Every finding on record at Pennswood Village

Based on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment. Findings include: Review of the facility's facility assessment, dated July 06, 2026, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with Employee E1, Administrator, on August 18, 2026, at approximately 11:40 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18 (b)(3) Management.28 Pa. Code 211.12 (d)(1) Nursing services.

Based on staff interviews, review of facility policy and clinical record review, it was determined that the facility failed clinically assess and notify the resident's physician after a change in condition for 1 out of 16 residents reviewed (Residents R12). Findings include: Review of Resident R12's September 2025 physician orders included the following diagnoses obesity, hypertension (high blood pressure); chronic pain; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety (intense, excessive and persistent worry and fear about everyday situations); muscle weakness, and osteoarthritis (the most common form of arthritis, characterized by joint pain and stiffness). Review of the facility policy, Changes in a Resident's Condition or Status revised February 2021 indicated that the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and his/her status. Continued review of the policy indicated that prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form (Situation-Background-Assessment-Recommendation) a tool used by nursing staff that includes, but not limited to, an assessment of the resident's current change in condition, including clinical findings.Review of a nursing note documented by Employee E3 (licensed nurse) dated September 20, 2025 at 5:29 p.m. revealed Resident returned to the unit from her apartment around 1710 (5:10 p.m.). Resident has a slurred speech and has difficulty making sentences. Eyes closing while talking to staff. Cheeks flushed. Resident unable to fully pull herself up when using Hoyer lift for sit to stand. Says she is sleepy and would like to take a nap. Resident was placed in her bed around 1725 (5:10 p.m.)Review of the resident's nursing notes did not show evidence that any other follow-up was initiated by licensed nursing staff (e.g. vital signs) regarding the above referenced changes in the resident's medical condition that the resident was observed as exhibiting. Continued review of the nursing notes did not show evidence that the physician was notified regarding the resident's change in medical condition on September 20, 2025 to see if there were any interventions/instructions/treatment and/or further assessments that the physician may have wanted nursing staff to implement for the resident. During an interview with Employee E3 on September 25, 2025 at 12:02 p.m. Employee E3, the note from September 20, 2025 that Employee E3 wrote was reviewed with her. During the interview, Employee E3 confirmed that that she observed the resident having slurred speech, having difficulty making sentences, and explained that the resident was closing her eyes while the resident was speaking to nursing staff upon the resident's return from her leave of absence outside of the facility. During the above referenced interview Employee E3 also confirmed that she did not conduct any clinical assessments of the resident after she observed the resident exhibiting the above referenced changes in her condition. Continued interview with Employee E3 on September 26, 2025 at 10:30 a.m. confirmed that she also did not notify the physician of the resident's change in medical condition. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(b)(2) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.5(g) Clinical records28 Pa. Code 211.12(c) Nursing services28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(2) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on staff interviews, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that the resident's physician orders were accurate for 1 out of 16 residents reviewed (Resident R12). Findings include: Review of the facility policy, Attending Physician Responsibilities, with a revision date of August 2025 indicated that attending physicians shall be the primary practitioners responsible for providing medical services, and coordinating the healthcare of each resident in the facility. Continued review of the policy indicated that each attending physician will be responsible for the following which included, but not limited to, accepting responsibility for initial and subsequent resident care; supporting discharges and transfers; providing appropriate care, and providing appropriate, timely, and pertinent documentation. The policy also indicated that the attending physician will seek, provide and analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care, and to support facility compliance with regulations, and care standards. Continued review of the policy also indicated that in consultation with facility staff, the physician will verify that treatments and services, including rehabilitation services, are medically necessary and appropriate in accordance with relevant criteria. Review of Resident R12's September 2025 physician orders included the following diagnosis: obesity, hypertension (high blood pressure); chronic pain; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety (intense, excessive and persistent worry and fear about everyday situations); muscle weakness, and osteoarthritis (the most common form of arthritis, characterized by joint pain and stiffness).Continued review of the September 2025 physician order included a physician's order dated March 12, 2025, and monthly thereafter, for the resident to have supervised leave of absence (LOA) visits. Resident may go on LOA supervised with meds.Review of the resident's nursing notes indicated that on May 6, 2025 at 11:26 p.m. the resident returned from her leave of absence for the day, and reported to nursing staff that she spilled hot tea on her thighs. Review of a progress note completed by the nurse practitioner on May 7, 2025, at 9:12 a.m. indicated that the resident had sustained 2nd degree burns on both thighs, as the result of the resident's spilling hot tea on her thigh.Review of a nursing note dated May 28, 2025 at 3:33 p.m. indicated that the resident was off the nursing unit on a leave of absence, and was found on the floor in her independent living apartment after she fell from her motorized scooter. The nursing note indicated that the resident was home alone, and was eventually found by her husband on the floor of her apartment when her returned home.Review of a nursing note on September 20, 2025 at 5:29 p.m. indicated that the resident returned from her leave of absence off the nursing unit, and was observed by nursing staff as having slurred speech, difficulty making sentences, and her eyes closing while the resident was speaking with staff.During an interview with the Director of Nursing (DON) on September 25,2025 at 9:30 a.m. and the Nursing Home Administrator, the DON regarding the above referenced incidents that occurred when the resident was on supervised leave of absence, per the current physician's order, the DON explained that the physician's order was incorrect, as the resident did not need supervision when she is off the nursing unit.During an interview with the resident's attending physician (Employee E4) on September 22, 2025 at 12:22 p.m. the physician confirmed that the physician order for supervised leave of absence for the resident that had been ordered since March 2025, was incorrect. The attending physician explained that the resident did not have to be supervised when she is on leave of absences. During the interview, the physician also confirmed that physician orders are reviewed monthly by the nurse practitioner and the attending physician. 28 Pa. Code 211.5. (f)(i) Medical records

