Every finding on record at Philadelphia Protestant Home

Based on a resident group interview, resident interview, review of facility policy and procedures, and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on three of the three nursing units. (Second floor, Third floor, Fourth floor). Findings Include: A review of facility policy titled Grievances/Complaints-(filing of) revised January 2023 states, Policy-The facility will assist residents, their representatives, other interested family members, or advocates in filing grievances or complains when such requests are made. Procedure- 1. Any resident, his or her representative, family member, or advocate may file a grievance or complaint concerning his or her treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. a. A grievance may be filed anonymously through secure drop boxes located on each unit Review of the requested facility grievance logs from the past six months January through June 2025 revealed only one grievance over the six month period. On June 26, at 11:33 a.m., a facility tour was conducted with the Social Worker, Employee E4. A tour was taken of the lobby area and each of the floors with nursing units (Second floor, Third floor, Fourth floor). The tour revealed there were no facility grievance forms readily accessible to residents without having to ask. Interview on June 26, 2025 at 11:43 a.m. with the Director of Social Services Employee E5 revealed the facility social worker usually interviews anyone that has a concern and fills out the form. 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)Resident rights

Based on review of facility documentation and staff interviews, it was determined that the facility failed to provide a safe environment for one of three nursing units reviewed. (Second floor) Findings Include: Review of facility policy titled, Medication Administration revised July 2018 states, Policy: Medications shall be administered in a safe and timely manner, and as prescribed. Further review of the policy procedure revealed, Medications will be administered in the following manner: a. Identify resident using two methods (asking them their name, using name band, and/or using picture in EMR) b. Review MAR for medications to be administered during current med pass time i. If needed, obtain any information (vital signs, blood sugar, etc) prior to administering medication. c. Check the label on medication blister pack against order in EMR to confirm correct resident, medication, dose, time, and route. d. Check expiration date on each medication blister pack. e. Dispense medication directly from blister pack into souffle/medication cup as applicable i. Multidose medications such as eye drops or inhalers should be also confirmed using the above method and prepared to be administered f. Medications will be administered by licensed nurse g. While administering medications to residents, the medication cart will be closed and locked when out of sight of the nurse. Observation of dining service on June 24, 2025 at 11:55 a.m. revealed a pantry area not being utilized next to resident tables that had various items on the top. Items included plastic bags, napkins, a radio, and a brown pill capsule. Licensed Nurse Employee E3 was asked on June 24, 2025 at 11:58a.m. to observed the brown pill and Employee E3 verified that the pill looked like a vitamin capsule. Licensed Nurse Employee E3 stated that the pill did not look like any that she dispenses to the residents on the second floor. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to revise a resident's care plans, related to accuracy of information, for one of 23 residents reviewed. (Resident R102) Findings Include: Review of facility policy, Care Planning Process revised July 2024 states, Policy-A comprehensive care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Further review under procedure revealed Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly. Review of Resident R102's clinical record revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Depression, Anxiety, Hyperlipidemia (high cholesterol), and Acute Kidney Failure (loss of kidney function). Review of Resident R102's nursing note dated June 7, 2025 revealed, Resident's Care Nurse reported that resident was making sexual comments towards her during care. Resident making comments about her breast and what size bra she wears. Care Nurse did inform resident that his conversation was inappropriate, and he was not to speak to her that way. Care Nurse did say that resident eventually refrained from making comments. Review of Resident R102's nursing note dated April 28, 2025 revealed, At the start of my 12-hour shift resident proceeded to ask me will I be in to flush foley in the morning. Have explained to resident on more than one occasion that catheter does not need to be flushed if not blocked or leaking. Resident currently has an order for as needed flush if catheter is blocked or leaking. Catheter is draining without difficulty. Sufficient output noted. Resident has made sexual remarks towards staff at times. Addition to proposing marriage to nursing staff. When staff does not respond appropriately to requests resident becomes anxious and rings call bell constantly through the night. Will request primary physician and psych to reevaluate behavior. Review of Resident R102's current care plan revealed there was no current plan or interventions in place for resident's inappropriate sexual behavior. The above findings were confirmed by the Director of Nursing on June 27, 2025 at 1:01 p.m. 28 Pa Code 211.10(a) Resident care policies

Based on review of clinical records, interview with staff and review of facility provided documentation, it was determined facility failed to ensure that one of 23 residents reviewed exercised right to go to bed and the time of her/his choosing. (Resident R67) Findings include: Review of facility policy 'Resident Rights,' revised October 13, 2012, indicates that the resident has the right to exercise his/her rights as a resident of this facility and as a citizen of the United States. Exercising rights means that residents have autonomy and choice, to live their everyday lives and receive care. Review of Resident R67's clinical record, on Friday, June 27, at 10:00am, revealed the diagnoses of adjustment disorder with depressed mood, anxiety disorder, abnormalities of gait and mobility, muscle weakness, abnormal posture, and subsequent encounter of falls. Review of Resident R67's Minimum Data Set (MDS resident assessment and care needs), completed April 7, 2025, indicated that Resident R67 required extensive assistance of two of more physical assist for transfers. Review of facility provided investigation report, completed on May 14, 2025, indicated that resident stated that staff members forced her to go to bed on May 3, 2025 when (she/he) was not ready. (She/He) stated that two women tried to put (her/him) to bed, (she/he) told them no, and then the nurse came in and told them to do what they needed to do. The resident stated the women then grabbed (her/his) by (her/his) arms and put (her/him) into bed. Resident was noted with bruising to bilateral arms the following day when (she/he) reported the incident to (her/his) family and nursing staff. Review of nursing notes, dated May 14, 2025, at 2:38 p.m., indicated family brought attention to several bruises on resident's bilateral upper extremities. Resident reports the right upper extremity feels sore. Statements collected from staff. Further review of investigation report revealed that resident right's committee met with employee. While unable to determine if bruising occurred from the alleged incident, it was determined that the resident's rights to participate in (her/his) care was violated when Licensed nurse, Employee E7 and Nurse aide, Employee E8, transferred resident to (her/his) bed without (her/his) permission. 