Every finding on record at Pennknoll Village

Based on observations and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures. Findings include: Observations on the 100 and 500 hall during the lunch meal delivery on June 16, 2026, at 12:44 p.m., revealed the lunch meal consisted of Salisbury steak or ham, sweet potatoes or mashed potatoes, peas, diced pears and ice cream. The last resident to be served on the 500 hall was at 12:57 p.m. The test tray on June 16, 2026, at 1:02 p.m. revealed that the temperature of the pureed Salisbury steak was 113.0 degrees (F), the iced tea was 58.2 degrees (F). The Salisbury steak tasted lukewarm, the iced tea was not cold, and the ice cream cup was melted and liquidated. These items were not palatable. These items were not served at the appropriate temperatures or textures. Interview with District Manager 2 on June 16, 2026, at 12:45 p.m. confirmed that food should be served at a palatable temperature, the drinks should be served cold, and the ice cream should have been served frozen. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.The facility's policy for food preparation, dated January 20, 2026, revealed that all utensils, food contact equipment, and food contact surfaces would be cleaned and sanitized after every use. The facility's policy for staff attire, dated January 20, 2026, revealed that all staff members would have facial hair properly restrained. Observations in the main kitchen on June 16, 2026, at 10:26 a.m. revealed the large bin of flour had the plastic scoop stored in the container, and the sugar bin had a plastic bowel stored in the container. Observations of the main kitchen floor revealed sugar packets, removable dried food debris, and other nonfood removable debris (a piece of black plastic). Interview with the District Manager 1 on June 16, 2026, at 10:26 a.m. confirmed that the scoops should not have been in the flour and sugar bins and indicated that they spread bacteria. Observations of tray line on June 16, 2026, at 12:15 p.m. revealed that District Manager 2, [NAME] 3, and [NAME] 4 had uncovered facial hair while plating and preparing food for delivery. They were not wearing any type of hair restraint. The kitchen floor remained with the same scattered debris. Interview with the District Manager 2 on June 8, 2026, at 1:05 p.m. confirmed that beard restraints should be worn while working in the kitchen and that the kitchen floor should be swept after each meal service. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that non pharmalogical interventions were attempted prior to the administration of a psychotropic medication for one of 37 residents reviewed (Resident 29). Findings include:The facility's policy regarding use pf psychotropic medications, November 13, 2025, indicated these medications should only be used to treat a resident's medical symptoms and not used for discipline or staff convenience.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated December 4, 2025, revealed that the resident was severely cognitively impaired, required assistance for care needs, had a diagnosis of dementia and was taking antianxiety medication.Physician orders for Resident 29 dated November 4, 2025, November 24, 2025, December 8, 2025, and December 25, 2025, revealed that the Resident was to be administered 0.5 milligrams (mg) of Lorazepam (antianxiety medication) every six hours for increased anxiety for 14 days.A review of Resident 29's electronic medication administration record (EMAR) dated November 2025, December 2025, and January 2026, revealed the Resident was administered 0.5 mg of Lorazepam on November 4, 2026 at 5:37 pm; November 13, 2025 at 4:35 p.m.; November 17, 2025, at 12:17 p.m., December 6, 2025, at 1:08 p.m.; December 17, 2025, at 8:22 a.m.; December 20, 2025, at 12:20 p.m.; and January 3, 2026, at 7:45 a.m.There is no documented non-pharmacological interventions attempted prior to the administration of Lorazepam.Interview with the Director of Nursing on January 23, 2025, at 3:51 p.m. confirmed that there were no non-pharmacological interventions prior to Lorazepam administration for the dates above for Resident 29, and there should have been. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of Food Committee minutes, as well as observations and resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the main kitchen.Findings include:Food committee minutes, dated April 2, 2026, revealed that residents were not being offered alternatives for meals, food was received ice cold, undercooked, or overcooked, and they were not being served what was on their meal ticket.Interview with Resident 2 on April 16, 2026, at 11:45 a.m. revealed that the kitchen had no staff.Observations in the main kitchen on April 16, 2026, at 12:15 p.m. revealed that the Director of Nursing and Licensed Practical Nurse 2 were running dishes through the dishwasher, and Nurse Aide 3 was assisting with tray line.Interview with the Director of Nursing at that time revealed that she was volunteering her time and helping out the kitchen. Interview with Licensed Practical Nurse 2 revealed that she assisted with gathering information for the completion of the MDS assessments and was asked to help in the kitchen. Interview with Nurse Aide 3 at that time revealed that she is the unit clerk and transportation and was pulled to help in the kitchen. She indicated that the last time she was pulled to the kitchen, she was there for three days.Interview with the Corporate Account Manager on April 16, 2026, at 12:40 p.m. confirmed that the kitchen was having staffing issues.28 Pa. Code 201.18(e)(6) Management.28 Pa Code 211.6(c) Dietary services.

Based on review of planned, written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu, and failed to inform residents of menu changes. Findings included: Review of the posted menus for the lunch meal on Wednesday, January 21, 2026, revealed that residents were to receive fried chicken, macaroni and cheese, sliced carrots, cornbread with margarine, and marble cake with white frosting and a beverage. The alternate meal was to be a hot dog with chili and cheese on a bun, potato wedges, creamy coleslaw and a beverage.Observations of a test tray for the lunch meal service on January 21, 2026, at 11:35 a.m. revealed baked chicken, not fried, and no cornbread was provided as per the menu. In addition, the alternate meal was meatballs and gravy with mashed potatoes, and not a hot dog with chili and cheese on a bun and potato wedges as posted.Interview with the Dietary Director and District Manager on January 21, 2026, at 12:25 p.m., revealed that the chicken was fried as per their recipe and the corn bread was not available and was changed to a dinner roll. The Dietary Director and District Manager confirmed that mashed potatoes were served instead of potato wedges and meatballs with gravy were served instead of a hot dog with chili and cheese on a bun. Additionally, they confirmed that what was on the menu is not what was served and that the change was not posted anywhere for residents to observe, nor were the residents informed verbally, and they should have been.28 Pa. Code 211.6(a) Dietary Service

Based on review of policies and Resident Council/Food Committee meeting minutes, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures.Findings include:The facility's policy regarding food and nutritional services, dated January 19, 2026, revealed that the food served will be palatable and at a safe and appetizing temperature.Resident Council/Food Committee meeting minutes, dated January 5, 2026, revealed that residents were asked if meals are served hot. Residents stated that the food is sitting too long in the carts and the food is often cold when it gets to them. Interview with Resident 10 on January 20, 2026, at 11:50 a.m. revealed the food was going downhill, it was over cooked, the meat was hard to chew, and it was cold.Interview with Resident 15 on January 20, 2026, at 12:24 p.m. revealed the food was awful, it was over cooked or undercooked. Observations of the lunch meal on January 20, 2026, at 12:12 p.m. revealed that Resident 36 could not eat her sliced carrots because they were too hard. She said she had mouth pain and the carrots were painful to eat. Interview with Nurse Aide 5 at the time of the observation revealed that she was unable to use a fork to cut the carrots.Interview with Resident 47 on January 20, 2026, at 12:00 p.m. revealed the food was not good, any type of food, all meals, and it was not hot.Observations of the lunch meal service in the main kitchen on January 21, 2026, revealed that the second hall cart containing the test tray left the main kitchen at 11:41 a.m., arrived on the nursing unit at 11:42 a.m., and the last resident was served at 11:55 a.m. The test tray was tasted at 11:56 a.m. and the chicken was 122.0 degrees Fahrenheit (F), the meatballs were 119.2 degrees F. the carrots were 124.9 degrees F, the sliced coleslaw was 55 degrees F. The meal was not palatable or at an appetizing temperature.Interview with the Dietary Director at the time of observation confirmed that the food temperatures should be higher for the hot foods, colder for the coleslaw, and should be served at a more appetizing temperature.28 Pa. Code 211.6(b) Dietary Services.

Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen was labeled, dated and secured. Findings include: The facility policy regarding food storage, dated January 19, 2026, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight. Proper labeling and dating ensures that all foods are stored, rotated and utilized in a manner that will minimize waste and ensure that items that are passed their due date are discarded.Observations in the kitchen's cooler on January 20, 2026, at 9:25 a.m. revealed that the following items were opened and not dated with an open date; one half bag (two pounds) of cabbage with carrots, three pounds of bacon, 25 cinnamon rolls, two and half pounds of Mozzarella cheese, a jar with a mixture of approximately eight pickles and tomatoes, one pound of broccoli salad, approximately three pounds of beefaroni and 30 cookies wrapped and undated. Observations in the kitchen's walk freezer on January 20, 2026, at 9:42 a.m. revealed that the following items were opened and not dated with an open date; a two pound box of stuffing and 12 muffins, in addition, 25 beef fritters and 15 sugar cookies were not labeled, dated or secured.Observations in the dry storage room on January 20, 2026, at 9:56 a.m. revealed that the following items were opened and not dated with an open date; a one pound plastic container of cheerios, a half pound bag of rice Krispie's, a two pound bag of brownie mix, two pounds of spaghetti and a half pound bag of dry milk. In addition, there was a half pound each of corn flakes and raisin bran and four and a half bags of coconut shavings that were expired, and one pound of Hershey [NAME] that was outdated and unsecured.Interview with the Dietary Manager on January 20, 2024, at 10:10 a.m. confirmed that all food items in the kitchen should be labeled, dated and secured, and they were not.28 Pa. Code 211.6(f) Dietary services.

