Every finding on record at Renaissance Healthcare & Rehabilitation Center

Based on observations and interview with staff it was determined that the facility failed to maintain a homelike environment related to dining for one of two floors observed (First Floor).Findings Include: Observation during the lunch meal service on July 15, 2026, at 12:20 p.m., on the first floor revealed residents were served their meals on disposable Styrofoam plates rather than reusable dinnerware. Interview on July 15, 2026, at 12:20 p.m. with the Food Service Director, Employee E7, confirmed the facility did not have enough reusable plates to serve all residents. The food service director employee E7stated the facility had run out of reusable plates and acknowledged additional plates had been ordered. Documentation of the purchased order was provided in the kitchen director stated new plates were expected to arrive the following day The facilities inability to provide an adequate supply of reusable dinnerware resulted in the use of disposable plates during the resident's meal service, demonstrating the facility failed to maintain sufficient essential equipment necessary to support routine dietary operations. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based upon review of resident records and interviews with staff it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility residents with transfers and discharges for two of 25 resident records reviewed (Resident R9 and R10).Findings include: Resident R9 was admitted to the facility diagnosed with heart disease. Review of clinical records revealed on January 19, 2026, the resident was transferred to the hospital due to a change in condition and abnormal vital signs. Resident R10 was admitted to the facility on [DATE], diagnosed with Malnutrition (lack of proper nutrition) and had a Gastrostomy (an artificial external opening into the stomach, to allow direct delivery of nutrition, fluids, or medications) used for nutrition. Review of Resident R10's clinical record revealed on April 8, 2026, the resident was observed with altered mental status, and was sent to the hospital for further evaluation. Further Review of Resident R10's clinical records revealed on July 4, 2026, the resident had an unplanned transfer to the hospital, diagnosed with pneumonia (lung infection). On July 17, 2026, at 11:30 a.m. an attempt was made to obtain the notices sent to the representative of the Office of the State Long-Term Care Ombudsman. The Nursing Home Administrator replied, We don't do that. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy, review of clinical records, review of facility documentation, and staff interview it was determined that the facility failed to review and revise a resident's care plan to address resident care needs for one of 25 residents reviewed (Resident R27). Findings include: Based on facility policy titled Therapeutic Leave Policy and Procedure undated, revealed the purpose of this policy is to establish guidelines, criteria, and procedures for residents requesting temporary therapeutic leave from the facility. The policy states that residents have the right to therapeutic leave in accordance with federal and state regulations and the resident's individual plan of care. The policy further states that the facility will facilitate therapeutic leave while ensuring the residents health, safety and continuity of care are maintained. the policy requires that therapeutic leave aligned with the goals of the resident's individual care plan and include advanced notice clinical assessment authorization sign out procedures and return to facility procedure. Review of Resident R27's Minimum Data St (MDS- federally mandated resident assessment and care screening) dated June 25,2026, revealed that Resident R27 was admitted into the facility on October 2, 2025. Resident R27 was assessed with a brief interview for mental status (BIMS - cognitive function assessment) score of 15 indicating he/she is cognitively intact. The MDS indicated resident R27 had no behaviors, including no wandering. Resident R27 utilized a walker and wheelchair for mobility, was independent with eating and oral hygiene, required supervision or setup assistance with several activities of daily living, and required partial to moderate assistance with transfers. Review of Resident R27's clinical record revealed the resident has diagnoses of coronary artery disease (CAD- condition in which narrowed or blocked arteries reduce blood flow to the heart muscle and increase the risk of chest pain and heart attack); hypertension (elevated blood pressure); atrial fibrillation (a-fib, an irregular heart rhythm that increases with risk of blood clots and stroke); asthma (a chronic inflammatory disease of the airways that can cause wheezing, coughing and shortness of breath); depression (a mood disorder that affects a person's emotions, motivation, thinking and daily functioning) and a personal history of pulmonary embolism (previously experienced a blood clot in the lungs). Review of Resident R27's medication regimen included an anti-depressant, anti-coagulant (blood thinner, which reduces the blood's ability to clot) and