Every finding on record at Penn Highlands Jefferson Manor

Based on review of facility policy and clinical and facility records and staff interview, it was determined that the facility failed to ensure Resident R1 was free of neglect during care, which resulted in actual harm of a left hip fracture requiring surgical repair for one resident (Resident R1). Findings include: Review of a current facility policy entitled, Abuse-Neglect and Exploitation revealed the following Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas (e.g. absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces, failure to apply safety alarms/devices, failure to follow the resident's plan of care, leaving a resident on the toilet for excessive amounts of time without returning to assist the resident, etc.). Neglect also occurs when a number of residents receive a lack of care in one or more regulatory groupings, a finding which reflects the facility's failure to have developed policies or implemented procedures to prohibit neglect. Resident R1's clinical record revealed an admission date of 1/8/24, with diagnoses that included dementia, anxiety, colon cancer, and osteoporosis. Review of a physician's order dated 10/15/25, directed that Resident R1 be assisted by two staff members while standing at a handrail. Review of physical therapy recommendation dated 10/23/25, directed that Resident R1 be assisted by two staff while standing at a hand rail for toileting. Review of Resident R1's potential for falls care plan initiated on 1/09/24, identified the resident as a transfer assist with 2 staff. Review of information submitted by the facility dated 1/9/26, revealed that Resident R1 was standing, holding onto a handrail bar, while a single staff member attempted to put on the resident's brief (incontinence product). During this time the resident fell to the floor injuring their left hip. Prior to this fall, resident safety interventions were to stand at a handrail with assistance of two staff members rather than one. A nurse's progress note dated 1/8/26, 11:37 a.m. documented that the nurse was alerted to assess Resident R1 in the main bathroom where Resident R1 was observed on the floor. The Nurse Aide (Employee E1) with the resident, stated that following a shower, the resident lost their balance and fell to the floor while being dried. The documenting nurse observed that one of the resident's legs appeared shorter than the other and that the resident complained of pain the nurse then called 911 to transfer the resident to the hospital. A nurse's note dated 1/8/26, at 5:16 p.m. documented that the during correspondence with the hospital it was determined that the Resident R1 had a broken hip and was being transferred to another hospital for further treatment. Review of an Employee Statement for Resident Incident/Accident form dated 1/8/26, revealed that NA Employee E1 documented that he/she showered Resident R1, stood the resident at a grab bar and while attempting to apply a brief, the resident's hand slipped from the bar and the resident fell to the floor. Review of a Witnessed Fall-SNF investigation form dated 1/8/26, revealed that NA Employee E1 disclosed that after showering Resident R1 he/she stood the resident at the shower room grab bar and while attempting to apply a brief the resident fell to the floor. During interview on 2/2/26, at 10:00 a.m., the Nursing Home Administrator (NHA) confirmed that Resident R1 required the assistance of two staff members while standing at a handrail rather than a single staff member and also confirmed that NA Employee E1 failed to obtain the assistance of another staff member while the resident was standing at a hand rail/grab bar which resulted in a fall with substantial harm of a hip fracture requiring surgical repair. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) (d)(1)(3)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall which resulted in the actual harm of a left hip fracture requiring surgical repair for one resident (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 1/8/24, with diagnoses that included dementia, anxiety, colon cancer and osteoporosis. Resident's R1's Minimum Data Set (MDS - periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 6/27/25, revealed Resident R1 was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) for transfers, changing position in bed and for toilet use. Review of a physician's order dated 10/15/25, directed that Resident R1 be assisted by two staff members while standing at a handrail. Review of physical therapy recommendation dated 10/23/25, directed that Resident R1 be assisted by two staff while standing at a hand rail for toileting. Review of information submitted by the facility dated 1/9/26, revealed that Resident R1 was standing, holding onto a handrail bar, while a single staff member attempted to put on the resident's brief (incontinence product). During this time the resident fell to the floor injuring their left hip. Prior to this fall, resident safety interventions were to stand at a handrail with assistance of two staff members rather than one. A nurse's progress note dated 1/8/26, 11:37 a.m. documented that the nurse was alerted to assess Resident R1 in the main bathroom where Resident R1 was observed on the floor. The Nurse Aide (Employee E1) with the resident, stated that following a shower, the resident lost their balance and fell to the floor while being dried. The documenting nurse observed that one of the resident's legs appeared shorter than the other and that the resident complained of pain the nurse then called 911 to transfer the resident to the hospital. A nurse's note dated 1/8/26, at 5:16 p.m. documented that the during correspondence with the hospital it was determined that the Resident R1 had a broken hip and was being transferred to another hospital for further treatment. Review of an Employee Statement for Resident Incident/Accident form dated 1/8/26, revealed that NA Employee E1 documented that he/she showered Resident R1, stood the resident at a grab bar and while attempting to apply a brief, the resident's hand slipped from the bar and the resident fell to the floor. Review of a Witnessed Fall-SNF investigation form dated 1/8/26, revealed that NA Employee E1 disclosed that after showering Resident R1 he/she stood the resident at the shower room grab bar and while attempting to apply a brief the resident fell to the floor. During interview on 2/2/26, at 10:00 a.m. the Nursing Home Administrator confirmed that Resident R1 required the assistance of two staff members while standing at a handrail rather than a single staff member and also confirmed that NA Employee E1 failed to obtain the assistance of another staff member while the resident was standing at a hand rail/grab bar which resulted in a fall with substantial harm of a hip fracture requiring surgical repair. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policies and clinical records, observations and staff interviews, it was determined that the facility failed to follow physician orders for two of 20 residents reviewed (Residents R7 and R16).Findings include: Review of a facility policy Medication Administration dated 4/29/25, revealed all medications are to be administered only as prescribed, and only by licensed practical nursing staff. If a dose of regularly scheduled medication is withheld or refused, the nurse is to pick the correct reason for medication not being given in the eMAR (electronic medication administration record) in the EMR (electronic medication record) for the resident. The nurse is then responsible for notifying the RN Supervisor so that the family and physician can be made aware for further orders. Medications ordered must be available for use and all medications on hand must have a corresponding order. Review of a facility policy entitled Physician Orders dated 4/29/25, revealed Part of the noting process is ensuring that tasks are addressed: additions, changes, corrections, and deletions and updating the care plans. Resident R7's clinical record revealed an admission date of 9/19/23, with diagnoses that included chronic diastolic congestive heart failure (when the heart's main pumping chamber becomes stiff and cannot fill properly to fill with enough blood, leading to fluid backup and heart failure), personal history of venous thrombosis (blood clot in a deep vein, DVT) and embolism (when a clot breaks off and travels throughout the veins typically to the heart and lungs), hyperlipidemia (high level of fats like cholesterol and triglycerides in the blood), and hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. Review of Resident R7's eMAR revealed a physician order with start date of 8/25/25, Xarelto (Rivaroxaban) give 20 mg (milligrams) by mouth one time a day for DVT. Resident R7's eMAR further revealed for the months of December and November 2025, that his/her Xarelto was not administered per physician order on 12/13/25, 11/01/25, and 11/10/25. A physician order with start date of 8/03/25, Levothyroxine Sodium (medication to treat thyroid disease) 100 mcg (micrograms) give one tablet by mouth one time a day for low thyroid hormone. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Levothyroxine Sodium 100 mcg was not administered per physician order on 12/13/25, 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Metoprolol Succinate ER 24 Hour Sprinkle 50 mg give one capsule by mouth one time a day for hypertension. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Metoprolol Succinate extended release 24 Hour 50 mg was not administered per physician order on 11/01/25, and 11/06/25. Resident R7's eMAR revealed a physician order with start date of 8/06/25, Protonix (medication to treat acid reflux) delayed release 40 mg give one tablet by mouth two times a day. Resident R7's eMAR further revealed for the month of November 2025, that his/her Protonix delayed release 40 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Sitagliptin 50 mg give one tablet by mouth one time a day for diabetes. Resident R7's eMAR further revealed for the month of November 2025, that his/her Sitagliptin 50 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Torsemide 20 mg give one tablet by mouth one time a day for cardiac heart failure. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Torsemide 20 mg was not administered per physician order on 11/10/25, and 12/13/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Rosuvastatin Calcium 20 mg give one tablet by mouth at bedtime for hyperlipidemia. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Rosuvastatin Calcium 20 mg was not administered per physician order on 11/21/25, and 12/01/25, and 12/16/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Gabapentin 100 mg give two capsules by mouth at bedtime for neuropathy. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Gabapentin 200 mg was not administered per physician order on 11/21/25, and 12/01/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Cyanocobalamin (form of vitamin B12) 1000 mcg give one tablet by mouth at one time a day for supplement. Resident R7's eMAR further revealed for the month of November 2025, that his/her Cyanocobalamin 1000 mcg was not administered per physician order on 11/10/25. During an interview on 12/17/25, at 12:20 p.m. the Director of Nursing (DON) confirmed the medications noted above were not administered per physician orders for Resident R7 during the months of November and December 2025, and the physician was not notified immediately regarding a medication that was unavailable to complete the physician orders for Resident R7. Resident R16's clinical record revealed an admission date of 12/1/23, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Left Heel Pressure Ulcer (damage to the skin and/or underlying tissue that usually occurs over a boney prominence). Review of Resident R16's clinical record revealed a physician's order dated for 9/26/25, for Left PRAFO (Pressure Relieving Ankle Foot Orthosis - a specialized orthotic device useful for individuals prone to heel skin breakdown, as it elevates the heel and can be adjusted for comfort and mobility). Observation on 12/15/25 at 4:00 p.m. revealed Resident R16 sleeping in bed with his/her PRAFO on the window ledge. Observation on 12/16/25, at 9:17 a.m. revealed Resident R16 laying in bed with his/her PRAFO on the window ledge. Observation on 12/17/25, at 11:42 a.m. revealed Resident R16 sitting in his/her wheelchair with his/her PRAFO on the window ledge. Observation on 12/17/25, at 1:10 p.m. revealed Resident R16 sleeping in bed with his/her PRAFO on the window ledge. Interview on 12/17/25, at 1:12 p.m. with Nurse Aide (NA) Employee E3 revealed he/she was told that Resident R16's son purchased it and puts it on Resident R16 in the evening when he comes in to visit and then he takes it off when he is ready to leave. NA Employee E3 stated he/she has never seen anything in the NA task instructing the staff on use of the PRAFO or to document use of the PRAFO. During an interview on 12/17/25, at 1:16 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R16's PRAFO was located on the window ledge and Resident R16 was not wearing it per physician orders. LPN Employee E2 also confirmed that there is a physician's order in place for the PRAFO to be worn at all times, but the clinical record lacked scheduling details, therefore it was not carried over into the NA tasks or Licensed Nurse Treatment Administration Record (TAR) to ensure staff were aware of the order and able to sign for usage. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to ensure medications were available from a pharmacy for timely medication administration to meet the needs of the resident for one of 20 residents reviewed (Resident R7). Findings include: Review of a facility policy Medication Administration dated 4/29/25, revealed all medications are to be administered only as prescribed, and only by licensed practical nursing staff. If a dose of regularly scheduled medication is withheld or refused, the nurse is to pick the correct reason for medication not being given in the eMAR (electronic medication administration record) in the EMR (electronic medication record) for the resident. The nurse is then responsible for notifying the RN Supervisor so that the family and physician can be made aware for further orders. Medications ordered must be available for use and all medications on hand must have a corresponding order. Review of a facility policy Preparation & General Guidelines dated 4/29/25, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Resident R7's clinical record revealed an admission date of 9/19/23, with diagnoses that included chronic diastolic congestive heart failure (when the heart's main pumping chamber becomes stiff and cannot fill properly to fill with enough blood, leading to fluid backup and heart failure), personal history of venous thrombosis (blood clot in a deep vein, DVT) and embolism (when a clot breaks off and travels throughout the veins typically to the heart and lungs), hyperlipidemia (high level of fats like cholesterol and triglycerides in the blood), and hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. Review of Resident R7's eMAR revealed a physician order with start date of 8/25/25, Xarelto (Rivaroxaban) give 20 mg (milligrams) by mouth one time a day for DVT. Resident R7's eMAR further revealed for the months of December and November 2025, that his/her Xarelto was not administered per physician order on 12/13/25, 11/01/25, and 11/10/25. A physician order with start date of 8/03/25, Levothyroxine Sodium (medication to treat thyroid disorder) 100 mcg (micrograms) give one tablet by mouth one time a day for low thyroid hormone. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Levothyroxine Sodium 100 MCG was not administered per physician order on 12/13/25, 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Metoprolol Succinate ER 24 Hour Sprinkle 50 mg give one capsule by mouth one time a day for hypertension. Resident R7's eMAR further revealed for the month of November and December 2025, that his/her Metoprolol Succinate extended release 24 Hour 50 mg was not administered per physician order on 11/01/25, and 11/06/25. Resident R7's eMAR revealed a physician order with start date of 8/06/25, Protonix (medication to treat acid reflux) delayed release 40 mg give one tablet by mouth two times a day. Resident R7's eMAR further revealed for the month of November 2025, that his/her Protonix delayed release 40 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Sitagliptin 50 mg give one tablet by mouth one time a day for diabetes. Resident R7's eMAR further revealed for the month of November 2025, that his/her Sitagliptin 50 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR further revealed for the month of November 2025, that his/her Protonix delayed release 40 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Torsemide 20 mg give one tablet by mouth one time a day for cardiac heart failure. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Torsemide 20 mg was not administered per physician order on 11/10/25, and 12/13/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Rosuvastatin Calcium 20 mg give one tablet by mouth at bedtime for hyperlipidemia. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Rosuvastatin Calcium 20 mg was not administered per physician order on 11/21/25, and 12/01/25, and 12/16/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Gabapentin 100 mg give two capsules by mouth at bedtime for neuropathy. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Gabapentin 200 mg was not administered per physician order on 11/21/25, and 12/01/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Cyanocobalamin (form of vitamin B12) 1000 mcg give one tablet by mouth at one time a day for supplement. Resident R7's eMAR further revealed for the month of November 2025, that his/her Cyanocobalamin 1000 mcg was not administered per physician order on 11/10/25. During an interview on 12/17/25, at 12:20 p.m. the Director of Nursing confirmed the medications noted above were not available from a pharmacy for administration per physician orders for Resident R7 during the months of November and December 2025, and the physician and/or pharmacy was not notified immediately regarding a medication that was unavailable to complete the physician order timely for Resident R7. 28 Pa. Code 211.9(a)(d)(f)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician orders and resident Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 22 residents reviewed (Resident R13). Findings include: The facility policy entitled Advance Directives dated [DATE], indicated that The Director of Nursing Services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care .The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included Type I diabetes (condition where the pancreas makes little or no insulin causing high blood sugar), hypertension (high blood pressure), and vitamin D deficiency. Resident R13's physician's orders dated [DATE], revealed an order for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). Resident R13's clinical record revealed a POLST dated [DATE], that identified Resident R13 requested Do Not Resuscitate-Allow Natural Death (DNR), Limited Additional Interventions. During an interview on [DATE], at 2:30 p.m. the Registered Nurse Supervisor Employee E2, confirmed Resident R13's physician's orders and POLST were not consistent with each other. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on observations and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of five units (Memory Lane). Findings include: Observation on Memory Lane on 1/06/25, at 3:00 p.m. revealed Resident R70 lying in bed with his/her eyes closed. Resident R70's wheelchair was at bedside and noted to have a dry, white, food-like substance on the seat cushion and on his/her bilateral arm rest. Observation on Memory Lane on 1/07/25, at 9:39 a.m. revealed Resident R1 lying in bed watching television. Resident R1's wheelchair was noted to be in the hallway and was observed to have a dried tan substance running down the left side of his/her seat cushion and the left side of his /her wheelchair base. Observation on Memory Lane on 1/07/25, at 1:00 p.m. revealed Resident R70 sitting in his /her wheelchair in the resident lounge. Resident R70's wheelchair cushion was not visible at time of observation, but bilateral arm rest continued to have a dry white food-like substance present. Observation at this time, also revealed Resident R1 sitting in his/her wheelchair watching television with the dried tan substance still present on the left side of his/her seat cushion and the left side of his/her wheelchair base. During an interview on 1/07/25, at 1:00 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Residents R1 and R70's wheelchairs were unclean with dried debris noted. LPN Employee E1 stated the wheelchairs should not be dirty. 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS - periodic assessment of resident care needs) for two of 22 residents reviewed (Residents R1 and R46). Findings include: Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/20/24, indicating he/she receives Jevity 1.5 (a high calorie, fiber fortified liquid supplement for tube feedings) at 50 milliliters (ml) per hours continuously. An MDS with an Assessment Reference Date (ARD) of 11/11/24, under section Swallowing / Nutritional Status Section K0520 Nutritional Approaches indicated to check all of the following nutritional approaches that apply while a resident of the facility and within the last seven days. Section K0520B Feeding Tube (examples - nasogastric or abdominal [Peg]) was not checked for Resident R1 to identify they were receiving a feeding tube while a resident of the facility and within the last seven days. During an interview 1/09/25, at 9:34 a.m. the Director of Nursing confirmed that Resident R1's MDS with an ARD of 11/11/24, Section K0520B was coded inaccurately and should have been checked for having a feeding tube while a resident at the facility and within the last seven days. Resident R46's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), and diabetes (a health condition that caused by the body's inability to produce enough insulin). Resident R46's clinical record revealed no evidence of weight loss or weight gain in the last month or six months. An MDS with an ARD of 7/12/24, under section Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as Yes, not on prescribed weight loss regimen. An MDS with an ARD of 9/10/24, under section Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as Yes, not on prescribed weight loss regimen. An MDS with an ARD of 12/09/24, under section Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as Yes, not on prescribed weight loss regimen and section K0310 Weight gain revealed for gain of 5% in the last month or gain of 10% or more in last 6 months was coded as Yes, not on physician prescribed weight gain regimen. During an interview on 1/08/25, at 1:32 p.m. with Dietary Technician Employee E9, he/she verified that Resident R46 did not have a weight gain or loss. He/she also confirmed that Section K0300 of the MDS's dated 7/12/24, and 9/10/24, was incorrectly coded for Resident R46 regarding weight loss and Section's K0300 and K0310 of the MDS on 12/09/24, was incorrectly coded for Resident R46 regarding weight loss and gain. 28 Pa. Code 211.5(f)(iv)(ix) Medical records 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 22 residents reviewed (Residents R46 and R56). Findings include: Review of Resident R46's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), and diabetes (a health condition that caused by the body's inability to produce enough insulin). Review of Resident R46's physician's orders revealed an order dated 11/17/24, for staff to turn and reposition every two hours. Review of Resident R46's care plans revealed a care plan for impaired mobility with an intervention to turn and reposition every two hours. Observations on 1/07/25, at 9:25 a.m., 11:20 a.m., 12:30 p.m., 12:50 p.m., 2:00 p.m., at 3:08 p.m., and at 3:15 p.m. all revealed Resident R46 was in his/her bed positioned on his/her buttocks. During an interview on 1/07/25, at 3:16 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed that Resident R46 has a physician's order to be turned and repositioned every two hours. He/she also confirmed that Resident R46 should be repositioned every two hours. Review of Resident R56's clinical record revealed an admitted [DATE], with diagnoses that included Dementia (a disease that affects short term memory and the ability to think logically), and hypertension (high blood pressure). Review of Resident R56's physician's orders revealed an order dated 9/26/24, for pillow boots to bilateral feet at all times except care. Review of Resident R56's care plans revealed a care plan for risk for skin breakdown with the intervention of pillow boots to bilateral feet at all times except care. Observations on 1/06/25, at 2:10 p.m. revealed Resident R56 was sitting in his/her wheelchair in the lounge with no pillow boots on bilateral feet and his/her pillow boots were lying on their bedside stand. Observations on 1/07/25, at 9:23 a.m., 10:10 a.m., and 11:20 a.m. all revealed Resident R56 was sitting in his/her wheelchair in the lounge with no pillow boots on bilateral feet and his/her pillow boots lying on their bed. Observations on 1/08/25, at 11:40 a.m. revealed Resident R56 was sitting in his/her wheelchair in the lounge with no pillow boots on bilateral feet and his/her pillow boots lying on their nightstand. During an interview on 1/08/25, at 11:45 a.m. LPN Employee E10 confirmed that Resident R56 was sitting in the lounge with no pillow boots on his/her bilateral feet. He/she also confirmed that Resident R56's pillow boots should be on his/her bilateral feet per physician's orders. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of two residents reviewed for respiratory services (Residents R51 and R1). Findings include: A facility policy dated 6/11/24, entitled Oxygen Administration indicated Verify that there is a physician's order for this procedure. Review the physician's order . for oxygen administration. Resident R51's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - condition when your lungs do not have adequate air flow), and peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs). Resident R51's Care Plan revealed a care plan for altered cardiac output and respiratory function with an intervention of oxygen at 3 lpm (liters per minute) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen), Licensed Nurse to ensure oxygen is in place, and being administered at ordered rate. Resident R51's clinical record revealed a physician's order dated 10/27/24, for oxygen at 3 lpm via nasal cannula for hypoxia (low oxygen levels). Further review revealed a physician's order to clean oxygen concentrator filter with hot soapy water weekly on Saturday. Observation on 1/07/25, at 9:50 a.m. revealed Resident R51 lying on his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 4 lpm. Further observation of the concentrator filers to bilateral sides of the oxygen concentrator revealed a large amount of a gray fluffy substance covering bilateral filters. During an interview on 1/07/25, at 10:10 a.m. Licensed Practical Nurse (LPN) Employee E8 confirmed that Resident R51's oxygen concentrator was on and set at 4 lpm and was not in accordance with the physician's order dated 10/27/24, for oxygen at 3 lpm. LPN Employee E1 also confirmed that the filters to the bilateral sides of the oxygen concentrator were covered in a gray fluffy substance and the filters should be clean per physician orders. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/20/24, for oxygen at 4 lpm via trach mask (mask that covers the tracheostomy site to administer oxygen). Further review of physician's orders revealed an order dated 5/20/24, to clean oxygen concentrator filter with hot soapy water weekly with tubing change on 11-7 shift weekly on Saturday. Observations on 1/06/25, at 12:53 p.m. and 1:55 p.m. revealed Resident R1's oxygen concentrator had a filter on the back of the concentrator that contained a gray dusty substance. During an interview on 1/06/25, at 1:55 p.m. Registered Nurse Employee E2 confirmed that the oxygen concentrator filter contained a gray dusty substance and should not, but was unsure as to how often or when they are to be cleaned. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) vial with the date it was opened, in one of five medication carts (Memory Lane) and failed to ensure medications for self-administration were properly secured for one of 22 residents reviewed (Resident R22). Findings include: Review of the facility policy entitled Vials and Ampules of Injectable Medications dated 6/11/24, indicated vials and ampules medications are used in accordance with the manufacturer's recommendations or the providers pharmacy's directions for storage, use, and disposal. It also indicated that at a minimum, the date opened must be recorded. Review of the facility policy entitled Self-Administration of Medications dated 6/11/24, indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of the residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. Observation on 1/07/25, at 8:30 a.m. revealed the Memory Lane medication cart contained an opened undated multi-dose Lantus insulin vial and the manufacturer's packaging was labeled to discard within 28 days of opening. During an interview at that time, Licensed Practical Nurse (LPN) Employee E1 confirmed that multi-dose vials/containers of medication are to be dated upon opening to ensure that staff discard them in a timely manner and the medication is not to be utilized past the medication expiration. Resident R22's clinical record revealed an admitted [DATE], with diagnoses that included diverticulitis (an inflammation or infection in the digestive tract), type II diabetes (condition where the pancreas does not make enough insulin), and hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). Resident R22's physician's orders dated 3/04/24, revealed an order indicating Resident R22 may self-administer medications. Medications must be returned to nurse in between administration times for safe keeping. Observation of Resident R22's room on 1/07/25, at approximately 10:00 a.m. revealed a plastic storage bin filled with multiple medications sitting on the resident's bedside tray table. At that time, Resident R22 stated he/she self-administers his/her medications and that the medications remain on his/her bedside tray table all day. During an interview on 1/07/25, at approximately 10:12 a.m. LPN Employee E6 confirmed that Resident R22's medications are given to him/her in a plastic storage bin and are left in Resident R22's room throughout the day, unsecured. During an interview on 1/08/25, at approximately 9:00 a.m. LPN Employee E7 confirmed that he/she would take Resident R22's medications to his/her room in the morning and the medications would remain unsecured in Resident R22's room until approximately 5:00 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for two of 22 residents reviewed (Residents R1 and R37). Findings include: Facility policy entitled Documentation dated 6/11/24, indicated to document information as soon as possible to ensure accuracy of the information and to reflect ongoing care and to document only care, treatment, and medication that have actually been provided or administered. Facility policy entitled Enteral Tube Feeding Via Continuous Pump dated 6/11/24, indicated the person performing the procedure should record the amount and type of enteral feeding and the average fluid intake per day. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/24/24, for flush enteral feeding tube with 150 milliliter (ml) of water every four hours (300 ml of water per shift plus more depending on medication administration) and with 50 ml of water before and after medication administration; a physician's order dated 5/20/24, for Jevity 1.5 (a high calorie, fiber fortified liquid supplement for tube feedings) at 50 ml per hour continuous via gastric tube (a total of 400 ml per shift and 1200 ml total of formula in a twenty-four hour period); and a physician's order dated 5/20/24, to document the amount of formula and water provided every eight hours - total intake every twenty-four hours. Review of documentation of water flushes for Resident R1 from 12/10/24, through 1/07/25, under staff tasks revealed Resident R1 received less than the ordered 300 ml of water flush per shift (not counting medication flushes) one time on day shift, one time on evening shift, and three times on overnight shift. Documentation also revealed that facility lacked any evidence of water flushes one time on day shift, eight times on evening shift, and three times on overnight shift. Review of documentation of formula intake for Resident R1 from 12/10/24, through 1/07/25, under staff tasks revealed Resident R1 received less than the ordered 400 ml of formula per shift four times on day shift, ten times on evening shift, and eleven times on overnight shift; and Resident R1 received more than the ordered 400 ml of formula per shift eleven times on day shift, seven times on evening shift, and eleven times on overnight shift. Documentation also revealed that facility lacked any evidence of formula being provided one time on day shift, seven times on evening shift, and three times on overnight shift. During an interview on 1/08/25, at 2:49 p.m. the Director of Nursing confirmed that Resident R1's clinical record contained incomplete and inaccurate documentation related to his / her tube feeding formula and water flushes. Resident R37's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and urinary tract infection (UTI). Resident R37's clinical record revealed a physician's order dated 12/15/24, for Keflex (antibiotic) 500 milligrams by mouth every twelve hours for UTI for seven days. Review of the Medication Administration Record (MAR) revealed the first dose was administered at 9:00 a.m. on 12/15/24, and the last dose was administered at 9:00 p.m. on 12/21/24. Resident R37's clinical record progress notes dated / timed for 12/21/24, at 10:22 p.m., 12/21/24 at 11:36 p.m., 12/22/24, at 2:25 p.m., 12/22/24, at 8:56 p.m., 12/23/24, at 11:38 a.m., 12/23/24, at 6:54 p.m., 12/24/24, at 5:11 a.m., 12/24/24, at 10:43 a.m., 12/24/24, at 11:09 p.m., 12/25/2024, at 12:10 a.m., 12/25/24, at 9:54 p.m., 12/25/23, at 11:07 p.m., 12/26/24, at 11:02 a.m., and 12/26/24, at 6:49 p.m. indicated Resident R37 was receiving Keflex for a UTI when the last dose was received at 9:00 p.m. on 12/21/24. During an interview on 1/08/25, at 12:23 p.m. the Director of Nursing confirmed that Resident R37's clinical record contained inaccurate documentation related to him/her receiving Keflex for a UTI. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during observation of tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing) care for one of three residents observed for care requiring EBP (Resident R1). Findings include: A facility policy entitled Enhanced Barrier Precautions dated 6/11/24, indicated that Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms to residents. The policy further stated that high contact resident care activities that require the use of gown and gloves for EBP's included devise care or use such as tracheostomies and that face protection may be used if there is also a risk of splash or spray. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 10/24/24, that identified for the use of Enhanced Barrier Precautions for Tracheostomy. Observation of tracheostomy care on 1/06/25, at 1:50 p.m. revealed signage on Resident R1's door identifying EBP. Personal protective equipment (PPE) was readily available outside Resident R1's door including goggles, surgical mask, gloves, and gowns. Registered Nurse (RN) Employee E2 had a surgical mask on, but pulled down below his/her nose, and gloves, and failed to DON (put on) required proper personal protective equipment (PPE) by not wearing a gown during tracheostomy care for Resident R1. During an interview on 1/06/25, at 1:56 p.m. RN Employee E2 confirmed he/she did not wear a gown as required stating that if the resident does not have an infection or COVID, he/she does not wear a gown and the additional PPE was not needed if the resident was well. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to comprehensively assess and monitor pressure ulcers within required timeframes for one of two residents with pressure ulcers reviewed (Resident R14). Findings include: A facility policy dated 6/11/24, entitled Pressure Ulcer Assessment / Prevention indicated When a pressure ulcer is found, regardless if upon admission or after, it must be documented in the electronic medical record and The Wound Nurse/RN [Registered Nurse] will complete weekly skin rounds and measure pressure ulcers, arterial / vascular ulcers, and surgical incisions. The findings will be documented in the electronic medical record. Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a chronic condition that affects the way the body processes blood sugar), diverticulitis (inflammation of pouches in the wall of the large intestines, and venous thrombosis (blood clot in the deep vein most commonly located in the leg or pelvis). Resident R14's clinical record progress notes revealed that on 7/11/24, staff observed an open area to Resident R14's coccyx. The progress note lacked an initial assessment including description and measurement of the pressure area. Further review of clinical record progress notes revealed the coccyx pressure ulcer was assessed / measured on 7/12/24, and then not again until 7/22/24, a period of 10 days and then not again until 8/5/24, a period of 14 days. During an interview on 8/15/24, at 1:22 p.m. the Director of Nursing confirmed that Resident R14's coccyx pressure ulcer was not assessed / measured upon initial finding of the area or as frequently as required from 7/12/24, through 8/5/24. 