28 Pa Code 201.29(j) Resident rights 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure two of seven nurse aides completed annual required 12-hour in-services (Employees E9 and E10) Findings include: Review of facility policy 'Education and Training of Staff,' revised March 31, 2025, indicated that it is the policy of the facility to establish and monitor ongoing education and training to improve staff competency in accordance with regulatory guidelines and organizational mission and values. Review of facility provided list of current nursing employees revealed Nurse aide, Employee E9, was hired on May 3, 2023. Further review of facility provided list of current nursing employees revealed Nurse aide, Employee E10, was hired on October 20, 2021. Upon request, facility was unable to provide evidence of required 12 hour annual in-services completed for Employees E9 and E10. Findings confirmed with facility's director of nursing and administrator. 28 Pa Code 201.14(a) responsibility of licensee 28 Pa Code 201.19(1)(3)(7) personnel policies and procedures

Based on the review of facility documentation, review of CMS regulations S483.70(n), interview with the staff, it was determined that the facility failed to ensure that the binding arbitration agreement contained required regulatory language under federal regulations S483.70(n) for 102 of 102 residents reviewed. Findings Include: Review of CMS regulation S483.70(n) revealed that S483.70(n) Binding Arbitration Agreements If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section. S483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility. S483.70(n)(2) The facility must ensure that: (i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; (ii) The resident or his or her representative acknowledges that he or she understands the agreement . S483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. S483.70(n)(4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. S483.70(n)(5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with S483.10(k). A list of Resident who was offered the arbitration agreement and signed the arbitration agreement was requested to the administrator on September 16, 2024 at 10:00 a.m. Facility provided a list of residents who signed arbitration agreement and who refused to sign the agreement. There was 102 residents who signed the agreement and 5 resident who was offered but refused to sign the agreement. A copy of the arbitration agreement which was offered to the resident or resident representative at the time of the admission was requested to the facility administrator for review. Review of Admission Agreement revealed the following information, In the event that any claim, controversy, dispute, or disagreement should arise between the Resident and the Home, whether arising out of, or relating to, the Resident's Agreement, the breach thereof, the subject matter thereof, or any legal duty incident thereto or independent thereof, and whether stated in tort, contract, or otherwise (collectively Controversy), excluding, however, only those claims by Home against Resident for collection by Home of unpaid balances owing by Resident to the Home for goods or services rendered to Resident, as well as guardianship proceedings, neither of which for the purposes of this Attachment F shall be considered a Controversy, both parties hereby agree that their Controversy shall be submitted to and settled exclusively by binding arbitration. Either party may commence arbitration by sending written notice to the other party demanding resolution of the Controversy through arbitration, and setting forth the nature of the Controversy, the dollar amount involved, if any, and the remedies sought (Arbitration Notice). (1) Within thirty (30) days after the receipt of the Arbitration Notice, the parties shall agree upon a single arbitrator. In the event that the parties are unable to agree upon a single arbitrator within such thirty (30) day period, each party shall have fifteen (15) days to appoint one (1) person each to act as an arbitrator. Such person shall have no personal or pecuniary interest, either directly or indirectly, from any source whatsoever, in the outcome of the Controversy, and such person shall not be an employee, contractor, director or agent of, or related to, either party. If either party fails to appoint an arbitrator within the allotted time, the other party may appoint an arbitrator for it; provided that such arbitrator meets the qualifications described above. Once two (2) arbitrators have been appointed, they shall have thirty (30) days from the date of the appointment of the last of the two (2) arbitrators to appoint a third arbitrator, who shall likewise be disinterested and meet the qualifications described above. Within fifteen (15) days after the date on which three (3) arbitrators are appointed, one (1) of those three (3) shall be selected by them to serve as Chairperson. (2) Binding arbitration shall be conducted in Philadelphia, Pennsylvania, in accordance with the rules and procedures set forth herein and, to the extent not inconsistent herewith, in accordance with the American Arbitration Association's Rules of Procedure for Arbitration. As soon as reasonably practicable, a hearing with respect to the Controversy or matter to be resolved shall be conducted by the arbitrator(s). As soon as reasonably practicable thereafter, the arbitrator(s) shall arrive at a final decision, which shall be reduced to writing, signed by the arbitrator(s) and mailed to each of the parties and their legal counsel. (3) The substantive law of the Commonwealth of Pennsylvania shall be applied by the arbitrator(s). Within thirty (30) days following the selection of the last arbitrator, the parties shall agree upon the nature and scope of discovery, including, without limitations, the number of interrogatories, demands for inspection of documents and tangible items, requests for admission, and the number and length of depositions. If the parties are unable to agree upon the nature and scope of discovery within such thirty (30) day period, then the nature and scope of discovery shall be determined solely by the arbitrator(s). The rules of evidence applicable to judicial proceedings shall not apply at the arbitration proceedings; evidence submitted by the parties may be admitted or excluded in the sole discretion of the arbitrator(s). (4) All decisions of the arbitrator(s) shall be final, binding and conclusive on the parties and shall constitute the only method of resolving disputes or matters subject to arbitration pursuant to this Attachment F. The arbitrator(s) or a court of appropriate jurisdiction may issue a writ of execution to enforce the arbitrator's[s'] judgment. Judgment may be entered upon such a decision in accordance with applicable law in any court having jurisdiction thereof. (5) Unless otherwise provided for in the decision of the arbitrator(s), the parties shall equally share all costs of arbitration; provided, however, that the arbitrator(s) may, in his/her or their sole and absolute discretion, include in the decision rendered a determination as to which party, if any, is the prevailing party and, if so, how much, if any, reimbursement the prevailing party shall receive from the non-prevailing party