Based on review of clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for one of 37 residents reviewed (Residents 20).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated January 7, 2026, revealed that the resident was always understood, always understood others, was cognitively intact, and required assistance from staff for daily care needs. Interview with Resident 20 on January 21, 2026, at 1:42 p.m. and January 22, 2026 at 4:13 p.m., revealed that her grandson brought her a new television for Christmas, but he was called to come and take it back. Resident 20 was not allowed to keep her new television and she wanted it.Interview with the Director of Maintenance on January 22, 2026, at 3:28 a.m. revealed that there was no facility policy or life safety code that determined the size of television that would be allowed in the facility. He confirmed that Resident 20's television was removed.Interview with the Nursing Home Administrator on January 22, 2026, at 2:42 p.m., revealed there was no policy or restriction about televisions brought from outside as personal property. 28 Pa. Code 201.29(j) Resident Rights.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for three of 37 residents reviewed (Residents 15, 86, 88,).Findings include: Interview with Resident 15 on January 20, 2026, revealed that the blinds in her room do not go up and they were broken. Interview with the Maintenance Director on January 22, 2026, confirmed that the blinds did not function, due to a broken string. Interview with the Nursing Home Administrator on January 22, 2026, at 3:49 p.m. confirmed that having a blind that does not move up and down was not homelike, and would need replaced. Observations on January 20, 2026 at 12:42 p.m. of Resident 86 in her room seated in a Broda chair (a specialized positioning chair to improve comfort). It was noted that the left arm of the chair had an area approximately twelve inches by five inches where the vinyl covering was torn off, and an area on the right arm of the chair approximately six inches by five inches where the vinyl covering was missing. In addition, the seam on the head rest was torn approximately one inch in width and the entire length of the headrest. Interview with Registered Nurse 1 on January 21, 2026, at 1:06 p.m. confirmed that Resident 86 uses a Broda chair. She revealed that when not in use Resident 86's Broda chair is stored in the shower room. Observations in the shower room on January 21, 2026 at 1:08 p.m. with Registered Nurse 1 confirmed that the vinyl on Resident 86's Broda chair was torn off on both arms and that the seem was tearing apart on the headrest. She further indicated that Resident 86 should not have been sitting in it and that it should be out of circulation. Interview with the Nursing Home Administrator on January 21, 2026, at 1:21 p.m. confirmed that Resident 86 should not have been sitting in a Broda chair with the vinyl torn off and the seams coming apart. Observations of Resident 88 sitting in a Broda chair on January 20, 2026, at 12:07 p.m., January 21, 2026 at 12:30 p.m., January 22, 2026, at 5:10 p.m., and January 23, at 9:12 a.m., revealed a blue pad on the chair that was ripped and torn and the white padding was exposed; the top corners and bilateral sides were also torn. The chair also has large accumulation of a brown sticky dried-on substance, a large amount of grime on the wheels, and a large amount of scattered food debris. Interview with Licensed Practical Nurse 2 on January 23, 2026, at 9:12 a.m. confirmed that Resident 88's Broda chair cushion was ripped and padding was sticking out and that the chair was not clean. Licensed Practical Nurse 2 revealed that a power washer was used to clean the chairs. Interview with the Director of Rehabilitation on January 23, 2026, at 10:05 a.m. confirmed that Resident 88 should not have been sitting in a Broda chair with the padding torn off and the stuffing sticking out. She indicated the chair was brand new when issued to Resident 88. Interview with the House Keeping Director on January 23, 2026, at 10:37 a.m. revealed that there was a monthly schedule for wheelchair cleaning. The wheelchairs should be cleaned once a month. The last time Resident 88's chair was cleaned was December 7, 2025, and he has yet to clean the chairs in January 2026. 28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on a review of facility policy, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with dental care as scheduled for one of 13 residents reviewed (Resident 1). Findings include:The facility's policy for Activities of Daily Living (ADLs), dated [DATE] indicated that residents would be provided oral hygiene as per their request or as per facility schedule protocols. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], indicated that the resident was cognitively intact and was dependent on staff for daily care needs including oral care.A review of Resident 1's task record, dated February 2026, indicated that the resident was tasked to have oral hygiene care after each meal. Observation of Resident 1 on [DATE] at 1:15 p.m. revealed that he ate his lunch meal while sitting in the hallway and then remained in the hallway until 1:53 p.m. at which time Nurse Aide 1 took the resident into his room to provide care. Observations of care with Nurse Aide 1 and Resident 1 revealed that she put the resident into bed, provided incontinence care then positioned him for a nap. Interview with Nurse Aide 1 on [DATE], at 2:04 p.m. confirmed that she readied Resident 1 for a nap after his lunch meal, provided incontinence care to him and that she did not provide oral care for him as he is care planned to receive. She stated that she did not have time to do it. Interview with the Director of Nursing on [DATE], at 2:45 p.m. revealed that staff did not have time to provide oral care after the resident finished his meal as he is care planned to receive.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, observations and staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for two of 37 residents reviewed (Resident 17, 57) who were at risk for falls. Findings include:The facility's policy regarding fall prevention and management, dated January 19, 2026, indicated that the facility will identify those residents at risk for falls upon admission, readmission, and quarterly and provide appropriate interventions to modify and/or compensate for risk factors, and that environmental interventions would be used to decrease the risk of the resident falling. The care plan will be updated to reflect resident-specific safety needs and interventions. The facility had no policy regarding the use of foot plates while transporting residents in the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated November 10, 2025, revealed that the resident was severely cognitively impaired, required assistance from staff for personal care needs, used a wheelchair, and had diagnoses that included stroke and hemiplegia (lose of feeling and control of half of the body. A care plan for Resident 20 dated January 31, 2025, revealed that the resident had impaired balance and activity intolerance due to a brain bleed. Resident was to have bilateral leg rests to the wheelchair for propelling. Observations of Resident 17 on January 22, 2026, at 2:40 p.m. revealed that the resident was transported in his chair by Registered Nurse 3 from the 200 Hall to the nurses station. Resident 17's feet were dangling and he was using one foot to support the other. Interview with Registered Nurse 3 at the time of the observation and January 22, 2026, at 3:19 p.m. respectively, revealed that the resident was able to self propel and that she was encouraging him to go to the activity. Registered Nurse 3 confirmed that Resident 17 should have his foot rests on when staff are propelling the resident's wheelchair. An interview with the Director of Nursing on January 22, 2026, at 11:09 a.m. confirmed that Resident 17 was unsafe with foot plates on while self propelling and that staff were keeping him safe. A quarterly Minimum Data Set (MDS) assessment for Resident 57, dated December 22, 2025, revealed that the resident was severely cognitively impaired, had a history of multiple falls, with the most recent fall resulting in a compression fracture of the thoracic and lumbar spine, had a current fall risk care plan that indicated that the resident was at risk for falls related to dementia, psychotic disturbances and anxiety, and that dycem (a mat that provides gripping and anti-slip stabilization) was to be placed between the mattress and the bed frame to reduce slippage. Observations of Resident 57's bed on January 22, 2026, at 3:20 p.m. revealed that there was no dycem between the mattress and the bedframe as care planned. Interview with he Director of Nursing on January 22, 2026, at 3:30 p.m. confirmed that Resident 57 did not have dycem between the mattress and bedframe as care planned, and she should have.Interview with the Nursing Home Administrator on January 22, 2026, at 3:53 p.m. confirmed that Resident 17 should have had foot rests in place while being transported in the facility, and that Resident 57 should have had dycem in place as ordered and care planned.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medications properly for one of 37 residents reviewed (Resident 47).Findings include:The facility's policy regarding medication storage, dated January 19, 2026, revealed that all drugs and biologicals would be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Current physician's orders for Resident 47, included orders for the resident to receive 100 milligrams (mg) of Allopurinol (used to treat gout) once a day, 10 mg of Fluoxetine (anti-depressant) one time day, 300 mg of Gabapentin (used to treat neuropathy/pain) three times day, and 1 gram of Methenamine Hippurate (antibiotic) one time a day.Observations on January 22, 2026, at 9:01 a.m. revealed that Registered Nurse 4 prepared medications for Resident 47, which included medication cards containing Allopurinol, Fluoxetine, Gabapentin, and Methenamine Hippurate. He flipped over the cards of medications on top of the medication cart, locked the medication cart and proceeded to enter Resident 47's room to administer her medications. The medications were left on top of the medication cart in the hallway unattended and out of Registered Nurse 4's sight.Interview with Registered Nurse 4 on January 22, 2026, at 9:03 a.m. confirmed that he should not have left the medications on top of the cart unattended.28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of facility policy, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents were provided with assistive devices for eating as ordered by the physician for one of 13 residents reviewed (Resident 1). Findings include:A review of the facility's policy regarding Use of Assistive Devices, dated January 19, 2026 revealed that the use of assistive devices for eating will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care.A comprehensive Minimum Data Set (MDS) assessment for Resident 1, dated January 17, 2026, revealed that the resident was cognitively intact, is dependent on staff for daily care tasks, including assistance with eating. Physician's orders for Resident 1, dated March 18, 2026, included an order to provide a rimmed plate for meals (a plate that has high sides), maroon spoons (special order to help the resident take small bites), and two handled cup with a spouted lid (special order to help with resident to not spill drinks). The resident's task record, dated April 2026, indicated that staff were to set the resident up with maroon spoons, a two handled cup with a spouted lid, and a rimmed plate for all meals.Observations of Resident 1 during the lunch meal on April 16, 2026, at 12:31 p.m. revealed that he did not have a rimmed plate, maroon spoons, or a two handled cup with a spouted lid. Interview with Nurse Aide 4 on April 16, 2026, at 12:31 p.m. confirmed that Resident 1 was to have a rimmed plate, maroon spoons, and handled cup with spout with his meal and that he did not. Interview with the Director of Nursing on April 16, 2026, at 2:45 p.m. confirmed that Resident 1 should have had his adaptive devices for eating as ordered by the physician. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending January 15 and May 29, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 23, 2026, identified repeated deficiencies related to homelike environment, ensuring that the resident's environment was free from accident hazards, failure to serve palatable food at appropriate temperatures, and to store and prepare food under sanitary conditions . The facility's plan of correction for a deficiency regarding a homelike environment cited during the survey ending January 15, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the facility's QAPI committee failed to successfully implement their plan regarding a homelike environment.The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the surveys ending on January 15 and May 29, 2025, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards. The facility's plan of correction for a deficiency for not serving palatable food at appropriate temperatures, cited during the survey ending January 15, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding palatable food and food temperatures. The facility's plan of correction for a deficiency regarding food storage and labeling, cited during the surveys ending January 15, 2025, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food storage and labeling. Refer to F584, F689, F804, F812.28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the proper hand-washing procedures were followed, and that proper infection control practices were followed for two of 37 residents reviewed (Residents 47, 80).Findings include:The facility's policy regarding hand hygiene, November 13, 2025, indicated that when staff washed their hands, they were to dry them with a single use towel and then turn the faucet off with a clean towel. Observations on January 22, 2026, at 8:55 a.m. revealed that Registered Nurse 4 administered medications to Resident 80. He then washed his hands and turned the faucet off with his clean hand and dried his hands with a paper towel. Observations on January 22, 2026, at 9:01 a.m. revealed Registered Nurse 4 administered medications to Resident 47. He then washed his hands and turned the faucet off with his clean hand and dried his hands with a paper towel.Interview with Registered Nurse 4 on January 22, 2026, at 9:03 a.m. confirmed that he should not have turned the faucet off with his clean hand.Interview with the Director of Nursing on January 22, 2026, at 11:30 a.m. confirmed that after Registered Nurse 4 washed his hands, he should have used a paper towel to turn the faucet off, according to their policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that residents were free from neglect which resulted in harm as evidenced by a fall with fracture for one of five residents reviewed (Resident 3). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated January 16, 2025, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Nurse aide documentation revealed that Resident 3 was an extensive assist of two for bed mobility and toileting at the time of the fall. The care plan for Resident 3, dated June 2, 2023, for a self-care performance deficit related to limited mobility included interventions for two assist with bed mobility. An occupational therapy note for Resident 3, dated for the certification period of May 2 to May 31, 2025, indicated that Resident 3 was dependent and in need of two assist for toileting hygiene. A nursing note for Resident 3, dated May 6, 2025, at 6:49 a.m., revealed that Registered Nurse 1 was called to the room where the resident was found on the floor between the beds. She was face down moaning in pain and was rolled onto her back with the support of three staff. A registered nurse assessment at that time revealed that there was bleeding and bruising to the nose and right side of the face, as well as skin tears to the right elbow and right shin. The resident was sent to the emergency room for evaluation. An emergency room X-ray report for Resident 3, dated May 6, 2025, at 10:59 a.m., revealed a nondisplaced fracture of the third digit of the right hand. An incident report for Resident 3, dated May 6, 2025, at 5:52 a.m. revealed that Nurse Aide 2 was in the resident's room providing incontinent care when the resident shifted her weight causing her to slip through the aide's arms and roll onto the floor between the beds. Nurse Aide 2 performed care by herself and did use a two person assist. A witness statement, dated May 6, 2025 at 5:52 a.m., revealed that the Nurse Aide 2 was removing Resident 3 from the bedpan when the resident shifted her weight and slid through her hands and off the bed. She indicated that the RN and other aide were in another room attending to a resident at that time. She went on to say that she was trying to get Resident 3 settled in time for the other aide to leave at 6:30 a.m., because at that time she would be by herself. In addition, she indicated that the resident was wanting to get off the bedpan as soon as possible. A fall investigation form, dated May 6, 2025, submitted at 3:24 p.m., indicated that one staff person was providing care at the time of the fall. Interview with the Director of Therapy on May 29, 2025, at 3:15 p.m. indicated that at the time of Resident 3's fall, she was a maximum assist of two for bed mobility. She went on to say that during the facility's morning meeting on the day of the fall, the Director of Nursing indicated that Resident 3 was to be an assist of two while removing the bedpan and not one. Interview with Resident 3 on May 29, 2025, at 3:25 p.m. indicated that on the day of the fall, the aide tilted her and she went off the bed. Additionally, she indicated that the there is usually two staff in the room assisting with her care. Interview with the Director of Nursing on May 29, 2025, at 6:14 p.m. confirmed that there should have been two nursing assistants providing care to Resident 3 while removing her from the bedpan. Nurse Aide 2 did not follow the resident's plan of care for a two person assist resutling in a fall from bed and a fracture. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that a safe environment was provided for one of five residents reviewed (Resident 3) resulting in a fall with fracture. Findings include: The facility's policy regarding fall prevention, dated January 16, 2025, revealed that the facility was to provide an environment that is free from accident hazards over which the facility has control, and provide supervision to prevent avoidable accidents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 16, 2025, indicated that the resident was cognitively intact, could understand and was understood. Nurse aide documentation revealed that Resident 3 was an extensive assist of two for bed mobility and toileting at the time of the fall. The care plan for Resident 3, dated June 2, 2023, for a self-care performance deficit related to limited mobility included interventions for two assist with bed mobility. An occupational therapy note for Resident 3, dated for the certification period of May 2 to May 31, 2025, indicated that Resident 3 was dependent and in need of two assist for toileting hygiene. A nursing note for Resident 3, dated May 6, 2025, at 6:49 a.m., revealed that Registerd Nurse 1 called to the room where the resident was found on the floor between the beds. She was face down moaning in pain and was rolled onto her back with the support of three staff. A registered nurse assessment at that time revealed that there was bleeding and bruising to the nose and right side of the face, as well as skin tears to the right elbow and right shin. The resident was sent to the emergency room for evaluation. An emergency room X-ray report for Resident 3, dated May 6, 2025, at 10:59 a.m., revealed a nondisplaced fracture of the third digit of the right hand. An incident report for Resident 3, dated May 6, 2025, at 5:52 a.m. revealed that Nurse Aide 2 was in the resident's room providing incontinent care when the resident shifted her weight causing her to slip through the aide's arms and roll onto the floor between the beds. A witness statement, dated May 6, 2025 at 5:52 a.m., revealed that Nurse Aide 2 was removing Resident 3 from the bedpan when the resident shifted her weight and slid through her hands and off the bed. She indicated that the RN and other aide were attending to another resident at that time. A fall investigation form, dated May 6, 2025, submitted at 3:24 p.m., indicated that one staff person was providing care at the time of the fall. Interview with the Director of Therapy on May 29, 2025, at 3:15 p.m. indicated that at the time of Resident 3's fall, she was a maximum assist of two for bed mobility. She went on to say that during the facility's morning meeting on the day of the fall, the Director of Nursing indicated that Resident 3 was to be an assist of two while removing the bedpan and not one. Interview with Resident 3 on May 29, 2025, at 3:25 p.m. indicated that on the day of the fall, the aide tilted her and she went off the bed. Additionally, she indicated that the there is usually two staff in the room assisting with her care. Interview with the Director of Nursing on May 29, 2025, at 6:14 p.m. confirmed that there should have been two nursing assistants providing care to Resident 3 while removing her from the bedpan. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: Review of food committee meeting minutes for 2024 revealed that the food is burnt, has been cold, and tasted bad. Interview with Resident 66 on January 12, 2025, at 10:47 a.m. indicated that the food tastes burnt and does not taste good, and it is cold at times. Interview with Resident 74 on January 12, 2025, at 1:22 p.m. indicated that the food is terrible and has no taste, there is too much pork, and it is cold. Observations of the kitchen's lunch meal tray line on January 14, 2025, revealed that it began at 12:10 p.m. and included macaroni and cheese, chicken, mashed potatoes, fruit cocktail, and coffee. The last tray was placed on the cart at 12:15 p.m. The cart left the kitchen and arrived on the unit at 12:16 p.m. and the last tray was removed from the cart and served at 12:27 p.m. The test tray was removed from the cart at 12:28 p.m. The macaroni and cheese was 141 degrees Fahrenheit (F), the chicken was 136.5 degrees F and dry to taste, the mashed potatoes were 136.5 degrees F and not palatable, the fruit cocktail was 61 degrees F and warm to taste, and the coffee was 138.3 degrees F. Interview with Director of Dietary on January 14, 2025, at 12:40 p.m. confirmed that the fruit cocktail was a little warmer than she liked. She stated that she had pulled it out of the refrigerator and did not put it back to keep it cold. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policy and Food Committee meeting minutes, and resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve resident grievances regarding cold food. Findings include: The facility's policy regarding food quality and palatability, dated March 18, 2024, revealed that food will be palatable, attractive, and served at a safe and appetizing temperature. Food Committee meeting minutes for January through August 2024 and October through December 2024 indicated that the residents were receiving cold food. A meeting with a group of residents on January 13, 2025, at 11:15 a.m. revealed that the residents have been served food that was cold and unpalatable. They stated that they have requested food that is served at the correct temperature. They stated that this had been occurring for at least one year. Interview with Director of Dietary on January 14, 2025, at 12:14 p.m. confirmed that she was aware that residents complained about cold food, and that it was brought up during the Food Committee meetings. She stated that she did not address the issue because the food that was temped in the kitchen was at the correct temperatures. 28 Pa. Code 201.29(i) Resident Rights. 28 Pa. Code 211.12(d)(5) Nursing Service.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 30 residents reviewed (Residents 40, 53). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated November 13, 2024, revealed that the resident was cognitively intact, was independent with daily care needs, had diagnoses that included high blood pressure, diabetes, and Parkinson's. Current physician's orders for Resident 40 included orders for the resident to receive 10 milligrams of Cetirizine at bedtime every Monday and Thursday for allergies, 100 micrograms of Synthroid daily for hypothyroidism (when the thyroid gland does not make enough thyroid hormones), 17 grams of Miralax daily for constipation, 30 milligrams of Diltiazem twice a day for high blood pressure, and 500 milligram of Tylenol twice a day for left knee pain. A review of Resident 40's Medication Administration Records (MAR's) for December 2024 revealed no documented evidence that the medications were administered as ordered on December 3, 9, 10, 12, 16, 18, 21, and 24, 2024. Interview with Resident 40 on January 14, 2025, at 11:41 a.m. revealed that he has not been receiving his medications per the physician orders. An interview with the Director of Nursing on January 14, 2025, confirmed that Resident 40's MAR revealed no documented evidence to indicate that the medications were administered on the dates listed above. An admission MDS for Resident 53, dated December 3, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, had diagnoses that included diabetes (a disease that interferes with blood sugar control), high blood pressure, and a stroke. Physician's orders for Resident 53, dated November 27, 2024, included orders for accuchecks every morning and at bedtime and to notify the physician if the blood sugar was less than 60 mg/dL or greater than 400 mg/dl. A review of the MAR for Resident 53, dated December 2024, revealed that on December 1, 2024, at 9:00 p.m. the resident's blood sugar was 32 mg/dl and on December 2, 2024, at 6:00 a.m. the resident's blood sugar was 41 mg/dl. There was no documented evidence that the physician was notified of these low blood sugars as ordered. Interview with the Director of Nursing on January 15, 2025, at 10:15 a.m. confirmed that the physician was not notified of Residents 53's low blood sugars mentioned above, and he should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's physician orders to prevent worsening of a non-pressure skin condition for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated February 9, 2023, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, was dependent on staff for transfers, and needed assistance of two staff members for daily care needs. Resident 