Every finding on record at Pickering Manor Home

Based on clinical record review and review of facility documentation it was determined that the facility failed to ensure that staff provided adequate supervision and assistance in order to prevent repeated falls for one of four sampled residents who were at risk for falls. (Resident 42)Findings includeClinical record review revealed that Resident 42 was admitted to the facility on [DATE], and had diagnoses that included supranuclear palsy, (neuro-degenerate disease involving a gradual deterioration of the brain), Parkinson's disease, cognitive communication deficit, anxiety, difficulty walking and unsteadiness on her feet. The Minimum Data Set assessment dated [DATE], indicated that the resident had some cognitive impairment, was dependent for toileting and had two or more falls since admission. A review of the care plan revealed that the resident was at risk for falls due to supranuclear palsy, Parkinson's disease and impaired mobility. There was an intervention dated June 2, 2025, for staff to assist and maintain one to one surveillance in the bathroom with the resident. Review of nursing notes and facility documentation revealed that Resident 42 fell a total of 26 times between May 9, 2025, through September 6, 2025. Twenty one of the falls were unwitnessed by staff and six of the falls were witnessed by staff. Twelve of the falls occurred in or near the bathroom, four of the falls were out of bed and two of the falls were out of her wheelchair. On May 11, 2025, a nurse noted that the resident was non-compliant with using the call bell and she was getting out of the wheelchair without assistance. The nurse also noted that the resident had been trying to get out of bed multiple times by herself. On May 12, 2025, at 10:38 a.m., a nurse noted that the resident was lowered to the floor by staff. On May 13, 2025, at 10:10 a.m., a nurse noted that staff witnessed the resident fall to her knees when she had attempted to stand after toileting. Review of facility documentation revealed that on May 13, 2025 at 7:33 p.m., the resident fell in the bathroom. On May 19, 2025, at 9:30 a.m., the resident had a fall in her bedroom. The facility investigation indicated that the resident stated she fell trying to transfer from the wheelchair to her bed. On June 1, 2025, at 9:30 a.m., an aide found her on the floor in her bathroom. Facility documentation dated June 9, 2025, at 1:34 p.m., indicated that the resident had an unwitnessed fall. She was found kneeling in front of her bathroom. On June 12, 2025, at 8:28 a.m., the resident had an unwitnessed fall in her bathroom. The facility investigation indicated that the resident had poor safety awareness, weakness and an unsteady gait. On June 19, 2025 at 1:30 p.m., the resident had an unwitnessed fall out of bed. She had tried to get up out of bed on her own into her wheelchair and fell. The facility investigation indicated that the resident had been agitated and restless and that she tended to get up out of bed by herself. On June 20, 2025, at 2:03 a.m., the resident had another unwitnessed fall out of bed. The facility investigation indicated that the resident had been confused prior to the fall. On July 7, 2025, at 4:45 p.m., the resident had an unwitnessed fall and was found on the floor in her room. On July 16, 2025, at 6:22 p.m., the resident had another unwitnessed fall in her room and had slid from her wheelchair. On July 17, 2025, at 8:30 a.m., she had an unwitnessed fall in the bathroom and again on July 22, 2025, at 9:16 a.m., she was again found on the floor in her bathroom. On July 23, 2025, at 2:56 p.m., the resident had a witnessed fall when an aide was taking her to the bathroom. The investigation indicated that the resident had leaned forward and fallen out of her wheelchair in the bathroom. On July 24, 2025, at 2:56 p.m., the resident had an unwitnessed fall in her bathroom. On July 27, 2025, at 5:42 p.m., she had a witnessed fall in her bathroom when she had leaned forward off of the toilet. On July 29, 2025, at 1:39 p.m., an aide took the resident to the bathroom and she fell when she leaned forward on the toilet. On July 30, 2025, the resident had two unwitnessed falls. At 8:01 p.m., she fell in the bathroom and at 9:37 p.m., she had a fall in her room and was found next to her bed. On August 13, 2025, at 1:46 p.m., on August 18, 2025, at 10:27 p.m., and again on August 30, 2025, at 9:30 p.m., the