Every finding on record at Pinecrest Manor

Based on review of facility policy, facility documents, and resident and staff interviews, it was determined that the facility failed to correct Resident Council concerns for a period of three months (April 2026 through June 2026). Findings: Review of facility policy, Resident Council, dated 11/18/25, indicated Staff is to follow up with any of the residents' concerns that were voiced at the meeting so they can be addressed at the next meeting. Review of facility policy, Dining Room, dated 11/18/25, indicated, To promote a home-like environment and enhance socialization. The policy also indicated that the dining room would be open seven days a week and that Restorative Aides would assist during the lunch meal and during the evening meal and on weekends, residents would be assisted by staff from the Nursing wings. Review of the Resident Council minutes over the past three months, April 2026 through June 2026, revealed a pattern/trend with issues regarding residents not being able to go to the dining room for the supper / evening meal and issues with meal trays being served cold due to sitting in the hallway for a period of time after the tray carts are delivered to the nursing units. Interviews with Residents R1, R2, R3, R4, R5, R6, R7, R8, and R9 indicated that the dining room is closed for the supper meal at least weekly and sometimes more. The interviews also indicated that the room trays sit in the hallway for a period of time before they are delivered to the residents and they are cold when they receive them. Interviews with nursing staff all indicated that the Nursing Supervisor determines if the dining room will be closed for supper by 3:30 p.m. on the day of closing. Information provided by the facility revealed that the dining room was closed for supper on the following dates in June and July, 6/6/26, 6/7/26, 6/18/26, 6/20/26, 6/21/26, 6/22/26, 6/23/26, 6/25/26, 6/26/26, 6/29/26, 6/30/26, 7/4/26, 7/7/26, 7/9/26, 7/11/26, 7/12/26 and 7/13/26. An interview with the Nursing Home Administrator on 7/17/26, at approximately 2:35 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding the dining room being closed for the supper meals and residents receiving cold trays from them sitting in the hallways for a period of time before receiving them April 2026, May 2026, and June 2026 Resident Council meetings. No evidence was provided to ensure that there was timely corrective actions regarding the residents' concerns that were verbalized and also stated in the Resident Council minutes for the past three months reviewed. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of five of 24 residents reviewed (Residents R94, R30, R105, R70, and R42).Findings include: MDS instructions for section J Health Conditions, Subsection J1800 Any Falls Since Admission/Entry or Reentry or Prior Assessment indicated Has the resident had any falls since admission/entry or reentry or the prior assessment whichever is more recent? MDS instructions for section K0300 indicated that if weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months to code yes. The MDS instructions further indicated to calculate 10 % weight loss in 180 days, start with the resident's weight closest to 180 days ago. MDS instructions for section PO200 revealed to identify all alarms that were used at any time (day or night) during the seven-day look-back period and to code the frequency of use as not used, used less than daily or used daily. The MDS instructions further indicated that a bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident's clothing. The MDS instructions further indicated that a chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident's clothing. MDS instructions for section N Medications, subsection N0350A Insulin Injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. MDS instructions for section N Medications, subsection N0350B Orders for Insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days. MDS instructions for section N Medications, subsection N0415E1 High-Risk Drug Classes: Use and Indication Anticoagulant - check if the resident is taking any medications by pharmacological classifications, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Resident R94's clinical record revealed an admission date of 11/08/25, with diagnoses that included displaced intertrochanteric fracture of the femur (fractured hip), high blood pressure, and history of falling. Resident R94's discharge MDS with an Assessment Reference Date (ARD- a look back period of time for the MDS assessment) of 12/19/25, revealed section J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? was coded as 0. No Resident R94's clinical record progress note dated 12/19/25, revealed that Resident R94 was found on floor and complaining of left hip and groin pain, orders obtained to send resident to ER for evaluation. Progress note dated 12/20/25, revealed Resident R94 was admitted with fractured femur under the hardware from previous fracture. During an interview on 1/29/26, at 1:00 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that Resident R94's 12/19/25, MDS was coded inaccurately regarding falls. Resident R30's clinical record revealed an admission date of 7/16/15, with diagnoses that included cerebral palsy (congenital disorder of movement/muscle tone/posture), anorexia nervosa ( an eating disorder in which people have a low body weight based on personal weight history), and depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed). Review of Resident R30's clinical record revealed evidence of weight loss in the last six months. On 4/02/25, Resident R30 weighed 76.1 pounds (lbs). On 9/01/25, he/she weighed 62.4 lbs which is a -18% Loss. On 3/10/25, Resident R30 weighed 73.9 lbs. On 9/01/25, he/she weighed 62.4 lbs which is a -15.56% Loss. On 2/05/25, Resident R30 weighed 77.8 lbs. On 9/01/25, he/she weighed 62.4 lbs which is a -19.79% Loss. Resident R30's quarterly MDS with an ARD of 9/1/25, under section K-Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as No or unknown. During an interview on 1/29/26, at 2:15 p.m. Registered Dietitian Employee E2 confirmed that Resident R30 did have significant weight loss and the MDS dated [DATE], for Section K-Swallowing/Nutritional Status Section K0300 Weight Loss was coded incorrectly and should have been coded as yes, not on prescribed weight-loss regimen. Resident R105's clinical record revealed an admission date of 12/02/25, with diagnoses that included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), high blood pressure and repeated falls. Resident R105's clinical record revealed a physician's order dated 12/2/25, for Chair/bed pull alarm-check function and placement every shift for fall/safety intervention. An admission MDS with an ARD of 12/9/25 revealed that section P0200A bed alarms, and P0200B chair alarms was coded