2 had diagnoses of kyphosis, cervical region (spine curves toward the front of the body) and general muscle weakness. Physician's orders for Resident 2, dated July 19, 2023, indicated to thoroughly cleanse MASD (moisture-associated skin damage) to the right clavicle (collar bone) and right neck/chest excoriation (scraped or abraded) with soap and water, dry well, apply DermaCol/Ag (a wound care dressing made of collagen and sodium alginate) to wound, and moisten wound bed with sterile water if needed to begin healing process. Cover the wound with optifoam gentle (a soft foam dressing that can be easily removed) and apply and an old pillow case length wise around the neck to separate every evening shift. Due to the location on the right clavicle area of the MASD, Resident 2's saliva and drool would accumulate causing the moisture. A non-pressure skin assessment was completed on July 24, 2023, and indicated that Resident 2's non-pressure area on the right clavicle measured 2.0 x 2.0 x 0.1 cm in size. The surrounding skin was intact and a small amount of serous red/pink drainage with an odor was noted to be present. A nursing note for Resident 2, dated July 25, 2023, at 5:30 a.m. revealed that Resident 2 complained to the CNA that her neck was very sore and stinky. The nurse went to the room and ask the resident what was wrong. The resident stated that her neck had not been done for three days. The nurse removed the old dressing from her neck, which was dated from Friday, July 21, 2023. There was a cottage cheese-like exudate under the neck fold with a foul odor and the wound dressing was dried to the wound bed on her collar bone. The treatment was performed per orders. The treatment was signed as administered for July 22, 23, and 24, 2023. The dressing that was dried to the wound was dated July 21, 2023. The Director of Nursing was made aware via paper statement and provided with the old dressing for viewing. The physician and responsible party were made aware and the registered nurse completed a non-pressure skin assessment. A non-pressure skin assessment was completed on July 25, 2023, and indicated that Resident 2's non-pressure area on the right clavicle measured 2.0 x 3.0 cm in size. The surrounding skin was intact with redness noted and a small amount of serous sanguineous drainage (a thin water fluid that is pink in color due to small amounts of red blood cells) with an odor was noted. A nursing note for Resident 2, dated July 26, 2023, at 9:17 p.m., revealed that there was a small to moderate amount of bleeding noted at dressing change. The resident had pain at the site, which is not her normal. Resident 2 was medicated for pain with positive effect and registered nurse was made aware. A nursing note for Resident 2, dated July 26, 2023, at 11:25 p.m., reveled that the registered nurse was made aware of the bleeding during dressing change and that the resident was medicated for pain with positive effect. Resident 2's vital signs were within normal limits. However, the resident was noted to have slight confusion during the shift. She was unable to recall recent events and who her care takers were. The resident was not in acute distress, and the Certified Registered Nurse Practioner (CRNP) was notified. A non-pressure skin assessment was completed on July 27, 2023, and indicated that Resident 2's non-pressure area on the right clavicle measured 2.5 x 3.5 cm in size. The surrounding skin was intact with redness and increased drainage. A nursing note for Resident 2, dated July 28, 2023, at 1:37 p.m., revealed that Resident 2's MASD was noted to be larger with increased drainage (odor is fungal in nature), and the wound nurse was consulted via live streaming video for recommendation. The wound nurse recommended to cleanse daily with soap and water, apply silver alginate to the wound bed, and cover with optifoam to absorb moisture. All parties were made aware of change and CRNP the approved changes. The facility's investigation determined that Licensed Practical Nurse 1 gave a verbal statement to the Director of Nursing on July 25, 2023. She stated that she forgot to do Resident 2's treatment on July 24, 2023. She stated that the hall is crazy and she had trouble remembering. She stated that it only happened on July 24, 2023. She did not give an explanation for the other two nights of missing the treatment. She stated that she writes her treatments down and then clicks them off before doing them. She stated that she knows that is not the proper procedure for administration of treatments. She also stated that she thought the treatment was twice a day. Licensed Practical Nurse 1 did not want to write down her statement. After giving a verbal statement to the Director of Nursing, Licensed Practical Nurse 1 was escorted out of the building after notification of her suspension. Interview with the Director of Nursing on August 2, 2023, at 3:30 p.m. confirmed that Licensed Practical Nurse 1 failed to administer Resident 2's treatment to right clavicle as ordered on July 22, 23, and 24, 2023, and documented that she did. Resident 2's non-pressure wound did increase in size and neglect was substantiated. Licensed Practical Nurse 1 was terminated for negligence and falsifying documentation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that two of 39 residents reviewed (Residents 22, 67) were free from sexual abuse perpetrated by another resident (Resident 296). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated February 9, 2023, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Sexual abuse was non-consensual sexual contact of any type with a resident. Sexual abuse includes unwanted intimate touching of any kind especially of breast and perineal area and forced observation of masturbation. Sexual contact was non-consensual when the resident lacks the cognitive ability to consent or does not want the contact to occur. A nursing note for Resident 296, dated March 1, 2023, at 10:25 p.m. revealed that the resident made multiple sexual comments towards nursing staff during the evening shift. Nursing staff attempted to redirect the resident and inform him that this kind of language and comments are not necessary and are inappropriate. Redirection was unsuccessful. A social services progress note for Resident 296, dated March 2, 2023, at 11:31 a.m. revealed there was an attempt to follow up with the resident about the comments that he made to nursing staff last night and if he said anything inappropriate, and he denied any such comments. A behavior care plan for Resident 296 was developed on March 2, 2023, and included interventions to discuss the resident's behavior. If he is reasonable, explain/reinforce why the behavior is inappropriate and/or unacceptable to the resident, redirect resident to positive conversation when he starts to make inappropriate comments, and remind the resident to use appropriate language if he starts swearing. The care plan was updated on March 6, 2023, to include frequent visualization of the resident. A nursing note for Resident 296, dated March 6, 2023, at 1:44 p.m. revealed that he had been using sexually explicit and violently motivated language. The medical doctor was notified and orders were requested. A social service note for Resident 296, dated March 7, 2023, at 6:69 a.m. (as a late entry note for March 3, 2023) revealed that Resident 296 had been in the hallway saying/yelling that he was looking for his [NAME] 45 to kill people because they were trying to steal his truck. He stated he was tired of people taking advantage of him. Resident 296 was able to be redirected and was taken to his room because he did not have socks or shoes on. Resident 296 laid on the bed while he was assisted with putting socks and gripper socks on. The resident fell asleep after his socks were put on. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated January 3, 2023, revealed that the resident was cognitively impaired; was understood; could understand; and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A nursing note for Resident 67, dated March 7, 2023, revealed that at approximately 3:20 a.m. Resident 296 forcefully asserted himself (was sexually aggressive) toward Resident 67 while she was sleeping. A social services note, dated March 10, 2023, revealed that Resident 67 was seen as a follow up to the recent event with another resident. Resident 67 indicated that she felt down and was unsure why she felt that way but did not accept any assistance from the social worker. Interview with Resident 67 on March 28, 2023, revealed that she did not know the resident that came into her room, but he climbed on top of her and fondled her. She said it was scary, and she told him to get off of her or she was going to kick him in the face. A quarterly MDS for Resident 22, dated February 27, 2023, revealed diagnoses that included dementia, anxiety and major depressive disorder; was confused; required assistance for care; and used a walker as a mobility device. A nursing note for Resident 22, dated March 7, 2023, revealed that at approximately 3:20 a.m. a resident forcefully asserted himself towards the resident while she was sitting by the nursing station. Interview with Nurse Aide 2 on March 28, 2023, at 11:08 p.m. revealed that she remembered the event on March 7, 2023. Nurse Aide 2 said that she heard someone calling for help and entered Resident 67's room and found Resident 296 lying half way on top of the resident. Resident 296 stated, I am going to f**k you. Nurse Aide 2 said she had to physically remove Resident 296 from on top of Resident 67, assisted him to his room where she toileted him, and put him in bed. Then she went to the nurse's station to report the incident to Nurse Supervisor 3. At that time, Resident 296 came out of his room, of his own accord, to the nurse's station where Resident 22 was sitting and the second incident occurred, but Nurse Aide 2 was not in direct sight to say what occurred. The prior shift reported that he had aggressive and agitated behaviors. Interview with the Nurse Supervisor 3 on March 28, 2023, at 11:17 p.m. revealed that Resident 296 was housed on the 100 Hall. After receiving a report of the incident, she assessed Resident 67, who was rattled and upset. When she returned to the nurse's station Resident 296 was there. Nurse Supervisor 3 considered Resident 269 a one-to-one observation, because he would carry out violent threats and harm other staff or residents. While on one-to-one, Resident 296 approached Resident 22, pulled down his pants, and started fondling himself. Resident 296 was redirected away from the resident and then directed to his room, where he remained until the ambulance arrived. Resident 296 was yelling, cursing and swearing the entire night. Information reported to the Department of Health on March 7, 2023, indicated that Resident 296 was immediately removed from the room and brought to the nurse's station. A discharge MDS for Resident 296, dated March 8, 2023, revealed that the resident was cognitively impaired and required extensive assistance with daily care activities. Resident 296 had diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrolled), cognitive communication deficit, and intellectual disabilities. The resident's care plan, dated March 2, 2023, revealed that he had behaviors related to inappropriate comments, cursing and swearing towards staff. Information reported to the Department of Health by the facility on March 7, 2023, at 3:30 a.m. revealed that Resident 296 was found in bed with Resident 67 and stated, I am going to f**k you. Both residents were clothed and Resident 296 was immediately removed from the room and taken to the nurse's station to monitor behavior. An event report, dated March 7, 2023, at 3:35 a.m., revealed that Resident 296 exposed his genitals to Resident 22 after being found on top of Resident 67. A nursing note, dated March 7, 2023, at 7:46 a.m., revealed that at approximately 3:20 a.m. Resident 296 forcefully self-asserted himself towards Residents 22 and 67, and that no injuries were noted. Resident 296 stated that he was going to shoot on-duty staff. 9-1-1 was called and resident was transported to the hospital for evaluation. There was no documented evidence in Resident 296's clinical record to indicate that new interventions were implemented to prevent further incidents of sexual abuse toward other residents and that there was no documented evidence that frequent visualizations of the resident were completed as care planned on March 6, 2023. Interviews with the Nursing Home Administrator and Director of Nursing on March 30, 2023, at 4:19 p.m. confirmed that there was no documented evidence that frequent visualizations of Resident 296 were done or that other interventions were implemented to prevent further incidents. 42 CFR 483.13 Resident Behavior and Facility Practices, 10-1-1998 Edition. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, by failing to develop and implement new interventions for fall/injury prevention for one of 39 residents reviewed (Resident 44) who had a history of falls, which resulted in a fracture; by failing to develop and implement new interventions for fall/injury prevention for one of 39 residents reviewed (Resident 56) who had a history of falls; by failing to complete a thorough investigation and assessment of falls to determine the possible cause and/or if care-planned interventions were in place at the time of the falls for one of 39 residents reviewed (Resident 68); by failing to ensure that residents were transported in a safe manner for one of 39 residents reviewed (Resident 74); and by failing to ensure that fall prevention interventions were in place as care planned for one of 39 residents reviewed (Resident 87). Findings include: The facility's policy regarding fall management, dated February 9, 2023, revealed post-fall strategies that the resident will be evaluated and post-fall care provided, will re-evaluate fall risk utilizing the Post-Fall Evaluation, will update care plan and nurse aide Kardex (a desktop file system that gives a brief overview of each patient) with intervention(s), the interdisciplinary team will review fall documentation and complete a root cause analysis, and review fall trends monthly during QAPI. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 44, dated February 27, 2023, revealed that the resident was understood, could understand, required assistance for care, was occasionally incontinent of bowel and bladder and had diagnoses that included Alzheimer's disease, stroke, and dementia. A care plan for the resident, dated November 3, 2022, revealed that the resident had a self-care deficit. Staff was to encourage the resident with walking to and from the bathroom with a wheeled walker and a moderate assist of one and required limited assist of one staff for toileting. A care plan, dated January 12, 2023, revealed that the resident had behavior problems related to refusal of care and was non-compliant with sensor alarms to his bed and chair (will turn them off or place objects on them so the alarm will not sound or will stop sounding). Staff were to anticipate the resident's needs. A care plan, dated February 27, 2023, revealed that the resident was at risk for falls related to deconditioning, muscle weakness, and fatigue. Staff will anticipate the resident's needs, be sure the resident's call light is within reach, and encourage the resident to use it for assistance as needed. Encourage the resident to use the call bell and wait for assistance when needed. Ensure that the resident is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in his wheelchair. Staff were to offer toileting frequently and were to have multiple urinals placed in the resident's room for the resident to have easy access for usage. A nursing note for Resident 44, dated July 3, 2022 at 8:45 p.m. revealed that at approximately 7:04 p.m. a falling star (an announcement used by the facility to inform staff when a resident has fallen) was announced to room [ROOM NUMBER]. Upon entering the resident's room the resident was sitting on his buttocks in his bathroom with his bilateral knees flexed upwards. The resident was alert and oriented to person, but otherwise confused as per his norm. The resident stated that he ambulated himself to the bathroom without the assistance of his quad cane to urinate. The resident is independent for transfers. The resident stated that he did urinate a small amount on the floor. When he attempted to ambulate back to his bed, he slipped in the urine and fell . A nursing note for Resident 44, dated August 12, 2022, at 2:50 p.m. revealed that the resident expressed increased weakness to bilateral lower extremities and was requesting assistance from staff for transfers. The resident is currently an independent transfer status. The assigned nurse aides were educated to ensure the resident has assistance when needed. A nursing note for Resident 44, dated August 19, 2022, at 3:15 p.m. revealed that a falling star was called. The resident was found kneeling on his right knee. The resident had been to the bathroom and toileted himself and reported that his right knee gave out. A therapy referral was made; however, there were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated October 19, 2022, 3:15 p.m. revealed that a falling star was called to the resident's room. He was found kneeling on his right knee. Resident 44 had been up to bathroom and toileted himself, and he reported that his right knee gave out causing him to fall. There were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated November 19, 2022, at 11:40 p.m. revealed that the resident was found sitting on the floor outside of the bathroom. The resident stated that his legs gave out and he went to his knees while ambulating to the bathroom. The care plan was updated to include verify the alarms. A nursing note for Resident 44, dated November 28, 2022, at 8:11 a.m. revealed that the resident was found lying on the floor in front of the restroom door. The resident stated that he had to use the restroom and got up unassisted. The resident's alarm did not sound. Staff made sure the alarm sounded before leaving the room. The care plan was updated to include make frequent offers to toilet. A nursing note for Resident 44, dated December 9, 2022, at 12:45 a.m. revealed that at approximately 11:00 p.m. on December 8, 2022, the nurse aide walked by the resident's room and noted that the resident was not in bed and was found sitting on the floor. The resident stated that he was walking and lost his balance. The resident was given new footwear. A nursing note for Resident 44, dated January 17, 2023, at 7:11 p.m. revealed that the resident had a unwitnessed fall in his room during shift change at 7:00 p.m. Staff heard a bang in the resident's room and responded finding the resident sitting on his buttocks beside his bed. The resident reported that he hit his head during the fall. The resident stated he had to piss. There was a urinal on the other side of his bed. The alarm on his wheelchair was turned off. The resident has a long history of non-compliance and turning alarms off and not waiting or calling for assistance. The wheelchair alarm was turned back on and another urinal was provided. The care plan was updated to include for the resident to have multiple urinals. A nursing note for Resident 44, dated February 27, 2023, at 9:42 p.m. revealed that at approximately 8:30 p.m., upon entering the room, the resident was found lying on the floor near the walkway. The resident stated that he lost his balance and fell to the floor. The resident did not have his walker by his side. The resident did not ring his call bell. A bowel and bladder program was to be evaluated for appropriateness. However, there was no documented evidence that the bowel and bladder evaluation was started until March 10, 2023. A nursing note for Resident 44, dated March 10, 2023, at 6:02 p.m. revealed that at approximately 5:50 p.m. the resident had a unwitnessed fall in the restroom. The resident ambulated unassisted to restroom and did not use a cane or wheelchair. The call bell was not on. The resident had non-skid socks in place. However, there were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated March 12, 2023, at 11:50 a.m. revealed that the nurse aide entered the resident's room to assist him with toileting and discovered him lying on the floor on his back between the bed and the window. The bed was in the low position and the call bell was in reach. The resident did not have gripper socks on. He reports that he was going to the restroom and was incontinent of bowel and bladder. No injuries were found; however, there were no new interventions put in place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated March 12, 2023, at 1:40 p.m. revealed that staff notified the registered nurse that the resident had a second fall. Nurse aides heard his plate crash to the floor. He was sitting on the floor between his bed and the window. He was complaining of severe pain to left hip and leg. The resident was sent to the hospital. A nursing note for Resident 44, dated March 13, 2023, at 10:16 a.m. revealed that the resident returned from the hospital at 7:00 p.m. on March 12, 2023. All scans were negative and no fractures noted. A nursing note for Resident 44, dated March 13, 2023, at 5:53 p.m. revealed that the resident was having extreme pain to left hip and leg. The physician was notified, and his reply was that he saw his x-rays and he has a fractured hip. The facility's investigation, dated March 12, 2023, revealed that Resident 44 did not ring for help and attempted to ambulate himself to the bathroom. Interview with the Director of Nursing on March 29, 2023, at 9:10 a.m. confirmed that she could not find any new interventions implemented to prevent Resident 44 from repeatedly transferring unassisted. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 8, 2023, revealed that the resident was cognitively impaired, was understood and could understand, required extensive assistance with care, and had a history of falls. A care plan for Resident 56, dated April 27, 2021, revealed that the resident was at risk for falls related to deconditioning, gait balance problems, unawareness of safety needs, and non-adherence to recommendations. Staff were to anticipate and meet the resident's needs and ensure that the resident was wearing appropriate footwear and non-skid socks when ambulating or mobilizing in wheelchair. A fall investigation form, dated April 30, 2022, indicated that Resident 56 had a witnessed fall in the hallway. Resident 56's sweater was caught in the wheel of her wheelchair. The clothing got stuck and she attempted to remove it; however, the resident ended up on the floor. As a result, the intervention was to provide education to Resident 56 to ask for assistance and staff education about removing extraneous items on the wheelchair. The care plan was updated to have staff inspect the wheelchair for extraneous items on the seat or handlebars and remove any items that may pose a risk to the resident while in motion. A fall investigation form date May 28, 2022, indicated that Resident 56 had an unwitnessed fall in the bathroom. Resident 56 was found on the floor in front of the toilet. The resident said she was leaning over to clean up urine on the floor and fell from the toilet. The resident used the call bell after the fall to alert staff. As a result the intervention to provide two-hour checks at night to offer assistance to the bathroom. There was no documented evidence that two-hour checks were implemented or documented. The care plan was updated for staff to check the resident through the night and offer toileting as needed. A fall investigation form, dated June 28, 2022, indicated that Resident 56 had an unwitnessed fall in her room. She transferred herself out of bed without assistance. The investigation revealed that the grippers on her socks were worn down. The care plan was updated to include new gripper socks and to check them to ensure proper grip and replace if the grips were worn. A fall investigation form, dated July 4, 2022, indicated that Resident 56 had an unwitnessed fall in the bathroom. Resident 56 utilized the bathroom call bell and staff responded and found her on the floor. The investigation determined that the resident was non-compliant with asking staff for assistance for toileting and transfers for toilet use. An intervention to have a bathroom door alarm was added to prevent further falls. The care plan was not updated with the new intervention. Observations and interview with Licenced Practical Nurse 1 on March 29, 2023, at 2:56 p.m., revealed that there was no alarm on Resident 56's bathroom door and has not been for a while. There was no documented evidence that a bathroom alarm was added following the fall. A fall investigation form, dated October 21, 2022, indicated that Resident 56 had an unwitnessed fall in her room. Resident 56 self-transferred out of her wheelchair to her bed without assistance. The investigation revealed that she was not wearing gripper socks. As a result, staff were to provide new gripper socks. The care plan was updated to include gripper socks were to be changed daily during a.m. care. A fall investigation form, dated March 5, 2023, indicated that Resident 56 had an unwitnessed fall out of her wheelchair in her room. Upon investigation, the resident's wheelchair had items around and under the cushion of the wheelchair elevating the back of the cushion and causing a forward slope of the chair. The care plan was updated to include an intervention to remove excess items from wheelchair for safety. A fall investigation form, dated March 19, 2023, indicated that Resident 56 had an unwitnessed fall out of her wheelchair in her room. An employee statement revealed that the resident's door was closed and that the resident had closed it to open the bathroom door. An assessment revealed that the resident had on regular socks without grippers and multiple items piled up on the back of the wheelchair and seat (clothing and napkins). Staff removed excess items from the wheelchair seat for safety. Interview with the Director of Nursing on March 30, 2023, at 1:44 p.m. confirmed that the interventions of removing excess items on the wheelchair and having adequate gripper socks on were repetitive, and also confirmed that there was no evidence the bathroom door alarm was ever implemented, and no evidence that two-hour checks for toileting were implemented or documented. A quarterly MDS assessment for Resident 68, dated July 5, 2022, indicated that the resident was able to understand and be understood by others; however, he was moderately cognitively impaired and required extensive assistance from staff for his daily care tasks including with walking. The resident's care plan, dated August 12, 2022, indicated