for the prevailing party's reasonable attorneys' fees, costs and any arbitration fees and expenses incurred in connection with the arbitration hereunder. The arbitrator(s) may, in their sole and absolute discretion, but need not, fix the amount of reasonable attorneys' fees and costs on the request of either party. (6) Notwithstanding anything to the contrary in this Attachment F, any party may seek a temporary restraining order or other interim injunctive or provisional relief from a court of proper jurisdiction without first resorting to the arbitration procedures set forth in this Attachment F. If any such relief is obtained, the arbitrator(s) shall address the continuance, modification, or termination of such relief in [his/her/their] order and the parties agree to abide by the arbitrator's[s'] decision regarding such relief. (7) Resident and Home specifically agree that this agreement to settle any Controversy, other than those set forth above, by binding arbitration, shall be valid, irrevocable, and enforceable, save upon such grounds as exist at law or in equity for the revocation of any contract, and further agree that the term Controversy specifically includes, but is not limited to, claims for personal injury and/or wrongful death. It was revealed that the facility arbitration agreement lacked the following regulatory requirements, S483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility. S483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. S483.70(n)(4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. S483.70(n)(5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with S483.10(k). Interview with facility administrator on September 18, 2024, at 9:30 a.m. confirmed that the facility arbitration agreement lacked the required regulatory languages set forth by S483.70(n). Administrator stated all residents or representatives were offered the arbitration agreement which was a part of the facility admission agreement. 28 Pa. Code 201.24 (b) Admission Policy 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on the review of clinical records, and staff interviews, it was determined that the facility failed to ensure that PRN (as needed) orders for psychotropic drugs are limited to 14 days without documented rationale by the attending physician or prescribing practitioner and the expected duration of the PRN order for one of five residents reviewed for medication regimen. (Resident R21) Findings Include: Review of physician order for Resident R21 dated March 25, 2024, revealed that there was an order for Ativan (this medication is used to treat anxiety) 0.5mg/0.5 ml every four hours as needed for agitation/aggression. Review of clinical record for Resident R21 revealed no evidence that the attending physician or prescribing practitioner documented the rationale for use of as needed psychotropic medication in the resident's medical record and indicated the duration for the PRN order. Interview with Nursing Home Administrator, Employee E1, on September 18, 2024, at 12:00 p.m. confirmed that Resident R21's clinical record did not contain evidence that the attending physician or prescribing practitioner documented the rationale for use of as needed psychotropic medication in the resident's medical record and indicated the duration for the PRN order. 28 Pa. Code 211.12(d)(1)(3) (5) Nursing services

Based on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to adequately supervise one of five residents reviewed and use assistive devices to prevent an elopement for one of 23 residents reviewed. (Resident R108) Findings include: Review of the facility policy titled elopement of resident dated May 2024 revealed that the facility was responsible to maintain the safety and security of all residents and to reduce the opportunity for elopement through effective training of staff and use of appropriate detection devices. The policy indicated that staff were to be trained to monitor residents in the facility who are at risk for wandering or exit seeking. The policy also indicated that a wander-guard tag containing a detection device that activates the door-locks would be used to prevent resident elopements. As noted the elevators are activated with this wander-guard tag which sets the elevator alarming device. The comprehensive admission assessment (MDS-an assessment of care needs) dated May 16, 2024 for Resident R108 indicated that this resident was admitted to the facility on [DATE]. The assessment indicated a BIMS (brief interview for mental status) report that Resident R108 was severely cognitively impaired. The assessment also indicated that this resident had no impairments and functional limitations of the upper and lower extremities. This assessment for Resident R108 indicated that this resident had a fall within the past month prior to admission. Clinical record review for Resident R108 indicated that the physical therapy (treatment that helps improve how your body performs physical movements) department had indicated on May 10, 2024 that this resident was ambulating 90 feet with care giver assist. The therapy progress notes for May 10 through May 16, 2024 indicated that Resident R108's level of function for ambulation was 200 feet with an assistive device (rolling walker). The occupational therapy (treatment that helps people overcome physical, emotional and social challenges and improve ability to perform daily tasks) department indicated that Resident R108 was able to independently stand 7 to 10 minutes with roller walker on May 20, 2024. Resident R108 was able to use assistive devise (roller walker) to facilitate functional mobility around the nursing unit on May 20, 2024. Clinical record review for Resident R108 indicated that the psychiatrist (a medical doctor with expertise in the field of mental, emotional and behavioral disorders) evaluated this resident on May 13, 2024. The resident complained to the psychiatrist that I don't want to be here I want to go home. The resident was very limited with reporting background information to the psychiatrist. The resident's husband was interviewed for this information. The resident's husband reported that Resident R108 had memory loss and frequent falls at home. Resident R108 reported to the psychiatrist that she was sad; because she was at the nursing facility. The psychiatrist indicated that Resident R108 had memory loss, memory impairment and dementia indicating that Resident R108's insight was impaired and that the resident was alert times one. The psychiatrist said that Resident R108 had adjustment disorder with anxiety and depressed mood. Clinical record review revealed a nursing progress note dated May 11, 2024 that indicated that Resident R108 was walking ten feet independently. The nursing staff also indicated that Resident R108 had some mental confusion with cognitive abilities. Clinical record review revealed a nursing assessment of functional abilities for Resident R108 on May 12, 2024. The assessment indicated that Resident 108 was ambulating as desired with no impairments of upper and lower extremities. Clinical record review revealed a nursing progress note dated May 16, 2024 that indicated that Resident R108 was constantly wandering on the nursing unit looking for her husband. Clinical record review revealed a recreational specialist (a professional who plans organizes and directs activities and programs for the residents) dated May 17, 2024 that indicated Resident R108 was reporting some loneliness, exhibiting forgetfulness at times and was observed ambulating independently throughout the fourth floor nursing