as not used. Observations between 1/27/26 and 1/29/26, revealed Resident R105 had a chair alarm attached while sitting in his/her wheelchair. Resident R105's clinical record revealed a completed Treatment Administration Record (TAR) for chair/bed pull alarm-check function and placement every shift since ordered on 12/2/25. During an interview on 1/30/26, at 9:05 a.m. RNAC Employee E1 confirmed Resident R105's MDS was coded inaccurately for section P0200A bed alarms, and P0200B chair alarms and should have been coded as Used Daily. Resident R70's clinical record revealed an admission date of 3/18/24, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and high blood pressure. Resident R70's quarterly MDS with an ARD of 6/6/25, revealed section N0350B Orders for Insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days. was coded 1. Resident R70's quarterly MDS's with an ARD of 9/2/25, and 12/3/25, revealed section N0350A Insulin Injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. was coded as 1. Review of R70's physician orders from 3/18/24, through 1/30/25, lacked evidence of Resident R70's being ordered or receiving insulin. During an interview on 1/30/26, at 9:07 a.m. RNAC Employee E1 confirmed that Resident R70 was never ordered and did not receive insulin and quarterly MDS's with ARD of 6/6/25, 9/29/25, and 12/3/25, were coded inaccurately regarding receiving insulin and changes in insulin orders. Resident R42's clinical record revealed an admission date of 1/9/19, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), and COPD. Resident R42's quarterly MDS with an ARD of 9/8/25, revealed section N0415E Anticoagulant - check if the resident is taking any medications by pharmacological classifications, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. was coded as No. Resident R42's physician orders revealed an order dated 8/5/25, for Apixaban (Eliquis - an anticoagulant medication used to reduce risk of stroke and blood clots in adults with A-Fib) 5 milligrams (mg) twice a day. Medication Administration Record (MAR) for September 2025, revealed Resident R42 received Apixaban twice a day during the entire 7-day lookback period. During an interview on 1/30/26, at 9:08 a.m. RNAC Employee E1 confirmed that Resident R42 received an anticoagulant medication during the entire 7-day lookback period and his/her 9/8/25, was coded inaccurately regarding use of anticoagulant medication. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R7).Findings include: Review of facility policy dated 11/18/25, entitled Care Plans: Interdisciplinary indicated the purpose is to provide a comprehensive care plan that includes measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs that are identified including those identified in the comprehensive assessment. The policy further stated that care plans will be reviewed quarterly and for significant changes and hospital returns as well as staff updating as required between care plan conferences. Resident R7's clinical record revealed an admission date of 5/29/29, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Schizoaffective Disorder )a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]). Resident R7's clinical record revealed a physician's order dated 10/25/25, for Novolog (medication used to treat diabetes) 12 units subcutaneously (sq - a short needle is used to inject a drug into the tissue layer between the skin and the muscle) every morning with breakfast, 12 units sq every afternoon with lunch, 10 units sq every evening, and coverage according to sliding scale with meals and at bedtime. Resident R7's clinical record further revealed an annual Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) with an Assessment Reference Date of (ARD - a look back period of time for the MDS assessment) of 10/30/25, indicating Resident R7 received insulin injections during the look-back period. Resident R7's clinical record lacked evidence that a care plan had been developed to address his/her usage of insulin. During an interview on 1/30/25, at 9:09 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that a care plan had not been developed to address Resident R7's use of insulin. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and drug manufacturer instructions, observation, and staff interview, it was determined that the facility failed to appropriately date and store medications in one of four medication carts reviewed (C Hall Medication Cart). Findings include: Review of facility policy dated 11/18/25, entitled Pharmaceutical Services and Medication Storage revealed the facility must adhere to all relevant state, federal, and local regulations, included those from the Department of Health, Food and Drug Administration, and Drug Enforcement Agency and State Boards of Pharmacy regarding the storage, handling, and administration of all medications. Manufacturer's guidelines for Trelegy Ellipta (medication used to treat Chronic Obstructive Pulmonary Disease [COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing] and Asthma [a long-term inflammatory disease of the airways that cause the airways to narrow and swell causing symptoms such as wheezing, coughing, chest tightness, and shortness of breath], indicated that Trelegy should be discarded six weeks after opening the foil tray or when the counter read 0, whichever comes first. Manufacturer's guidelines for Fluticasone Salmeterol also known as Advair Diskus (maintenance medication used to prevent flare-ups or worsening COPD and prevent asthma attacks), indicated that Fluticasone Salmeterol should be safely thrown away in the trash one month after the foil pouch is opened or when the counter reads 0, whichever comes first. Observation on 1/27/26, at 1:19 p.m. of C-Hall Medication Cart, revealed one Trelegy Ellipta Diskus with the foil container opened, diskus in use, and diskus lacking an open date and one Fluticasone Salmeterol Diskus out of the foil package, diskus in use, and diskus lacking an open date. At the time of observation, Licensed Practical Nurse Employee E3 confirmed the Trelegy Ellipta and Fluticasone Salmeterol were both opened, in use and lacked an open date. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store schedule II-V medications in a separately locked, permanently affixed compartment in three of four medication rooms reviewed (A/B, C/D and E/F); the facility failed to prevent the opportunity for potential unauthorized access of medications on two of four medication carts observed (D and F); and the facility failed to appropriately discard outdated medications for one of four medication carts reviewed (E wing). Findings include: Review of facility policy entitled Narcotic Policy PCM dated 2/06/25, revealed Schedule II-V medications are stored in a permanently affixed, double-locked compartment separate from all other medications. Review of facility policy entitled Medication cart: Med Pass Guidelines dated 2/06/25, revealed that Multi-dose vials such as insulin must have either opened on date or used by date which should be checked prior to administration. Review of facility policy entitled Pharmaceutical Services and Medication Storage dated 2/06/25, revealed Medications will be in containers that meet regulatory requirements and stored safely. Except for those medications requiring refrigeration .medications intended for internal use are stored in a medication cart . Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin (medication to treat diabetes and help control blood sugar levels) must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on 2/10/25, at 2:55 p.m. of C and D wings medication room refrigerator revealed a clear plastic locked box and inside the clear plastic box were two carpujects (a syringe device for the administration of injectable fluid medications) of Lorazepam (a controlled antianxiety medication). The shelf with the clear plastic box containing the Lorazepam was not permanently affixed to the refrigerator allowing the shelf and the Lorazepam to be removed from the refrigerator. During an interview at the time of observation with Licensed Practical Nurse (LPN) Employee E6, he/she confirmed that the clear plastic box containing Lorazepam was not permanently affixed to the refrigerator. He/she also confirmed that the schedule II-V medications should be stored in a separately locked permanently affixed compartment. Observation of drug storage on 2/10/25, at 3:12 p.m. of A and B wings medication room refrigerator revealed a clear plastic locked box and inside the clear plastic box was one carpuject and one vial of Lorazepam. The shelf with the clear plastic box containing the Lorazepam was not permanently affixed to the refrigerator allowing the shelf and the Lorazepam to be removed from the refrigerator. During an interview at the time of observation with LPN Employee E7, he/she confirmed that the clear plastic box containing Lorazepam was not permanently affixed to the refrigerator. He/she also confirmed that the schedule II-V medications should be stored in a separately locked permanently affixed compartment. Observation of drug storage on 2/10/25, at 3:16 p.m. of E and F wings medication room refrigerator revealed two carpujects of Lorazepam lying on the refrigerator shelf. The refrigerator lacked a separately locked permanently affixed compartment for the schedule II-V medications which allowed the Lorazepam to be removed from the refrigerator. During an interview at the time of observation with LPN E5, he/she confirmed that the Lorazepam was not in a separately locked compartment that was permanently affixed to the refrigerator. He/she also confirmed that the schedule II-V medications should be stored in a separately locked permanently affixed compartment. Observation of drug storage on 2/10/25, at 3:16 p.m. of E wing medication cart revealed an open pen of Lantus insulin with no date indicating when the pen was opened. During an interview at the time of observation with LPN Employee E5, he/she confirmed that the open Lantus Insulin lacked an opened date. He/she also confirmed that due to the Lantus insulin having no opened date the insulin should have been discarded. Observation of the D wing medication cart on 2/10/25, at 4:30 p.m. revealed that the medication cart was sitting in front of a resident's room with the back of the cart facing into the hallway. On the back of the medication cart were two open shelves with an open bottle of MiraLAX, an open bottle of Pepto-Bismol, and two bottles of Robitussin, one that had been opened. Further observations revealed that the nurse continued to two other resident rooms leaving the back of the cart facing into the hallway and out of view while in a resident's room. During an interview at the time of observations with LPN Employee E4, he/she confirmed that there were medications on the shelf on the back of the medication cart which were out of view and could allowed unauthorized access to the medications. He/she also confirmed that the medications should not be accessible and should be locked in the medication cart. Observation of the F wing medication cart on 2/10/25, at 4:50 p.m. revealed that the medication cart was sitting in front of a resident's room with the back of the cart facing into the hallway. On the back of the medication cart were two open shelves with an open bottle of MiraLAX, an open bottle of Milk of Magnesium, three bottles of Robitussin, two that were opened and two open bottles of Robitussin DM. Further observations revealed that the nurse continued to two other resident rooms leaving the back of the cart facing into the hallway and out of view while in a resident's room. During an interview at the time of observations with LPN Employee E5, he/she confirmed that there were medications on the shelf on the back of the medication cart which were out of view and could allowed unauthorized access to the medications. He/she also confirmed that the medications should not be accessible and should be locked in the medication cart. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan for one of 23 residents reviewed (Resident R99). Findings include: A facility policy entitled, Care Plan: Baseline (IPOC) dated 2/06/25, revealed Baseline PCM IPOC will be entered and developed for each resident within 48 hours. Resident R99 's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, anemia, and acute kidney injury. Resident R99 's clinical record lacked evidence that a baseline care plan was initiated for Resident R99. During an interview on 2/12/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the clinical record of Resident R99 lacked evidence that a baseline care plan was initiated. 28 Pa. Code 211.12(d)(1) Nursing services

Based on reveiew of clinical records, observations and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of seven of 23 residents interviewed (Residents R80, R12, R34, R37, R93, R79, and R51). Findings include: Independent interview on 2/10/25, at 4:13 p.m. revealed that Resident R51 disclosed that he/she cannot walk, uses an electric wheelchair for mobility, and requires a mechanical lift to transfer. Resident R51 shared that there are times (especially on off shifts and weekends) when he/she waits on the toilet for an hour to get help, and that he/she has waited so long to get to the bathroom, he/she soiled his/her clothing. Resident R51 also stated that staff will come in and turn off the bell, and not return. Interviews during the Resident Council meeting on 2/11/25, between 1:00 p.m. and 2:15 p.m. revealed that six out of six alert and oriented residents were in attendance (Residents R80, R12, R34, R37, R93, and R79) and reported concerns related to staff not responding to their call bells timely, and all six residents