50 and 212). Findings include: Review of Resident 50's hospital readmission skin assessment dated [DATE], indicated resident had a left medial ankle venous stasis ulcer (slow healing sores on the legs caused by poor circulation). Review of the admission MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated December 25, 2023, section M1030 Number of Venous and Arterial Ulcers indicated that Resident 50 did not have any venous or arterial ulcers. Interview with the Director of Nursing, on April 19, 2024, at 1:30 p.m. confirmed that Resident 50 was admitted with the venous ulcer and the the assessment did not accurately reflect the resident's status. Review of Resident 212's clinical progress note dated March 29, 2024 revealed Patient was admitted to Room [number] via stretcher accompanied by two attendees on March 29, 2024 at 1630 [4:30 p.m.] with DX [diagnosis] of left foot infection MRSA [methicillin resistant staph aureus]. Patient oriented to room medications discussed denies pain/discomfort at this time. VSS [vital signs stable] safety measures in place. Review of Resident 212's Admission/5 day MDS failed to reveal the diagnosis of MRSA to Resident 212's left foot. Interview with the Director of Nursing and Nursing Home Administrator on April 19, 2024 at 1:30 p.m. confirmed that Resident 212's admission MDS did not accurately reflect Resident 212's status. 483.20 Accuracy of Assessments Previously cited 6/23/23 28 Pa. Code 211.5(f) Clinical records Previously cited 6/23/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 6/23/23

Based on clinical record review and interview with staff, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred or discharged for three of three residents reviewed (Residents 50, 64, and 76). Findings include: Review of Resident 50's clinical record revealed a nursing progress note dated December 15, 2023, revealed that the resident had a new order to be sent to the hospital to be evaluated due to bilateral lower extremity pain. Further review of Resident 50's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 50's transfers from the facility to the hospital. Review of Resident 64's nursing progress notes dated March 17, 2024, at 10:14 p.m., revealed resident was sent back to the hospital for further treatment (right knee infection). Review of Resident 64's clinical record failed to reveal the State Ombudsman's office was notified of Resident 64's transfers from the facility to the hospital. Review of Resident 76's clinical progress notes dated January 12, 2024 revealed Resident 76 was sent to the hospital and admitted as a result of a urinary tract infection. Further review of Resident 76's clinical record failed to reveal evidence that the State Ombudsman's office was notified of the transfer to the hospital. Interview with the Nursing Home Administrator on April 19, 2024, at 10:40 a.m. confirmed that the facility did not notify the State Ombudsman's office when residents were transferred or discharged . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, staff interview, and facility policy and procedure and facility documentation, it was determined the facility failed to ensure that transfers were executed safely for one of 12 residents reviewed resulting in actual harm to the resident. (Resident B13). Findings include: Review of facility policy titled Using a Portable Lifting Machine, revised May of 2010, revealed the portable lift can be used by one nursing assistant if the resident can participate in the lifting procedure. If not, two nursing assistants will be required to perform the procedure. Review of resident B13s [DIAGNOSES REDACTED]. Review of resident B13 Annual Minimum Data Set (MDS-periodic assessment of resident needs and status) revealed the resident was a total dependence on staff for transfers. Review of Resident B13 ' s care plan for Activities of Daily Living (ADLs) revealed resident is a Hoyer Lift for transfers with staff assists of two. Review of the Home Health Agency (agency that provides a 24 hour nursing assistant for resident care) resident cardex (listed care needs for resident) revealed the resident required a mechanical lift (Hoyer lift) for transfer from bed to wheelchair with assist of two. Review of Resident B13 ' s nurses notes dated October 26, 2013 at 7:00 p.m. that stated CNA heard a pop from right humerus (upper arm bone) while repositioning resident, had pain screaming when gently lifting right arm. Review of the physician orders [REDACTED]. Review of the radiology report of the humerus x-ray done on October 26, 2013 revealed a fractured humerus. Further review of the physician orders [REDACTED]. Review of the counseling report from the Home Health Agency who employed the CNA that was providing care to Resident B13 when the fractured humerus occurred revealed the CNA was transferring the resident from the wheelchair to the bed without assistance. The resident ' s hand was caught between the bed and the chair and the CNA heard a pop when completing the transfer. Interview with the director of nursing (DON) on July 25, 2014 at approximately 10:00 a.m. revealed that the CNA from the home health agency initially told her staff that she heard a pop from the residents arm as she turned away to get a pillow while turning the resident in the bed. When interviewed by the Home Health Agency, the CNA stated that she was transferring the resident from the wheelchair to the bed and that is when the resident ' s arm got stuck between the bed and the chair. The DON confirmed the staff providing care to the resident did not transfer as care planned resulting in actual harm to the resident. 28 PA Code: 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 6/3/13 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/3/13 28 Pa. Code 211.12(d)(3) Nursing services