resident fell and the facility investigation indicated that she had been in bed prior to the falls.On September 2, 2025, at 6:33 p.m., an aide had taken the resident to the bathroom. The facility investigation further indicated that the aide had transferred her to the toilet and stepped away. When the aide returned to the bathroom to reposition the resident to her wheelchair she noticed the resident standing on her own. She lost her balance and fell onto the shower bench. On September 3, 2025, at 9:25 a.m., the resident again fell in her bathroom. The investigation indicated that the resident had got up on her own, got back to her wheelchair and was trying to get into bed. The resident told the aide that she had fallen when she was going to the bathroom. On September 6, 2025, at 8:00 a.m., the resident had an unwitnessed fall out of bed. The resident stated at this time that she had wanted to get up out of bed. There was no documented evidence that the facility had provided adequate supervision at the times when the resident was frequently exhibiting behaviors, specifically attempts to get out of her bed, out of her wheelchair or when she stood unassisted by staff in order to prevent falls. In addition, the facility failed to provide the one to one surveillance on a consistent basis as per her care plan when the resident was using the bathroom. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 13 sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure, atrial fibrillation, and hypertension. A physician's order dated July 1, 2025, directed staff to weigh the resident daily and to notify the physician if there was a two to three pound (lb.) gain in 24 hours or a five pound gain in a week. A review of the care plan indicated that Resident 1 was at risk for fluid overload due to congestive heart failure. A review of weight documentation between August 17, 2025, and September 17,2025 revealed that there was no evidence that staff weighed Resident 1 as ordered on August 21, 25, and 27, 2025, and on September 3, 5, 8, and 15, 2025. Resident 1 had a 7.5 lb. weight gain on August 19, 2025, and a three lb. weight gain on September 2 and 11, 2025. There was no documented evidence that staff notified the physician of the weight gain. In an interview on September 18, 2025, at 11:20 a.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted to weigh the resident as ordered. In an interview on September 18, 2025, at 11:35 a.m., the Assistant Nursing Home Administrator confirmed that there was no documented evidence that staff notified the physician of the weight gain. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, staff interview, and observation, it was determined that the facility failed to properly store food and maintain sanitary conditions in the main kitchen and in the rehabilitation unit kitchen. Findings include: Review of the facility's policy entitled, Refrigerated Storage Checkpoints, dated [DATE], revealed that foods were to be labeled, dated and used by the use-by date or discarded. An interview with the Director of Dining Services (DDS) on [DATE], at 10:15 a.m., revealed all opened food products were to have an opening date noted on them. Observations during the tour of the main and rehabilitation unit kitchens on [DATE], at 10:14 a.m., revealed the following: In the main kitchen walk-in cooler, there was a puddle of a red liquid substance on the floor under the shelves where meat was thawing. There was a pan of sliced ham steaks that was not dated. In the walk-in freezer, there was an unwrapped chicken patty and an ice cream sandwich on the floor under the shelves. There were two dished containers of macaroni and cheese and stewed tomatoes with a use-by date of [DATE]. In the dry storage area, there was a sugar packet and syrup container on the floor and an opened ketchup packet that had dried ketchup splattered on the wall behind the condiment box shelves. There was a single glove on a shelf next to a container of opened shredded coconut. In the cooks' preparation area, there was a drawer with clean whisks that had a layer of food debris along the bottom of it. In the rehabilitation unit kitchen upright cooler, there was an opened container of sour cream with a use-by date of [DATE], and an uncovered broken egg. In the upright freezer, there were three undated, opened bags of a cinnamon raisin bagel, sliced angel food cake, and home fries. There was a roast pork with a use-by date of [DATE]. In the rehabilitation dining room serving area, in the reach-in cooler, there were three undated, opened containers of orange juice concentrate, liquid egg product, and butter packages. In the reach-in freezer, there was an opened plain bag with one onion bagel in it that was not dated. In an interview on [DATE], at 11:00 a.m., the DDS confirmed these items should have been dated, expired items should have been removed, and the food items were for use in the skilled areas. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity to one of 13 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 had diagnoses that included dementia. According to the Minimum Data Set assessment, dated October 31, 2023, the resident was cognitively impaired and required set up assistance from staff to eat. Review of Resident 10's current care plan revealed that staff was to provide necessary assistance at meals. Observations during breakfast on November 7, 2023, and lunch on November 6 and 7, 2023, revealed the resident was eating her meals with her fingers. The resident was observed ripping pieces from a whole chicken breast and eating the pieces with her hands, scooping sliced carrots and mashed potatoes with a gravy into her mouth with her fingers, eating pancakes with syrup and slices of banana by hand, and eating whole cubes of beef in a gravy with her fingers. During the observations, the resident's fingers and hands had food and gravy or syrup on them and food was observed on her clothing protector. At no time did staff redirect or assist the resident. CFR 483.10(a) Resident Rights Previously cited 12/29/2022

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one of 12 sampled residents. (Resident 20) Findings include: Clinical record review revealed that Resident 20 had diagnoses that included dementia, depression, and dysphagia. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance from staff for activities of daily living. A physician's order dated December 5, 2022, directed staff to provide regular utensils, not plastic. On December 27, 2022, at 1:18 p.m., Resident 20 was observed in the dining room. The resident was eating food from a bowl with her fingers, there was a plastic spoon observed on Resident 20's lap. At 1:26 p.m., Nurse Aide (NA) 1 retrieved the plastic spoon from Resident 20's lap and proceeded to feed the resident while standing. NA 1 continued to feed the resident while standing until her meal was completed at 1:35 p.m. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 201.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to thoroughly investigate alleged violations of abuse for one of 12 sampled residents. (Resident 10) Findings include: Review of the facility policy entitled, Resident Abuse and Neglect Prevention Policy, last reviewed July 21, 2022, revealed that all reported instances of abuse would be promptly investigated. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included dementia, depression, and anxiety. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment and exhibited behavioral symptoms not directed at others on one to three days during the review period. On May 19, 2022, a nurse documented that Resident 10 grabbed a female resident's hand and placed it over his private area. On May 19, 2022, a nurse also documented that Resident 10 was observed caressing a resident inside her thighs. On June 20, 2022, a nurse documented that Resident 10 was observed standing over a female resident who stated the resident touched her shoulder and asked her to have sex. On September 7, November 6, 7, 9 and 23, 2022, nurses documented that Resident 10 was following female residents and making sexual comments. There is no documented evidence that these incidents were thoroughly investigated. In an interview on December 29, 2022, at 10:04 a.m., the Director of Nursing confirmed the alleged violations of resident-to-resident abuse were received but were not investigated. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further limitations in range of motion for two of 12 sampled residents. (Resident 23, 25) Findings include: Clinical record review revealed that Resident 23 had diagnoses that included unsteadiness on feet, muscle weakness, abnormalities of gait and mobility, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 23 had no cognitive impairment and required extensive assistance with transfers. Review of the care plan revealed Resident 23 received a restorative nursing program (RNP) to prevent decline in mobility. The intervention was for staff to assist her to ambulate (walk) to and from the dining room three times a day. In an interview on December 27, 2022, at 11:28 a.m., Resident 23 stated that staff does not walk her. There was no documented evidence that Resident 23 was ambulated or offered to ambulate 24 out of 26 times in December 2022. In an interview on December 29, 2022, at 1:12 p.m., the Director of Nursing (DON) confirmed there was no documentation that Resident 23 was ambulated or offered to ambulate. Clinical record review revealed that Resident 25 had diagnoses that included dementia, anxiety, abnormal posture, and muscle weakness. Review of the MDS assessment dated [DATE], revealed that the resident required extensive assistance from staff for activities of daily living and had limitations in range of motion to both lower extremities (hip, knee, ankle, foot). Review of the care plan revealed the resident was at risk for deterioration in functional abilities. The intervention was for staff to follow therapy recommendations. Review of a physical therapy discharge summary dated March 8, 2022, revealed that the therapist recommended a RNP for active and passive range of motion for Resident 25. There was no evidence that a RNP was implemented per the therapist's recommendations. In an interview on December 29, 2022, at 10:05 a.m., the DON stated the the RNP was not implemented per the therapists recommendation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store food under sanitary conditions on one of three nursing units (skilled unit). Findings include: Review of the facility policy entitled, Nursing Station Refrigerators, dated July 20, 2021, revealed that the unit refrigerators were to be maintained in a sanitary condition with a temperature range of 41 degrees Fahrenheit or lower. Observations of the West Wing unit refrigerator on January 4, 2022, revealed an internal temperature of 50 degrees Fahrenheit at 11:53 a.m., and 49 degrees Fahrenheit at 1:30 p.m. On January 5, 2022, at 10:15 a.m., the temperature was 49 degrees Fahrenheit. All temperatures were above the safe refrigeration temperature of 41 degrees Fahrenheit or lower. In an interview on January 6, 2022, at 1:30 p.m., the Nursing Home Administrator confirmed the unit refrigerator temperatures were not within the guidelines for food safety. CFR 483.60 (i) Food Safety Requirement Previously cited 1/21/21 28 Pa Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendation was reviewed and acted upon for one of 20 sampled residents. (Resident 13) Findings include: Clinical record review for Resident 13 revealed that on October 23, 2021, the pharmacist had recommended a gradual dose reduction of an antipsychotic medication ([MEDICATION(S)]). There was no documentation in the clinical record to support that the physician had responded to and acted on the pharmacist's recommendation. In an interview on January 6, 2022, at 12:35 p.m., the Director of Nursing confirmed that the pharmacy recommendations had not been timely reviewed and acted upon by the physician. 28 Pa. Code 211.0(f)(3) Pharmacy services.

Based on observation and review of facility documentation, it was determined the facility failed to store food under sanitary conditions on one of two nursing units (East wing). Findings include: Observations of the unit refrigerator on the East wing nursing unit on January 19, 2021, revealed an internal temperature of 50 degrees Fahrenheit at 1:37 p.m., and 1:46 p.m., and 51 degrees Fahrenheit at 1:54 p.m., which was above the safe refrigeration temperature of 41 degrees Fahrenheit. Review of the temperature log revealed the internal temperature of the refrigerator was 48 degrees Fahrenheit at 2:30 p.m. on January 16, 2021, and 46 degrees Fahrenheit at 2:30 p.m. on January 17, 2021. There was no documented evidence to confirm the refrigerator received the appropriate maintenance following the findings of temperatures above 41 degrees Fahrenheit on these dates. During the same observation there were two 32 ounce containers of orange juice with expiration dates of January 9, 2021 and January 17, 2021. In an interview conducted on January 20, 2021 with the Nursing Home Administrator and Maintenence Director, the Administrator acknowledged that the refrigerator had not been serviced following the findings of temperatures above 41 degrees Fahrenheit. 28 Pa. Code 201.18 (b)(3) Management.