unit. Clinical record review revealed a nursing progess note dated May 17, 2024 at 6:00 p.m., that indicated that Resident R108 was having more confusion beyond her baseline which was dementia with confusion. Clinical record review revealed a nursing progress note dated May 17, 2024 at 7:30 p.m., that indicated Resident R108 was observed with increased confusion and wandering episodes. The resident was asking the nursing staff, where is my husband ? why is he not visiting? The progress note indicated that nurse staff tried to redirect Resident R108 but were unsuccessful. Resident R108 then stated to the nursing staff I want to kill myself, I hope to jump out a window. Clinical record review revealed a nursing progress note dated May 18, 2024 that indicated that Resident R108 was found to be missing from the fourth floor nursing unit. The staff searched the interior of the facility for Resident R108. The facility security department found the resident sitting outside the building on the stoneledge at the main gate or main entrance to facility. Interview with the Director of Nursing, Employee E2, at 10:00 a.m., on September 17, 2024 revealed that Resident R108 did not have an alarming device on her person, at the time of the elopement. The Director of Nursing, Employee E2, reported that the resident did not have a wander-guard device care planned for her safety. The Director of Nursing reported that Resident R108 exited the fourth floor nursing unit without staff knowledge by way of the elevator. Resident R108 did not have a wander-guard; therefore there was no alarming or locking of the elevator unit that occured on May 18, 2024. The resident used the elevator from the fourth floor traveled to the first floor (ground floor) of the facility. Resident R108 walked out the rear entrance; without a rolling walker, to the facility and walked along the side of the building past the security entrance and out to the edge of the facility property to a [NAME]. The resident was found sitting on the stone wall. Observations of the stone wall on September 17, 2024, with the Director of Nursing, revealed that the [NAME] was located in front of a sidewalk and following that sidewalk was a double lane roadway to the entrance of the facility. Further interview with the Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 at 10:30 a.m., on September 18, 2024 confirmed that the wander-guard system was designed to activated an alarm at the elevators on the fourth floor that had to be dismanteled in order for the elevator to operate. 28 PA. Code 201.14(a)(b) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(d)(e)(1) Management 28 PA Code 211.10(a)(b)(c)(d) Resident care policies

Based on observations, interviews with staff, and a review of facility policies, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings Include: Review of facility policy titled, Food and Supply Storage dated 1/23 states, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Further review of the policy reads, Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy by or use by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Initial tour of the dietary department completed on November 1, 2023 at 10:06 a.m. with the Director of Dining Employee E4 and Dietary Manager Employee E5. Observation of the walk-in refrigerator on November 1, 2023 at 10:19 a.m. revealed two bags of cheese cubes opened, unlabeled, with no open date or use by date. Two lunch meat ham opened, unlabeled, with no open date or use by date. Two lunch meat ham labeled with a use by date of October 30, 2023. One American cheese opened, unlabeled, with no open date or use by date. One mozzarella cheese opened, unlabeled, with no open date or use by date. Observation of the walk-in freezer on November 1, 2023, at 10:26 a.m. revealed a package of turkey burgers opened, unlabeled, with no open date or use by date and a bag package of pork sausage opened, unlabeled, with no open date or use by date. The above findings were confirmed by the Director of Dining, Employee E4 on November 1, 2023 at 10:28 a.m. 28 Pa. Code: 201.14 (a) Responsibility of licensee 28 Pa. Code: 201.18(e) (1) Management 28 Pa. Code 201.18(b)(3) Management

Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure residents received pneumococcal immunizations for three of five residents reviewed for immunization concerns (Resident R47, R92 and R53). Findings include: Clinical record review for Resident R47 revealed that the resident was admitted to the facility on [DATE]. Resident 47's clinical record contained no documented evidence that the facility administered or offered the pneumococcal vaccine; or evidence that Resident R47 had received the pneumococcal vaccine before her admission to the facility. Clinical record review for Resident R92 revealed that the resident was admitted to the facility on [DATE]. Resident 92's clinical record contained no documented evidence that the facility administered or offered the pneumococcal vaccine; or evidence that Resident R92 had received the pneumococcal vaccine before her admission to the facility. Clinical record review for Resident R53 revealed that the resident was admitted to the facility on [DATE]. Resident 53's clinical record contained no documented evidence that the facility administered or offered the pneumococcal vaccine; or evidence that Resident R53 had received the pneumococcal vaccine before her admission to the facility. Interview on November 2, 2023, at 1:09 p.m. with the Infection Control Nurse, Employee E3, stated every resident will be offered pneumococcal vaccine upon their admission to the facility. A resident's history of receiving vaccine in the community or if a resident decline vaccine would be documented in the clinical record. Employee E3 confirmed that there was no documented evidence that pneumococcal vaccine was offered, given or history was documented for Resident R47, R92 and R53. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, facility policy review, drug information review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent (%). Two medication errors out of 25 medication administration opportunities observed during medication administration (Medication Error Rate of 8%). Findings include: The facility's medication error rate was 8% based on observation of 25 medication administration opportunities with two errors observed. Review of physician order for Resident R45 dated March 31, 2021, revealed an order for Polyethylene Glycol 3350 powder to give 17 grams once daily for constipation, mix in 6 ounces of liquid. Further review of the physician order dated September 20, 2021, revealed an order for Hormel Med Pass liquid (Nutritional supplement liquid) to give 4 oz three times daily. Review of physician order for Resident R61 dated December 20, 2022, revealed an order for Lidocaine external 4% patch (medicated patch to relieve pain) apply in the morning and remove after 12 hours. Patch to be removed according to the applying schedule. Review of Medline (national library of medicines) drug information, available at https://medlineplus.gov/druginfo/ revealed that Never apply more than 3 of the lidocaine 5% patch or lidocaine 1.8% topical systems at one time, and never wear them for more than 12 hours per day (12 hours on and 12 hours off). If you wear too many lidocaine transdermal patches or topical systems or wear them for too long, too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose. Observation of the morning medication pass for Resident R45 on November 2, 2023, at 9:38 a.m., with Employee E8, licensed practical nurse, revealed that Employee E8 took 17 grams of Polyethylene Glycol 3350 powder in a cup and mixed it with one ounce of juice. Employee also had 4 oz of Nutritional supplement liquid with her when she entered Resident R45's room for medication administration. Observation of the morning medication pass for Resident R61 on November 2, 2023, at 9:54 a.m., with Employee E8, licensed nurse, revealed that Employee E8 removed the old patch that was still applied on residents' right knee from previous application. Employee E8 then applied the new patch right after removing the old patch. Interview with Licensed nurse, Employee E8 on November 2, 2023, at 10:07 a.m., confirmed that the staff should have removed the lidocaine patch that applied on previous day for Resident R61. Employee R8 also confirmed that she only mixed the Polyethylene Glycol 3350 powder in one ounce of liquid not in 6 ounce as ordered by the physician. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to assess the need for specialized occupational therapy services according to the professional standards of practice for one out of one resident reviewed for rehabilitation services (Resident R82). Findings include: Review of facility policy Therapy Screen dated February 8, 2023, revealed that Therapy screens are to be initiated when a resident may benefit from PT, OT or ST services. When a change in a resident's condition or a new need is identified a rehab screen is initiated. Request for Rehab Screen form will be completed by the clinical team member requesting the screen. Rehab director will initiate screen with appropriate discipline to determine resident's needs and document outcome of screen. A dining observation completed on November 1, 2023, at 11:39 a.m. in fourth floor dining room, revealed that Resident R82 was attempting to drink juice from a can which was placed on the table without using his arm or holding the can in his hand/s. Resident leaned to the table with juice on it and appeared struggling to drink the liquid. Further observation of Resident R82 revealed that the resident was provided with regular utensils, spoon and fork. Resident was observed with severe shaking while he was scooping and feeding himself. Resident appeared to have struggled to hold the utensils properly in his hand due to severe shaking. Review of dietician progress note dated October 26, 2023, revealed that an occupational therapy (OT) screen was requested due to staff reported concern of shaking with beverages. It was documented that the resident might benefit for adaptive cup and a message was left for Rehab Director. During an interview on November 3, 2023, at 9:30 a.m. with Director of Therapy, Employee E9 stated that Resident R82 was not on the case load and the resident was not screened by OT. Employee E9 also confirmed that there was no documented screen available with the therapy department for Resident R82. During an interview on November 3, 2023, at 9:56 a.m. with Dietician, Employee E10, stated she requested a therapy screen for Resident R82 for his tremors. Employee E10 stated she observed Resident R82 when he was eating, he would benefit from adaptive equipment. During an interview, on November 3, 2023, at 10:45 a.m. with Registered Nurse, Employee E11 stated that the resident had tremors during eating and he was using regular utensils. Employee E11 also confirmed that there was no screen placed as recommended by the dietician. 28 Pa Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies.

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for seven of seven months of antibiotic stewardship program data reviewed. (April 2023 to October 2023). Findings include: A review of facility policy entitled Antibiotic Stewardship, dated July 2023, revealed To ensure infections are evaluated and treatments ordered only when specific criteria for infection is met. In the event a resident is symptomatic for an infection, the resident will be added to the infection surveillance log, then staff will: f. Follow McGeer criteria for determining an HAI. If necessary, report to PA=PSRS and inform responsible party in writing. k. Surveillance on affected units for new cases of affected organism will be done by ICP/DON) A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders. Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures (e.g., prevalence surveys) provide a snap-shot of information; while others, like nursing home initiated antibiotic starts and days of therapy (DOT) are calculated and tracked on an ongoing basis. Selecting which antibiotic use measure to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT. At the time of the survey ending November 3, 2023, the facility failed to demonstrate their actions designed to implement an effective antibiotic/antimicrobial stewardship program which includes a system to effectively monitor antibiotic usage and prevent inappropriate use of antibiotic. Facility did not submit evidence of ASP program, surveillance, tracking, analysis which was requested to Infection Control Nurse, Employee E3 on November 2, 2023, at 1:09 p.m. Facility submitted two months of pharmacy generated Antibiotic Class Medication report which did not include the actions designed to implement an effective antibiotic/antimicrobial stewardship program which includes a system to effectively monitor antibiotic usage and prevent inappropriate use of antibiotics. An interview with the Director of Nursing, Employee E2, November 3, 2023, at 11:30 a.m. confirmed that there were no documented evidence of an effective antibiotic stewardship program and system of appropriate use of antibiotics as required. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documentation, and staff interviews it was determined that the facility failed to implement appropriate tracking and surveillance of infection for seven of seven months reviewed. (April 2023 to October 2023) Findings Include: Review of Facility policy Infection Control dated October 2022 revealed that The objectives of our infection control policies and procedures are to: a. Investigate, control, and prevent infections in the facility. It shall be the responsibility of the Quality Assessment and Assurance committee, through the infection control committee, to assure that infection control policies and procedures are implemented and followed. Further review of the facility infection control policies available for review at the time of survey revealed no evidence of facility practices, tools, or protocols related to ongoing systematic collection, analysis, interpretation, and dissemination of resident infection in the facility. Review of National Healthcare Safety Network(NHSN) tool for tracking healthcare -associated infections titled Long-Term care facility Component Manual dated January 2023, revealed, Surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff, and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. Surveillance may include process surveillance and outcome surveillance. Process surveillance includes reviewing practices by healthcare workers directly related to resident care to identify whether facility infection prevention and control policies are being followed. Examples may include hand hygiene adherence, appropriate use of personal protective equipment such as gowns, gloves, and facemasks, adherence to safe injection practices, and infection prevention and control practices used during wound care. Using outcome surveillance, facilities incorporate infection criteria, such as those provided to NHSN users, to identify and report evidence of suspected