Based on review of clinical record, facility documentation, facility policy and interviews with staff, it was determined the facility failed to protect the resident's right to be free from physical abuse by Employee E1 which resulted in actual harm to Resident R1 who sustained a bruise and hematoma (collection of blood outside of a blood vessel) to right hand and wrist for one of three residents reviewed (Resident R1). Findings include: Review of facility policy titled Abuse Policy, revised 2023, revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease (brain disease that causes memory loss and other cognitive impairment), Hypothyroidism (thyroid gland does not produces enough hormones), and Anxiety disorder. Review of Resident R1's quaterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs), dated January 20, 2025, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of Resident R1's care plan, initiated on March 03, 2023, revealed Resident R1 can be resistive to care as evident by refusing care and refusing to get dressed related to Alzheimer's disease and Dementia mild with psychotic disturbance. One intervention included if Resident R1 resists ADL's (activities of daily living), reassure resident, leave and return 5-10 minutes later and try again. Review of Resident R1's nursing note, dated March 21, 2025, at 11:41 a.m, indicated Resident R1 was in the lounge and staff observed a hematoma measuring 4.7 centimeters (cm) x 3.8 cm to right dorsal (back) hand. Area is tender to touch and purple in color. Resident frequently attempts to self transfer from bed and from wheel chair. Resident at times can be combative with staff during care, (she/he) will attempt to swat away and refuse care. Provider notified of new finding. Review of Resident R1's physician note, dated March 21, 2025, at 2:13 p.m., revealed physician assessed Resident R1's hematoma on right hand and wrist. Hematoma measured 7 to 8 cm in diameter, raised, and slightly tender to touch. Continued review of physician note dated March 21, 2025, revealed it was reported Resident R1 was punched in the stomach by one of the aides during care. Physician returned to reassess Resident R1and noted no injuries on abdomen or chest. Review of facility investigation dated, March 21, 2025 at 1:30 p.m., revealed Nurse Aide, Employee E2, reported to Director of Nursing, Employee E3, of an abuse incident that occurred on March 21, 2025 during morning care. Nurse Aide, Employee E2, stated she was providing Resident R1 morning care with assistance from Nurse Aide, Employee E1. Resident R1 began kicking and punching the staff. Nurse Aide, Employee E2, then observed Nurse Aide, Employee E1, punch Resident R1 on the right side of her abdomen and grabbed Resident R1's wrist / hands and twisted aggressively. Further review of facility investigation revealed Nurse Aide, Employee E1, was immediately removed from the nursing unit at 1:35 p.m. Police was immediately notified at 1:44 p.m., county area agency on aging at 1:49 p.m., Ombudsman notified at 2:15 p.m. Power of Attorney notified. Verbal statement taken. Skin assessment completed on [Resident R1], findings were new bruise/hematoma to right dorsal hand/wrist. Physician assessed [Resident R1] at 2:20 p.m., no findings noted to abdomen, no complaints of pain and or discomfort expressed by [Resident R1] at this time, [Resident R1] does not recall situation related to cognitive impairment. Police substantiated abuse incident. Additional review of facility documenation revealed the allegation of abuse was substantiated by the facility. Interview conducted on April 02, 2025 at 11:00 a.m. with Administrator, Employee E3, and Director of Health Services, Employee E4, confirmed the above incident was substantiated. The facility failed to ensure that Resident R1 was free from physical abuse by Employee E1. This failure resulted in actual harm to Resident R1 who sustained a bruise and hematoma to right hand and wrist. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, hospital records, facility documentation, facility policies, FDA (Food and Drug Administration) guidelines, and interviews with staff, it was determined the facility failed to provide care and services that meet the professional standards of quality and as outlined in resident's plan of care for one of 13 residents reviewed (Resident R17). The facility failed to accurately and timely notify the physician after Resident R17 who was on blood thinner medication, sustained a fall in the bathroom. The facility failed to conduct comprehensive assesment of Resident R17 in a timely manner after the resident showed abnormal blood pressure levels following the fall and after the administration of a routine anti-coagulant medication. The facility's failure resulted in Resident R17 not receiving emergency medical care for approximately 10 hours after the fall, sustaining a subdural hemorrhage which required transfer to the hospital and expiring in the hospital. This failure placed Resident R17 in an Immediate Jeopardy situation. (Resident R17) Findings Include: Review of facility policy Notification of Changes in Resident's Status dated [DATE], revealed Purpose: To assure that each resident and/or resident representative is notified timely of accidents that result in injury and have the potential for physician intervention; significant changes in status; significant changes in treatment; abnormal lab, radiology or other diagnostic test results; transfer or discharge associated with the health or safety of the resident; change in roommate status or change in resident rights under Federal or State law or regulations. Further review of facility policy revealed Pennswood Village shall provide timely notification to each resident and/or resident representative of accidents that result in injury and have the potential for physician intervention, significant changes in condition, significant change in treatment, transfer/discharge status related to health or safety of the resident or other individuals in the facility, roommate status or change in resident rights under Federal or State law or regulations. The Community will notify the physician in person, by telephone or in writing of the following changes or events: a. An accident which results in injury and has the potential for requiring physician intervention. b. A significant change in physical, mental, or psychosocial status. Significant change is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. c. Abnormal lab, radiology or other diagnostic test results may be communicated to the ordering clinician. d. A need to alter treatment significantly. Significant alteration is the need to discontinue or change an existing form of treatment due to adverse consequences, or to commence new form of treatment. e. A decision to transfer or discharge a resident related to health or safety of the resident or other individuals in the facility. Review of FDA guidelines for the medication Xarelto revealed that XARELTO increases the risk of bleeding and can cause serious or fatal bleeding. In deciding whether to prescribe XARELTO to patients at increased risk of bleeding, the risk of thrombotic events should be weighed against the risk of bleeding. Promptly evaluate any signs or symptoms of blood loss and consider the need for blood replacement. Bleeding Risks -advise patients to report any unusual bleeding or bruising to their physician. Inform patients that it might take them longer than usual to stop bleeding, and that they may bruise and/or bleed more easily when they are treated with XARELTO [see Warnings and Precautions (5.2)]. If patients have had neuraxial anesthesia or spinal puncture, and particularly, if they are taking concomitant NSAIDs (non-steroidal anti-inflammatory) or platelet inhibitors, advise patients to watch for signs and symptoms of spinal or epidural hematoma, such as back pain, tingling, numbness (especially in the lower limbs), muscle weakness, and stool or urine incontinence. If any of these symptoms occur, advise the patient to contact his or her physician immediately. Increased risk of bleeding: XARELTO can cause bleeding which can be serious and may lead to death. This is because XARELTO is a blood thinner medicine (anticoagulant) that lowers blood clotting. During treatment with XARELTO you are likely to bruise more easily, and it may take longer for bleeding to stop. You may have a higher risk of bleeding if you take XARELTO and have certain other medical problems. Review of facility reported incident dated [DATE], revealed Resident R17 was noted on [DATE], at approximately 3:00 a.m. observed sitting on the floor in the bathroom with the resident's back against the wall. The resident's pants were down, and the floor was wet with urine. Resident R17 stated, I hit my head. The resident was awake and alert, speech was clear and answered appropriately. Neuro checks initiated and was within normal limits. Resident was able to move all extremities and denied pain. [Resident R17] was noted with increased blood pressure post fall, which was discussed with [Nurse Practitioner, Employee E4], as well as current clinical presentation offering no other complaints at this time and no visible signs of injury, recommended to continue current plan of care and give morning medications. Morning medications given including Furosemide and Cardizem. In the early afternoon around 12:30 p.m. the resident was noted with complaint of head pain, left eye pain, nausea, as well as vomiting. The physician was called, and ordered to send the resident to the hospital for evaluation. Resident was transferred to the hospital. Upon arriving to the emergency room , a CT (computed tomography) scan was completed and Resident R17 was noted with a 16 millimeter (mm) subdural hematoma (pool of blood between the brain and its outermost covering) with a 6 mm midline shift (displacement of brain tissue that occurs when the brain is pushed to one side of its natural centerline. It can be caused by a number of things, including traumatic brain injury). Family wished for conservative management per trauma team and no surgical intervention, goal was comfort. Resident R17 passed away at the hospital. Review of facility incident report dated [DATE], revealed that Resident R17 was found sitting on the floor. Resident stated, I hit my head, The time of the incident was documented as 2:05 a.m. Further review of the incident report revealed that the physician notification time was 3:40 p.m. There was no documentation of mode of communication and physician response. There was no documented evidence that physician responded to the notification. Review of medication administration record for Resident R17 for [DATE] revealed that the resident received Xarelto 15 milligrams (mg) every evening at 6 p.m. and the resident received a dose on [DATE]. Review of care plan for Resident R17 dated [DATE] revealed that resident was on anticoagulant therapy Xarelto related to Atrial fibrillation (irregular and rapid heartbeat) with care plan intervention including monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of neurological assessment dated [DATE], at 2:15 a.m. revealed that resident's blood pressure (BP) after the fall was ,d+[DATE] (normal blood pressure is ,d+[DATE]). It was also documented that the resident complained of pain of on a scale, 3 out of 10. There was no documentation of the pain location or type of pain. Review of neurological assessment dated [DATE], at 2:30 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 2:45 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 3:00 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 3:30 a.m. revealed that the blood pressure (BP) was 180 /78. Review of neurological assessment dated [DATE], at 4:00 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 5:00 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 6:00 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 6:55 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 7:55 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 11:55 a.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of neurological assessment dated [DATE], at 12:15 p.m. revealed that the blood pressure (BP) was ,d+[DATE]. Review of Resident R17's clinical record failed to reveal documented evidence the physician was notified of Resident R17's high blood pressure levels and the use of anticoagulant medication until [DATE] approximately 7:30 a.m. Review of hospital record dated [DATE], revealed Resident R17 presented for evaluation of the ground-level fall sustained at 2:00 a.m. 10 hours later resident developed headache, nausea, vomiting. In emergency room resident received Kcentra for reversal of Xarelto coagulopathy and seizure prophylaxis. CT scan revealed cerebral hemorrhage (16 mm subdural hematoma and 6 mm midline shift). Family chosen conservative management and comfort measures were initiated. Resident died on [DATE], and the reason was documented as subdural hematoma. Interview with Nurse Practitioner, Employee E4 on [DATE], at 12:07 p.m. stated she was not on call on [DATE]. She came to the facility around 7:00 a.m. and heard that the resident had a fall, later around 7:30 a.m. she became aware the resident was having high blood pressure. Employee E4 stated resident was due for (his/her) morning medication and she asked staff to give the medication. She did not order any other medication. She was not aware of resident's status until around 12 noon on [DATE]. Employee E4 stated staff were expected to recheck the blood pressure an hour or two after the medications were given and notify the provider to see response of the blood pressure or to initiate additional interventions. Interview with Registered Nurse, Employee E5 on [DATE], at 12:28 p.m. stated she was the supervisor on duty for [DATE]. She asked the nurse to give the morning medication after the resident was noted with high blood pressure. She was not sure if the charge nurse rechecked Resident R17's blood pressure or if the blood pressure came down in response to the medication. Employee E5 stated later when she assessed the resident around 12 or 1 p.m. resident was vomiting and had nausea. Interview with Registered Nurse, Employee E6 on [DATE], at 9:33 a.m. stated she was the night shift supervisor when the resident fell at 2:05 a.m. She created the incident report. She sent an e-mail (electronic communication) to physician around 3:40 a.m. to notify of the fall. Employee E6 stated she was not sure if any physician saw the e-mail or responded to the e-mail. Employee E6 stated she was aware that the resident hit her head during the fall. Employee E6 stated she was aware of the high blood pressure and confirmed the physician was not notified in a timely manner. Review of an e-mail message sent to the providers on [DATE], at 3:45 a.m. revealed that Hello, (Resident R17) fell last night in (Resident R17)'s bathroom, no apparent injuries at this time. Further review of the email notification failed to reveal evidence the staff notified the provider of resident hitting head, being on anticoagulant medication, pain level of 3, or high blood pressure after the fall. Interview with Nursing Home Administrator and Registered Nurse, Clinical Service Director, Employee E3 on [DATE], at 9:33 a.m stated staff should call physician if there is a change in condition. Employee E7, Licensed Nurse, who provided care to the resident on [DATE] when resident fell was not available for an interview. Interview with Physician, Employee E8 on [DATE], at 2:00 p.m. stated staff should call the physician via phone if there an emergency or urgent care need that necessitates a physician response regardless of the time. Staff could e-mail for non-emergency notifications that require physician response but should complete a follow up call if no response received in an hour. Physician stated he was the physician for Resident R17. He stated that staff should notify the physician immediately after the fall via phone of a resident who sustain a fall with suspected head injury such as hitting head during fall. Staff should also make the physician aware if the resident is taking anticoagulant medication which increases risk for brain injury. The physician should also made aware of the high blood pressure or vital signs changes after a fall when resident hit their head. Physician, Employee E8 also stated that staff should re-check the blood pressure at least in two hours after a medication was given for high blood pressure. A follow up interview with Nurse Practitioner, Employee E4 on [DATE], at 2:30 p.m. stated she was not aware the resident was on blood thinner medication when the staff notified them about Resident R17's high blood pressure after the fall. Employee E4 stated she would have looked at the resident's condition in a different way and would have changed her decision if she was aware of Resident R17 being on Xarelto. Employee E4 stated Xarelto increased the risk of head injury and bleeding after falls involving hitting the head. Interview with Nursing Home Administrator and Registered Nurse, Clinical Service Director, Employee E3 on [DATE], at 2:40 p.m. confirmed the staff did not notify the physician in a timely and appropriate manner after Resident R17 sustained a fall in which the resident hit his/her head and observed with pain, high blood pressure. Nursing Home Administrator and Employee E3 confirmed there was no documented evidence that the staff notified the resident's physician of high-risk anticoagulant medication which the resident was taking. Nursing Home Administrator and Employee E3 also confirmed there was no documented evidence the staff re-checked Resident R17's blood pressure in timely manner after medication was administered for high blood pressure. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 1:16 p.m. for the facility's failure to provide care and services that meets the professional standards of quality and as outlined in resident's plan of care. Failure to accurately and timely notify the physician after Resident R17 who was on a blood thinner medication, fell in the bathroom and hit he/her head. Failure to re-assess Resident R17 in a timely manner after the resident experience in abnormal high blood pressure levels following the fall and after routine medication was administered. These failure placed Resident R17 at risk for serious harm including death. The facility submitted a written plan of action on [DATE], and implemented a plan of action which included the following: - Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident. - Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response. - Education has been implemented of all RNs (Register Nurse) and LPNs (Licensed Practical Nurse) regarding the revised facility policy of Notifying Changes in Resident's Status. This education includes assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs will have completed education by the end of the day [DATE]. 100% of RNs and LPNs will have completed education by the end of the day [DATE]. If staff are not available, they will be educated prior to the start of their next shift in facility. - Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) for four quarters. On [DATE], at 3:47 p.m. the action plan was reviewed, additional clinical records were reviewed, policy verified, interviews were conducted with staff to confirm that the in-service education was completed. The Immediate Jeopardy was lifted on [DATE], at 4:02 p.m. 201.14(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility records, job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility related to ensuring that the facility provided care and services that met the professional standards of quality and as outlined in resident's plan of care. Nursing Home Administrator and Director of Nursing failed to ensure that accurately and timely notification of the physician after Resident R17 who was on a blood thinner medication, fell in the bathroom. Nursing Home Administrator and Director of Nursing failed to ensure proper procedures were followed related to re-assessing Resident R17 in a timely manner after the resident was assessed with elevated blood pressure levels following a fall and after routine medication was administered. This placed Resident R17 at risk for serious harm or impairment and resulted in an immediate jeopardy situation for one of 13 residents reviewed. (Resident R17) Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed that The Nursing Home Administrator assures regulatory operations of (facility name) in accordance with current federal, state, county, local . standards. The Nursing Home Administrator oversees Quality Assurance and Performance Improvement and HIPAA programs. The Nursing Home Administrator is a member of the Senior Management Team, sharing the overall responsibility for the operations of the Community. Develop, maintain, and assure compliance with written policies and procedures . Interpret policies to staff, residents, families, visitors and government agencies. Review accidents and incidents and make recommendations for an effective safety program for residents. Perform the duties of abuse investigator. This includes, but is not limited to, carrying out abuse investigation and prevention protocol. Initiate and coordinate abuse investigations. Review of the job description for the Director of Nursing (DON) revealed that The Director of Nursing is authorized to take any reasonable action necessary to carry out the responsibility delegated to her/him so long as such action does not deviate from established policy and practice as defined by Pennswood Village and the current Pennsylvania Professional Nursing Practice Act in the management of all resident services in the Skilled Nursing Facility. Directs, coordinates, and supervises the nursing activities of (facility name). Complies with federal, state, and local regulations and standards for operating a long-term care facility. Coordinates housekeeping, food, transportation, and maintenance personnel as they relate to the (facility name) with the assistance of the department heads involved. Assist in establishing and maintaining policies pertaining to all aspects of total resident care in (facility name). Review and ensure compliance of (facility name) with federal, state, and local standards and implement these standards. Review and ensure compliance with established personnel policies . Consult with Medical Director to ensure implementation of medical policy and the individual resident's plan of care. Review of facility policy Notification of Changes in Resident's Status dated [DATE], revealed Purpose: To assure that each resident and/or resident representative is notified timely of accidents that result in injury and have the potential for physician intervention; significant changes in status; significant changes in treatment; abnormal lab, radiology or other diagnostic test results; transfer or discharge associated with the health or safety of the resident; change in roommate status or change in resident rights under Federal or State law or regulations. Review of Federal Drug Administration guidelines for Xarelto revealed that XARELTO increases the risk of bleeding and can cause serious or fatal bleeding. Increased risk of bleeding: XARELTO can cause bleeding which can be serious and may lead to death. This is because XARELTO is a blood thinner medicine (anticoagulant) that lowers blood clotting. During treatment with XARELTO you are likely to bruise more easily, and it may take longer for bleeding to stop. You may have a higher risk of bleeding if you take XARELTO and have certain other medical problems. Review of facility reported incident dated [DATE], revealed that Resident R17 was noted on [DATE], at approximately 3:00 a.m. sitting on the floor in her/his bathroom with her back against the wall. The resident's pants were down, and the floor was wet with urine. Resident R17 stated, I hit my head. The resident was awake and alert, speech was clear and was able to answer appropriately. Neuro checks initiated and was within normal limits. Resident was able to move all extremities and she denied pain. Resident R17 was noted with increased blood pressure post fall, which was discussed with Employee E4, Nurse Practitioner as well as current clinical presentation offering no other complaints at this time and no visible signs of injury, recommended to continue current plan of care and give morning medications. Morning medications given including Furosemide and Cardizem. In the early afternoon around 12:30 p.m. Resident R17 was noted with complaint of head pain, left eye pain, nausea, as well as vomiting, provider called, and order obtained to send resident to the hospital for evaluation. Resident was transferred to the hospital. Upon arriving to the emergency room , a CT (computed tomography) scan was completed and Resident R17 was noted with a 16 millimeter (mm) Subdural hematoma (a pool of blood between the brain and its outermost covering) with a 6 mm midline shift (a displacement of brain tissue that occurs when the brain is pushed to one side of its natural centerline. It can be caused by a number of things, including traumatic brain injury). Family wished for conservative management per trauma team and no surgical intervention, goal was comfort. Resident R17 passed away at the hospital. Review of facility incident report dated [DATE], revealed that Resident R17 was found sitting on the floor. Resident stated, I hit my head. The time of the incident was documented as 2:05 a.m. Further review of the incident report revealed that the physician notification time was 3:40 p.m. There was no documentation of mode of communication and physician response. There was no documented evidence that physician responded to the notification. Review of medication administration record for Resident R17 for [DATE], revealed that the resident received the anti-coagulant medication Xarelto 15 milligrams (mg) every evening at 6 p.m. and the resident received the last dose on [DATE]. Review of neurological assessment from [DATE], at 2:30 a.m. through [DATE] at 12:15 p.m. revealed that resident's blood pressure (BP) was elevated. It was also documented that the resident complained of pain of on a scale, 3 out of 10. There was no documentation of the pain location or type of pain. There was no documented evidence in the clinical record that the physician was notified of Resident R17's high blood pressure levels and her use of anticoagulant medication after the fall until approximately [DATE] at 7:30 a.m Resident R17's neuro check showed abnormal/elevated blood pressure throughout all the assessment. Review of hospital record date [DATE], revealed that Resident R17 presented for evaluation of the ground-level fall sustained at 2:00 a.m. 10 hours later resident developed headache, nausea, vomiting. In emergency room resident received Kcentra for reversal of Xarelto coagulopathy and seizure prophylaxis. CT scan revealed cerebral hemorrhage 16 mm subdural hematoma and 6 mm midline shift. Family chosen conservative management and comfort measures were initiated. Resident died on [DATE] and the reason was documented as subdural hematoma. Interview with Registered Nurse, Employee E6 on [DATE], at 9:33 a.m. stated she was the night shift supervisor when the resident fell at 2:05 a.m. She created the incident report. She sent an e-mail (electronic correspondence) to physician around 3:40 a.m. to notify of the fall. Employee E6 stated she was not sure if any physician saw the e-mail or responded to the e-mail. Employee E6 stated she was aware that the resident hit her/his head during the fall. Employee E6 stated she was aware of the high blood pressure and confirmed that the physician was not notified in a timely manner. Review of an e-mail message sent to the providers on [DATE], at 3:45 a.m. revealed that Hello, (Resident R17) fell last night in her bathroom, no apparent injuries at this time. Further review of the e-mail notification revealed no evidence that the staff notified the provider of resident hitting head, being on anticoagulant medication, pain level of 3 or high blood pressure after the fall. Interview with Administrator and Registered Nurse, Clinical Service Director, Employee E3 on [DATE], at 9:33 a.m . stated staff should call physician if there is a change in condition. Interview with Physician on [DATE], at 2:00 p.m. stated staff should call the physician via phone if there an emergency or urgent need that need a physician response regardless of the time. Staff could email for non-emergency notifications that require physician response but should complete a follow up call if no response received in an hour. Physician stated she was the physician for Resident R17. He stated staff should notify the physician immediately after the fall via phone of residents sustain fall with suspected head injury such as hitting head during fall. Staff should also make the physician aware if the resident is taking anticoagulant which increases risk for brain injury. Physicians should also made aware of the high blood pressure or vital signs changes after a fall when resident hit their head. Physician also stated staff should recheck the blood pressure at least in two hours after a medication was given for high blood pressure. A follow up interview with Nurse Practitioner, Employee E4 on [DATE], at 2:30 p.m. stated she was not aware that the resident was on blood thinner when the staff notified them about Resident R17's high blood pressure after the fall. Employee E4 stated she would have looked the resident's condition in a different way and would have changed her decision if she was aware of Resident R17 being on Xarelto. Employee E4 stated Xarelto increased the change of head injury and bleeding after fall involving hitting the head. Interview with Nursing Home Administrator and Registered Nurse, Clinical Service Director, on [DATE], at 2:40 p.m. confirmed that the staff did not notify the physician in a timely and appropriate manner after Resident R17 sustained a fall, observed with pain, and assessed with high blood pressure. Nursing Home Administrator and Employee E3 confirmed that there was no documented evidence that the staff notified the physician of high-risk anti-coagulant medication which the resident was taking. Nursing Home Administrator and Employee E3 also confirmed that there was no documented evidence that the staff re-checked Resident R17's blood pressure in timely manner after medication was administered for high blood pressure. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and regulations were followed, contributing to the Immediate Jeopardy situation. Refer to F684 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.18(b)(3) Management