that the resident was at risk for falls related to deconditioning. Interventions on the care plan included to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, bed in low position, bilateral fall mats while in bed, bilateral pool noodles while in bed, encourage resident to ask for assistance when reaching out of bed for items, encourage resident to keep remote control within reach, ensure that the resident is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in wheelchair daily, frequent visualizations related to falls, monitor for malfunctioning sensor alarm, offer nutrition at bedtime, offer the resident to be out of bed to chair when restless, offer tactile objects in an attempt to decrease agitation, use a sensor chair/bed electronic alarm, and check placement and function every shift. A nursing note for Resident 68, dated July 25, 2022, at 3:30 p.m. revealed that staff was called to the resident's room and found the resident lying on his left side on the floor in front of his bathroom door. He had socks on, but no pants or brief. The resident reported that he was trying to take himself to the bathroom. His wheelchair was in the bathroom beside the toilet and the brief was on the toilet. Resident 68's left elbow had a skin tear and the back of his head was noted to have a laceration approximately 1.5 centimeter (cm). Orders were received to send him to the hospital. There was no documented evidence that Resident 68's fall was investigated. A nursing note for Resident 68, dated August 17, 2022 at 3:20 p.m. revealed that the resident had an unwitnessed fall at 3:20 p.m. The resident was found lying on his right side in front of the bathroom door with his chair in the bathroom. The resident was visualized by staff five minutes prior in his wheelchair in the hallway self-propelling without any complaints. Staff had entered another resident's room to provide care when the fall occurred. The wheelchair alarm was on and working and non-skid socks were in place. The resident reported that he took himself to the bathroom and urinated and when he was getting back into his chair he just fell . There were no other witness statements obtained from other staff involved in the residents care that afternoon in an attempt to determine what may have caused the resident to self-transfer to the bathroom. A nursing note for Resident 68, dated October 12, 2022, at 10:05 a.m. revealed that the resident was found by the social services assistant sitting between his bed and the bathroom. He had appropriate footwear on, the call bell was in place, and the bed was in a low position, but the bed alarm was not on. The resident stated that he was trying to go to the bathroom. His bed alarm was turned off and his fall mats were not in place on the floor. There were no other statements obtained from staff who were involved in the resident's care to determine if the bed alarm was on and if the fall mats were in place. A nursing note for Resident 68, dated February 1, 2023, at 3:50 p.m. revealed that the resident had an unwitnessed fall in his room out of his bed. Staff were in another resident's room when they heard the bed alarm sound. Staff entered his room and found him on his knees beside his bed. However, the investigation did not included to see if the fall mats were in place at the time of the fall. Interview with the Director of Nursing on March 30, 2023, at 12:45 p.m. confirmed that there was no documented evidence that Resident 68's fall on July 25, 2022, was investigated and that no additional statements were obtained regarding Resident 68's falls on August 17, 2022; August 28, 2022; and October 12, 2022, and that additional statements should have been obtained from all caregivers involved in the resident's care to include when the resident was last toileted. The Director of Nursing also confirmed that the investigations were not thoroughly investigated to include if all care-planned interventions were in place at the time of the falls. A quarterly MDS assessment for Resident 74, dated February 16, 2023, indicated that the resident was severely cognitively impaired and required extensive assistance from staff for bed mobility, transfers, and locomotion on the unit. Resident 74's care plan, dated May 17, 2022, indicated that he had a deficit with self-care performance related to activity intolerance, impaired balance, limited mobility, and limited range of motion A visual/bedside kardex report for Resident 74, current as of March 8, 2023, revealed that bilateral leg rests were to be used on the wheelchair to provide assistance for staff with propelling. Observations of Resident 74 on March 27, 2023, at 10:46 a.m., revealed that he was sitting in his wheelchair holding on to the ice cart. At 11:20 a.m., the resident had fallen asleep and let go of the ice cart. Licenced Practical Nurse 1 proceeded to push the wheelchair from outside of room [ROOM NUMBER] to room [ROOM NUMBER] while the resident was asleep and both of the resident's feet were sliding on the ground. An interview with Licenced Practical Nurse 1 on March 27, 2023, at 11:23 a.m. revealed that Resident 74's foot rests were forgotten and he had not thought about putting the footrests on, but will make sure they were in place next time, as they should be in place for transport. Interview with the Director of Nursing on March 28, 2023, at 10:30 a.m. confirmed that footrests should have been in place before assistance was provided when a resident was unable to self-propel. An admission MDS for Resident 87, dated January 28, 2023, indicated that he was confused, required extensive assistance of two for bed mobility, extensive assist of one for transfers, limited assistance of two for ambulation in his room, and he had a history of falls. A diagnosis record for Resident 87, dated March 7, 2023, included repeated falls, unsteadiness on his feet, vascular dementia, and anxiety. A nursing note for Resident 87, dated February 23, 2023, indicated that at 12:05 a.m. he was found on the floor beside the right side of his bed and that he had rolled out of his bed. A measure to prevent future falls included fall mats to bilateral sides of the bed to be used when he was in bed. A nursing note, dated February 23, 2023, indicated that at approximately 2:30 a.m. Resident 87's alarm sounded, and he was found on the floor beside his bed. A nursing note, dated February 24, 2023, indicated that at approximately 3:35 a.m. the resident was found on the floor beside his bed and a measure to prevent further falls was to use pool noodles at the sides of the resident's bed. The plan of care for Resident 87, dated February 23, 2023, indicated that he was to have fall mats to bilateral sides of the bed. The task record for nurse aides, dated February 24, 2023, indicated that pool noodles were to be utilized at the sides of Resident 87's bed. Observations of Resident 87 while in bed on March 27, 2023, at 10:16 a.m. and March 28, 2023, at 3:45 p.m. revealed that there was a fall mat on the floor on the left side of the bed only. Observations of Resident 87 on March 29, 2023, at 10:3 a.m. revealed that he was in bed lying on his right side and there were no pool noodles noted on the sides/surface of his bed. Interview with Nurse Aide 7 on March 27, 2023, at 12:02 p.m. revealed that the resident was only to have the fall mat on the left side of the bed. Interview with Registered Nurse 8 on March 28, 2023, at 3:50 p.m. revealed that the resident was to have a fall mat on each side of the bed. Interview with the Director of Nursing on March 29, 2023 at 11:50 a.m. indicated that bilateral fall mats and pool noodles should be in place when the resident is in bed. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for 12 of 58 residents reviewed (Residents 9, 14, 23, 34, 49, 68, 70, 71, 99, 100, 103, 106). The facility's failure created a situation in which two of these residents (Residents 103, 106) were placed in Immediate Jeopardy related to a lack of proper infection control procedures for cohorting residents. Findings include: Pennsylvania Health Alert Network (PAHAN) - 609, Core Infection Prevention and Control Measures for Long-term Care Facilities, dated December 1, 2021, revealed that nursing homes must follow Centers for Medicare and Medicaid Services (CMS) core principles of COVID-19 infection prevention (e.g., in QSO-20-39-NH). These are consistent with principles provided by the Centers for Disease Control and Prevention (CDC) and the Department of Health. For additional information to outline the facility's response to a new suspected, probable, or confirmed case of COVID-19 in a facility staff or resident, or when a resident has been exposed to COVID-19, refer to guidance provided in PA-HAN-610 or its successor. Core prevention measures for COVID-19 in long-term care facilities in Pennsylvania include: Identify a COVID-19 care unit dedicated to monitoring and care for residents with confirmed [CONDITION(S)]-COV-2 infection. Determine the location of the COVID Care Unit and create a staffing plan. Doing this before residents or Healthcare Professional (HCP) with [CONDITION(S)]-CoV-2 infection are identified in the facility will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Facilities that have already identified cases of [CONDITION(S)]-CoV-2 infection among residents but have not developed a COVID Care Unit should work to create one unless the proportion of residents with [CONDITION(S)]-CoV-2 infection makes this impossible (e.g., the majority of residents in the facility are already infected). The location of the COVID Care Unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. The COVID Care Unit should have dedicated entrance and exit points such that HCP not working in that unit do not need to pass through. Identify HCP who will be assigned to work only on the COVID Care Unit when it is in use. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID Care Unit and other units during the same shift. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Ideally, environmental services (EVS) should be dedicated to this unit, but to the extent possible, EVS should avoid working on both the COVID Care Unit and other units during the same shift. To the extent possible, HCP dedicated to the COVID Care Unit (e.g., NAs and nurses) will also be performing cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. HCP should bring an Environmental Protection Agency (EPA)-registered disinfectant (e.g., wipe) from List N into the room and wipe down high-touch surfaces (e.g., light switch, doorknob, bedside table) before leaving the room. HCP working on the COVID Care Unit should have access to a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Ensure HCP practice source control measures and physical distancing in the break room and other common areas (i.e., other than while eating, HCP wear a respirator or source control and sit at least 6 feet apart while on break). Ensure that high-touch surfaces in staff break rooms and work areas are frequently cleaned and disinfected (e.g., each shift). PAHAN - 610, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities (LTCF), dated December 1, 2021, revealed that close contact is someone who was within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period during their infectious period. The infectious period begins from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to specimen collection date of the positive test). Isolation for residents: The term isolation refers to the implementation of measures for a resident with COVID-19 infection during their infectious period, to prevent transmission to other residents, HCP, or visitors. Isolation in LTCF residents includes: Use of standard and transmission-based precautions for COVID-19; a private room with a private bathroom or with another resident with laboratory confirmed COVID-19, preferably in a COVID Care Unit; and restrict the resident to their room with the door closed. In some circumstances (e.g., memory care units) keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway; follow visitation guidance as outlined in QSO-20-39-NH; restrict residents to medically-necessary outings during the isolation period; monitor by assessing symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam at least three times a day; and follow the guidance in PA-HAN-554 to determine duration of isolation for residents. To implement Zone-based guidance in your facility, refer to guidance in PA-HAN-570. For all other outbreak response approaches where a mixture of quarantine and non-quarantine for residents might occur on a single unit, Transmission-Based Precautions, room restrictions, and other quarantine measures must be assigned to the care of each individual resident. PAHAN - 570, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-Term Care Facilities, dated May 10, 2021, revealed that residents needed to be cohorted to separate units in three zones, based on test results: 1. COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. 2. Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. 