diuretic (promotes the elimination of excess fluid and sodium from the body). Review of resident R27's clinical record revealed a physician's order dated October 2nd, 2025, stating the resident may leave the facility for social or therapeutic activities when residents condition permits. Review of resident R27's clinical record and nursing notes revealed a repeated pattern of extended leaves of absences (LOA) that were not anticipated at time of departure and resulted in resident remaining out of the facility beyond expected return date on the following dates: February 5, 2026, March 30, 2026, May 9, 2026. Review of resident R27's comprehensive care plan dated October 4, 2025, revealed the resident's preference for independent leisure activities, with an intervention dated April 1, 2026, that the resident has frequent leave of absences with family. Further review of Resident R27's care plan revealed it did not contain individualized interventions addressing the residents' repeated pattern of extended and unplanned leaves of absence, including occasions when the resident failed to return to the facility as is expected for one or more days. The care plan lacked interventions related to communication with the facility regarding delayed returns, physician notification, medication and treatment management during prolonged absences, assessment of risks associated with missed medications or treatments, or measures to address the residents recurring pattern of not returning as scheduled. 28 Pa. Code 211.10 (c) Resident Care policies28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of facility policy, review of facility documentation, review of clinical records, observation, and staff and resident interviews it was determined that the facility failed to provide necessary treatment and services consistent with professional standards of practice, physician orders, and the comprehensive care plan for two of 25 residents reviewed (Resident R2 and R129).Review of the facility's policy titled, Change in a Resident's Condition or Status revised January 2026, states that the facility promptly notifies the physician of changes in the resident's medical/mental condition. The same policy indicates that the nurse will record in the resident's medical record relative to changes in the resident's medical/mental condition or status. Resident R2 was admitted to the facility on [DATE], diagnosed with peripheral vascular disease (narrowed arteries that reduce the flow of blood to your limbs), heart failure, and pulmonary (lung) disease. Further review revealed Resident R2's care plan for cardiovascular status initiated in November 2025 states, Vital Signs as ordered. Notify physician of any abnormal readings Review of Resident R2's hospital records dated March 16, 2026, indicated the resident experienced a fall at the facility and noted the resident with ongoing issues with labile blood pressures (sudden, unpredictable changes in blood pressure that can reach concerning levels) and presyncope (feels as if you are going to faint), and occasionally syncope (fainting). The same records indicate that at the time of the fall, on March 15, 2026, the resident felt, lightheaded and dizzy, lost consciousness, and then fell to the floor. The hospital records noted that the resident's blood pressure normally runs low in the morning and spike in the afternoon. The hospital records further stated that all medications to treat the resident's high blood pressure were discontinued. Interview with Resident R2 on July 14, 2026, at 2:00 p.m. stated, At 2:30 P.M. yesterday I asked my nurse to take my blood pressure because I didn't feel right. I was shaky and felt my hands trembling. I knew it was my blood pressure I was afraid I was going to pass out again. When the nurse, (Employee E13), took my blood pressure it was very high. He wrote down the blood pressures for me. I got even more upset because the nurse wouldn't call the doctor. Continued interview with Resident R2 on July 14, 2026, revealed the resident also informed his/her physician and cardiologist of the elevated blood pressures. Observations on July 14, 2026, at 2:00 p.m. with Resident R2 revealed the written note was observed with three sets of blood pressures documented as follows: 186/117, P (pulse) 75, taken standing, 185/117 P 75 and 175/107 while sitting. According to the American Heart Association, this would classify as a hypertensive urgency (Hypertensive Urgency is defined by the American Heart Association and American College of Cardiology as a severe elevation in blood pressure, typically a systolic blood pressure of =180 mmHg and/or diastolic blood pressure of =120 mmHg, without evidence of acute target organ damage), the highest risk for life threatening complications. Review of Resident R2's clinical record revealed no documented evidence the blood pressures were documented in the resident's clinical record and revealed no documented evidence a progress note was written to document the findings of the assessment. Interview with Resident R2's nurse, Employee E13 on July 15, 2026, at 11:00 a.m. confirmed the above incident with Resident R2's. The nurse, Employee E13, confirmed Resident