Based on the review of facility documentation, review of clinical records, review of facility policy and interview with the staff, it was determined that the facility did not ensure that a resident with limited range of motion received appropriate services according to the professional standards of practice for one of two residents reviewed who required range of motion exercises. (Resident R22) Findings include: Review of an undated facility policy Functional Limitations Improvement Program Restorative Nursing Guidelines revealed that The therapists establish a treatment plan, in coordination with the physician, for each resident based on an evaluation. This plan is developed and shared with the interdisciplinary team members and identifies and set goals with the resident. The goal of the rehabilitation team may include increase range when there is limitation. Teach skills to develop function when there is limitation. All restorative nursing program must be included in the plan of care. The plan of care needs to include: Problem and needs of the residents, Expected outcome, Goal that are realistic, measurable and specific for the resident. Observation of Resident R22 on April 25, 2023, at 12:45 p.m. revealed that the resident was eating lunch and Nursing Assistant, Employee E5, was assisting the resident. Employee E5 stated resident did not have any range of motion services or restorative programs scheduled. Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R22 dated January 17, 2023 revealed that the resident had limited range of motion in one side of upper extremity. Further review of the MDS revealed that the resident was not receiving any restorative nursing services includes active or passive range of motion. Review of physical therapy discharge summary recommendation dated November 8, 2022 revealed that, Restorative Nursing Program: To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following restorative nursing programs has been completed with the interdisciplinary team: Transfers and ROM (Range of motion) (Active). Review of physician orders for Resident R22 for the month of April 2023 revealed an order for restorative nursing services. Review of care plan for Resident R22 initiated on October 22, 2022, revealed no evidence that the facility developed a plan of care related to Resident R22's limited range of motion and restorative nursing. Review of clinical record revealed no documented evidence that Resident R22 received range of motion services or restorative services as recommended. Interview with the Director of Nursing on April 26, 2023, at 1:30 p.m. confirmed that Resident R22 did not have a restorative or range of motion program as recommenced. 28 Pa. Code: 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records, review of facility policy, review of facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to one resident who had a history of falls with injuries, resulting in actual harm to the resident (Resident R3), who sustained a fractured wrist and a [CONDITION(S)] requiring five staples following two subsequent falls. Additionally, the facility failed to provide a safe shower chair to one resident (Resident CL188) resulting in a fall. The facility's failure to provide adequate supervision and a safe shower chair resulted in falls with injury for two of 17 residents reviewed. Findings include: A review of the facility policy titled, Falls and Management of Fall Risk, dated January 2020, revealed that the facility will strive to promote a safe and secure environment for our residents while maintaining the highest level of function within the resident's existing limitations. We will continually and collaboratively work to minimize fall risk and associated injury. Staff will identify interventions related to the resident's specific risks and causes and update resident plan of care accordingly. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. A review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), muscle weakness, abnormalities of gait and mobility. Review of Resident R3's fall risk assessment completed on October 1, 2020, identified the resident as at moderate risk for falls. Further review of Resident R3's fall risk assessment dated [DATE], revealed that the resident was identifed as at high risk for falls. A review of Resident R3's admission Minimum Data Set (MDS - periodic review of the residents needs) dated October 8, 2020, revealed that the resident was severely cognitively impaired in decision making skills and needed supervision for ambulation and the physical assistance of one person to transfer from one surface to another. A review of Resident R3's care plan titled, falls dated October 1, 2020, revealed that the resident was to be assisted with transfers and ambulation. The care plan titled, activity of daily living, dated October 1, 2020, indicated that the resident required supervision with ambulation. A review of the care plan titled, behavior problems, dated October 1, 2020, directed staff to monitor the resident's location so safety is not compromised. A review of the clinical record for Resident R3 revealed nurses' notes dated November 22, 2020, at 5:45 p.m. which indicated that the nurse went into the resident's room to answer a call bell. The resident was in her own chair sitting at the table eating dinner. The resident was seen getting up out of her chair when her foot caught behind the chair leg and the resident fell on her right side. The resident did not hit her head. The resident was having intense right upper leg/hip area pain. The resident was sent to the hospital. A review of documentation submitted by the facility dated November 22, 2020, at 5:45 p.m. confirmed that Resident R3 was eating dinner in her room and got up and tripped on the leg of the chair. The resident fell on her right side and had decreased range of motion. The resident was subsequently sent to the hospital and admitted with a right intertrochanteric fracture. (fractured hip). Review of a radiology report dated November 22, 2020, confirmed that Resident R3 had a fracture of the right femoral neck (fractured hip). Review of Resident R3's, Physical Therapy Progress and Discharge Summary, note dated December 23, 2020, revealed, needs supervision for all mobility due to impaired cognition and decreased safety awareness. Additionally, the therapy note indicated that Resident R3 was a, Fall risk, impaired cognition and safety . Interview with the Resident Assessment Coordinator Nurse, Employee E3, on April 22, 2021, at 2:00 p.m. revealed that the chair in Resident R3's room was removed from the resident's room to prevent another fall. Continued review of the clinical record for Resident R3 revealed a nurses' note dated January 8, 2021, at 1:55 p.m. indicating that the resident was noted to be ambulating by herself within the central rotunda (near the nursing station) while the nurse was at a distance down the hallway returning from break. The resident was then observed falling backwards and landing upon her left upper extremity. No head injury was observed. The left wrist was noted to be limp and displaced with limited range of motion. Review of documentation submitted by the facility dated January 8, 2021, at 1:55 p.m. confirmed that Resident R3 was sitting in the common area when the resident stood up and began to ambulate with out assistance. The resident was seen by the nurse down the hall, the nurse attempted to get to the resident to assist her, however the resident lost her balance and fell landing on her left arm. The resident was noted with pain and decrease range of motion to her left wrist. The resident was subsequently transferred to the hospital. Review of Resident R3's radiology report dated January 8, 2021, revealed . Impression: acute left distal radial and ulnar fracture (fractured left wrist). A review of the facility's investigation dated January 8, 2021, revealed that, Resident was observed walking on her own by this nurse (Employee E20) upon walking down the hallway. She (Resident R3) was then observed falling backwards and fell on her left upper extremity. No head injury observed. VSS (vital signs stable). Residents left wrist was noted to be limp with limited range of motion. Further review of the facility investigation revealed that, staff were educated/disciplined on the need to follow the resident's plan of care. Resident is supervision with ambulation with a walker. Requires cueing and steering management. Reviewed care plan. Fall precautions and ADL (activity of daily living) assistance are current. Resident exhibits impaired safety awareness and requires consistent supervision. Interview with licensed nursing staff, Employee E20, on April 23, 2021, at 11:30 a.m. revealed that he was working the 7:00 a.m. to 3:00 p.m. shift on January 8, 2021. Employee E20 stated that he took his break and had told another nurse that he was taking his break. When he was returning to the unit from his break, he observed Resident R3 down the hallway get up and fall onto her left arm. Further review of Resident R3's clinical record revealed a nurses' note dated March 8, 2021, at 10:08 p.m. that indicated, Resident with unwitnessed fall from the chair she was last seen sitting in. She was lying on her back in a well lit Rotunda (area near nursing station) in the threshold between the kitchen (staff were in the kitchen ), and, her Rt (right) hand was holding the Right side of her head as she was sobbing. As blood was dripping from her head. 911 was called, report given. Staff RN applied light pressure with clean sheet to the right posterior side of her head her neck remained stable. The note further indicated that the resident was sent to the hospital at 10:22 p.m. Review of nursing documentation dated March 9, 2021, at 1:10 a.m., revealed that Resident R3 returned from the hospital with five staples to her head. Review of documentation submitted by the facility dated March 8, 2021, at 10:10 p.m. revealed that the resident was sitting in the common area, and then the resident was observed lying on the ground in the doorway of the community pantry, located a couple of feet from the chair that she was sitting in. The resident was noted with a laceration on the back of her head. Pressure applied and emergency medical assistance was called. The resident was sent to the hospital and received five staples at the site of the laceration. A review of a written statement by nursing assistant, Employee E23, dated March 28, 2021, revealed that at 10:10 p.m. the resident fell at the kitchen door and hit her head. The resident was toileted 30 minutes prior to fall. Between that time, I was handing out waters. I last witnessed the resident sitting in the grey chair with shoes and hip pads on. With tray in front of resident, two minutes prior to fall. A review of a written statement by licensed nursing staff, Employee E24 dated March 9, 2021, revealed that Employee E23, . informed me while I was charting in the west chart room. I ran to the rotunda (area near another nursing station) and saw the resident was on the floor in the kitchen doorway. and . resident hit her head. A review of the facility investigation of Resident R3's fall dated March 8, 2021, revealed that the resident was noted to be in view of staff in the nursing office at 10:08 p.m. At 10:10 p.m. nursing assistant, Employee E23, was in the kitchen making ice water. She heard a noise and turned around and the resident was on the floor between the kitchen and rotunda (the area near the nursing station). The resident was holding the right side of her head and blood was dripping between her fingers. 911 was called. Continued review of the fall investigation dated March 8, 2021, revealed that following the Resident R3's third fall with an injury, the facility had increased supervision to the resident. The investigation documentation indicated that Resident R3 was to have one to one (constant direct supervision) in place from outside agency during the 7:00 p.m. to 7:00 a.m. shift. The facility failed to provide proper supervision to Resident R3 who was assessed at high risk for falls, was noted with a lack of safety awareness and had a prior history of a fall with an injury. This lack of appropriate supervision resulted in the resident sustaining in two subsequent falls with injuries, a fractured left wrist and a [CONDITION(S)]. A review of Resident CL188's closed clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of: Parkinson disease (a disorder of the central nervous system that affects movement, often including tremors.), muscle weakness, lack of coordination, [CONDITION(S)] (a condition in which bones become weak and brittle) and abnormalities of gait. Review of Resident CL188's Fall Risk assessment dated [DATE], revealed that the resident was identified as at high risk for falls. A fall risk assessment dated [DATE], revealed that the resident was identifed as at high risk for falls and had decreased muscular coordination. A review of the Resident CL188's quarterly Minimum Data Set (MDS- a periodic review of the resident's needs) dated July 27, 2020, revealed that the resident was severely cognitively impaired. Further review of the MDS assessment indicated that the resident was not steady during surface to surface transfer and only able to stabilize with staff assistance. A review of Resident CL188's care plan titled falls potential for falls, related to altered balance, Parkinson, Dementia and peripheral [CONDITION(S)], dated January 22, 2020, revealed that the resident was identifed as an assist with transfers and ambulation per activity of daily living care plan. A review of the activity of daily living care plan, dated January 22, 2020, revealed that the resident needs assistance with bathing and hygiene related to Parkinson, and gait dysfunction. The resident requires extensive assistance with one with transfers and requires limited assistance with one with ambulation. A review of documentation submitted by the facility dated October 27, 2020, revealed that the resident had a fall on August 31, 2020, while sitting in a shower chair and leaned backward and fell off the shower chair. The resident was assessed for injury and, there was a small abrasion on his upper back . and, complain of pain in mid to lower back. The nurse practitioner assessed the resident the day of the fall and ordered an X-ray of the Lumbo-sacral spine for lower back pain and to r/o (rule out) fracture. The X-ray was completed that day 8/31/2020 and the conclusion was [CONDITION(S)] changes of lumbar spine and no acute fracture. A review of the facility investigation of the fall dated August 31, 2020, revealed that at 10:10 a.m. the resident was in the shower room with nursing assistant, Employee E26, sitting in a shower chair. The resident slipped backward and fell on his back. The resident did not hit his head. Licensed nursing staff, Employee E13, assessed the resident. A 2.5 centimeter small abrasion was observed on resident's right upper back. The resident complained of sharp pain to mid and lower back and an X-ray was ordered. Further review of the facility investigation revealed that the immediate action taken was for the equipment to be removed from service and sequestered. Further review of facility investigation revealed the resident was noted with decreased core strength prior to fall. The resident will utilize a shower chair with a back to help support posture. A review of a written statement by nursing assistant, Employee E26, dated August 31, 2020, stated around 10:30 a.m. this morning, I was in the [NAME] shower room with Resident CL188, prepping to give him a shower. I was undressing the resident while he sat on the shower stool (shower chair with no back). While taking off his socks the resident raised his legs and leaned backwards causing both himself and the stool to fall backward. The resident fell on to his back, however he did not hit his head. I went to grab the nurse who assessed him. I noticed two small abrasion along the middle of his back. The resident reported pain in his lower back. Along with the nurse the two of us helped the resident into the shower chair. Interview with licensed nursing staff, Employee E13, on April 23, 2021, at 10:00 a.m. revealed that she worked the 7:00 a.m. to 3:00 p.m. shift on August 31, 2020. Employee E13 could not recall that Employee E26 asked what shower chair should be used or any special instructions. Interview with Employee E17, the Director of Physical and Occupational Therapy, on April 23, 2021, at 9:20 a.m. confirmed that the shower chair with no back was not an appropriate shower chair for Resident CL188, to be seated in, with his diagnosis of Parkinson and gait dysfunction. 28 Pa. Code 201.18 (a)(1) Management 28 Pa. Code 211.12(d)(5) Nursing services