or confirmed healthcare associated infection or communicable disease. Examples of outcome surveillance include monitoring staff and residents for infection events, which may be indicative of an outbreak or a complication as a result of care received in the facility, such as C. difficile infection or urinary tract infection. A facility that conducts targeted surveillance, also referred to priority directed surveillance, focuses surveillance activities on high risk, preventable, and/or high consequence infections significant to their resident population. For example, by focusing on device associated infections in high-risk units, such as skilled nursing or ventilator-dependent, facilities are able to implement prevention measures to reduce infection risks among residents in those units. Another example of targeted surveillance is monitoring epidemiological significant organisms, such as multi-drug resident organisms (for example, MRSA, VRE, and CRE) or C. difficile among residents in the facility. By focusing staff time and resources on a smaller number of clinically important events, more time is available for detailed data collection and analysis to identify trends and opportunities for prevention. Since targeted surveillance methods may result in missed infections and potential outbreaks, facilities should have a facility-wide process in place to detect outbreaks and multi-drug resistant organisms. A request was made to Infection Control Nurse, Employee E3 for infection tracking of the facility on November 2, 2023, at 1:09 p.m., for facility infection tracking log for COVID-19 and other infections. Review of facility documentation revealed that no infection tracking for non-COVID-19 infection were available. Review of infection control meeting minutes dated July 27, 2023, revealed that the facility had nosocomial infection rate of 1.32%. which included three respiratory infections, one urinary tract infection, two cellulitis, and two skin infections. There was no other infection tracking or report available for July, August, September and October. Interview with Director of Nursing, Employee E2 on November 3, 2023, at 9:30 a.m., confirmed that the facility did not have evidence of infection surveillance and facility identified the non-compliance and was in the process of implementing infection surveillance/tracking. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records, facility policies and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one incident of resident injury sustained during a resident transfer from bed to wheelchair for one of three residents reviewed for accidents. (Resident R77). Findings include: Review of the facility policy titled, Accident Investigation revised, June 2023, revealed, It is the policy of The Philadelphia Protestant Home to investigate any resident injuries to attempt to find the cause. Statements will be obtained by staff that were involved. Review of facility policy, titled, Abuse, Neglect, Misappropriation of Property dated January 2023, revealed, Types of Abuse: Mistreatment: means inappropriate treatment or exploitation of a resident. Investigation: When an incident of abuse, neglect, exploitation, misappropriation of property or an injury of unknown origin is alleged, suspected or found, an incident report must be filed, and an investigation initiated immediately. Obtain statements from resident, other residents, and staff as needed. Statements should be handwritten and signed when possible. Review of care plan for Resident R77 dated January 15, 2023, revealed that the resident required max assist of 2 person for transfers. Resident was also at risk for falls due to the history of the falls with right hip fracture. Review of facility investigation dated May 22, 2023, revealed that Resident R77 sustained a large laceration during a two person transfer from the sharp edges on the right lower extremity. Further review of the investigation revealed that the wheelchair was checked by the maintenance for sharp edges and no sharp edges noted. Staff was educated on proper transfer technique and notify if any changes in resident's ADLs (Activities of Daily Living) and transfer. Interview with Nursing Aide, Employee E7 on November 3, 2023, at 11:45 a.m. stated when she was transferring Resident R77 from bed to wheelchair with another employee, resident's leg slid and hit on the edges of wheelchair. The other employee was an orientee. Employee E7 also stated she did not remember what the resident was wearing on the foot or if the resident was wearing appropriate footwear or socks. Review of the statement from Nursing Aide, Employee E7, dated May 22, 2023, revealed that while resident was transferred for shower to wheelchair, her right leg hit the sharp edges on the wheelchair. Further review of the investigation revealed no evidence that the facility interviewed or obtained written statement from the other employee who assisted Employee E7 to transfer Resident R77 on May 22, 2023. Investigation also revealed no documented evidence if the resident was wearing appropriate footwear or socks. There was also no documented evidence of the type of assistance the other employee provided during the transfer. Interview with the Director of Nursing, Employee E2, on November 3, 2023, at 11:45 a.m. confirmed that the facility did not obtain statement from the orientee who provided assistance for Resident R77 on May 22, 2023. Employee E2 also confirmed that the facility investigation did not reveal evidence if the resident was provided appropriate foot wear or socks. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges as required for three of 22 residents reviewed (Residents R28, R21 and R75). Findings include: Review of progress notes for Resident R28 revealed a health status note, dated September 10, 2023, at 11:45 p.m. which indicated that the resident had a change in condition including shortness of breath and low oxygen levels and was ordered by the on-call nurse practitioner to be transferred to a local hospital emergency department for further evaluation. Review of progress notes for Resident R21 revealed a transfer to hospital summary note, dated June 6, 2023, at 2:38 p.m. which indicated that the resident had abnormal labs and was ordered by the nurse practitioner to be transferred to a local hospital emergency department for further evaluation. Review of progress notes for Resident R75 revealed a health status note, dated September 17, 2023, at 6:20 p.m. which indicated that the resident had an x-ray result that was positive for an acute hip fracture and was ordered by the practitioner to be transferred to a local hospital emergency department for further evaluation. Further review for Residents R28, R21 and R75's clinical records revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of the above facility-initiated emergency transfers. Interview on November 2, 2023, at 1:17 p.m. the Director of Nursing revealed that the facility did not have a policy regarding facility-initiated transfers and discharges. Continued interview confirmed that the Office of the State Long-Term Care Ombudsman was not notified in a timely manner as required of facility-initiated emergency transfers and discharges. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Policy: Food and Supply Storage, which was revised in January 2022, states that opened food will be covered, labeled, and dated. And a chart which shows that ground meet should be stored below whole meats. An initial tour of the Food Service Department was conducted on January 3, 2023, at 10:00 a.m. with Employee E8, Food Service Director (FSD), which revealed the following: Observations in the walk-in refrigerator revealed a tray of long tubes of thawing ground beef stored over whole pork loins and whole beef roasts, and an open gallon of whole milk which was open but had no date when the product was opened. Observation in the hot production area revealed a ceiling tile which was hanging down and electric conduit and boxes which were covered in grease and dust and grime. Observation of the hot holding oven the middle door gasket was broken and held on with black tape which was torn and frayed. Observation in the fourth-floor pantry revealed dirt, dust and water stains on the under shelf of the steam table. Interview with FSD at 10:30 a.m. on January 3, 2023, confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 PA Code: 201.18(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management