Based on clinical record review and observation, it was determined that the facility failed to ensure that dignity was promoted for two of 16 sampled residents. (Residents 16, 35) Findings include: Clinical record review revealed that Resident 16 had a [DIAGNOSES REDACTED]. Observation on (MONTH) 14, 2019, at 11:11 a.m., revealed that the resident was seated in a resident lounge and was being provided with foot care from a podiatrist. There were two other residents present in this same lounge while the care was being provided by the podiatrist. The facility failed to ensure that podiatry care was provided to the resident in dignified, private manner. Clinical record review revealed that Resident 35 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 8, 2019, indicated that the resident was alert and oriented and required extensive assistance from staff for activities of daily living including personal hygiene. Review of the care plan identified a problem area that included limited ability to complete hygiene without assistance from staff. Observation on (MONTH) 16, 2019, at 1:34 p.m., revealed that the resident's nails were dirty, long, and uneven in length with some jagged edges. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure completion of a Minimum Data Set (MDS) assessment for one of 16 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was discharged from the facility with no return anticipated on (MONTH) 2, 2019. There was no documented evidence that a MDS assessment was completed to reflect the discharge with no return anticipated when the resident was discharged from the facility. On (MONTH) 16, 2019, at 10:30 a.m., the Director of Nursing stated that the MDS assessment had not been completed when the resident had been discharged from the facility on (MONTH) 2, 2019. 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and staff interview, it was determined that the facility failed to develop a care plan with interventions to address the use of an anti-coagulant medication for one of four sampled residents who was on an anti-coagulant medication. (Resident 18) Findings include: Clinical record review revealed that Resident 18 had [DIAGNOSES REDACTED]. On (MONTH) 16, 2019, a physician ordered for staff to administer an anti-coagulant medication ([MEDICATION NAME]) every day. The Minimum Data Set assessment dated (MONTH) 29, 2019, indicated that the resident had been administered an anti-coagulant (blood thinning medication) in the last seven days of the assessment period. Review of the Medication Administration Records for June, (MONTH) and (MONTH) 2019, revealed that the resident had been receiving the anti-coagulant medication as ordered by the physician. There was no documented evidence that a care plan had been developed with interventions to address the use of the anti-coagulant medication. In an interview on (MONTH) 16, 2019, at 10:30 a.m., the Director of Nursing stated that there had not been a care plan developed to address the use of the anti-coagulant medication. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/27/19

Based on clinical record review, review of facility documentation and resident interviews, it was determined that the facility failed to prevent resident neglect that resulted in a serious injury (a fractured right tibia - lower leg bone) for one resident, who was dependent on staff for assistance with transfers, out of 12 residents reviewed (Resident 32). Findings include: Clinical record review revealed that Resident 32 was admitted to the facility on (MONTH) 10, (YEAR), and had [DIAGNOSES REDACTED]. According to the admission Minimum Data Set assessment (MDS - a periodic evaluation of resident care needs) dated (MONTH) 17, (YEAR), the resident had a history of [REDACTED]. On (MONTH) 14, (YEAR), at 2:44 p.m. a social worker noted that the interdisciplinary team met to discuss Resident 32's care needs and determined that the resident was receiving treatment from physical and occupational therapists for her decreased mobility. The social worker further noted that the interdisciplinary team determined that the resident required two staff members to safely assist the resident from a seated to a standing position. On (MONTH) 15, (YEAR), staff identified on the comprehensive plan of care that the resident required assistance with standing from the seated position, and that staff was to follow the recommendations of the therapy department when providing assistance. According to training records, on (MONTH) 25, (YEAR), staff from the therapy department trained 10 nurse aides on how to safely care for Resident 32, including using two people to assist the resident to transfer. Employee 5 was present at the training. On (MONTH) 8, (YEAR), at 3:36 a.m. a nurse noted that Resident 32 had a very difficult time