Based on a Resident Council meeting, review of facility policy and procedures, and staff interview, it was determined that the facility failed to ensure that the Grievance process was posted in a place that was visible for residents to read, understand, follow and complete, for three of three residents (Residents R4, R7 and R22). Findings include: Review of the facility policy and procedure titled, Resident Rights, under grievances section; indicated The facility must make information on how to file a grievance or complaint available to the resident further it states notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievance anonymously. During a resident council meeting on April 21, 2021 at 1:30 PM, with three residents, (Residents, R4, R7 and R22), that were identified as being alert and oriented, indicated, being unaware of how to file a grievance, if they had a concern. Resident R4 responded when asked if she knew the grievance procedure she reported that she would talk to her neighbor. Resident, R7 and R22, indicated the same response, talk to my neighbor. Additionally, the interview revealed that the residents were unaware of the identity of their grievance officer and the grievance procedure. Interview with Employee E19, Activity Director, on April 22, 2021, at 10:00 AM revealed, that the employee did not know who was the contact person related to a facility grievance and did not know where information was posted about how one would complete paper work to file a grievance. Observation of the wall area with Employee E19 on April 22, 2021, at 10:20 AM, where information is posted, revealed no information related to a grievance form or a contact person for a grievance was available. There was no dedicated place to confidently place the grievance form was available. Additionally, contact information for the Grievance official was not wheelchair accessible and was not legible from a distance. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(d)(i) Resident rights