confirmed that it is common to wait over an hour for your call bell to get answered, especially on 3-11 shift and weekends, and that they have just learned to do what they can for themselves and let other stuff go because you can't get help anyways. Resident R12 shared that he/she waited this morning until 10:30 a.m. to get his/her shower and then decided he/she would have to go ahead and get dressed before lunch so he/she could attend the meeting at 1:00 p.m. Resident R12 also stated that he/she has not been walked by staff and that his/her walker hasn't been out of the closet in months. Resident R34 shared that he/she can't remember last shower I got, and that he/she washes up at the sink. Resident R34 also stated that he/she sleeps in a recliner because he/she knows they can get out of it on his/her own to get to the bathroom when needed. Resident R79 shared that he/she is independent in his/her room and can transfer from surface to surface on his/her own, but that he/she observes and witnesses long call bell waits. Resident R93 confirmed you just know that if they are short-staffed you aren't going to get help anytime fast, and especially on evenings and weekends, you just don't ring because no one's going to answer it. Resident R80 shared that he/she is supposed to be walked Monday, Wednesday, and Friday and if there are not enough nurse aides, the restorative aides (RA) get pulled to work the floor, and he/she hasn't been walked in a couple of weeks. Review of Resident R80's clinical record revealed a physician's order dated 7/17/24, for walking three times a week, and review of the Restorative Detail Report revealed that he/she hadn't been walked since 1/31/25. During an interview on 2/12/25, at 9:45 a.m. Licensed Practical Nurse Employee E8 confirmed Resident R80 had not been walked since 1/31/25, due to restorative staff being pulled to the floor to work as nurse aides, and that today there are two restorative staff on the floor as nurse aides until 11:00 a.m. and then will switch to performing restorative duties. Observation on 2/13/25, at 8:47 a.m. revealed RA Employee E3 was providing feeding assistance to a dependent resident. During an interview at that time, RA Employee E3 verified that they are pulled to the floor to work as nurse aides due to nursing being short staffed and that often only leaves time during the day for restorative duties with about three residents from 1:30 p.m. to 3:00 p.m. and working around other afternoon activities for the residents. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on observations, review of clinical records and facility policy, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during wound care for one of 23 residents reviewed (Resident R13). Findings include: A facility policy entitled, Handwashing and Hand Hygiene dated 2/06/25, revealed that hand hygiene be performed after handling soiled equipment and after removing gloves. Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), Venous stasis (a condition that occurs when blood doesn't flow properly from the legs back to the heart), and congestive heart failure (CHF- long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Observation of wound care on 2/12/25, at 9:27 a.m. revealed the following: Licensed Practical Nurse (LPN) Employee E1 donned (put on) a clean gown and gloves, positioned Resident R13's left leg, removed the sock, changed gloves, removed the soiled dressing, changed gloves, cleansed the wound, changed gloves, applied the medication to the wound, changed gloves, and applied the clean dressing. LPN Employee E1 failed to perform hand hygiene each time he/she changed his/her gloves, or four times throughout the dressing change. Registered Nurse (RN) Employee E2 donned a clean gown and gloves, assisted with positioning Resident R13's left leg, removed gloves, used bare hands to pick up and move garbage can next to end of bed, donned gloves, picked up and held Resident R13's left foot at the ball of the foot and near the Achille's, and using his/her gloved finger pointed to areas on wound near the open surface of the wound during the dressing change. RN Employee E2 failed to perform hand hygiene after touching the garbage can before donning clean gloves. During an interview at that time RN Employee E2 and LPN Employee E1 confirmed that they should have performed hand hygiene before donning clean gloves. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to initiate a baseline care plan for one of 22 residents reviewed (Resident R201) and failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 22 residents reviewed (Resident R99). Findings include: A facility policy entitled, Care Plan: Baseline (IPOC) dated 2/21/24, stated Baseline PCM IPOC will be entered and developed for each resident within 48 hours. Resident R201 's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and peripheral arterial disease (narrowing of arteries, usually in the leg that result in reduced blood flow). Resident R201 's clinical record lacked evidence that a baseline care plan was initiated for Resident R201. During an interview on 3/13/24, at 1:23 p.m. the Nursing Home Administrator confirmed that the clinical record of Resident R201 lacked evidence that a baseline care plan was initiated. Resident R99's clinical record revealed an admitted [DATE], with diagnoses that included history of a stroke (damage to the brain from interruption of its blood supply), cardiovascular disease (disease of the heart or blood vessels), history of falling, and anxiety. Resident R99's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R99 and/or his/her representative. During an interview on 3/14/24, at 12:05 p.m. the Director of Nursing confirmed that the clinical record of Resident R99 lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 22 residents reviewed (Resident R7). Findings include: Review of facility policy entitled Care Plan: Interdisciplinary dated 2/21/24, stated the purpose is to Provide a comprehensive care plan that includes measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs that are identified including those identified in the comprehensive assessment, and formulate individualized treatment plans that promote maximum functioning and well-being and Nursing staff must notify RNAC (Registered Nurse Assessment Coordinator) of changes that could initiate new or additional care plans. Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Dementia (a group of symptoms affecting memory, thinking, and social abilities), Seizures, and High Blood Pressure. Resident R7's clinical record revealed a physician's order dated 5/30/23 indicating Wanderguard (a bracelet applied to a resident's wrist or ankle or a device used by the resident for mobility [walker or wheelchair]to alert the staff of residents attempts to leave the facility) to prevent resident from leaving the facility unattended. The clinical record lacked evidence that a care plan had been developed to address Resident R7's risk for wandering or elopement and use of wanderguard bracelet. During an interview on 3/13/24, at approximately 3:37 p.m. the Nursing Home Administrator and Director of Nursing confirmed that a care plan had not been developed to address Resident R7's wandering or elopement risk and use of a wanderguard bracelet. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and manufacturer's instructions, observation, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner for one of two medication rooms observed (Unit A/B medication room). Findings include: Review of facility policy entitled PPD [solution used for tuberculosis testing upon admission and for employment], Administration dated 2/21/24, revealed Discard bottle 30 days after opened. Review of manufacturer's recommendations for Tubersol PPD indicated that vials which are entered and in use for 30 days should be discarded. Observation of drug storage on 3/13/24, at approximately 11:12 a.m. in Unit A/B medication storage room refrigerator revealed and an opened vial of Tubersol PPD without an open date, therefore the staff were unable to determine the discard date. During an interview at that time, Licensed Practical Nurse Employee E2 confirmed that the opened Tubersol PPD vial lacked an open date and staff were unable to determine the discard date. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for two of 20 residents reviewed (Residents R2 and R91). Findings included: Review of facility policy dated 3/10/23, entitled Care Plan: Baseline (IPOC [Interdisciplinary Plan of Care]) revealed that Comprehensive IPOC will be completed by day 21 of stay and updated throughout entire stay. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (lung disease that results in difficulty breathing), obstructive sleep apnea (sleep disorder that results in a person stopping and starting to breathe while sleeping), and high blood pressure. Observation on 4/26/23, at 1:32 p.m. revealed that Resident R2 was utilizing oxygen at two liters per minute via nasal cannula (tube that goes through the nose used to deliver oxygen) and that Resident R2 had a c-pap (a machine used when sleeping to provide positive airway pressure to treat sleep apnea) that he/she uses nightly. Review of Resident R2's clinical record revealed a physician's order dated 12/7/22, for oxygen administration at two liters per minute via nasal cannula and a physician's order dated 3/28/23, for c-pap on at bedtime and off in the morning. Review of Resident R2's comprehensive care plan on 4/27/23, lacked reference to Resident R2 having sleep apnea or the usage of oxygen and c-pap. During an interview on 4/27/23, at 2:25 p.m. Licensed Practical Nurse Assessment Coordinator Employee E1, confirmed that a care plan had not been developed to address Resident R2's usage of oxygen or c-pap. Review of Resident R91's clinical record revealed an admitted [DATE], with diagnoses that included kidney failure, diabetes, and arthritis. Review of Resident R91's clinical record revealed a physician's order dated 2/25/23, for dialysis (a blood purifying treatment given when kidneys are not functioning properly) three times a week on Monday-Wednesday-Friday. Review of R91's comprehensive care plan on 4/27/23, lacked reference to Resident R91 requiring dialysis. During an interview on 4/27/23, at 10:58 a.m. Registered Nurse Assessment Coordinator Employee E2, confirmed that a care plan had not been developed to address Resident R91 requiring dialysis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of 19 residents reviewed (Resident R75). Findings include: Review of a facility policy entitled, Psychotropic Medication Review and Gradual Dose Reduction dated 3/10/23, indicated that the use of PRN psychotropic medications (which are not antipsychotic) will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician/prescriber, PRN psychotropic medications ordered must have the prescribing practitioner document the specific condition and indication for use in the clinical record, and all PRN extended psychotropic medications ordered will be discontinued after seven days unless the appropriate rationale is documented. Review of Resident R75's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's dementia (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), memory impairment, anxiety, and depression. The clinical record revealed a physician's order dated 2/17/23, for Alprazolam (Xanax-medication to treat anxiety) 0.25 milligrams (mg) twice daily by mouth PRN for anxiety, that lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Resident R75's clinical record revealed that the PRN Xanax was administered twice in February, and eight times in March 2023. During an interview on 4/27/23, at 2:25 p.m. Licensed Practical Nurse Assessment Coordinator Employee E1 confirmed that there wasn't a 14-day stop date if there wasn't one in the order. During an interview on 4/28/23, at 9:55 a.m. the Nursing Home Administrator confirmed that Resident R75's order for PRN Xanax lacked the required 14-day stop date and a clinical rationale documented by the physician to extend the PRN stop date past the required 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of two medication carts observed (C Hall). Findings include: Review of a facility policy entitled, Medication Cart: Med Pass Guidelines dated 9/30/20, indicated that the medication cart is to be kept in view of the nurse or locked at all times. Observation on 8/17/21, at 9:10 a.m. revealed that Registered Nurse (RN) Employee E1 prepared medications for a resident from the C Hall medication cart parked in the hall between rooms C-6 and C-8 and proceeded into room C-8 to administer medications to a resident sitting in a chair near the window on the far side of the room and did not securely lock the C Hall medication cart which was left out of sight of RN Employee E1. During an interview on 8/17/21, at 9:10 a.m. RN Employee E1 confirmed that if the medication cart is out of site, it needed to be locked, but that he/she believed the cart to be in sight while he/she administered the medications in room C-8. Further observation revealed that RN Employee E1 was not able to see the top of the cart or the drawers of the medication cart from the far side of room C-8 while administering medications. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of facility policies, and staff interviews it was determined that the facility failed to serve a breakfast meal timely and maintain safe serving temperatures for one resident (Resident R4). Findings include: Review of a facility policy entitled Tray Identification/Delivery/Pick Up dated 9/30/20, indicated that meal trays will be delivered to the nursing units within 15 minutes of being assembled on tray line and trays must be delivered within 45 minutes. Review of a facility policy entitled Food Handling Guidelines dated 9/30/20, hot foods should be held hot for service at a temperature of 140 degrees Fahrenheit (F) or higher and cold foods should be held cold for service at a temperature of 41 degrees F or less. Observation on 8/17/21, at 8:35 a.m. revealed a breakfast meal tray sitting on the tray table in room C-1 and that Resident R4 was sleeping. During an interview on 8/17/21, at 8:50 a.m. Nurse Aide (NA) Employee E3 stated that the breakfast trays usually reach the unit around 7:30 - 7:45 a.m. and that aides pass the trays going down the hall from C-1 to C-12 to residents who eat in their rooms, then feed residents in the lounge before picking up eaten trays from rooms in the hall. During an interview on 8/17/21, at 9:13 a.m. NA Employee E2 verified that Resident R4's untouched tray remained in his/her room and that he/she will be fed when he/she gets up. Observation on 8/17/21, at 9:35 a.m. NA Employee E3 entered room C-1, provided Resident R4 with a clothing protector, removed the lid from the hot foods plate, and prepared to set up Resident R4's meal tray for consumption. At that time, NA Employee E3 confirmed he/she was going to assist Resident R4 with eating. On 8/17/21, at 9:37 a.m. with the assistance from the Dietary Patient Coordinator the following food temperatures were obtained from Resident R4's breakfast tray and revealed: coffee- 103 degrees F, cream of wheat- 106 degrees F, French toast- 94 degrees F, sausage- 93 degrees F, and orange juice- 57 degrees F. During an interview at that time, the Dietary Patient Coordinator confirmed that the breakfast trays had left the kitchen at 7:54 a.m. or one hour and 41 minutes prior to when Resident R4 was going to be assisted with the meal and food temperatures were not maintained at a safe serving temperature. 28 Pa. Code 211.6(c)(d) Dietary services 28 Pa. Code 201.29(j) Resident rights

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to comprehensively assess and monitor pressure ulcers within required timeframes for one of five residents with pressure ulcers reviewed (Resident R19). Findings include: Current facility policy entitled Pressure Ulcer: Prevention and Management Guidelines dated 7/29/20, indicated that Ulcer is to be measured weekly if pressure or deep tissue injury (DTI) . Resident R19's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R19's clinical record assessment entitled Integumentary Assessment (Skin Assessment) revealed that measurements and assessment of Resident R19's left posterior heel was completed on 5/24/21, and not again until 6/17/21, a period of twenty-four days. During an interview on 6/24/21, at 3:09 p.m. the Nursing Home Administrator, Director of Nursing and Registered Nurse Employee E1 confirmed that Resident R19's pressure ulcer measurements / assessments were not completed as frequently as required from 5/24/21, through 6/17/21. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.5(f) Clinical records

Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of twenty-three residents reviewed (Resident R19). Findings include: Resident R19's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Integumentary (Skin) assessment dated [DATE], at 9:48 a.m. completed by a Registered Nurse (RN) revealed Resident R19 had a venous stasis ulcer measuring 1.3 centimeters (cm) x 1.0 cm x 0.3 cm on their left posterior heel. On 5/27/21, at 8:57 a.m. Physician Assistant documented a Stage 3 area to the left heel with wound type identification being vascular / pressure and determination of an acquired status being pressure. Integumentary assessment dated [DATE], at 9:15 a.m. completed by a RN and assessment dated [DATE], at 1:00 p.m. completed by a Licensed Practical Nurse (LPN) indicted area to left posterior heel is venous stasis. On 5/28/21, at 2:54 p.m. Resident R19's physician documented Resident R19 was being seen for reevaluation of pressure ulcer on the left heel and his/her impression indicated it was a Stage 2 pressure ulcer. Integumentary assessment dated [DATE], at 9:00 a.m. completed by a LPN indicated left posterior heel is other skin abnormality. On 6/14/21, at 8:30 a.m. Resident R19 was seen at the wound clinic where physician documented Resident R19 had an open wound with likely Stage 3 pressure ulcer on her left heel. The assessment completed at the wound clinic as well as the treatment orders received from the wound clinic also indicated left heel is a pressure ulcer. Integumentary Assessment completed 6/14/21, at 12:00 p.m; 6:00 p.m.; and again at 8:00 p.m. by a LPN indicated area to left posterior heel is venous stasis. Integumentary assessment dated [DATE], at 9:35 p.m. completed by a RN contains measurements, but continues to refer to the left heel as a venous stasis area. Integumentary Assessments dated 6/19/21, at 9:00 a.m.; 6/20/21, at 6:00 p.m.; 6/22/21, at 8:00 p.m., and 6/23/21, at 6:00 p.m. by an LPN indicated area to left posterior heel is venous stasis. Integumentary assessment dated [DATE], at 1:00 p.m. completed by a LPN indicated left heel is a pressure ulcer. During an interview on 6/24/21, at 3:09 p.m. RN Employee E1 confirmed that even after the physician assistant documented on 5/27/21, the physician documented on 5/28/21, and the wound clinic documented on 6/14/21, that the area to the left heel was a pressure ulcer facility, staff continued to document the left heel as a venous stasis ulcer. During an interview on 6/25/21, at 10:13 a.m. Nursing Home Administrator confirmed facility staff were not accurately documenting the type of ulcer that was present on the left heel based on physician assistant, physician, and wound clinic documentation. 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to assure that medications were properly dated when opened and discarded in a timely manner for two of four units reviewed (B and D Units). Findings include: Manufacturer's recommendations for [MEDICATION(S)] and [MEDICATION(S)] (fast acting insulins) and [MEDICATION(S)] (a long acting insulin) storage, indicated to discard after 28 days after opening. A facility policy entitled Med Pass Guidelines updated [DATE], directed that the expiration dates be checked prior to administration. Observation of drug storage on [DATE], from 10:15 a.m. through 10:25 a.m. revealed an opened vial of [MEDICATION(S)] insulin dated as opened on [DATE], stored in the D Unit medication room labeled for emergency use. Observations of he B Unit medication cart revealed two vials of [MEDICATION(S)] insulin and one vial of [MEDICATION(S)] labeled as opened on [DATE], [DATE] and [DATE] respectively, and labeled as expired on [DATE], [DATE] and [DATE], respectively. During an interview at the time of the observations, the Director of Nursing confirmed that the opened vials of insulin should not have been in current use and were not discarded as required. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation and policy and procedures, and interviews with residents and staff, it was determined that the facility failed to ensure that residents were free from neglect during transfers for two of 24 residents reviewed (Residents R35 and R122), resulting in actual harm to Resident R122 who sustained a fall that resulted in the dislocating of their left hip prosthesis. This deficiency is cited as past non-compliance (Resident R122). Findings include: The facility policy related to abuse, dated (MONTH) 31, (YEAR), defined neglect as the 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. The facility policy titled, Transfer Status, dated 05/31/18, indicated that all residents would be evaluated by therapy to determine a transfer status, the transfer evaluation would be entered in the electronic health record and care plan, and posted in the closet of the resident's room. The policy further indicated that all staff involved in a resident transfer would review the transfer process posted in the resident's closet prior to transferring the resident. Resident R35's clinical record revealed that Resident R35 was severely cognitively impaired, admitted to the facility on (MONTH) 23, 2014, and had current [DIAGNOSES REDACTED]. Resident R35's clinical record included a physician order [REDACTED]. Facility documentation, dated (MONTH) 12, (YEAR), revealed that on (MONTH) 12, (YEAR), at 4:30 p.m. during an investigation regarding a [MEDICAL CONDITION] femur on Resident R35, Nurse Assistant (NA) Employee E9 had gotten Resident R35 out of bed by himself/herself. Resident R35 did not show any signs of pain at the time of the improper transfer and propelled them self around facility as per usual. Also, the investigation revealed that NA Employee E11, assisted NA Employee E9 transferring Resident R35 back into bed. Resident R35 had an increase in pain on (MONTH) 13, (YEAR), at approximately 5:00 a.m. An x-ray report of the left hip obtained following the increase in pain on (MONTH) 13, (YEAR), revealed a left femoral neck fracture. The family was made aware and the decision not to treat was made. A physcian's progress note dated (MONTH) 23, (YEAR), revealed that given Resident R35's comorbidities, advanced age, and [MEDICAL CONDITION] that surgical intervention for the fractured femur was not warranted. Facility documentation related to the event, dated (MONTH) 12, (YEAR), at 4:30 p.m. revealed that NA Employee E9 stated that he/she transferred Resident R35 from the bed without assisstance and without difficulty, also stated that Resident R35 did not complain of pain or show signs of pain at any time. Documentation also indicated that NA Employee E11 indicated that he/she assisted Resident R35 back to bed without a lift when called in to assist NA Employee E9. Facility documentation dated (MONTH) 14, (YEAR), reflected that the facility substantiated the allegation of neglect of Resident R35 by NA Employees E9 and E11. Documentation also revealed that the cause of Resident R35's left femur fracture was not determined. During an interview on (MONTH) 15, (YEAR), at 2:02 p.m. the Nursing Home Administrator and the Director of Nusing confirmed that NA Employees E9 and E11, transferred Resident R35 on (MONTH) 12, (YEAR), without the use of a total lift, failed to look at the physician ordered transfer status [REDACTED]. They also confirmed that the cause of Resident R35's left femoral neck fracture was not determined. Resident R122's clinical record revealed that Resident R122 was alert and oriented, admitted to the facility on (MONTH) 23, (YEAR), and had current [DIAGNOSES REDACTED]. During an interview on (MONTH) 13, (YEAR), at 2:51 p.m. Resident R122 stated that several months ago he/she sustained a fall and broke his/her hip, stating, it was my own fault. Resident R122 then stated that several weeks after the fall, two nursing assistants (Nursing Assistants (NA) Employee E4 and NA Employee E5) transferred him/her wrong resulting in being lowered to the floor and injuring the previously fractured/repaired hip. Resident R122 stated, I'm suffering from it . I think it's worse than it was. Facility documentation, dated (MONTH) 8, (YEAR), revealed that on (MONTH) 8, (YEAR), at 3:30 p.m. NA Employee E4 and NA Employee E5, during the process of transferring Resident R122 from a reclining chair in his/her room to a wheeled toilet chair, the resident's legs gave out and Resident R122 was assisted to the floor. The documentation indicated Resident R122 complained of pain in the left hip following the event, with both knees adducted (positioned toward the midline of the body). An x-ray report of the left hip obtained following the event on 09/08/18, revealed that Resident R122's left hip prosthesis (artificial joint) was dislocated superiorly (out of the joint space toward the upper part of the body). Resident R122 was transferred to the hospital for surgical repair. Facility documentation related to the event, dated (MONTH) 8, (YEAR), at 4:00 p.m. revealed that NA Employee E4 stated that he/she attempted to stand Resident R22 from a chair, with the assistance of NA Employee E5 when Resident R122 turned to dead weight and started pulling towards the floor . just lowered him/her to the floor. The documentation further indicated that NA Employee E4 asked her (Resident R122) how he/she was transferred because he/she has not transferred Resident R122 since surgery. Documentation also indicated that NA Employee E5 indicated that he/she wasn't familiar with many transfer statuses of residents on Resident R122's hallway when called in to assist NA Employee E4. Facility documentation related to the event dated (MONTH) 8, (YEAR), further indicated that Licensed Practical Nurse (LPN) Employee E6 was called to the room by NA Employees E4 and E5 to find Resident R122 sitting on the floor, complaining of pain in the left hip at a level of ten, on a scale of one to ten with ten being the most severe. Upon asking NA Employees E4 and E5 regarding Resident R122's transfer status, the employees stated, assist of two. LPN Employee E6, upon referencing the transfer status documented in Resident R122's closet, indicated the transfer assessment revealed stand up lift for all transfers. Resident R122's clinical record included a physician order [REDACTED]. Physician documentation dated (MONTH) 1, (YEAR), indicated that Resident R122 was evaluated following the [MEDICAL CONDITION] dislocation of (MONTH) 8, (YEAR), and that Resident R122 has low level pain in the left hip every day, worse when he/she moves, that the pain had escalated somewhat and was directly located over the lateral hip (left) and described as jaggy and radiating to the knee. Facility documentation dated (MONTH) 13, (YEAR), reflected that the facility substantiated the allegation of neglect of Resident R122 by NA Employees E4 and E5 related to an improper transfer. During an interview on (MONTH) 15, (YEAR), at 2:02 p.