transferring from her chair while using the bathroom. Later that day, at 7:36 a.m. a nurse noted that Resident 32 stated that she fell during her transfer to the (bathroom) and had pain in her right knee. Review of information dated (MONTH) 9, (YEAR), submitted by the facility revealed that on (MONTH) 8, (YEAR), at 7:20 a.m. the resident was assisted to the toilet by two staff members. After the resident finished using the toilet, one staff attempted to transfer the resident off the toilet without assistance in accordance with therapists' recommendation or the plan of care. An X-ray of the right leg was performed on (MONTH) 8, (YEAR), that showed a hairline crack in the right tibia (the large long bone of the lower leg) near the knee. On (MONTH) 10, (YEAR), the resident was examined by the orthopedist (a physician specializing in treating problems of the bones). At that time, he ordered that the resident remain in bed due to the injury. The orthopedist ordered a CT (computerized axial tomography) scan (a highly detailed X-ray) that confirmed the presence of the fracture. After the orthopedist obtained the results of the CT scan, he ordered toe touch weight bearing (allowing the resident to put her right foot on the floor without putting any weight on it) and a right knee immobilizing brace. On (MONTH) 24, (YEAR), the orthopedist again examined the resident, and determined that the resident would need surgery to repair the fracture. In an interview conducted on (MONTH) 25, (YEAR), at 1:03 p.m. the resident confirmed that she fell because Employee 5 tried to assist her without a second aide. The resident further stated that she has been in pain every day ever since the fall. Documentation provided by the facility revealed that the facility substantiated the allegation of neglect. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/9/16 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/9/16

Based on observation, policy review, and staff interview it was determined that the facility failed to ensure that sanitary conditions were provided during meal service in the dining room. Findings include: Review of the facility policy titled, Dietary Services, last reviewed on (MONTH) 23, (YEAR), revealed that staff was to perform hand hygiene after handling dirty dishes and before touching food, clean dishes, and silverware. On (MONTH) 24, (YEAR), from 12:45 p.m. through 1:30 p.m. staff was observed during lunch in the main dining room clearing dirty dishes and garbage, while serving meals and assisting residents with their meals. Staff did not wash or sanitize their hands between tasks. In an interview on (MONTH) 26, (YEAR), at 1:30 p.m. the Director of Nursing confirmed that staff was to perform hand hygiene after clearing dirty dishes, before serving meals or assisting residents. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/9/16

Based on facility policy and personnel file review it was determined that the facility failed to obtain personal reference checks at the start of employment for one of 5 newly hired employees sampled (Employee 5). Findings include: The facility Resident Abuse and Neglect Prevention Policy last reviewed (MONTH) 23, (YEAR), revealed that potential employees were to be screened for a history of abuse prior to employment. Part of that process included reference checks from previous and/or current employers. Review of Employee E5's personnel file indicated that Employee E5 applied for employment at the facility in (MONTH) (YEAR). Review of the reference checks performed by the facility revealed no documented evidence that the facility checked with Employee 5's previous employers to rule out a possible history of mistreatment of [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19 Personnel policies and procedures.

Based on clinical record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were complete to accurately reflect the resident's status for four of 12 sampled residents. (Residents R28, R19, R27, R46) Findings include: Clinical record review revealed that Resident R28's MDS assessment dated [DATE], inaccurately identified that the resident with an inserted catheter was frequently incontinent of bladder in Section H, and also failed to identify that the resident had one fall since the prior assessment dated [DATE] in Section J. Clinical record review revealed that Resident R19's MDS assessment dated [DATE], failed to identify that the resident had a fall in Section J. Clinical record review revealed that Resident R27's MDS assessment dated [DATE], failed to identify that the resident had a fall with major injury in Section J. Clinical record review revealed that Resident R46's MDS assessment dated [DATE], failed to identify that the resident had a fall with injury in Section J. 28 Pa. Code 211.15(f) Clinical records.