Based on observation, review of a clinical record, facility policy and procedures and staff interviews, it was determined that the facility failed to ensure that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of facility policy and procedure, titled Medication and Treatment Orders indicated Orders for medications and treatment will be consistent with principles of safe and effective order writing. It furthers stated, Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such as medications in this state. A review of Resident R19 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident R19's clinical record revealed a person-entered care plan, dated June 11, 2020, which indicated encourage adequate hydration. No straws . Observation of Resident R19 on April 22, 2021, at 11:45 AM, with Employee E13, Licensed Nurse, confirmed that Resident R19 had a straw in his water cup and reported some CNAs staff bring his cup with the straw and when I'm in his room I would take it out. He is not supposed to have it. Interview with Director of Rehabilitation, Employee E5 on April 22, 2021, at 12:30 PM indicated, the reason why Resident R19 has no straw order due to him being an aspiration risk and lack of oral motor strength. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa Code: 211.12(d)(1) Nursing services.

Based on observation and interview with facility staff, it was determined that the facility failed to enhance residents' dignity for one of 17 residents reviewed, related to signage (Resident R1). Findings include: During the initial tour of the facility on April 21, 2021, at 10:30 a.m. an observation was made of Resident R1's room which revealed a home made sign, was hanging, (on an 8 by 11 inch), piece of paper, which read in large print and in one's hand writing, Please let (the residents first name) know where you are taking her and where she is for orientation at all times. Thank you. Press button on front of dresser - it will tell her where she is!! An interview with Employee E13, Licensed nurse, on April 21, 2021, at 11:15 a.m. confirmed the presence of the signage hanging in Resident R1's room. Observation and interview with Employee E19, Activities Director, on April 23, 2021, at 1:20 p.m. confirmed the presence of the signage hanging in Resident R1's room and confirmed that it did not enhance the dignity of Resident R1. 483.15(a) Dignity 28 Pa. Code: 201.29(j) Resident rights.

Based on observations, review of facility documentation, review of clinical records and interviews with staff, it was determined that the facility failed to ensure that dignity was maintained for two of 20 residents reviewed (Residents R7 and R17). Findings include: Observation on March 9, 2020, at 1:10 p.m. revealed Resident R7 yelling out and making delusional statements towards staff. The resident appeared irritable. Review of Resident R7's quarterly Minimum Data Set (MDS - a required periodic assessment), dated September 16, 2019, revealed that the resident was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Continued review of the MDS revealed that the resident was unable to complete an interview to assess for mental status and was assessed by staff to be moderately cognitively impaired (poor decision making with cues and supervision required). Review of Resident R7's care plan, dated December 17, 2018, revealed that the resident had impaired cognition related to dementia, required assistance with activities of daily living and behaviors. Continued review of the care plan indicated that the resident exhibited repetitive verbalizations, resistance to care, verbal outbursts, hallucinations and delusions. Interventions for these behaviors included distraction, speaking in an appropriate tone, attempt to change the subject, and provide validation and reassurance. Review of a psychiatric assessment for R7, dated August 15, 2019, revealed that the resident had some verbal agitation and was often easily redirected. Review of Resident R17's annual MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R17's care plan, dated December 27, 2019, revealed that the resident had impaired memory and communication related to dementia. Interventions included explaining what you are going to do, face the resident and use plain simple language, cue and reorient as needed, speak in a calm friendly voice, speak clearly in an appropriate tone and offer reassurance. Review of facility documentation, dated October 16, 2019, revealed that a dietary employee observed Resident R7 yelling out and that in response, Employee E5, nurse aide, stated to Resident R7, Hey, look at me, shut up, just shut up. Employee E5 then took Resident R7 down the hall. Continued review of the facility documentation revealed that next, Employee E4, nurse aide, brought Resident R17 into a lounge area. Resident R17 was verbalizing about being saved and naming different people. Employee E4 responded they are not working today and Resident R17 become increasingly frustrated and louder. Then the dietary employee observed Employee E4 tell the resident to shut up and walk away. Interview on March 10, 2020, at 2:00 p.m. the Director of Nursing stated that she reviewed video footage of the above events and found the dietary employee to be a credible witness. She agreed that the residents were not treated in a dignified manner. The facility failed to maintain dignity for two residents. 28 Pa Code 201.29(j) Resident rights

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that the resident's wishes for Advance Directives (one's wishes on life-sustaining medical or surgical treatment), were reflected accurately in the clinical record for two of 20 resident records reviewed (Residents R11 and R14). Findings include: Review of the facility policy Advance Directives, dated as last revised October,2017 stated, that the purpose of the policy was to assure that residents are educated about choices related to their healthcare and that these wishes are respected an honored. The same policy also stated that when a resident was admitted to the facility that the medical file would be reviewed to verify that the resident signed an Advance Health Care Declaration and/or Medical Durable Power of Attorney (Healthcare Power of Attorney). Under Procedure, the policy stated that if the resident, family member, surrogate, or any other concerned party presents the facility with a copy of the resident's Advanced Directive, the facility must comply with the Advance Directive to the extent permitted under state law. Review of the clinical record for Resident R14 revealed that the resident was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Review of a POLST (Pennsylvania's Orders for Life Saving Treatment) form signed and dated by the resident on (MONTH) 16, (YEAR), indicated DNR (Do Not Resuscitate) and no intubation (DNI - use of a tube or machine to help a person breathe). Review of the physician's note of (MONTH) 26, (YEAR), revealed that it was confirmed with Resident R14 that she did not want to be intubated or resuscitated under any circumstance. The same physician note of (MONTH) 26, (YEAR) stated that she would have a do not hospitalize order, with the understanding that this order can be revoked at any point. Review of the physician's orders for the resident dated (MONTH) 26, (YEAR) revealed that the Code Status for Resident R14 was DNR (Do Not Resuscitate)/Do Not Hospitalize. Interview with the Director of Nursing on (MONTH) 2, 2019, at approximately 1:30 p.m. confirmed that the physcian's orders for Resident R14 was DNR/Do Not Hospitalize, and did not include the additional wishes of the resident for no invasive airway techniques (DNI - do not use a tube or machine to help a person breathe).accurately reflect the wishes of the resident for emergency care measures, as indicated on the POLST form. Review of the clinical record for Resident R11 revealed that the resident was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of a POLST (Pennsylvania's Orders for Life Saving Treatment) form signed and dated by the resident's wife on (MONTH) 10, (YEAR), indicated DNR (Do Not Resuscitate) and no intubation (DNI - use of a tube or machine to help a person breathe). Review of the physician's orders for the resident with a start date of (MONTH) 10, (YEAR), and renewed monthly thereafter, revealed that the Code Status for Resident R11 was DNR (Do Not Resuscitate)/Limited Interventions. Interview with the Director of Nursing on (MONTH) 2, 2019, at approximately 1:30 p.m. confirmed that the physcian's orders for Resident R11 was DNR/Limited Interventions, and did not include the specific limited interventions to be utilized and did not reflect the wishes of the resident for emergency care measures, as indicated on the POLST form. The facility failed to ensure accurate documentation was maintained regarding the resident's wishes for resuscitation upon life-threatening medical conditions. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/11/18. 28 Pa. Code 201.18(b)(1) Management Previously cited 10/11/18. 28 Pa. Code 201.29(j) Resident rights Previously cited 10/11/18 28 Pa. Code 211.5(f) Clinical records Previously cited 10/11/18 28 Pa. Code 211.12(d)(1)(5) Nursing service Previously cited 10/11/18