3. Unexposed (Green Zone) were any residents in the facility who were not tested and were thought to be unexposed to COVID-19. Staff should be designated by zone as much as possible to minimize risk to exposed (Yellow) and non-exposed (Green) residents. PAHAN - 627, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities, dated February 15, 2022, revealed that if signs and symptoms of COVID-19 develop: Perform [CONDITION(S)] testing, implement isolation while results are pending, place roommate(s) who are not up to date with all recommended COVID-19 vaccine doses under quarantine immediately. Remove roommate quarantine if an alternative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .e., roommate quarantine does not need to be a full 10 days if the resident is determined to not have COVID-19 infection), and do not place a person with suspected COVID-19 into a COVID Care Unit prior to confirmation of infection by positive test result. Guidance from the Centers for Disease Control (CDC - a national public health agency), dated April 30, 2020, included that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. Interview with the Nursing Home Administrator on April 28, 2022, at 10:00 a.m. revealed that Resident 106's room (room [ROOM NUMBER]) was a Red Zone due to her being a new admission that was tested COVID-19 positive during her recent admission to the hospital. An admission note for Resident 106, dated April 26, 2022, at 5:09 p.m. revealed that the resident entered the facility from the hospital and she was COVID-19 positive and under isolation. A facility's hospital report sheet for Resident 103, dated April 27, 2022, at 2:27 p.m. revealed that the resident had a complaint of a sore throat and cough while in the hospital. Her roommate in the hospital was positive for COVID-19. Multiple tests were completed on the resident and all were negative. The last COVID-19 test was negative on April 26, 2022. A progress note for Resident 103, dated April 27, 2022, at 3:20 p.m. revealed that the resident was readmitted to the facility from the hospital into room [ROOM NUMBER]-B. A progress note for Resident 103, dated April 27, 2022, at 10:30 p.m. revealed that the resident's COVID-19 test was negative. A progress note for Resident 103, dated April 28, 2022, at 11:30 a.m. revealed that the resident's COVID-19 test was negative. Observations of Residents 103 and 106 on April 28, 2022, at 10:15 a.m. and 2:10 p.m. revealed that they resided in the same room that was identified as a Red Zone with no type of barrier between them. Interview with Registered Nurse 4 on April 28, 2022, at 10:22 a.m. revealed that Resident 106 became COVID-19 positive during her admission in the hospital and Resident 103 was exposed to a COVID-19 positive roommate during her admission in the hospital. Resident 103's COVID-19 test was negative, but she was symptomatic, so she was presumed positive and placed into isolation with Resident 106. Interview with the Assistant Director of Nursing/Infection Preventionist on April 28, 2022, at 11:46 a.m. revealed that Resident 103 was tested for COVID-19 at the hospital on April 26, 2022, and was negative. On April 26, 2022, she was told through report that Resident 103 developed a sore throat and that she was in the same room as a positive resident, so she was presumed COVID-19 positive. That is why she was placed into isolation. An interview at 12:10 p.m. revealed that Resident 103 was tested for COVID-19 when she was readmitted to the facility and was negative at that time. An interview at 1:40 p.m. revealed that because Resident 103 was in the hospital with a COVID-19 positive patient as a roommate and the resident was experiencing symptoms, she was presumed COVID-19 positive and could be placed in the same room as Resident 106. A COVID-19 test result for Resident 70, dated January 21, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 14, dated January 14, 2022, revealed that the resident was negative. Daily census information revealed that Residents 70 and 14 were roommates at the time that Resident 70 had a positive test result on January 21, 2022, and there was no documented evidence that either resident was moved following Resident 70's positive test result. Daily census information for Residents 70 and 14, dated January 22, through 27, 2022, revealed that they remained as roommates during that time period. A progress note for Resident 14, dated January 27, 2022, at 11:07 p.m. revealed that at approximately 9:00 p.m, the resident complained of generalized fatigue (a lingering tiredness that is constant and limiting) and not feeling well all over. A Rapid COVID-19 test was performed and the results were noted to be positive. Interview with the Nursing Home Administrator on April 30, 2022, at 1:55 p.m. confirmed that there was no documented evidence that Residents 70 and 14 were moved following Resident 70's positive test result. A nursing note for Resident 23, dated February 9, 2022, at 10:02 a.m. revealed that the resident had a large emesis of undigested food. The resident stated that he got nauseated all of a sudden. A nursing note for Resident 23, dated February 10, 2022, at 3:20 p.m. revealed that the resident tested positive for COVID-19. The Nursing Home Administrator, resident and family were aware and precautions were being taken per protocol. Daily census information, located in the resident's electronic health record, revealed that Resident 23 and 71 were roommates on February 10, 2021. There was no documented evidence that either resident was moved following Resident 23's positive COVID-19 test result until the next day on February 11, 2022. Interview with the Nursing Home Administrator on April 29, 2022, at 3:07 p.m. confirmed that there was no documented evidence that Resident 23 or 71 were moved following Resident 23's positive COVID-19 test result until the next day on February 11, 2022. Interview with Pennsylvania Department of Health Epidemiology Research Associate 5 on April 28, 2022, at 2:33 p.m. revealed that she could confirm that nothing has changed in regards to cohorting negative residents with known COVID-19 positive cases. The most current guidance PA-HAN 627 and all previous HAN's do advise against mixing confirmed positive cases with those who may have been exposed, but have received a negative test result. The facility's policy regarding COVID-19 Pandemic Plan, dated March 2, 2020, and revised March 11, 2022, revealed that staff performing testing will use recommended PPE (respirator/mask if respirator not available, eye protection, gloves, and gown) during specimen collection. Observations of Registered Nurse 6 on April 28, 2022, at 4:18 p.m. revealed that she entered Resident 68's room with only a N95 mask and gloves. She obtained a COVID-19 test from the resident and then returned to a cart with her supplies sitting in the doorway of the resident's room. She then placed a face shield and re-entered the room and obtained a COVID-19 test on Resident 100. She then returned to her cart and then went to Resident 9 and 49's room and obtained COVID-19 tests on the residents while only wearing a face shield, N95, and gloves. She then went to Resident 99 and 34's room and obtained COVID-19 tests on the residents while only wearing a face shield, N95, and gloves. Interview with Registered Nurse 6 on April 28, 2022, at 3:29 p.m. confirmed that she should have been wearing a gown along with the face shield, N95, and gloves when obtaining the COVID-19 tests on the above residents. Interview with the Assistant Director of Nursing/Infection Preventionist on April 28, 2022, at 4:07 p.m. confirmed that Registered Nurse 6 should have been wearing a gown along with the face shield, N95, and gloves when obtaining the COVID-19 tests on the above residents. On April 28, 2022, at 2:46 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to cohorting COVID-19 positive and negative residents in the same room, and for failing to follow established infection control guidelines. The NHA was provided the IJ template. The facility submitted and implemented an immediate action plan that included ensuring that each resident's most recent COVID-19 test result was reviewed. Resident 103 (who tested negative) was moved out of the room where she was previously residing with Resident 106 (who tested positive) to a single room for quarantine. An area was designated to cohort COVID-19 positive residents together. The facility developed an infection control education plan for all current and future staff, including agency staff, and staff who were currently off work related to testing positive for COVID-19. The education included cohorting positive and negative residents in the proper infection control zones. The Immediate Jeopardy was lifted on April 29, 2022, at 11:39 a.m. when it was confirmed that the facility moved all residents into the correct infection control zones in accordance with their COVID-19 test results, educated the majority of staff, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards to residents who were at risk for falls for one of 44 residents reviewed (Resident 61), resulting in a fall with a [MEDICAL CONDITION]. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated (MONTH) 9, 2019, revealed that the resident was understood and could understand; required assistance from two staff for bed mobility, transfers, toileting, and personal hygiene; required extensive assistance from one staff for dressing; and had [DIAGNOSES REDACTED]. The resident's care plan dated (MONTH) 26, (YEAR), revealed that he was at risk for falls and staff were to follow the facility's fall protocol. However, the falls care plan did not indicate how much assistance the resident required for bed mobility. The resident's care plan for daily care tasks, dated (MONTH) 26, (YEAR), revealed that he was dependent on two staff for transfers, dressing, grooming, personal hygiene, and locomotion. The care plan contained a bed mobility program, which indicated that the resident required the assistance of two and was to roll frequently from the right side to his back and back to his right side, and two staff were to assist him to turn and reposition in bed each shift. A revision to the resident's care plan, dated (MONTH) 17, (YEAR), revealed that the resident was totally dependent on two staff for repositioning and turning in bed frequently and as needed. Occupational therapy notes for Resident 61, dated (MONTH) 13, (MONTH) 3 and (MONTH) 12, 2019, revealed that the resident previously required moderate assistance with side rolling. He had impairments in balance, fine motor coordination, mobility, strength, and planning and problem solving, resulting in limitations and/or participation restrictions in the areas of self care, mobility, and general tasks and demands. The note of (MONTH) 12, 2019, revealed that the resident was dependent for bed mobility. A nursing note for Resident 61, dated (MONTH) 5, 2019, at 4:46 p.m. revealed that a nurse aide was giving personal care to the resident with the bed in an elevated position and with the resident positioned on his right side. The nurse aide said she pulled the resident to the left side of the bed prior to turning him. After cleansing, she asked him if he was okay on his side and the resident indicated that he was. She then looked to the end of the bed to retrieve the liner to put under him, and when she looked away, the resident fell off the bed to the fall mat. The nurse found him lying on his back on the fall mat on the right side of his bed, and he complained of a headache and right hip pain. The physician was contacted and ordered a right hip x-ray. The nurse aide was told that the resident needed the assistance of two for care. A nursing note for Resident 61, dated (MONTH) 5, 2019, at 10:22 p.m. revealed that the facility received an x-ray report, which indicated that the resident had a possible [MEDICAL CONDITION], the physician was notified, and the resident was sent to the hospital for further x-rays. A fall investigation report for Resident 61, dated (MONTH) 5, 2019, revealed that the resident's transfer and bed mobility status was assistance from two staff. The resident received assistance from only one staff, not two, and the potential cause of the fall was that the resident was not safe on his side with one staff assisting. The report indicated that the resident needs the assistance of two staff for safety. A witness statement completed by Nurse Aide 7, dated (MONTH) 5, 2019, revealed that she was providing care for Resident 61 and had him on his side facing the roommate. She asked him if he was okay on his side. She turned her head and he rolled off the bed onto the floor. A hospital discharge summary for Resident 61, dated (MONTH) 13, 2019, revealed that the resident had been hospitalized for [REDACTED]. Interview with the Director of Nursing on (MONTH) 2, 2019, at 3:45 p.m. confirmed that Resident 61's care plan indicated that he required the assistance of two for bed mobility. She stated that the resident's task list indicated that he needed the assistance of one with bed mobility. However, review of the task list dated (MONTH) 26, (YEAR), revealed that the resident was on a restorative nursing program for bed mobility, which included that the resident was to have the assistance of two to roll frequently from his right side, to his back, and back to his right side. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/17/19, 6/29/18, 6/8/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/2717. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/29/18 9/27/17, 6/8/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 5/17/19, 1/16/19, 6/29/18, 5/8/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/16/19, 6/29/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/17/19, 1/16/19, 6/29/18, 5/8/18, 6/8/17.