28 Pa. Code 211.5(ii)(viii)(ix) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of Title 49. Professional and Vocational Standards, facility policy, and clinical records and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted initial and/or follow-up resident wound assessments for two of two residents reviewed with wounds (Residents R14 and R15). Findings include: Review of the Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 5/25/24, indicated that under Responsibilities of the RN, 21.22, General Functions. (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The 21.141 Definitions, Practice of practical nursing revealed The performance of selected nursing acts in the care of the ill, injured or infirm under the direction of a licensed professional nurse, a licensed physician or a licensed dentist, which do not require the specialized skill, judgement and knowledge required in professional nursing. The 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. A facility policy dated 6/11/24, entitled Pressure Ulcer Assessment / Prevention indicated The Wound Nurse/RN will complete weekly skin rounds and measure pressure ulcers, arterial / vascular ulcers, and surgical incisions. The findings will be documented in the electronic medical record. Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a chronic condition that affects the way the body processed blood sugar), diverticulitis (inflammation of pouches in the wall of the large intestines, and venous thrombosis (blood clot in the deep vein most commonly located in the leg or pelvis). Resident R14's clinical record progress notes revealed that on 7/11/24, staff observed an open area to Resident R14's coccyx. Progress note dated 7/12/24, revealed an assessment of the coccyx wound that was completed by Licensed Practical Nurse (LPN) Employee E1. Progress notes dated 7/22/24, and 8/05/24, revealed an assessment of the coccyx wound that was completed by LPN Employee E2. Progress note dated 8/12/24, revealed an assessment of the coccyx wound that was completed by LPN Employee E3. There was no evidence that the comprehensive wound assessment was completed by an RN on 7/12/24, 7/22/24, 8/05/24, or 8/12/24. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a condition that affects a persons memory, thinking, and behaviors), osteoarthritis (degenerative joint disease that results from the breakdown of joint cartilage and bones), and peripheral vascular disease (disorder of the blood vessels outside the heart that can affect the brain, legs, feet, and other organs). Resident R15's clinical record progress notes dated 6/07/24, 6/14/24, 6/21/24, 6/28/24, 7/05/24, 7/12/24, 7/29/24, 7/26/24, 8/02/24, and 8/09/24, revealed an assessment of the right hip wound that was completed by LPN Employee E1. Progress note dated 8/06/24, revealed an assessment of the right hip wound that was completed by LPN Employee E2. Progress note dated 8/13/24, revealed an assessment of the right hip wound that was completed by LPN Employee E4. There was no evidence that the comprehensive wound assessment was completed by an RN on 6/07/24, 6/14/24, 6/21/24, 6/28/24, 7/05/24, 7/12/24, 7/29/24, 7/26/24, 8/02/24, 8/06/24, 8/09/24, or 8/13/24. During an interview on 8/14/24, at 1:27 p.m. the Nursing Home Administrator and Director of Nursing confirmed that wound assessments and documentation were conducted by an LPN, and not completed by an RN or completed with the oversight of an RN for Residents R14, and R15. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from attempting to inflict self-harm for one of two residents reviewed with a history of suicide ideation and resulted in an Immediate Jeopardy situation (Resident R3). Findings include: Resident R3's clinical record revealed an admitted [DATE], with diagnoses that included Bipolar Disorder with severe psychotic features (condition characterized by the presence of either delusions or hallucinations or both), major depressive disorder, generalized anxiety disorder, Agoraphobia with panic disorder (phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs), and post-traumatic stress disorder (mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). Resident R3's hospital discharge records dated 12/28/23, revealed that the reason for his/her admission to the hospital was due to making suicidal statements, and having delusional thoughts. Hospital records from 3/27/24, revealed that the reason for his/her admission to the hospital was due to wrapping his/her call bell cord around his/her neck, and having delusional thoughts. Resident R3's physician's orders revealed; an order dated 3/14/24, to keep a tap bell within reach at all times, and 3/28/24, to keep a tap bell at bedside. Resident R3's current care plans revealed: -Potential for falls initiated 12/29/23, indicated for his/her call bell to be within reach at all times when in room. -Impaired mobility initiated 12/29/23, indicated to keep his/her call bell in reach and remind Resident R3 not to transfer without assistance. -Potential for infection initiated 12/29/23, indicated to keep his/her call bell within reach when in room. -Physical behaviors related to bipolar disorder initiated 3/28/24, indicated for a tap bell at bedside. -Self-care deficits initiated 12/29/23, and updated on 3/14/24, for a tap bell within reach at all times. Resident R3's clinical record revealed: -12/28/23, an admission note: resident spoke to himself/herself the whole way but not to others, diagnosis of suicidal ideation. -12/29/23, 1/03/24, repetitive chanting -1/02/24, practitioner admission assessment note: suicidal ideations, waving a gun at police, history of overdose, hallucinations, delusions, paranoia, combative with hospital staff. -1/03/24, readmission practitioner note stated the hospital stay was complicated by behaviors, hallucinations. -1/09/24, psychotropic evaluation: frequent delusions that are harmful to self or others. -1/13/24- throwing dishes, silverware, and cup, told staff he/she was fighting with the devil. -1/18/24- chanting about the devil chasing him/her, disturbing other residents. -1/21/24- chanting, reported the devil was after him/her, throwing drink, swearing in the dining room. -1/25/24- yelling out Hallelujah, hallelujah, praise, praise, praise the lord repeatedly. Throwing pillows at the devil, the devil has a hold on his/her heart, auditory hallucinations, telling staff he/she is God, St. [NAME] is God, the guy shuffling in the hall is the one true God. -2/02/24- calling out for staff to pray with him/her. -2/02/24- practitioner note stated the resident has daily struggles with hallucinations, voices acute concerns about the devil and his presence in the facility. -2/26/24- voices telling resident to get out of bed, referenced battling with the devil, reported being frightened. -2/27/24- practitioner note stated the resident reported constantly hearing voices from the devil. -2/29/24- practitioner note reported that the resident confirmed he/she knows the voices are just hallucinations but can't ignore them and is getting depressed they aren't improving. -3/02/24- threw his/her water cups and cans of soda at roommate. -3/05/24- care plan note indicated the resident continues to experience hallucinations/delusions but is more aware of them. -3/07/24- fearful, chanting for staff, requesting they stay because the devil is after him/her. -3/08/24- yelling, throwing objects (cell phone, water pitcher, tv remote). In dining room chanting and reported the devil was after him/her again. -3/18/24- referral made to inpatient psych center. -3/19/24, 3:24 a.m. - yelling, disruptive, chanting and throwing items from bedside. -3/19/24, 3:28 a.m.- found with call bell wrapped around his/her neck three times, chanting, call bell removed, and 15-minute checks started. -3/19/24, 3:33 a.m.- call made to Crisis. -3/19/24, 3:52 a.m. found with call bell cord around his/her neck again, confirmed trying to hurt themselves, and sent for evaluation. -3/20/24- admitted to inpatient psych center. -3/28/24, 12:01 a.m.- found with call bell around his/her neck, taken out of reach and tap bell provided, 15 minutes later had blankets around his/her head. -3/28/24, 12:44 a.m.- found call bell around his/her neck, call bell removed and tap bell provided, chanting, and hollering out, found again with bed control cord around neck and placed out of reach by staff. -3/29/24- Practitioner readmission note indicated the resident was sent to hospital on 3/19/24, after multiple attempts to wrap a call bell cord around the neck which were felt to be acts of suicide, returned to facility 3/27/24. -3/31/24, 6:27 a.m. found with call bell wrapped around neck, removed, resident stated that the devil was after him/her, order to send to the hospital. -3/31/24, 6:53 a.m. progress note indicated that resident began with behaviors between 3:30 and 4:00 a.m., and eventually found with the call bell wrapped around his/her neck and that the call bell was last seen laying along the pillow a few minutes prior. -3/31/24, 7:06 a.m. when emergency services arrived the resident had the call bell wrapped around his/her wrist. Prior to Resident R3's transfer to the hospital on 3/31/24, his/her clinical record revealed 47 departmental assessment notes that indicated there were no safety concerns and that the call light was within reach. In an interview on 4/09/24, at 12:36 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that Resident R3 should not have had access to his/her call light cord and that the facility should have taken more safety measures to prevent him/her from attempting self-harm. The facility failed to implement sufficient safety measures to prevent residents with a history of suicidal attempts/ideations from attempting self-harm, putting a resident with a history of suicide attempts/ideations at risk and causing an Immediate Jeopardy. The NHA and DON were notified of the Immediate Jeopardy (IJ) situation on April 9, 2024, at 12:39 p.m. An Immediate Action Plan was requested and the IJ template was provided to the NHA. The Immediate Action Plan was provided by the NHA and DON on April 9, 2024, at 3:38 p.m. which was accepted at 3:43 p.m. The plan included: 1. Educate all direct care staff on signs and symptoms of suicidal ideations and appropriate action to take regarding resident safety. 