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to properly assess and monitor resident weights and laboratory studies to ensure that each resident maintained acceptable parameters of nutritional status, for one of 20 residents reviewed (Resident R26). Findings include: Review of facility policy, Weight Policy/Procedure for Woolman, dated (MONTH) 5, (YEAR), revealed that residents would be weighed regularly in order to monitor their nutritional status and permit appropriate dietary changes to be made; and if there is a three pound change in a resident's weight (increase or decrease), staff would weigh the resident again within 48 hours. The policy further indicated that if the resident had a cast, brace or other device, staff would note that information next to the recorded weight. Review of the clinical record for Resident R26 revealed the resident was originally admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. Review of a nursing note, dated (MONTH) 4, (YEAR), at 8:14 p.m., revealed Resident R26 was readmitted to the facility from an acute care hospital with a [DIAGNOSES REDACTED]. Review of the plan of care for nutritional status, dated (MONTH) 4, (YEAR), revealed Resident R26 was at risk for unintentional weight loss due to age and dementia, and that staff would monitor the resident's oral intake, weights and labs. Review of readmission physician's orders [REDACTED]. low, can cause overactive [MEDICAL CONDITION] and potential weight loss). Review of a physician note, dated (MONTH) 9, (YEAR), at 2:15 p.m., revealed that Resident R26 returned from the hospital on (MONTH) 4, (YEAR), with a TSLO brace (Thoracolumbosacral Orthosis-brace that supports the lower back), that it was very loose and is causing some pain on the right side of her chest wall . There does not seem to be any benefit from the brace at this point and is probably causing more harm than terms of pain and potential for skin breakdown. I will DC (discontinue) the brace. Review of the electronic weight data for Resident R26 revealed a recorded weight of 151.6 pounds on (MONTH) 1, (YEAR); 150.4 pounds on (MONTH) 5, (YEAR); and readmission weight of 162.3 pounds on (MONTH) 6, (YEAR). Review of a nutrition note dated (MONTH) 12, (YEAR), at 2:57 p.m., revealed that Resident R26 was noted to weigh 162.3 pounds on (MONTH) 6, (YEAR), indicating a 11.9 pound (7.3 percent) weight gain since (MONTH) 5, (YEAR), and that the dietitian asked nursing staff to reweigh the resident. Further review of the clinical record revealed no documentation that the resident was reweighed within 48 hours per facility policy, or that staff documented if the resident was wearing the TSLO brace at the time the resident was weighed. Further review of the electronic weight data revealed a recorded weight of 142.2 pounds on (MONTH) 3, (YEAR). Further review of the clinical record revealed no documentation that the resident was reweighed within 48 hours per facility policy with a documented weight change from 162.3 pounds on (MONTH) 6, (YEAR); to 142.2 pounds on (MONTH) 3, (YEAR). Review of a certified registered nurse practitioner (CRNP) note dated (MONTH) 6, (YEAR), at 9:49 a.m., indicated that for the past two weeks, Resident R26 was experiencing nausea (nausea started 10/22/18), that when the resident sits up for breakfast or morning medications, she feels nausea and that if anything is ingested, she will vomit. The note added that Resident R26's appetite is decreased, eating little to no breakfast, half of lunch, but is eating dinner, and that due to weight loss of eight pounds since (MONTH) 5, (YEAR), the CRNP would contact the facility's dietitian for evaluation. Review of a dietitian note, dated (MONTH) 9, (YEAR), at 1:19 p.m., revealed Resident R26, seems to experience nausea after she is transferred from her bed to her chair, that she seems to tolerate her food better the longer she rest (sic) between transfers, and that Resident seems to be eating most during dinner. The dietitian's note added, Will continue to monitor intake, and weight. Review of another dietitian note, dated (MONTH) 4, (YEAR), at 6:15 p.m., indicated that significant weight changes were noted at one and six month lookback periods, and that the RD (registered dietitian) would continue to monitor intake, weight, skin (whether skin remains intact) and labs. Review of an annual Minimum Data Set (MDS-periodic assessment of needs) dated (MONTH) 3, (YEAR), revealed the CAA (Care Area Assessment) Summary indicated nutritional status as a triggered concern area for Resident R26, with a note indicating the resident is at risk for unintentional weight loss related to, recent [DIAGNOSES REDACTED]. Further review of the electronic weight data revealed on (MONTH) 5, (YEAR), documentation indicated resident refused to be weighed. Further review of the clinical record on (MONTH) 4, 2019, revealed no documentation that staff attempted to reweigh Resident R26 after (MONTH) 5, (YEAR), and no documentation of any other weights since (MONTH) 3, (YEAR). Review of electronic weight data dated (MONTH) 7, 2019, at 11:17 a.m., revealed Resident R26's recorded weight was 138 pounds, indicating an additional documented four pound weight loss from 142.2 pounds on (MONTH) 3, (YEAR). Further review of the clinical record revealed no documentation that staff assessed if more frequent weight monitoring may be necessary for Resident R26; no documentation that staff assessed if a TSH level needed to be obtained to determine if the resident's dose of [MEDICATION NAME] was appropriate (if the TSH level was too low, the physician could evaluate if the [MEDICATION NAME] dose needed to be adjusted so the resident was not losing weight unintentionally from too much [MEDICATION NAME]); and no documentation that any weight was obtained from (MONTH) 3, (YEAR), until (MONTH) 7, 2019, for Resident R26, a resident identified by the facility to be at risk for unintentional and ongoing weight loss. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 8, 2019, at approximately 2:45 p.m., confirmed that there was no documentation that a reweight was performed after readmission weight change was greater than three pounds on (MONTH) 6, (YEAR), and if the resident was wearing the TLSO brace at the time of the weight; no documentation that a reweight was performed after weight change of greater than three pounds was recorded on (MONTH) 3, (YEAR); no documentation that facility staff reassessed the resident to determine if more frequent weight monitoring, other than monthly, was required; and no documentation that a TSH level was obtained after (MONTH) 24, (YEAR) (average monitoring for TSH every 3 to 6 months per physician's orders [REDACTED]. The facility failed to adequately monitor weights and labs to ensure Resident R26 maintained acceptable parameters of nutritional status. 28 Pa. Code 211.5(f) Clinical records Previously cited 10/11/18 28 Pa. code 211.6(d) Dietary services 28 Pa. code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 10/11/18

Based on a review of clinical records and interviews with staff and residents, it was determined that the facility failed to ensure residents received services furnished by outside providers, for one of 10 residents reviewed (Resident R26). Findings include: Review of the clinical record for Resident R26 revealed the resident was originally admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. Review of a nursing note, dated (MONTH) 4, (YEAR), at 8:14 p.m., revealed Resident R26 was readmitted to the facility from an acute care hospital with a [DIAGNOSES REDACTED]. Review of a hospital Patient Visit Report dated (MONTH) 4, (YEAR), revealed Resident R26 was to be seen by a neurosurgeon (physician who specialized in operations on the nerves, brain and spine) in 14 days, for follow up from the resident's [DIAGNOSES REDACTED]. Review of a physician note, dated (MONTH) 9, (YEAR), at 2:15 p.m., revealed that Resident R26 returned from the hospital on (MONTH) 4, (YEAR), with a TSLO brace (Thoracolumbosacral Orthosis-brace that supports the lower back), that it was very loose and is causing some pain on the right side of her chest wall . There does not seem to be any benefit from the brace at this point and is probably causing more harm than terms of pain and potential for skin breakdown. I will DC (discontinue) the brace. She will .visit with neurosurgery in 2 weeks. Review of another physician note, dated (MONTH) 22, (YEAR), at 1:04 p.m., revealed, She is seeing the surgeon (neurosurgeon follow-up appointment) tomorrow. Further review of the clinical record revealed no documentation that Resident R26 was seen by the neurosurgeon as recommended in the hospital documentation. Interview with the Director of Nursing on (MONTH) 7, 2019, at approximately 12:45 p.m., confirmed there was no documentation that Resident R26 had the follow-up appointment with the neurosurgeon as recommended after sustaining a compression [MEDICAL CONDITION] lumbar vertebra. The facility failed to ensure residents received services furnished by outside providers. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/11/18 28 Pa. Code 201.18(b)(1) Management Previously cited 10/11/18 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.21(b) Use of outside resources