R2 told him he/she did not feel well, and agreed the resident didn't look well and appeared shaky. The nurse, Employee E13, confirmed all three high blood pressures were not documented in the resident's chart nor was the physician made aware. When asked, the nurse explained, Resident R2's blood pressure wasn't high in the morning (documented that morning at 8:30 a.m. 128 / 72) and that the resident doesn't have high blood pressure, because he/she wasn't on any medication. Review of Resident R2's physician note dated, July 15, 2026, stated that Resident R2 was seen by cardiology and amlodipine 2.5 mg (a medication for high blood pressure) was added because of a few high blood pressure readings the resident had up to 180's. The physician note continues that Resident R2 described feeling shaky and flushed at the time of the high blood pressure readings, and his/her BP (blood pressure) was checked a few times, and it went to the 180's . However, when this happened none of these readings have been reported in the EMR (Electronic Medical Record.) The same physician's note stated, if the systolic blood pressure is greater than 150, consistently, for more than 2 readings The physician should be called. Review the facility's policy titled Medication Administration dated January 2026, revealed medications are to be administered safely, timely, and in coordinates with the prescribers' orders. The policy assigns the director of nursing responsibility for supervising personnel who administer medications and overseeing medication administration practices. The policy further states that medications are to be administered according to prescribed orders and require time frames, with administration times based on residents' clinical needs. Medication errors are to be documented, reported, and review through the facilities quality assurance and performance improvement (QAPI) program to identify opportunities for process improvement and staff education. The policy requires medications to be administered within one hour of the prescribed administration time unless otherwise specified. When a medication is withheld, refused, or administered outside the scheduled time, the individual administrating the medication is required to document the occurrence on the medication administration record in accordance with the facility policy. Review of the Food and Drug Administration (FDA) approved prescribing information for Catapress TTS - 2 Clonidine transdermal systems application instructions is to apply one patch every seven days on the same day each week. The prescribing information cautions against interruption of clonidine therapy because abrupt discontinuation can result in rebound hypertension. Review of Resident R129's clinical record revealed a physician order dated March 10, 2026, for Catapress TTS -2 (Clonidine) Transdermal Patch (treats high blood pressure), 0.2 milligrams to be applied once weekly, every Tuesday as ordered by the physician. Observation on Wednesday July 15, 2026, during medication administration revealed Resident R129 did not have the prescribed clonidine transdermal patch in place. Observation of Resident R129's skin confirmed no patch was present. Review of Resident R129's medication administration record (MAR) revealed the facility documented that the previously applied patch was removed on Tuesday July 14, 2026, at 6:59 a.m., and a new clonidine transdermal patch was applied at 9:00 a.m. that same day, Tuesday July 14, 2026. Interview on July 15, 2026, with licensed nurse, Employee E5, confirmed he/she was responsible for administering the clonidine transdermal patch on July 14, 2026. Licensed nurse, Employee E5, acknowledged that although the MAR documented that the patch had been applied on July 14th, the medication was not administered because the patch was not unavailable. Continued interview with licensed nurse, Employee E5, on July 15, 2026, revealed he/she applied the patch when it became available on July 15, 2026. Licensed nurse, Employee E5, confirmed that the medication was administered late, confirmed physician was not made aware of the missed administration yesterday, and further confirmed it was not accurately documented in the medication administration record. Interview with Director of Nursing, Employee E2, confirmed Resident R129's prescribed clonidine patch was not administered as ordered. 28 Pa. Code 211.9 (a)(1) Pharmacy Services 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of clinical records and interviews with resident and staff, it was determined that the facility failed to provide treatment/services to maintain or improve range of motion/mobility for one of 25 residents reviewed (Resident R34). Findings include: Review of Resident R34 clinical record revealed the resident was admitted on [DATE], diagnosed with orthopedic care following a surgical amputation and acquired absence of the bilateral toes. Interview with Resident R34 on July 14, 2026, at 11:00 a.m. indicated he/she is no longer receives restorative services (refers to interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). The resident stated he/she used to receive the services, but it just stopped. Review of Resident R34's discharge therapy instructions revealed programs for restorative range of motion and transfers were established since May 2025. Review of Resident R34's care plan revealed the care plan was reviewed and revised on July 2, 2026, for the resident to continue restorative therapy. Further review of Resident R34 clinical records revealed no documented evidence the resident was receiving the service. On July 17, 2026, at 3:27 p.m. during an interview with Employee E12 confirmed Resident R34 does not receive the service. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization related to a diagnosis of Post Traumatic Stress Disorder (PTSD) for two of two residents reviewed (Resident R27 and R12). Findings include: Review of facility policy titled Trauma Informed Care and Culturally Competent Care dated January 2026, defines trauma as an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening that results in lasting adverse effects on the individual's mental, physical, social, emotional, spiritual well-being, or overall functioning. The policy further defines trauma informed care as an approach to providing care that recognizes, understands, and responds to the effects of trauma. the policy stated that trauma informed care requires staff to recognize the prevalence, signs, and symptoms of trauma and incorporate the knowledge into resident assessments, individualized care plans, facility policies, procedures, and care practices to minimize the risk of re traumatization and provide personal center person-centered care. The purpose of this policy is to ensure staff provides care in accordance with professional standards of practice by recognizing and addressing the needs of trauma survivors while minimizing the risk of re-traumatization. The policy states that all staff are to receive education on trauma-informed care and care should be based on evidence-based trauma informed and resilience-oriented practices. Further review of facility policy Trauma Informed Care and Culturally Competent Care requires the facility to assess residents for trauma related needs as a part of the assessment process, recognize that trauma triggers are highly individualized identify and minimize exposure to potential triggers, and develop individualized, person-centered care plans in collaboration with the resident and when appropriate the resident's family or representative. The policy also emphasizes incorporating residents' cultural preferences, language needs, value and past trauma into care planning, promoting safety, trust, collaboration, empowerment and respect and providing staff education and community resources to support implementation of trauma informed care practices. Review of resident R27's comprehensive care plan dated October 3, 2025, revealed Resident R27 has a problem of potential and or altered mood state related to depression and Post Traumatic Stress Disorder (PTSD). Interventions included administering prescribed psychotropic medications, encouraging visitation, socialization and activities of residents choice, engaging the resident in discussions that promote self-worth, monitoring for gradual douche reduction when appropriate, moderate monitoring the effectiveness and side effects of medication, obtaining psychology and psychiatry consultations as needed, and having a social service provide support and encourage the residents to express feelings as needed. Further review revealed of Resident R27's care plan revealed no documented evidence it contained individualized, trauma informed interventions specific to the resident R27's diagnosis of post-traumatic stress disorder (PTSD). The care plan did not identify the residents known trauma history, individualized trauma triggers, strategies to minimize re-traumatization, resident specific coping mechanisms, environmental modifications, staff approaches to care, where interventions to address behaviors or emotional responses associate with PTSD. The care plan did not reflect implementation of the facility's trauma informed care policy which requires individualized assessment identification of trauma related triggers and development of person-centered interventions to address the unique needs of residents with a history of trauma. Review of Resident R12's comprehensive care plan dated June 29, 2026, revealed Resident R12 has a problem of potential and or altered mood state related to post traumatic stress disorder (PTSD). The care plan interventions included encourage visitation, socialization, and activities of the resident R12's choice; engaging the resident and topics of interest that promote well-being; obtaining psychology and psychiatry consultations is needed; and having social services provide support and encourage the resident to express feelings of need. Further review revealed the care plan did not include individual trauma informed intervention specific to the resident R12's diagnosis of PTSD. The care plan lacked resident specific interventions addressing trauma history commonly known triggers, strategies to prevent re-traumatization, individually coping techniques, staff approached the care, environmental modifications, or other personal centered interventions consistent with the facilities trauma informed care policy. 