2. Resident on return to facility will not have a corded call bell. She will be given a tap bell and screened daily by nursing staff for signs or symptoms of increasing depression or suicidal ideations for a duration of one week, then every other day for one week, then weekly indefinitely. 3. DON with LNAC will audit current resident records for histories of suicidal ideation or attempts by close of business on 4/9/24. 4. LNAC will update care plans of current residents to reflect these histories and include interventions, which will become standard for any resident entering with history of suicidal ideation or attempts by close of business on 4/9/24. 5. Administrator and DON will educate RNAC, LNAC, and Social Worker 4/10/24 on standard care plan interventions related to historical suicidal ideation or attempts. These will include ensuring there is no access to common suicidal methods and will be individualized based on resident history and current assessment. Beginning on 4/10/24 the Columbia Suicide Severity Rating Scale (CSSRS) will be administered by an RN on all new admissions. A licensed nurse (RN or LPN) will administer the CSSRS weekly, indefinitely, for those residents with a known suicidal ideation history. Residents scoring low risk with no history will require no follow up. Residents scoring low risk with a history of suicidal ideation will continue to be monitored and standard interventions in place with no additional referrals or notifications needed. Residents scoring moderate risk with or without a history of suicidal ideations or attempts will be referred for behavioral health consult and MD notified during daylight hours. Residents scoring high risk, with or without a history of suicidal ideations or attempts will immediately provide supervision until an evaluation has been completed and the resident deemed safe or sent to acute care for an evaluation. MD will be notified as soon as possible for further review and recommendations. 6. Educate all direct care staff on each resident's individual care plan needs regarding suicidal ideations. 7. All Items in this action plan will be reviewed at quarterly QAPI. On April 10, 2024, at 3:43 p.m. the Immediate Jeopardy was lifted after ensuring the Immediate Action Plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(d)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to follow physician's orders related to safe transfers for five of seven residents reviewed (Residents R6, R10, R11, R16, and R17). Findings include: A facility policy entitled Mechanical Lift Policy dated 4/20/23, indicated that at least two qualified nursing personnel are required to always operate mechanical (designed to lift and transfer patients from one place to another) lifts. Resident R6's clinical record revealed an admitted [DATE], with diagnoses that included broken right lower leg, stoke, abnormal gait/mobility, and spinal stenosis (condition that happens when the space inside the backbone is too small and can put pressure on the spinal cord and nerves that travel through the spine). Resident R6's clinical record revealed a physician's order dated 11/28/22, to transfer with a mechanical lift and assistance of two. A current care plan entitled impaired mobility included to use a mechanical lift to use the shower. Resident R6's clinical record revealed an annual Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 2/07/24, Section C (Cognitive Patterns) C0500 indicated that Resident R6's Brief Interview for Mental Status (BIMS- 15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) score was seven (moderately impaired cognition). Observation on 4/09/24, at 9:15 a.m. revealed Resident R6 sitting in his/her wheelchair on a mechanical lift sling. Interview at that time with Resident R6 confirmed that sometimes there is only one helper using the lift. Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included anaplasmosis (illness caused by bacteria that's spread by ticks and often causes lameness, joint pain, fever, lethargy, and lack of appetite), irregular heartbeat, heart failure, kidney failure, and muscle weakness. Resident R11's clinical record revealed a physician's order dated 1/29/24, to transfer with a full mechanical lift and assistance of two. A current care plan entitled impaired mobility included to use a full mechanical lift with the assistance of two to get out of bed, and assist of two and a sit-to-stand lift when out of bed. The 5-Day MDS dated [DATE], Section C0500 indicated Resident R11's BIMS score was 15 (intact cognition). Observation on 4/09/24, at 10:50 a.m. revealed Resident R11 sitting in his/her wheelchair on a mechanical lift sling. Interview at that time with Resident R11 confirmed that sometimes there is only one person helping him/her in the lift. Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included heart disease, high blood pressure, anxiety, and dysthymic disorder (milder, but long-lasting form of depression). Resident R16's clinical record revealed a physician's order dated 3/14/22, to transfer with a full mechanical lift and assistance of two. A current care plan entitled falls included to use a full mechanical lift with the assistance of two to transfer. A quarterly MDS dated [DATE], Section C0500 indicated Resident R11's BIMS score was 13 (intact cognition). Observation on 4/09/24, at 11:53 a.m. revealed Resident R16 sitting in his/her chair on a mechanical lift sling. Interview at that time with Resident R16 confirmed that sometimes there is only one person helping him/her in the lift. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included chronic inflammatory demyelinating polyneuropathy (CIDP- is a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), malnutrition, heart valve block, blood clots in the legs, and arthritis. Resident R17's clinical record revealed a physician's order dated 6/17/22, transfer with a full mechanical lift and assistance of two. A current care plan entitled falls included to use a full mechanical lift with the assistance of two to transfer. An annual MDS dated [DATE], Section C0500 indicated Resident R11's BIMS score was 13 (intact cognition). Observation on 4/10/24, at 10:15 a.m. revealed Resident R17 sitting in his/her chair on a mechanical lift sling. Interview at that time with Resident R17 confirmed that sometimes there is only one staff operating the mechanical lift. Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included dislocated right hip, multiple sclerosis (disease that impacts the brain, spinal cord, and optic nerves, which make up the central nervous system and controls everything we do), and paraplegia (specific pattern of where you can't deliberately control or move your muscles of your legs). Resident R10's clinical record revealed a physician's order dated 11/18/22, transfer with a mechanical lift. A current care plan entitled impaired mobility included to use a full mechanical lift with the assistance of two to transfer. A quarterly MDS dated [DATE], Section C0500 indicated Resident R10's BIMS score was 15 (intact cognition). Observation on 4/10/24, at 12:30 p.m. revealed Resident R10 sitting in his/her wheelchair on a mechanical lift sling. Interview at that time with Resident R10 confirmed that he/she is transferred many times with one staff using the lift, and unless he/she wants to wait hours to get out of bed, it is necessary, and that staffing is a concern of his/hers for this reason. Interviews on 4/09/24, at 9:30 a.m. with Employees E1 and E2 confirmed that sometimes they use the mechanical lifts by themselves due to having to hunt someone down to help them. Interview on 4/10/24, at 12:55 p.m. with the Director of Nursing confirmed that all mechanical lift transfers should be done with two staff members. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 18 residents reviewed (Resident R3). Findings include: Resident R3's clinical record revealed an admitted [DATE], with diagnoses that included Bipolar Disorder with severe psychotic features (condition characterized by the presence of either delusions or hallucinations or both), major depressive disorder, generalized anxiety disorder, Agoraphobia with panic disorder (phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs), and post-traumatic stress disorder (mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). Resident R3's hospital discharge records dated 12/28/23, revealed that the reason for his/her admission to the hospital was due to making suicidal statements, and having delusional thoughts. Hospital records dated 3/27/24, revealed that the reason for his/her admission to the hospital was due to wrapping his/her call bell cord around his/her neck, and having delusional thoughts. Resident R3's physician's orders revealed; an order dated 3/14/24, to keep a tap bell within reach at all times, and 3/28/24, to keep a tap bell at bedside. Resident R3's current care plans revealed: -Potential for falls initiated 12/29/23, indicated for his/her call bell to be within reach at all times when in room. -Impaired mobility initiated 12/29/23, indicated to keep his/her call bell in reach and remind Resident R3 not to transfer without assistance. -Potential for infection initiated 12/29/23, indicated to keep his/her call bell within reach when in room. -Physical behaviors related to bipolar disorder initiated 3/28/24, indicated for a tap bell at bedside. -Self-care deficits initiated 12/29/23, and updated on 3/14/24, for a tap bell within reach at all times. Interview on 4/09/24, at 12:36 p.m. with the Nursing Home Administrator and Director of Nursing confirmed that Resident R3's care plans related to call bell use and tap bell use were confusing and the call bell interventions should have been updated when the tap bell was ordered. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and self-harm prevention interventions were effectively implemented in the facility. Findings include: The job description for the NHA revealed that the NHA is responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and physical management of the facility, residents, and equipment in such a manner that the purpose of the facility will be established and maintained in accordance with current Federal, State, and Local standards, guidelines, regulation, and established policies. The job description for the DON specified that the primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Based on the findings in this report that identified the facility failed to consistently supervise and maintain all safety interventions to prevent self-harm for their residents, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, facility documents, and clinical records, and staff and resident interviews, it was determined that the facility failed to have sufficient staff with the appropriate skill sets to provide nursing services. Findings include: A facility policy entitled Nursing Department Staffing dated 2/14/24, indicated, This facility provides sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, psychosocial and spiritual well being of residents and Sufficient personnel are assigned and on duty to assure safe effective nursing care, including relief personnel during vacations, holidays, and sick leaves. Review of resident council minutes dated 12/22/23, and 2/3/24, indicated that residents feel the facility needs more staff and that call bells are not being answered timely on evening shift and on overnight shift. Facility nurse staffing reviewed for 3 weeks and included 3/3/24 revealed on 2/11/24, Certified Nursing Assistant (CNA) ratios were not met on dayshift, on 2/16/24, CNA ratios were not met on evening shift, on 2/17/24, CNA ratios were not met on dayshift, evening shift, and the minimum Per Patient Day (PPD) was not met, on 2/18/24, CNA ratios were not met on evening shift and the minimum PPD was not met, on 2/29/24, the minimum PPD was not met, on 3/1/24, CNA ratios were not met on evening shift and overnight shift, on 3/2/24, the CNA ratios were not met on evening shift, overnight shift, and the minimum PPD was not met, and on 3/3/24, the CNA ratios were not met on dayshift and the minimum PPD was not met. Clinical documentation for Resident R3 on 2/03/24, revealed that Resident R3 was ordered for the Licensed Practical Nurse (LPN) to obtain vital signs every shift for 72 hours, then daily, and to chart under vitals in the electronic medical record and daily skilled charting. The LPN documented in the progress notes at 10:59 a.m. and 11:00 a.m. that the LPN was unable to complete due to floating (same staff person has to work between different areas within the facility) to two different halls. Clinical documentation for Resident R4 on 2/03/24, revealed that Resident R4 was ordered for the LPN to obtain vital signs monthly and chart under vitals in the electronic medical record every day shift every 1 month(s) starting on the third for 1 day(s). The LPN charted in the progress notes at 1:27 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R5 on 2/03/24, revealed that Resident R5 was ordered to be weighed daily with mechanical lift for congestive heart failure. The LPN charted in the progress notes at 1:45 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R8 on 2/03/24, revealed that Resident R8 was ordered for the LPN to do a weekly skin evaluation every afternoon, every Saturday. The LPN charted in the progress notes at 1:46 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R6 on 2/03/24, revealed that Resident R6 was ordered 15-minute visual safety checks. The LPN charted in the progress notes from 1:49 p.m. to 10:02 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R7 on 2/03/24, revealed that Resident R7 was ordered Zinctral External Paste (topical treatment for a skin wound) to be applied to the sacrum/coccyx/buttocks every shift as a preventative. The LPN charted in the progress notes at 1:52 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R2 on 3/05/24, revealed that Resident R2 was ordered for the Registered Nurse (RN) to provide tracheostomy (trach-surgical procedure that creates an opening in the neck to place a tube into the windpipe) care and change trach sponge every day and evening shift. The treatment record lacked evidence that trach care was provided on 3/05/24. Staff interview conducted with RN Employee E1 on 3/6/24, at 12:30 p.m. revealed that resident treatments are being missed due to working short staffed and LPNs floating from second floor to third floor. At 2:25 p.m., he/she revealed they did not perform tracheostomy care for Resident R2 on 3/05/24, due to working short staff and not having time. Staff interview conducted with CNA Employee E2 on 3/6/24, at 11:15 a.m. revealed he/she is often alone on a hall with 20 or more residents with a float who covers several halls. Staff interview conducted with CNA Employee E3 on 3/6/24, at 11:30 a.m. revealed over the weekend he/she was alone on his/her hall with 24 residents and the LPN could not assist with resident care because the LPNs were floating and busy doing the medications and treatments. He/She knows residents were sitting soiled for extended periods of time and that the meal carts sat for over 30 mins before the trays could be passed. Staff interview conducted with LPN Employee E4 on 3/6/24, at 11:20 a.m. revealed LPNs are often floating from second to third floor and LPNs are forced to take over two medication carts. He/She expressed concern regarding floating because it is unsafe, and the nurses are more likely to make mistakes. Additionally, the LPNs try to assist the CNAs who are often working short staff with resident care. Staff interview conducted with LPN Employee E5 on 3/6/24, at 11:35 a.m. revealed LPNs are forced to take over two medication carts and float from second to third floor frequently and although they may be meeting the staff ratios, this is unsafe, and they feel pressured to take the second medication cart even if they don't want to. Staff interview conducted with CNA Employee E6 on 3/6/24, at 12:40 p.m. revealed he/she is often alone on the third floor with 15 or more residents and revealed he/she must wait for assistance for maxi-lift (mechanical lift requiring more than one staff person to assist a resident) residents from a CNA float or the LPN when not busy doing their job. He/She confirmed there are several maxi-lift residents, and this requires two staff members. Staff interview conducted with CNA Employee E7 on 3/6/24, at 12:45 p.m. revealed he/she has been a float several times and in one day has floated from one side of the second floor with 20 plus residents', to the locked memory care unit with 15 plus residents, and up to the third floor with 15 plus residents. he/she fears this is not safe leaving the other CNAs alone to float to several halls on different floors, and feels it is especially unsafe on the memory care unit. Staff interviews conducted with LPN Employee E8 and RN Employee E9 on 3/6/24 at 1:00 p.m. revealed they assist with medication pass at times and that they have witnessed LPNs taking over two medication carts and floating from the second to the third floor. Interview conducted with Resident R11 on 3/6/24, at approximately 11:17 a.m. revealed he/she is independent so does not need as much help from the staff, but he/she is concerned with the short staff for the residents that really need the help. He/She stated they are always running short and fears it is affecting care. Review of Resident R11's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation) evaluation dated 3/4/24, revealed a score of 14 and was cognitively intact. Interview conducted with Resident R10 on 3/6/24, at approximately 11:32 a.m. revealed he/she is concerned with the staffing and stated, they need more help. Review of Resident R10's BIMS evaluation dated 2/12/24, revealed a score of 14 and was cognitively intact. Interview conducted with Resident R5 on 3/6/24, at approximately 11:50 a.m. revealed the staffing in the facility is not good and stated, the residents can sense the staff is stressed out, rushed, and overwhelmed. Review of Resident R5's BIMS evaluation dated 2/2/24, revealed a score of 13 and was cognitively intact. During an interview on 3/6/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the required CNA ratios and minimum PPD for the dates listed above, and that the facility needs to work on the provision of adequate staffing levels. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(4) Nursing services