Based upon review of facility policies and procedures, review of clinical records and facility documentation and interviews with residents and staff, it was determined that the facility did not ensure allegations of abuse were thoroughly investigated for one of 29 residents reviewed (Resident R27). Findings include: Review of facility policy title Abuse, Neglect, Misappropriation of Property revealed that the Director of Security will compile a formal incident report along with corroborative statements from witnesses and the alleged perpetrator if appropriate. Administration will, based on fact finding, notify the field office of The Department of Health and other government agencies. A PB22 form will be completed and sent to the Department of Health field office. To protect the resident during an investigation, the home shall immediately develop and implement a plan of supervision or suspension or reassigned the accused employees until the investigation and a determination of guilt or innocence is made. This plan must be noted to the State agency when reported. Review of Resident R27 's investigation report revealed that the resident was admitted with diagnosis of type 2 diabetes with ophthalmic and other circulatory complications, hypertensive heart disease with heart failure, adjustment disorder with mixed anxiety and depressed mood, mild cognitive impairment (early stage of memory loss), hyperlipidemia (high cholesterol), insomnia (sleep disorder), glaucoma (sight disorder), anxiety, pain. Continued review of Resident R27 investigation report completed on July 21, 2022 revealed that resident reported pain in her right hand wrist. Swelling was present when assessed, certified registered nurse practitioner and doctor were notified, and an x-ray was ordered. Resident's daughter was notified and reported that she received phone call from her mother complaining that the person taking care of her was rough and pulled her arm during care. Perpetrator, nurse aide, Employee 16 was identified and a statement was obtained. According to alleged perpetrator's statement, When I was giving the resident pm care, everything was ok. Review of an additional statement obtained from the Occupational Therapist, Employee 17, revealed that Resident 27 complained of pain in right hand wrist, x-ray results were negative, with slight edema noted, and no range of motion restrictions noted. Review of right-hand x-ray results dated July 21, 2022, reveal severe degenerative arthritic change seen throughout hand and wrist, and in particular in the proximal and distal interphalangeal as well as first carpometacarpal joints .Soft tissue swelling and moderate calcific deposit of the wrist. Further review of the investigation revealed that the facility failed to complete a thorough investigation by not completing a State report (PB-22) for investigation of alleged abuse, neglect, misappropriation of property. Review of nursing schedule and assignment dated July 23, 2022 revealed that alleged perpetrator was assigned to care for Resident 27 during investigation which was completed on July 28, 2022. The facility failed to obtain statements from all residents assigned to nurse aide, Employee E16. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, a review of facility policy, and interviews with residents and staff, it was determined that the facility failed to establish grievance policies and procedures that identified a grievance official and post the grievance policy in a prominent location in the facility. Findings include: Review of facility policy Grievances/Complaints (filing of), revised November 2022, revealed the facility will assist residents and their representatives in filing grievances or complaints when such requests are made. Further review of the policy revealed that the administrator has delegated the responsibility of grievances and/or complaint investigation to the Pathways Administration Team. A tour of the facility at 11:00 a.m. on January 3, 2023, revealed no observations of a policy or procedure for resident or family to fill grievances. A group interview was conducted on January 4, 2023, at 10:30 a.m. with the following alert and oriented residents: Resident R24, Resident R69, Resident R48, Resident R66, Resident R41 and Resident R57. During the group interview, residents reported that they did not know who the grievance official was or how to contact this individual. They stated that to file a grievance they would go to the nurse or the Activity Director to report concerns. Residents were not aware any postings of who to see or how to file a grievance. Interview conducted with the Nursing Home Administrator, Employee E1, on January 4, 2023, at 1:30 p.m. revealed there was no person identified by name, as grievance official, with contact information, who is responsible for overseeing the grievance process and acknowledged that the policy was not prominently posted in the facility. 28 Pa. Code 201.18(b)(3) Management

Based on a review of clinical records and facility policies and interviews with facility staff, it was determined the facility failed to ensure that advanced directives selected by a resident were reflected in physician orders for one of 23 residents reviewed (Resident R74). Findings include: A review of facility policy, Advance Directives revised October 3, 2022, states that the facility will be sensitive to the concerns and needs of residents and families while assisting them in implementing their wishes. A review of Resident R74's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses including ataxia (poor muscle control that causes clumsy voluntary movements), anxiety disorder (a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear). Further review of Resident R74's clinical record revealed an Advance Directive, dated March 23, 2020, signed by the resident and two witnesses. The Advance Directive describes the resident's wishes for health care in a medical emergency and states that she does not want cardiac resuscitation, she does not want mechanical respiration, she does not want tube feeding, she does not want blood or blood products, she does not want surgery or invasive diagnostic tests, and she does not want kidney dialysis. A review of Resident R74's active physician's orders as of January 4, 2023, revealed a May 11, 2022, physician order for Full Code (all life-saving and life-sustaining treatments to be used). During an interview with the Administrator, on January 4, 2023, at 1:30 p.m. it was verified that Resident R74's physician order for Full Code did not provide for her wishes per her selections on the Advance Directive dated March 23, 2020. 28 PA Code: 201.29(a) Resident rights.