28 Pa. Code 211.10 (c) Resident Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for one of two floors (First Floor).Findings include: Review of the facilities policy titled Meal Distribution Policy last revised February of 2023, revealed meals are to be transported to resident dining locations in the manner that ensures proper temperature maintenance, protects against contamination, and provides timely and accurate meal delivery. the policy further states that all food items are to be transported properly to maintain appropriate temperatures and that nursing staff are responsible for verifying meal accuracy and timely delivery. Review of standards for food service safety revealed hot foods should be held at 135 degrees Fahrenheit or greater. Interview with Resident R2 on July 14, 2026, at 2:00 p.m. revealed the resident attends food committee meetings and complaints brought up by the residents include that the food is always cold, tasteless, or too many spices. Resident R2 stated the residents complain about the food, but the facility doesn't do anything about it and nothing changes. Review of the facility documentation dated July 15, 2026, revealed breakfast items were held on the steam table, in the main kitchen, at acceptable temperatures for food service safety prior to meal service. Review of facility documentation dated July 15, 2026, revealed the following temperatures were recorded of the breakfast food items prior to meal service that were held in the steam table: Oatmeal recorded at 175 degrees Fahrenheit, and scrambled eggs recorded at 142 degrees Fahrenheit. Observation of breakfast meal service on July 15, 2026, revealed resident meal trays are plated via tray line in the main kitchen and delivered to the nursing units in enclosed food carts where they are then hand delivered to each resident. Observations on July 15, 2026, revealed it took approximately 25 minutes for staff to pass resident meal trays once the food cart was delivered to the unit. A test tray was conducted on July 15, 2026, on the first-floor nursing unit during the breakfast meal service. Twenty-five minutes after the delivery of the food truck to the unit, the final meals were served and a test tray was completed which revealed the following: scrambled eggs measured 100 degrees Fahrenheit, and the oatmeal measured 104 degrees F demonstrating a significant loss in temperature from the documented holding temperatures in the kitchen. Foods were deemed not palatable for temperature. Interview with kitchen director at time of observation confirmed the delays and meal distribution process contributed to food being served at reduced temperatures. The facility failed to ensure meals were transported and served in a timely manner to maintain palatable food temperatures. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of clinical records, and interview with staff and residents it was determined that the facility failed to maintain complete and accurate medical records for two of 25 residents reviewed (Resident R2 and R129). Findings include: Review of the facility policy titled, Charting and Documentation, revised January 2026, states, Any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record . the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], and has diagnoses of peripheral vascular disease, heart failure, and pulmonary (lung) disease. Review of Resident R2's physician orders dated April 8, 2026, instructed the resident to wear a heart monitor for 30 days which was completed on May 8, 2026. Further review of Resident R2's physician orders contained an active order for nursing to replace the heart monitor leads every 48 hours though the heart monitor was no longer an active order. Review of the Electronic medication administration (EMAR) report revealed nursing continued to report the leads were still being replaced every 48 hours. Interview on July 15, 2026, at 10:00 a.m. with Licensed Practical Nurse, Employee E14, confirmed Resident R2's heart monitor was no longer in use. Interview with Resident R2 on July 14, 2026, at 2:00 p.m. stated, he/she asked his nurse to take his blood pressure because he did not feel well and the blood pressures were as high as 186/117. According to the American Heart Association a reading this high would be classified as a hypertensive crisis, the highest risk for a life -threatening complications to occur such as a stroke or heart attack. Review of Resident R2 clinical record revealed no evidence the high blood pressures were recorded in the resident's clinical record, nor was a progress note written documenting these findings. Interview with Resident R2's nurse, Employee E13 on July 15, 2026, at 11:00 a.m. confirmed the incident with Resident R2 and stated the resident did not appear well and confirmed the resident told him he didn't. Employee E13 confirmed all three critically high blood pressures were not documented in the resident's chart nor was a progress note written. Review of Resident R129's clinical record revealed a physician order that the resident is prescribed Catapress TTS -2 (Clonidine) Transdermal Patch, 0.2 milligrams