Based on observations, resident and staff interview, it was determined that the facility failed to maintain clean and sanitary common areas on one of two floors observed and clean and sanitary resident rooms for three of five residents reviewed (Residents R11, R10, and R5). Findings include: Observations made at approximately 11:00 a.m. on 3/6/24, revealed the hallways and common areas on the second floor had a thick layer of dirt, there was debris, straw wrappers, and napkins on the floors, fuzzy dust on and under furniture, and spots which appeared to be liquids that were completely dry and sticky on hallway floors and in resident rooms. There was only one housekeeper observed cleaning during the visit in one resident's room on the second floor and not in any common areas. Review of Resident R11's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation) evaluation dated 3/4/24, revealed a score of 14 and was cognitively intact. Interview conducted with Resident R11 on 3/6/24, at approximately 11:17 a.m. revealed he/she is very dissatisfied with the housekeeping and advised there is dry fecal matter on the floor next to his/her roommate's bed and that it has been there for a couple of days. Observations in Resident R11's room made at the time of the interview, revealed dirt, dust, and debris under all the beds in the room. Footwear was sticking to the floor while walking around the room and there was what appeared to be dry fecal matter on the floor next to R11's roommate's bed. Review of Resident R10's BIMS evaluation dated 2/12/24, revealed a score of 14 and was cognitively intact. Interview conducted with Resident R10 on 3/6/24, at approximately 11:32 a.m. revealed he/she is not happy with housekeeping and pointed out how dirty the floors were in the hallway and his/her room. Observations made at the time of the interview, revealed a layer of thick dirt on the floors in Resident R10's room and in the hallway on the second floor. Review of Resident R5's BIMS evaluation dated 2/2/24, revealed a score of 13 and was cognitively intact. Interview conducted with Resident R5 on 3/6/24, at approximately 11:50 a.m. revealed housekeeping is not good and pointed out the dust on his/her stands. Observations made at the time of the interview, revealed fuzzy dust located on Resident R5's window/shelf area and dresser. During an interview and tour on 3/6/24, at approximately 12:30 p.m. Registered Nurse Employee E1 confirmed the dirty conditions in the common areas and resident's rooms on the second floor of the facility, including what appeared to be dry fecal matter on Resident R11's floor and noted his/her shoes sticking the floor during the tour. During an interview on 3/6/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that housekeeping was an issue within the facility. 28 Pa. Code 201.18 (b)(1)(3) Management

Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of five residents reviewed (Resident 3), resulting in harm to Resident 3 due to a fall that resulted in fractures of the finger, hip, and shoulder. Findings include: The facility's policy regarding abuse and neglect, dated (MONTH) 20, (YEAR), indicated that all residents would be treated with kindness, dignity, and consideration, and no abusive handling, language, or any other treatment by anyone would be tolerated. Should an incident or suspected incident of resident abuse, neglect, or serious injury of unknown origin be reported, the Nursing Home Administrator or designee would investigate the alleged incident. The facility's policy regarding safety alarms, dated (MONTH) (YEAR), revealed that any resident who had an alarm (a device that sounds when a resident attempts to get up unassisted) should never be left unattended when the alarm was not on (i.e. when the resident was using the restroom). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated (MONTH) 14, (YEAR), revealed that the resident was confused, required extensive assistance from one staff member for transfers and toileting, was not steady moving on and off the toilet, was only able to stabilize herself with staff assistance, and had a history of [REDACTED]. An incident note for Resident 3, dated (MONTH) 9, (YEAR), at 7:45 a.m. revealed that the resident was assisted to the bathroom and the licensed practical nurse (LPN) informed the resident that she would be right outside the door, to give privacy, and instructed her to ring the call bell (that was placed in her hand) when she was through. Soon after, Resident 3 was heard yelling help me and when the LPN opened the bathroom door, Resident 3 was lying on her right side on the bathroom floor. The resident complained of severe pain to the right shoulder/collar bone area and had a deformity of the area, and had a skin tear on the right elbow. The resident was unable to perform a hand grasp of the right hand and could not shrug or raise her right arm at all. A physician's orders [REDACTED]. A nursing note at 9:25 a.m. revealed that the hospital informed the facility that the resident had fractures to the right shoulder, the right hip, and left finger. X-ray reports, dated (MONTH) 9, (YEAR), confirmed that Resident 3 had a [MEDICAL CONDITION] proximal humerus and base of the greater tubercle (shoulder), fractured right femoral neck (hip), and a fractured left ring finger. Education records for Licensed Practical Nurse 1 revealed that she signed that she received education regarding the facility's safety alarm policy on (MONTH) 30, (YEAR). A written statement from Licensed Practical Nurse 1, dated (MONTH) 9, (YEAR), revealed that she assisted Resident 3 to the bathroom and told her that she would be right outside the door and to ring her call bell that she put in her hand, or to just say that she was done. She then heard the resident yelling for help and when she went in to get the resident, she was lying on her right side on the bathroom floor. The resident stated that she slipped. An interview with the Director of Nursing on (MONTH) 27, (YEAR), at 2:30 p.m. confirmed that Licensed Practical Nurse 1 failed to follow the facility's safety alarm policy and should not have left Resident 3 alone in the bathroom. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 12/3/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/20/17, 8/11/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/20/17, 12/3/16, 8/11/16.

Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of hazards to residents who were at risk for falls for one of five residents reviewed (Resident 3), resulting in a fall with fractures. Findings include: The facility's policy regarding safety alarms, dated (MONTH) (YEAR), revealed that any resident who had an alarm (a device that sounds when a resident attempts to get up unassisted) should never be left unattended when the alarm was not on (i.e. when the resident was using the restroom). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated (MONTH) 14, (YEAR), revealed that the resident was confused, required extensive assistance from one staff member for transfers and toileting, was not steady moving on and off the toilet, was only able to stabilize herself with staff assistance, and had a history of [REDACTED]. An incident note for Resident 3, dated (MONTH) 9, (YEAR), at 7:45 a.m. revealed that the resident was assisted to the bathroom and the licensed practical nurse (LPN) informed the resident that she would be right outside the door, to give privacy, and instructed her to ring the call bell (that was placed in her hand) when she was through. Soon after, Resident 3 was heard yelling help me and when the LPN opened the bathroom door, Resident 3 was lying on her right side on the bathroom floor. The resident complained of severe pain to the right shoulder/collar bone area and had a deformity of the area, and had a skin tear on the right elbow. The resident was unable to perform a hand grasp of the right hand and could not shrug or raise her right arm at all. A physician's orders [REDACTED]. A nursing note at 9:25 a.m. revealed that the hospital informed the facility that the resident had fractures to the right shoulder, the right hip, and left finger. X-ray reports, dated (MONTH) 9, (YEAR), confirmed that Resident 3 had a [MEDICAL CONDITION] proximal humerus and base of the greater tubercle (shoulder), fractured right femoral neck (hip), and a fractured left ring finger. A written statement from Licensed Practical Nurse 1, dated (MONTH) 9, (YEAR), revealed that she assisted Resident 3 to the bathroom and told her that she would be right outside the door and to ring her call bell that she put in her hand, or to just say that she was done. She then heard the resident yelling for help and when she went in to get the resident, she was lying on her right side on the bathroom floor. The resident stated that she slipped. An interview with the Director of Nursing on (MONTH) 27, (YEAR), at 2:30 p.m. confirmed that Licensed Practical Nurse 1 failed to follow the facility's policy and should not have left Resident 3 alone in the bathroom. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 8/11/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/3/16, 8/11/16. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/3/16, 8/11/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 12/3/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/20/17, 8/11/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/20/17, 12/3/16, 8/11/16.