Based on clinical record review, policy review and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse or neglect for two of five sampled residents who had injuries of unknown origin. (Residents R7, R27) Findings include: Review of the the facility's policies Resident Abuse & Neglect Prevention Policy and Accident & Incident Reporting last reviewed on June 29, 2017, revealed that the facility was to investigate all reported instances of abuse including injuries of unknown origin. This included thoroughly investigating the possible causes of skin tears and bruising of unknown origin. According to policy, the investigation was to include statements from staff who cared for the resident from the last three shifts prior to the identification of the bruise or skin tear of unknown origin. Clinical record review revealed that Resident R7 had a [DIAGNOSES REDACTED]. On July 23, 2017, at 5:51 a.m. a nurse documented that Resident R7 was found with bruising and swelling of the left outer eye. The facility was unable to provide documentation to support that the facility thoroughly investigated this bruising, including statements from staff who cared for the resident in the three prior shifts, to rule out abuse or neglect. Clinical record review revealed that Resident R27 had a [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], identified that the resident had some memory impairment and required extensive staff assistance to complete all activities of daily living. On May 10, 2017, at 2:39 p.m. a nurse documented that Resident R27 was found with a bruise on the left side of the rib cage. The facility was unable to provide documentation to support that the facility thoroughly investigated this bruising, including statements from staff who cared for the resident in the three prior shifts. On May 20, 2017, at 2:24 p.m. a nurse documented that Resident R27 was found with a skin tear on the back of her right hand. There was one staff statement that indicated that the resident was all over building that morning and in all rooms of other residents. There was no further evidence to support that the facility thoroughly investigated this skin tear to rule out abuse or neglect. In an interview on August 3, 2017, at 11:53 a.m. the Director of Nursing stated that the facility had no evidence to support that the facility investigated Residents R7 and R27 injuries of unknown origin to rule out resident abuse or neglect. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, policy review and staff interview, it was determined that the facility failed to adequately assess and provide supervision to prevent a resident elopement (exiting the facility without staffs' knowledge) for one of 12 sampled residents. (Resident 015) For an additional resident in the sample, the facility failed to assess a fall to determine possible reasons for the fall and potential interventions to prevent additional falls. (Resident R022) Findings include: Review of the facility Elopement Prevention policy dated August 3, 2016, revealed that the facility was to use a pro-active approach in the prevention of resident elopement. This included identification of resident at risk for wandering based on behaviors, implementing preventative measures such as an AlphaWatch bracelet (a device that triggers a lock on doors when a wandering resident approaches), increased supervision by staff, and updating the plan of care to include all relevant interventions. Clinical record review revealed that Resident R015 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated June 8, 2016, indicated that the resident had cognitive impairment and required assistance from staff to move about the facility safely. On June 4, 2016, at 10:44 p.m., a nurse noted that the resident was confused and had attempted to leave the floor. The nurse also noted that the resident may need (an AlphaWatch) bracelet and required increased monitoring. There was no documented evidence that the resident was evaluated for an AlphaWatch bracelet or that the resident ' s wandering behavior was included on the plan of care. There was also no documented evidence that any additional supervision was provided to the resident due to the new exit-seeking behavior. On June 9, 2016, at 3:00 p.m., a nurse noted that the resident was found in the facility parking lot and that he was looking for his car. Review of the facility's Accident & Incident Reporting policy, dated August 3, 2016, revealed that all resident falls were to be investigated for causation and to prevent reoccurrence. Clinical record review revealed that Resident R022 was legally blind and had [DIAGNOSES REDACTED]. An MDS assessment dated [DATE], identified that the resident had memory impairment, needed staff assistance to transfer and walk and had a fall. On April 13, 2016, at 11:02 a.m., a nurse documented that Resident R022 had fallen in her room. The facility was unable to provide evidence that a post fall investigation was conducted to determine possible causes for the fall and additional measures to be implemented to prevent additional falls. The resident fell again on May 23, 2016. In an interview on September 8, 2016, at 11:55 p.m., the Director of Nursing stated that a post fall assessment had not been completed after the fall on April 13, 2016, as required by facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/17/16 28 Pa. Code 211.10(d) Resident care polices. Previously cited 8/17/16

Based on observation and a review of staff postings, it was determined that the facility failed to post the actual hours worked by registered nurses, licensed practical nurses and certified nurse aides directly responsible for resident care by shift. Findings include: On September 7, 2016, at 9:48 a.m., the daily nursing staff postings on the units failed to include the actual hours for registered nurses, licensed practical nurses and certified nursing assistants working in the facility. Further review of daily nursing staff postings from September 2 through September 6, 2016, revealed that the postings also failed to include the actual hours of the nursing staff on duty. 28 Pa. Code 201.18(a) Management.