to be applied once weekly, every Tuesday as ordered by the physician. Observation on Wednesday July 15, 2026, during medication administration revealed Resident R129 did not have the prescribed clonidine transdermal patch in place. Observation of Resident R129's skin confirmed no patch was present. Review of Resident R129's medication administration record (MAR) revealed the facility documented that the previously applied patch was removed on July 14, 2026, at 6:59 a.m., and a new clonidine transdermal patch was applied at 9:00 a.m. that same day, Tuesday July 14, 2026. Interview on July 15, 2026, with licensed nurse, Employee E5, confirmed he/she was responsible for administering the clonidine transdermal patch on July 14, 2026. Licensed nurse, Employee E5, acknowledged that although the MAR documented that the patch had been applied on July 14th, the medication was not administered because the patch was not unavailable. Interview on July 15, 2025, with licensed nurse, Employee E5, confirmed the medication administration record was inaccurate, and Resident R129's clonidine transdermal patch was not applied on July 14, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of the facilities policy, review of facility documentation, and staff interviews, it was determined the facility failed to develop and implement an effective building specific water management program designed to identify common monitor, and control the risk of Legionella growth within the facilities water system.Findings include: Review of the facility's policy titled Water Management Program undated, revealed the policy was intended to minimize the presence of pathogenic biological agents and waterborne contaminants within the facility's domestic hot and cold-water systems and other aerosol generating water systems. The policy stated the water management program was part of the facilities infection prevention and control program and was overseen by the QAPI and Safety Committee. the policy further stated that the program was based on the Centers for Disease Control Prevention (CDC) and ASHRAE standard 188 recommendation for developing a Legionella water management program. The policy indicated the facility would conduct a facility risk assessment to identify locations where Legionella and other waterborne pathogens could grow and spread; implement a water management program that includes physical controls, temperature management, disinfectant level monitoring disinfectant level monitoring, visual inspections, and environmental testing; established testing protocols and acceptable control limits; document testing results and corrective actions; perform routine maintenance, cleaning, and disinfection of the water systems and equipment; maintain records of maintenance and treatment activities; conduct semiannual independent laboratory testing, and provide orientation and annual training to staff responsible for the water management program. Further review of the facility policy revealed the policy was a general template, referencing the name of the community and did not contain building specific information or documentation demonstrating implementation of the program at the surveyed facility. Review of the Center for Disease Control and Prevention (CDC) guidance titled Developing a Water Management Program to Reduce Legionella Growth and Spread in the Building dated June 24th, 2021, revealed that a water management program should be building specific and designed to identify areas within the building's water system where Legionella bacteria may grow and spread in order to reduce the risk of Legionnaires disease. The CDC guidance identifies essential elements of an effective water management program including: -Establishing a multidisciplinary water management team -Develop a description and flow diagram of the building's water systems -Identify areas and devices where Legionella growth and transmission may occur -Develop corrective actions when control limits are not met. -Verify and validate that the program is functionally effective Documenting, communicating, and reviewing all program activities at least annually and whenever significant changes occur to the building water system. Review a facility documentation revealed the facility was unable to provide a building specific water management program demonstrating these required elements. The documentation provided consists of only the facilities water management program policy and laboratory results of environmental water sampling. The facility did not provide documentation identifying a water management team, a building specific water system description or flow diagram, a hazard analysis identifying locations at risk for Legionella growth, established control measures and monitoring procedures, corrective action protocols, verification and validation activities, or documentation demonstrating ongoing implementation and annual review of the program. Interview on July 17, 2026, with Nursing Home Administrator, Employee E1, confirmed the documentation provided is all that was available for the water management program. 28 Pa. Code 201.14 (a) Responsibility of Licensee. 28 Pa. Code 201.18 (a) Management.