Based on clinical record reviews and facility investigation reports, as well as staff and family interviews, it was determined that the facility failed to ensure that the staff were properly trained in safe methods for wheelchair transports for one of 27 residents reviewed (Resident R9), which resulted in a fracture for the resident. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R9, dated May 18, 2017, indicated that the resident was alert and oriented, could understand others and make himself understood, required the extensive assistance of one person for locomotion both on and off the nursing unit, and had limited range of motion of his lower extremities along with muscle weakness and lack of coordination. An occupational therapy initial evaluation, dated May 12, 2017, revealed that Resident R9 had a history of [REDACTED]. Resident R9's care plan, initiated May 12, 2017, indicated that the resident was at risk for injury due to a history of a stroke with left-sided weakness. A nursing note for Resident R9, dated May 19, 2017, at 3:00 p.m. indicated that during shift-to-shift report, Nurse Aide 1 came to the desk and reported that Resident R9 and his family member told Nurse Aide 1 that when he was being transported to therapy in the morning, the foot rests of his wheelchair were not in place, and the therapist told the resident that it was only a short distance and it would be all right; but during the transport, the resident's leg dropped and got drug up under the wheelchair. A nursing note for Resident R9, dated May 19, 2017, at 5:18 p.m. revealed that Resident R9 complained of burning in his leg and pain that was rated as a four on a scale of one to ten, a note at 7:48 p.m. indicated that the resident complained of severe leg pain that was rated as an eight out of ten, and a note at 7:59 p.m. indicated that the physician was contacted and new orders for different pain medication and an X-ray were obtained. The X-ray report, dated May 19, 2017, revealed a fractured left ankle bone. Review of the information dated May 20, 2017, submitted by the facility indicated that an investigation of the incident revealed that Resident R9 was being transported to an activity by an activity assistant (not a therapist) when the incident occurred. A written statement from Activity Assistant 2, dated May 20, 2017, indicated that she was taking Resident R9 to an activity at approximately 9:45 a.m. on May 19, 2017, and while pushing him, his left foot dropped down under the wheelchair and he complained of pain, so she stopped pushing him, informed the nurse assigned to his hallway about the incident, and took him back to his room. The statement by Activity Assistant 2 indicated that she noted that the resident did not have his foot rests on his wheelchair, but she did not know that he needed them. She stated that Resident R9 told her he could hold them up (his legs) and she told him if he needed a rest to let her know and she would stop. The facility's investigation information indicated that neither the resident's care plan nor the Kardex (a quick reference tool for staff that highlights important aspects regarding resident's individualized care needs) reflected the need for foot rests on Resident R9's wheelchair. The investigation identified that the facility had no policy related to the use of wheelchair foot rests for transport. Interview with Activity Assistant 3 on June 6, 2017, at 1:15 p.m. revealed that she had been in her current position for two years and that transporting residents in wheelchairs to and from activities was a routine part of the job. She stated that prior to the incident involving Resident R9 she had never been taught or trained regarding the use of foot rests when transporting a resident in a wheelchair. Interview with Activity Assistant 4 on June 7, 2017, at 2:10 p.m. revealed that she had been in her current position as an activity assistant for almost one year; and up until the incident involving Resident R9, when transporting residents via wheelchair, she would ask them to hold their legs up if they did not have foot rests on the chair. She indicated that she did not recall any formal training regarding when foot rests were needed during her initial orientation nearly one year ago. Interview with Nurse Aide 6 on June 6, 2017, at 11:10 a.m. revealed that she had been a nurse aide for seven years and was trained to always use foot rests when transporting any resident in a wheelchair. Interview with Nurse Aide 8 on June 6, 2017, at 11:20 a.m. revealed that she had been a nurse aide for two years and was trained to always use foot rests when transporting any resident in a wheelchair. Interview with Nurse Aide 5 on June 6, 2017, at 1:40 p.m. revealed that she had been a nurse aide for [AGE] years and was trained to always use foot rests when transporting any resident in a wheelchair. Interview with Licensed Practical Nurse 9 on June 8, 2017, at 12:30 p.m. revealed that she had been a nurse for five years and was trained to always use foot rests when transporting a resident in a wheelchair. Interview with the Activities Director, who was a trained nurse aide, on June 7, 2017, at 6:00 p.m. revealed that her three activity assistants were not trained as nurse aides, and she believed that her staff would have received safe wheelchair transport training with the facility's general orientation upon hire. Interview with the Director of Nursing on June 8, 2017, at 1:15 p.m. confirmed that there was no documented evidence that the activity assistants received any training regarding safe wheelchair transport and that they should have been instructed to always use foot rests when moving residents via wheelchair through the hallways. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/29/15. 28 Pa. Code 201.20(b)(c) Staff development. 28 Pa. Code 211.12(d)(2) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/12/16, 5/12/16, 12/10/15, 6/29/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/18/16, 9/12/16, 5/12/16, 12/10/15, 6/29/15.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards from the use of side rails for 10 of 37 residents reviewed (Residents R2, R4, R8, R9, R11, R17, R18, R19, R21 and R28), placing the safety of Resident R8 in Immediate Jeopardy. The facility also failed to ensure that the residents' environment was free from accident hazards caused by rough and/or sharp edges on handrails and a heater knob. Findings include: The facility's policy regarding side rail screening, dated May 13, 2015, indicated that all residents would be screened on admission and quarterly for the use of side rails as an enabler versus a restraint. The policy failed to include screening of side rails as potential accident hazards. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R8, dated April 15, 2015, indicated that the resident had short and long-term memory impairment, was severely cognitively impaired for decision making, required the assistance of staff for bed mobility and had a history of [REDACTED]. The recommendation following these assessments was for the resident to have half-length side rails on both sides of the bed. There was no documented evidence that these evaluations included an assessment to determine if the use of the side rails posed a safety hazard for the resident. A nursing note and incident report, dated March 1, 2015, indicated that Resident R8 was found on the floor, beside the right side of his bed, and that the half-length side rails were up at the time of the fall. The incident report also indicated that the resident may have scooted himself and/or leaned over the side rail and fell on to the floor, and as a result of the fall, the resident had a quarter-sized red mark on his left hip and bruising to both forearms. A Falls Committee note, dated March 2, 2015, and a therapy screen dated March 3, 2015, revealed no documented evidence that, following the resident's fall out of bed on March 1, 2015, the continued use of the side rails was assessed as a safety hazard for the resident. Observations on June 22, 2015, at 2:22 p.m. and 2:25 p.m., revealed that Resident R8 was in a bed that was equipped with side rails on both sides that were positioned in the middle of the bed and the bed was also equipped with an air mattress. The resident was lying sideways with his feet close to the rail on his right side, and his head near the rail on the left side. Observations on June 23, 2015, at 9:20 a.m., revealed that the resident was in bed with the head of the bed elevated, and he was sliding down in the bed with his head close to the left side rail. Interviews with Nurse Aides 1 and 2, on June 22, 2015, at 4:30 p.m., revealed that Resident R8 frequently slid down in bed or was sideways, and they frequently had to help him straighten out in bed. Interviews with the Nursing Home Administrator and a Nurse Consultant on June 25, 2015, at 3:00 p.m., confirmed that potential safety hazards created by the use of side rails and/or the air mattress for Resident R8 were not assessed. They further indicated that the air mattress was placed on the resident's bed on February 6, 2015, but after its placement, an assessment for any safety hazards associated with the use of the air mattress, in conjunction with the side rails, was not completed. A quarterly data collection/side rail evaluation, dated June 9, 2015, for Resident R28 indicated that the resident had altered safety awareness due to cognitive decline and a history of falls. The evaluation recommended half-length side rails to both sides of the bed. An incident report, dated May 16, 2015, revealed that the resident slept too close to the edge of the bed, rolled off the bed, struck her head/face, and sustained a bruise and abrasion on the outer aspect of her right eye orbit. Another incident report, dated June 17, 2015, also indicated that the resident slept too close to the edge of the bed, fell on to the floor, and her knees were reddened from the fall. There was no documented evidence that the use of side rails was assessed as a possible safety hazard for the resident. A quarterly MDS assessment, dated May 19, 2015, revealed that Resident R2 was confused, required extensive assistance with care, and had a [DIAGNOSES REDACTED]. The evaluation recommended the use of side rails but also indicated that the use of side rails did not appear to be indicated. An incident report, dated June 2, 2015, revealed that a bruise was found on the resident's right upper elbow. The report indicated that the resident was non-ambulatory, had a history of [REDACTED]. There was no documented evidence that an assessment of the side rails as a possible safety hazard for the resident was completed. A quarterly data collection/side rail evaluation, dated June 7, 2015, for Resident R18 revealed that the resident had altered safety awareness due to cognitive decline, difficulty with balance, poor trunk control and half-length side rails were recommended on both sides of the resident's bed. There was no documented evidence that the use of side rails was assessed as a possible safety hazard for the resident. Observations on June 24, 2015 at 11:30 a.m., revealed that the resident was in bed with side rails in use on both sides of the bed. A quarterly data collection/side rail evaluation, dated May 28, 2015, for Resident R19 revealed that the resident was non-ambulatory and demonstrated poor bed mobility. The evaluation recommended the use of side rails to provide safety but also indicated that the use of side rails did not appear to be indicated at that time. There was no documented evidence that the use of side rails was assessed as a possible safety hazard for the resident. Observations on June 24, 2015 at 1:08 p.m., revealed that the resident was in bed with side rails in use on both sides of the bed. Quarterly data collection/side rail evaluations, dated May 22, 2015, for Resident R4; June 3, 2015, for Resident R11; May 15, 2015, for Resident R17; February 10, 2015, for Resident R21; and May 13, 2015, for Resident R9, revealed that there was no documented evidence that the use of side rails was assessed as a possible safety hazard for the residents. Interviews with the Nursing Home Administrator and a Nurse Consultant on June 25, 2015, at 3:00 p.m., revealed that none of the side rails in use for residents were assessed as potential safety hazards. On June 25, 2015 at 3:15 p.m., the Nursing Home Administrator was informed that the health and safety of Resident R8 was in Immediate Jeopardy due to the lack of assessment regarding the resident's side rail use as a safety hazard and the resident's risk for injury from side rail use related to his poor cognition, independent bed mobility with poor body control, history of a fall from bed and use of an air mattress. The facility submitted and implemented a plan to ensure Resident R8's safety by changing his bed to one without side rails and to complete assessments of side rail use as a possible safety hazard for all residents currently using side rails. The Immediate Jeopardy was removed during an on-site visit on June 26, 2015 at 2:15 p.m. Observations in the 200 hallway on June 23, 2015, at 11:45 a.m., revealed that the wooden hand rail by Room 202 had a rough, sharp area and the wooden hand rail by Room 201 had a nail sticking out. Observations in the 400 hallway on June 23, 2015, at 12:05 p.m., revealed that the wooden hand rail by Room 414 was broken and had a nail sticking out. Observations in the 200 hallway on June 23, 2015, at 1:35 p.m., revealed that a heater located on the lower wall had a protruding knob that was broken with sharp edges. Interview with the Maintenance Technician on June 24, 2015, at 10:40 a.m., confirmed that the heater knob was sharp. She indicated that the facility needs new handrails. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 3/16/15, 6/19/14. 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. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/16/15, 10/9/14, 8/22/14, 6/19/14, 1/22/14.