Based on a review of clinical records, facility policies and procedures and facility documentation and interviews with staff, it was determined that the facility failed to ensure that all alleged violations involving resident abuse were reported, as required, to the Department of Health for one of 20 residents reviewed. (Resident R15). Findings include: Review of the facility policy, Abuse - Zero Tolerance, dated effective February, (YEAR), stated that verbal abuse was any oral, written or gestured language that includes disparaging and derogatory terms to residents and/or families, or within hearing distance, regardless of their age, ability to comprehend or disability. The same policy stated that when an allegation of abuse is suspected or reported, it shall be identified and an investigation shall immediately commence; that suspected or reported abuse or allegation of abuse would be immediately reported to the Director of Nursing or Nursing Home Administrator, and indicated that they would be responsible for the investigation. The policy further stated that the Director of Nursing, Nursing Home Administrator, or designee, would notify the Department of Health, via the electronic event reporting system or the hotline (in the event of serious bodily injury) of the allegation of abuse; and also would immedicately notify the local Office on Aging of an allegation of abuse in accordance with the requirements of the law, and would follow-up with the written report as required. The policy also stated that at the conclusion of the investigation a PB - 22 (report of the allegation and facility investigation if perpetrator was identified) would be completed and forwarded to the Department of Health. Review of the clinical record for Resident R15 revealed that the resident was admitted to the facility on (MONTH) 5, (YEAR) from an acute hospital with [DIAGNOSES REDACTED]. activities). Review of the quarterly Minimum Data Set (MDS - assessment of resident care needs), dated (MONTH) 12, (YEAR), indicated that there was a BIMS (brief Interview for mental status) score of 3, indicating that the resident was severely cognitively impaired, and noted that Resident R15 was understood and understood others. Review of nursing progress notes of (MONTH) 24, (YEAR), at 9:05 p.m., revealed that Resident R15 had made statements that staff were mean to her, and no one would come to help her. The same nursing progress note stated that the resident also stated that she had fallen on knees and was calling for help but was able to get up, and that was why her hip was hurting. The documentation stated further that the resident was assessed by the licensed nurse and was found to be without any injury. Also, the same documentation stated that the resident's family was present when these statements were made by Resident R15. The Nursing Home Administrator and the Director of Nursing confirmed during an interview on (MONTH) 9, 2019, at approximately 2:00 p.m., that the allegation of abuse by Resident R15 was not reported to the Department of Health or government agencies, as required. The facility failed to ensure that all alleged violations involving abuse and neglect were reported to the Pennsylvania Department of Health, government agencies and/or law enforcement, as required. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/11/18 28 Pa. Code 201.18(a)(b)(2)(3)(e)(1) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 10/11/18 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.19(j) Resident rights Previously cited 10/11/18 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 10/11/18

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide adequate assessment and monitoring for care and maintenance of intravenous (IV-tube inserted through the skin into a vein to administer fluids and medications) catheters, for one of 20 residents reviewed (Resident R48). Findings include: Review of undated facility nursing policy, Peripherally Inserted Central Catheter (PICC) Line Dressing Change, revealed that dressings over a PICC line (type of IV catheter used for long term delivery of IV medications and fluids) would be changed seven days or sooner if the dressing became loose, soiled or wet, and that during the dressing change, the licensed nurse would measure the external length of the catheter (amount of catheter tubing that is visible outside of the vein). The policy further instructed that the licensed nurse would document the external length of the catheter upon dressing change. Review of undated facility nursing policy, Flushing (infusing salt water solution to prevent a PICC line from clotting) Open-Ended Peripherally Inserted Central Catheter (PICC), indicated that the licensed nurse would attach a saline (salt water solution) syringe to the PICC line catheter cap or valve and slowly aspirate (draw back on the syringe plunger) until brisk blood return is obtained (brisk blood return indicates the catheter is functioning properly and is not blocked or clogged). The policy further stated that if resistance (inability to flush easily and smoothly) is met when flushing, the licensed nurse would assess for occlusion (blockage) and notify the nursing supervisor and/or physician on how to proceed. Review of undated facility nursing policy, Removal of a Peripherally Inserted Central Catheter (PICC), revealed that upon removal of a PICC line, the licensed nurse would assess the integrity of the catheter (if it appears intact or broken) and measure and compare the length of the catheter with the length upon insertion. If there is a discrepancy with the catheter being shorter than original length, the licensed nurse would immediately apply a tourniquet above the site, notify the resident's physican, and send the resident to the hospital for evaluation. The policy further stated that this information would be documented in the clinical record. Review of the clinical record for Resident R48 revealed the resident was admitted to the facility from an acute care hospital on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. Review of a nurse's note dated (MONTH) 28, (YEAR), at 10:12 p.m., revealed Resident R48's PICC line was located in the right upper arm. Review of admission physician's orders [REDACTED]. Review of a nurse's note dated (MONTH) 6, (YEAR), at 9:09 a.m., revealed that the resident's right upper arm PICC line was in place, that it flushed easily, but minimal blood return was noted before the IV antibiotic was adminstered. The note further stated that after the IV antibiotic infusion was completed and the licensed nurse attempted to flush the PICC line, resistance was noted with no blood return, and that the resident's physician was notified. Review of a nurse's note dated (MONTH) 6, (YEAR), at 3:02 p.m., revealed that Resident R48's physician instructed staff to contact the hospital's [MEDICATION NAME] Radiology (department in a hospital that performs procedures under x-ray observation) to have the resident's PICC line changed, and until that appointment could be scheduled, staff could continue to administer the IV antibiotics through the existing PICC line. Review of a nurse's note dated (MONTH) 7, (YEAR), at 6:29 p.m., revealed Resident R48 went out to an acute care hospital to have the PICC line replaced. Review of hospital documentation contained in the clincal record, dated (MONTH) 7, (YEAR), stated that Resident R48's existing PICC line was removed without incident and measured 37 centimeters (cm) which was consistent with the length when initially placed; that a new single lumen (one port) PICC line was inserted into the right arm, that the total length of the new PICC was 40 cm, that 1.0 cm catheter length was exposed; and that the PICC was ready for immediate use. Review of the Treatment Administration Record (TAR) for Resident R48 revealed the dressing over the resident's PICC line was documented as changed on (MONTH) 11, 18 and 25, (YEAR). Further review of the clinical record revealed no documentation regarding the external length of the catheter upon dressing change. Review of a nurse's note dated (MONTH) 8, (YEAR), at 12:07 p.m., revealed that Resident R48's PICC line was removed by the licensed nurse, and that, Entire length of PICC line visualized which was 37 cm. Further review of the clinical record revealed no documentation regarding assessment of the integrity of the catheter upon removal; and no documentation regarding discrepancy in total length of the catheter upon removal (40 cm total length in hospital documentation dated (MONTH) 7, (YEAR), and 37 cm total length upon removal by the facility's licensed nurse on (MONTH) 8, (YEAR). Interview with the Director of Nursing on (MONTH) 9, 2019, at approximately 2:00 p.m., confirmed there was no documentation of the external length of Resident R48's PICC line upon dressing changes on (MONTH) 11, 18 and 25, (YEAR); no documentation of the integrity of the PICC line catheter upon removal on (MONTH) 8, (YEAR); and no documentation regarding resolution to the 3 cm catheter discrepancy upon removal on (MONTH) 8, (YEAR). The facilty failed to adequately assess and monitor one resident with a PICC line. 28 Pa. Code 211.5(f) Clinical records Previously cited 10/11/18 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/11/18 28 Pa. Code 211.12(d)(2) Nursing services

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to notify the physician about falls and bruises of unknown origin for two of two residents reviewed (Residents R1 and R2). Findings include: Review of the facility policy Investigation for Resident Falls Personal Care and Skilled Nursing dated as revised on 1/2018 revealed a Level 2 (Temporary Minor Harm/Damage) incident requires Document fall event in r/L Solutions by appropriate responding staff and under section d. to do the following, Notification of physician (speak with physician to obtain orders, verify treatment plan) and POA (can leave message but follow-up to acknowledge receipt of message). Review of the r/L Solutions reports on (MONTH) 11, (YEAR), at 1:00 p.m. for Resident R1 revealed an incident on (MONTH) 24, (YEAR), where Resident R1 was identified as having a Level 2 Temporary Minor Harm or Damage bruise of dimensions 6.5 cm (centimeters) by 4 cm on the left back to waist area. The notification area of this document revealed that the physician and Power of Attorney (POA) were not notified of the incident. Review of clinical records on (MONTH) 11, (YEAR), at 1:00 p.m. for Resident R1 revealed a Skin Evaluation Record dated (MONTH) 24, (YEAR), at 10:48 p.m. for a 6.5 cm by 4 cm purple bruise resolving to the lower left back. Review of clinical records on (MONTH) 11, (YEAR), at 1:00 p.m. for Resident R1 revealed a Progress note dated (MONTH) 25, (YEAR), at 12:26 a.m. that reads, PI 1/9 S/p (status [REDACTED]. Resident can not remember how she got the bruise. Denied pain or discomfort. Will continue to monitor. Further review of the clinical record revealed no documented evidence that the physician was notified of the resident's bruise. Review of Resident R2's closed clinical record revealed a nurse's progress note dated (MONTH) 20, (YEAR), where a bruise was noted on the posterior of the resident's left knee. Review of the facility's investigation regarding the resident's bruise revealed that the bruise measured 10.5 cms (centimeters) X 0.5 cms and that the facility had classified the bruise as a Level 2 Temporary Minor Harm or Damage. Further review of Resident R2's closed clinical record revealed no documented evidence that the physician was not notified of the resident's bruise. Interview with the Director of Nurses on (MONTH) 11, (YEAR), at 2:55 p.m. confirmed that per the facility's policy, the physician should have been notified of Resident R2's bruise. The director of nursing further confirmed that there was no documented evidence that the physician was notified of the bruise on the posterior of the resident's left knee. The facility failed to notify the physician of resident temporary harm or damage to two residents. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 1/12/16 28 Pa. Code: 201.18(b)(1) Management Previously cited 1/12/16 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(1)(5) Nursing services Previously cited 1/12/16