Based on observations of the meals and dietary services, reviews of the resident council and food committee meeting minutes, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to provide meals at regular time frames and in accordance with resident needs and preferences. (Residents R2, R28, R68, R97, R114 and R116). Findings include: A review of the facility's policy titled food and nutrition services dated October 2001 revealed that it was the responsibility of the facility to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs and preferences. The policy also said that meals would be provided within the scheduled mealtime frame and in accordance with the resident's medication requirements. The policy also said that meals were scheduled at regular times to assure that each resident receives at least three meals a day. Mealtimes were to be posted in the facility in common areas. Observations of the noon meal services for the residents living on the second-floor nursing unit on September 8, 2025, revealed that the meal delivery times that were established and posted throughout the facility were not being adhered to. The residents were observed sitting in the dining room or in their rooms at 11:30 a.m., waiting for their noon meal to arrive at 12:00 p.m., the food beverage delivery from the dietary services department was not complete until 1:30 p.m., one hour and a half beyond the established mealtime schedule. The residents were heard asking the staff where the foods and fluids were being kept, since they were hungry, after waiting for two hours for the final meal truck to be delivered to the second-floor nursing unit. A review of the facility's established mealtime scheduled for the second-floor nursing unit revealed that meals were supposed to arrive between 12:00 p.m. and 12:40 p.m. The first-floor nursing unit meal trays were listed and scheduled for arrival at 11:50 a.m.Interview with the director of dietary services, Employee E7, at the time of the above observation revealed that there were new staff members in the kitchen that were not familiar with their job responsibilities. The director of dietary services confirmed that the meals were not being delivered to the nursing units promptly and in accordance with the established mealtime scheduled that was posted on each nursing unit. Interview with licensed practical nurse, Employee E3, at 9:30 a.m., on September 9, 2025, confirmed that the nursing staff on second floor had been waiting at least an hour beyond the established mealtime schedule on a daily basis for several months. A review of the June 26, 2025, resident council and food committee meeting minutes revealed that the residents were concerned about the late delivery of meal trays to the nursing units. A review of the resident council and food committee meeting minutes for July 31, 2025, revealed that residents were not happy that food trucks and meals were arriving late to the nursing units. A review of the resident council and food committee meeting minutes for August 28, 2025, revealed that the residents were concerned about the food truck delivery and meal delivery to the nursing units reporting that the dietary services were not operating in a timely manner. A group meeting was held with alert and oriented residents on September 09, 2025, at 11:00 a.m. Present at the meeting were Resident's R2, R28, R68, R97, R114 and R116. When the group was asked if there had been a problem with meals being late, all residents agreed that the meals have been late, like yesterday. Resident R6 said that recently, in the past few weeks the meals have been late a lot and added that the food is not always warm when he gets it. Resident R4 added that her food is late and often cold too. During observations on first floor unit, dining room, on September 8, 2025, at 12:00 noon residents received beverages at 12:33 pm and were not served meals until 1:00 pm. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.18c(b)(1)(3)(6) Management

Based on review of clinical records, review of facility policy and interview with staff, it was determined facility did not ensure to develop and care plan related to a resident's diagnosis for one of six residents reviewed (Resident R133)Findings include: Review of facility policy 'Comprehensive Person- Centered Care Plans,' revised March 2022, indicated that the care plan reflects currently recognized standards of practice for problem areas and conditions.Review of Resident R133's clinical record revealed the diagnoses of osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), osteoporosis (condition in which bones become weak and brittle), osteopenia (bone loss).Review of facility provided documentation revealed that on May 6, 2025, Resident R133 complained of pain to the right side, stating that maybe it occurred when Nurse aide, Employee E9, was repositioning her in bed. X-ray revealed a fracture to the 9th rib. Per hospital records resident is at high risk for fractures due to severe osteoporosis.Further review of facility provided investigation report, completed by the Director of Nursing on June 5, 2025, revealed that the medical director reviewed the resident's condition and noted that resident has had severe osteoporosis since 2016 with very high risk for fractures.Review of R133's care plan revealed no evidence of goals or interventions related to resident's high risk for fractures and medical diagnosis of osteoporosis.Interview conducted on September 11, 2025 at 11:00 am with the Director of Nursing confirmed that there was no care plan developed related to the resident's diagnosis of osteoporosis. 28 Pa Code 211.10(a) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based upon review of clinical records, interview with staff and review of facility documentation, it was determined that the facility did not ensure a resident receive treatment and care in accordance with professional standards of practice, to a laceration identified after a fall incident for one resident of 24 resident records reviewed (Resident R17).Findings include:Review of Resident R17's clinical record revealed that the resident was admitted to the facility in March 2022 with the diagnosis of dementia. The resident was assessed to be at high risk for falls. Review of the information submitted on July 9, 2025, to the State Survey Agency revealed that on July 7, 2025, Resident R17 was lowered to the floor by a nurse aide when the resident was being toileted. The resident, who was soiled received a shower after the incident and it was then the staff noted that the resident was bleeding under her right axillary (armpit area).Review of Resident R17's clinical record revealed no evidence of a clinical assessment completed at the time that the nor monitoring by nursing when the wound was first discovered. A late entry note created on July 13, 2025, that detailed the resident had a fall on July 7, 2025, at 10:39 a.m. and noted that Skin issues had not been evaluatedFurther review of Resident R17's clinical record revealed the following morning on July 8, 2025, the wound was assessed by the wound specialist that described the wound as a large open area with muscle exposure with sanguineous (bright red in color) moderate discharge from the resident's right arm. After this assessment the resident was sent 911 to the hospital for further evaluation.Review of Resident R17's July 8, 2025, hospital records described the wound as a laceration, 7 x 5 cm, deep to muscle that required sutures.Interview with the Director of Nursing on September 11, 2025, at 2:00 p.m. was unable to show evidence of the nurse's initial assessment of the wound, treatments, physician orders, and/or ongoing monitoring once the wound was found, prior to Resident R17 transfer via 911 to the hospital.