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employees E4 and E5 improperly transferred Resident R122 on (MONTH) 8, (YEAR), neglecting to reference the physician ordered transfer status [REDACTED]. This deficiency is cited as past non-compliance. On (MONTH) 8, (YEAR), the facility initiated a plan of correction to address the substantiated allegation of neglect during Resident R122's transfer that included the following: termination of NA Employee E4; re-education of NA Employee E5 by the facility clinical educator on (MONTH) 21, (YEAR), prior to return to the clinical setting, in the safe transfer of residents per physician order [REDACTED].(YEAR), for a total of 202 observations with no evidence of non-compliance with safe transfer methods. Documentation provided by the facility during an interview on (MONTH) 15, (YEAR), at 3:30 p.m. with the NHA and DON confirmed that the facility had achieved compliance with safe transfers as indicated by Quality Assurance review at this time and will continue to monitor on a random basis. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/14/17, 10/21/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 09/14/17 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/21/16 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 09/14/17, 10/21/16

Based on resident and staff interviews, review of clinical records, facility documentation and policy and procedures, it was determined that the facility failed to ensure that one of two residents reviewed (Residents R122) was transferred by an assistive device as ordered by the physician resulting in actual harm. This deficiency is cited as past non-compliance. Findings include: The facility policy titled, Transfer Status, dated (MONTH) 31, (YEAR), indicated that all residents would be evaluated by therapy to determine a transfer status, the transfer evaluation entered in the electronic health record and care plan, and posted in the closet of the resident's room. The policy further indicated that all staff involved in a resident transfer will review the transfer process posted in the resident's closet prior to transferring the resident. Resident R122's clinical record revealed that Resident R122 was alert and oriented, admitted to the facility on (MONTH) 23, (YEAR), and had current [DIAGNOSES REDACTED]. During an interview on (MONTH) 13, (YEAR), at 2:51 p.m. Resident R122 stated that several months ago he/she sustained a fall and broke his/her hip, stating, it was my own fault. Resident R122 then stated that following that several weeks after the fall, two nursing assistants (Nursing Assistants (NA) Employee E4 and NA Employee E5) transferred him/her wrong resulting in being lowered to the floor and injuring the previously fractured/repaired hip. Resident R122 stated, I'm suffering from it . I think it's worse than it was. Facility documentation dated (MONTH) 8, (YEAR), revealed that on (MONTH) 8, (YEAR), at 3:30 p.m. NA Employee E4 and NA Employee E5, during the process of transferring Resident R122 from a reclining chair in his/her room to a wheeled toilet chair, the resident's legs gave out and Resident R122 was assisted to the floor. The documentation indicated Resident R122 complained of pain in the left hip following the event, with both knees adducted (positioned toward the midline of the body). An x-ray report of the left hip obtained following the event on (MONTH) 8, (YEAR), revealed that Resident R122's left hip prosthesis (artificial joint) was dislocated superiorly (out of the joint space toward the upper part of the body) and Resident R122 transferred to the hospital for surgical repair. Facility documentation related to the event dated (MONTH) 8, (YEAR), at 4:00 p.m. revealed that NA Employee E4 stated that he/she attempted to stand Resident R22 from a chair, with the assistance of NA Employee E5 when Resident R122 turned to dead weight and started pulling towards the floor . just lowered him/her to the floor. The documentation further indicated that NA Employee E4 asked her (Resident R122) how he/she was transferred because he/she hadn't transferred Resident R122 since surgery. Documentation also indicated that NA Employee E5 indicated that he/she wasn't familiar with many transfer statuses of residents on Resident R122's hallway when called in to assist NA Employee E4. Facility documentation related to the event dated (MONTH) 8, (YEAR), further indicated that Licensed Practical Nurse (LPN) Employee E6 was called to the room by NA Employees E4 and E5 to find Resident R122 sitting on the floor, complaining of pain in the left hip at a level of ten, on a scale of one to ten with ten being the most severe . Upon asking NA Employees E4 and E5 regarding Resident R122's transfer status, the employees stated, assist of two. LPN Employee E6, upon referencing the transfer status documented in Resident R122's closet, indicated the transfer assessment revealed stand up lift for all transfers. Resident R122's clinical record included a physician's orders [REDACTED]. Physician documentation dated (MONTH) 1, (YEAR), indicated that Resident R122 was evaluated following the [MEDICAL CONDITION] dislocation of (MONTH) 8, (YEAR), and that Resident R122 had low level pain in the left hip every day, worse when he/she moves, that the pain had escalated somewhat and was directly located over the lateral hip (left) and described as jaggy and radiating to the knee. During an interview on (MONTH) 15, (YEAR), at 2:02 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the facility failed to ensure that Resident R121 was safely transferred per physician's orders [REDACTED]. This deficiency is cited as past non-compliance. On (MONTH) 8, (YEAR), the facility initiated plan of correction to address the substantiated allegation of neglect during Resident R122's transfer that included the following: termination of NA Employee E4; re-education of NA Employee E5 by the facility clinical educator on (MONTH) 21, (YEAR), prior to return to the clinical setting, in the safe transfer of residents per physician order [REDACTED].(YEAR), for a total of 202 observations with no evidence of non-compliance with safe transfer methods. Documentation provided by the facility during an interview on (MONTH) 15, (YEAR), at 3:30 p.m. with the NHA and the DON confirmed that the facility had achieved compliance with safe transfers as indicated by Quality Assurance review at this time and will continue to monitor on a random basis. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/14/17, 10/21/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 09/14/17 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/21/16 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 09/14/17, 10/21/16