Based review of facility policy, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide the necessary assistance to safely transfer one resident (Resident R28) and failed to provide the appropriate level of supervision during meals for another resident (Resident R 107), which resulted in actual harm related to a laceration and a burn for two of 28 residents reviewed (Resident R28 and R 107). Findings include: Review of facility policy, Abuse, Neglect, Misappropriation of Property, dated last reviewed (MONTH) (YEAR), revealed that Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record for Resident R28 revealed a quarterly Minimum Data Set assessment (MDS- assessment of resident care needs) dated (MONTH) 29, (YEAR) which indicated that the resident was severely cognitively impaired and required the physical assistance of two or more persons for transfers. Continued record review for Resident R28 revealed a physician's orders [REDACTED]. Review of facility documentation, submitted on (MONTH) 27, (YEAR), revealed that Resident R28 was transferred on (MONTH) 27, (YEAR), during morning care and sustained a laceration to her right leg which measured 3.5 cm (centimeters) by 2.2 cm by 2.5 cm. Resident R28 was subsequently sent to the hospital and received six sutures for the laceration. Review of the facility's investigation of this incident revealed that a nurse aide had transferred Resident R28 by herself and stated that when she made rounds the previous nurse aide had told her that the resident was a one person assist. Interview on (MONTH) 4, 2019, at 12:00 p.m. with the Nursing Home Administrator (NHA) confirmed that the nurse aide on (MONTH) 27, (YEAR), did not follow orders for Resident R28 related to the need for the physical assistance of two staff persons for transfers which resulted in the resident receiving a laceration which required hospital treatment and six sutures. The facility failed to provide the appropriate level of staff assistance while transferring Resident R28. Resident R28 sustained a laceration during the transfer which required a hospital evaluation and six sutures. Review of facility policy, Hot Beverage Temperature Guidelines, dated reviewed (MONTH) 22, (YEAR), revealed that Hot beverages may pose a safety risk to residents even when the temperature, at the point of service, is within the 150-155 range. Facilities must ensure that these beverages are served in a no risk manner. Review of Resident R 107's clinical record revealed that the resident was admitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS- an assessment tool used to determine resident care needs) completed on (MONTH) 23, (YEAR), indicated that the resident's cognitive skills (an activity related to thinking, reasoning or remembering) for daily decision making was poor and moderately impaired. She required cueing (verbal directions) and supervision. Further review revealed that the resident required extensive assistance with one person physical assistance with eating. Review Resident R 107's care plans dated (MONTH) 2, (YEAR), revealed that the resident had [MEDICATION NAME] degeneration (an eye disorder that may lead to [MEDICAL CONDITION]). The care plan further identifed that the resident was at risk for injuries due to poor vision and directed staff to observe the resident for safety. Additionally, the care plan indicated that the resident needed limited/extensive assist for activities of daily living because the resident was legally blind. The care plan further directed staff to assist the resident as needed while eating. Review of information submitted by the facility, dated (MONTH) 5, (YEAR), revealed that Resident R107 had spilled soup on her lap while in the dining room at approximately 11:00 a.m. and had one blister about the size of a quarter. The facility investigation revealed redness on the right thigh measured 7 cm x 12 cm and left thigh measured 6 cm x 3 cm (centimeters, length x width; 1 inch = approximately 2.5 centimeters). Further review of information submitted by the facility indicated that the resident'[MEDICAL CONDITION] daily treatments with [MEDICATION NAME] Cream (an antibiotic cream used in the treatment of [REDACTED]. Continued review of the information submitted by the facility revealed a witness statement written by Employee E6, Nursing Assistant, which stated that she took the resident to the dining room and came out to get more residents. I got to the door I noticed she (Resident R 107) was screaming. I burn myself its hot'. Additionally, Employee E6's statement indicated that the dietitian had given the cup of soup to the resident, which was still in the resident's hand. Employee E6 further indicated in the witness statement that the temperature of the soup served to Resident R 107 was 160 degrees Fahrenheit (F). Review of Nurses' notes for Resident R 107 dated (MONTH) 9, (YEAR), revealed a blister noted on right thigh measuring 2 cm (centimeters) x 2.2 cm and 1.8 x 1.2 and on left thigh blister 1.7 x 1.2 cm. A review of the Dining Services temperature audit form of the soup for (MONTH) 5, (YEAR), confirmed that the temperature of the soup was documented as 160 degrees Fahrenheit. Interview with the Nursing Home Administrator (NHA) on (MONTH) 7, (YEAR), at approximately 4:00 p.m. confirmed that the soup was placed near a visually impaired resident who required supervision during meals. The facility failed to provide adequate supervision for one resident who sustained a burn to her right and left thighs from hot soup. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/17/17, 12/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 11/17/17, 12/09/16 28 Pa. Code 201.18(b)(3) Management Previously cited 11/17/17 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/09/16 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/17/17, 12/09/16

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision related a burn for one of 28 residents reviewed (Resident R 107). Findings include: A review of Resident R 107's clinical record revealed that the resident was admitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set assessment (MDS) (an assessment tool used to determine resident care needs) completed on (MONTH) 23, (YEAR), indicated the resident's cognitive skills (an activity related to thinking, reasoning or remembering) for daily decision making was poor and moderately impaired. She required cueing (giving encouragement and verbal directions) and supervision. Further review revealed that the resident was an extensive assistance with one person physical assist with eating. A review of the resident's care plans dated (MONTH) 2, (YEAR), revealed that Resident R 107 had [MEDICATION NAME] degeneration and was at risk for injuries due to poor vision, and included an intervention to observe the resident for safety. An additional care plan revealed that the resident needed limited/extensive assist for activities of daily living because she was legally blind, with an intervention to assist resident as needed, related to eating. Review of facility policy, Hot Beverage Temperature Guidelines, dated (MONTH) 5, 2007 and reviewed (MONTH) 22, (YEAR), revealed the policy to specifically cover coffee and hot water with no mention of soup. Further review revealed that Hot beverages may pose a safety risk to residents even when the temperature, at the point of service, is within the 150-155 range. Facilities must ensure that these beverages are served in a no risk manner. Review of information submitted by the facility, dated (MONTH) 5, (YEAR), revealed that the resident spilled soup on her lap while in the dining room at approximately 11:00 a.m. and had one blister about the size of a quarter. The facility investigation revealed redness on the right thigh measured 7 cm x 12 cm and left thigh measured 6 cm x 3 cm (centimeters, length x width; 1 inch = approximately 2.5 centimeters). It was indicated that the temperature of the soup was listed for that day was documented on the Dining Services temperature audit form at 160 degrees Fahrenheit (F). Further review indicated that temperature guidelines for soup, at point of service, was listed at 160 degrees F. Nurses' notes, dated (MONTH) 9, (YEAR), revealed a blister noted on right thigh measuring 2 cm x 2.2 cm and 1.8 x 1.2 and on left thigh blister 1.7 x 1.2 cm. Further review of the witness statement written by Employee E6, Nursing Assistant, revealed that she took the resident to the dining room and came out to get more residents. I got to the door I noticed she was screaming. 'I burn myself its hot'. Further review of information submitted by the facility indicated that the resident'[MEDICAL CONDITION] daily treatments with [MEDICATION NAME] Cream (an antibiotic cream used in the treatment of [REDACTED]. Interview with the Nursing Home Administrator (NHA), on (MONTH) 7, (YEAR), at approximately 4:00 p.m. revealed that soup was placed near a visually impaired resident who required supervision during meals. The facility failed to provide adequate supervision for one resident who was visually impaired who sustained a burn to her right and left thigh from hot soup. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 11/17/17, 12/09/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/17/17, 12/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 11/17/17, 12/09/16 28 Pa. Code 201.18(b)(3) Management Previously cited 11/17/17 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/09/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/17/17, 12/09/16