Based on observations, review of clinical records, facility documentation, facility policies, procedures, and interviews with staff, it was determined that the facility failed to ensure that Private Duty Nursing Personnel were able to demonstrate competency of resident care skills for two of 15 residents reviewed (Residents R31 and R46). Findings include: Review of facility policy, Private Duty Nursing Personnel, dated as revised in August 2014, revealed that private duty nursing personnel must follow the facility's established nursing care polices and procedures, and may never proceed with a procedure or treatment that they do not understand or are not licensed to perform. An interview with the Director of Nursing (DON) on January 11, 2016 at 1:15 p.m. confirmed that Private Duty Nursing Personnel are not to provide care or feed the residents of the facility. Observations of Resident R31 on January 7 & 8, 2016 during the noon meal revealed that Employee E4 was feeding this resident in the resident's private room, #33. An interview with Employee E4 on January 11, 2016 at 1:00 p.m. revealed that she had previously fed Resident R31 but no longer does so. A review of Resident R31's clinical record revealed that the resident required a Mechanical Soft (a diet consistency for those with a chewing/swallowing problem) diet with pre-cut meats. Nursing notes dated January 4 & 5, 2016, revealed documentation that Resident R31 was being fed by the Private Duty Companion. An interview with the DON confirmed this documentation and confirmed that Private Duty Nursing Personnel were not to be feeding the residents of the facility. There was no training or competencies related to feeding for this Private Duty Nursing Personnel. Review of Resident R46's Comprehensive MDS (minimum data set-periodic assessment of needs) assessment completed on September 11, 2015, revealed that the resident was severely cognitively impaired and required supervision with meals. Further review of clinical documentation revealed that Resident R46 had a private companion. Observations of Resident R46 on January 11, 2016 at 12:00pm in the [MEDICATION NAME] Dining Room during the noon meal revealed that the resident was falling asleep at the dining table. Employee E7, private duty companion, then began to assist this resident with the meal. Employee E7 was observed to bring an 8 oz. cup of coffee up to Resident R46's mouth encouraging the resident to drink which the resident refused. Employee E7 then attempted to feed Resident R46 half of a tuna sandwich but the resident again began to fall asleep. Interview with the Administrator and DON on January 12, 2016, at 1:45 p.m., confirmed there was no documentation related to each private duty companion regarding their knowledge of facility policies and procedures or ability to perform care and services to each resident for Residents R31 and R46. The facility failed to provide adequate oversight of the Private Duty Nursing Personnel. 28 PA Code: 201.14(a) Responsibility of licensee. 28 PA Code: 201.18(a) Management. 28 PA Code: 201.18(b)(1) Management. 28 PA Code: 201.18(b)(3) Management. 28 PA Code: 201.18(e)(1) Management. 28 PA Code: 211.10(c) Resident care policies 28 PA code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility documentation and interview with staff it was determined that the facility failed to conduct criminal and job reference background checks for 4 of 10 private duty companions. Findings included: Review of the resident roster with the director of nursing on January 11, 2016 at 12:30 p.m., revealed that the facility had a number of residents who employed private duty companions obtained through the facility's program or on their own (from outside agencies). Review of documentation for Employee E3, Employee E4, Employee E5 and Employee E6, current private duty companions, revealed that the facility had failed to obtain either on its own or through the private agency, evidence of a criminal background check and or job references as required. Interview with the director of nursing and the administrator on January 12, 2016 at 1:30 p.m. confirmed that the facility had failed to obtain this information prior to the employment of these individuals as required. 28 PA Code 201.18(e)(1) Management. 28 PA Code 201.19 Personnel policies.

Based on observation, clinical record review, facility documentation review and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed/obtained for medication administration and preoperative instructions, and failed to adequately and timely assess or intervene for one resident with a fractured leg for three of 13 residents reviewed (Residents CL1, R50, and R37), resulting in actual harm to Resident CL1. Findings include: A review of CL1's clinical record revealed a face sheet (Demographic Informational) which included the [DIAGNOSES REDACTED]. A review of nursing notes beginning October 3, 2011, at 3:00 a.m. revealed that the resident was dependent on staff for all of her needs, was alert with some confusion. A review of subsequent nursing notes from October 3, 2011, at 3:00 p.m. through October 8, 2011, at 6:55 a.m. revealed that the resident enjoyed attending activities, was pleasant and cooperative, expressed no pain/discomfort, enjoyed speaking with staff and other residents and was eating most of her meals. A review of a nursing note, dated Saturday, October 8, 2011, at 2:00 p.m. revealed that Resident CL1 had a swollen shin and the Physician was notified and ordered an Ultrasound to rule out a blood clot, to be completed on Monday, October 10, 2011, of her left shin. The Ultrasound report revealed that the left leg was without a blood clot. A review of nursing notes beginning October 11, 2011, at 10:00 a.m. revealed that Resident CL1 was becoming increasingly sensitive to the slightest touch, punching the charge nurse in her back when she carefully moved Resident CL1's leg. Another nursing note at 9:00. p.m. on October 11, 2011, revealed that the resident was uncooperative with staff during evening care screaming and attempting to hit staff. A physician's note dated October 13, 2011, identified Resident CL1's left leg with ecchymosis (bruising) and some [MEDICAL CONDITION] (swelling) of the leg and foot and that the resident had pain with movement. review of nursing notes on October 13, 2011 revealed that the resident remained in bed. A nursing note on October 14, 2011, revealed that the resident was sensitive to touch, expressed pain during morning care in her left leg and at 10:00 p.m., even after ordered pain medication administration the resident became "extremely agitated trying to hit staff, stating you are hurting me," on each movement/touch. Further review of nursing notes on October 16, 17, 19, 22, and 23, 2011, all revealed that Resident CL1 continued to complain of pain, attempting to hit staff even after ordered pain medication was given. A review of the Resident CL1's physician's note, dated October 28, 2011, revealed that the resident's "left leg still with some disfiguration and discoloration, remains uncomfortable with touch." The physician documented that a left leg X-ray be completed and that the resident stay on bed rest. A review of the X-ray results, dated as completed on October 28, 2011, revealed that Resident CL1 had a displaced fracture of Fibula and Tibia ( the two bones of the lower leg). A review of a physician's note from an Orthopedist, dated October 29, 2011, revealed that the resident required surgical repair of her left leg to include a nail placed into her left Tibia bone so the she could be moved from her bed to a chair. A review of a nursing note dated November 2, 2011 at 4:50 p.m. revealed that the Resident CL1 was transferred to the hospital for surgical repair of her fractured left leg and the Patient Transfer Form, dated November 4, 2012, from the hospital, noted that the resident is returning to the facility after a surgical repair of her left lower extremity on November 3, 2012. An interview with the Director of Nursing on January 20, 2012, at 10:30 a.m. confirmed that the resident continued to be weight bearing from October 8, 2011, when this left shin injured area was identified through October 28, 2011,(20 days later) and was transferred via a lift where the resident needed to bear weight and turn right/left from and to her bed and chair. Another interview with the Administrator and Director of Nursing on January 20, 2012, at 12:15 p.m. confirmed that the only intervention added between October 8, 2011, when the injured left leg was identified and October 28, 2011, when the fractured left leg was identified was additional pain medications. The facility failed to adequately and effectively assess Resident CL1's continuing indications of pain to the left leg in a timely manner resulting in a delay in treatment for one resident identified with a fractured left leg requiring a surgical repair and resulting in actual harm to the resident. Review of Resident R50's clinical record revealed physician's orders, dated December 27, 2011, for the resident to be NPO after MN (nothing by mouth after midnight), related to surgery scheduled for December 28, 2011, to implant Inter Stim neurotransmitters (internal bladder stimulation used to treat [MEDICAL CONDITION], overactive bladder, and urge incontinence with leakage). The orders indicated that any cardiac, blood pressure, or [MEDICAL CONDITION] medication could be administered to Resident R50 two hours prior to her departure, at 6:45 a.m. Nurse's documentation, dated December 28, 2011, detailed that Resident R50's nothing by mouth status was maintained, with the exception of having taken [MEDICATION NAME] (blood pressure medication), [MEDICATION NAME] (medication for high blood pressure, chest pain, and heart rhythm disorders), and [MEDICATION NAME] ([MEDICAL CONDITION] medication). Nurse's documentation, later that morning, reported that the facility was notified that the procedure was now postponed and rescheduled for December 30, 2011. Review of Resident R50's clinical record found no physician's orders for preoperative instructions related to the procedure rescheduled for December 30, 2011, including medication administration or food/fluid intake prior to the 2:00 p.m. procedure. Review of Resident R50's December 2011 MAR (medication administration record) found that [MEDICATION NAME], and [MEDICATION NAME] were administered, while medications including [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (used to treat dementia associated with [MEDICAL CONDITION]), and multiple vitamins and supplements were circled as held/not administered. Interview with licensed nurse Employee E3 on January 20, 2012 at 10:10 a.m., confirmed that pre-op orders had not been obtained for Resident R50's December 30, 2011procedure, and medication was held without a physician's order. Review of Resident R50's clinical record revealed physician's orders, dated January 17, 2012, for the resident's aspirin and [MEDICATION NAME] (bloodthinning medication) to be held as of that day, prior to a second surgical procedure scheduled for January 20, 2012. There was no evidence available for review on January 20, 2012, at 10:00 a.m., to indicate that physician's orders were obtained related to Resident R50's food/fluid intake, or medication administration other than bloodthinners, before the operative procedure on January 20, 2012. This finding was confirmed in an interview with licensed nurse Employee E3 on January 20, at 10:15 a.m. Review of Resident R37's clinical record revealed a physician's order, dated January 12, 2012, for vitamin B12 to be given every month. Review of Resident R37's January 2012 MAR found that the ordered dose of B12 was administered on January 13, 2012, via a SC/subcutaneous (under the skin) injection. There was no indication available for review on January 19, 2012, at 10:00 a.m., that the physician was contacted to determine the route of administration, either by mouth, by injection under the skin, by injection into the muscle, prior to the "SC" injection. This finding was confirmed in an interview with licensed nurse Employee E4 on January 19, 2012, at 10 a.m. An order clarification, dated January 19, 2012, indicated the B12 was to be administered IM/intramuscularly. 483.25 Quality of care. 28 Pa.Code: 211.12(d)(5) Nursing services. 28 Pa.Code: 201.18(b)(1) Management.