Based upon review of clinical records and interviews with resident and staff, it was determined the facility failed to ensure that a resident received services to maintain vision for one of 24 resident records reviewed (Resident R83). Findings include: Review of Resident R83's clinical record revealed that the resident was admitted to the facility in November 2021, with the diagnosed with diabetes. Interview with the resident on September 8, 2025, at 9:30 a.m. stated it had been a while since her last eye doctor's appointment and said, I think I'm due Review of Resident R83's clinical record revealed an ophthalmologist appointment dated March 6, 2024, for suspected glaucoma and cataracts instructed to monitor annually. Further review of the medical record revealed no further appointments had been made. This was confirmed with the Director of Nursing on September 10, 2025, at 11:30 am when the facility could not locate a follow-up appointment for Resident R83's yearly evaluation for ophthalmology. 28 Pa Code 211.12(d)(3) Nursing services

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two of three residents receiving dialysis reviewed (Residents R1, and R32 ).Findings include:Review of facility policy 'Care of Resident with End Stage Renal Disease,' revised September 2010, stated that staff caring for residents with ESRD (End Stage Renal Disease), including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents, including education and training of staff on the type of assessment data that is to be gathered about resident's condition on a daily or per shift basis.Further review of policy indicated that agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: how information will be exchanged between the facilities.Review of Resident R32's clinical record revealed the medical diagnoses of end stage renal disease, dependance on renal dialysis, type 2 diabetes mellitus (failure of the body to produce insulin).Further review of Resident R32's clinical record revealed a physician order for dialysis services on Mondays, Wednesdays and Fridays.Review of Resident R32's communication report on unknown date revealed the following information missing: vital signs, code status, changes in condition, and facility's nurse name/date.Review of Resident R32's dialysis communication report dated April 16, 2025, revealed missing pre-weight information and missing post weight/total fluid removed information.Review of Resident R32's dialysis communication report dated April 18, 2025, revealed missing pre-weight information as well as all missing resident information not completed by dialysis staff.Review of R32's dialysis communication report dated April 28, 2025, revealed missing pre-weight information.Review of R32's dialysis communication report dated May 14, 2025, revealed missing pre-weight informationReview of R32's dialysis communication report dated June 30,2025, revealed missing post - weight and total fluid volume removed information.Review of Resident R57's clinical record revealed a physician's order for hemodialysis every Tuesday, Thursday and Saturday with a 10:45 a.m. chair time at a local dialysis center. Further review of Resident R57's dialysis log record revealed that none of the four pages available to review from September 2025, were completed by the dialysis center or signed by the dialysis center nurse. Interview with the Unit Manager, Employee E3, on September 10, 2025, at 12:15 p.m. confirmed that the dialysis center had failed to complete the clinical documentation on all four of the pages in September for Resident R57. She stated that they often have to call the dialysis center for the pre and post weights. Interview with the Unit Clerk, Employee E6, on September 10, 2025, at 12:30 p.m. confirmed that the dialysis center had not completed the log pages for Resident R57 for September. She stated that it was not like the dialysis center not to complete this and that she would have to call them. An interview on September 10, 2025, at 2:15 p.m. with the Director of Nursing, acknowledging that the log sheets should be completed each time the resident goes to dialysis by both the facility nurse and the dialysis center staff. 28 Pa. Code: 211.10(c) Resident care policies 28 Pa Code 211.5(f)(ix) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Pharmacy Services Facility did not ensure to provide medications and/or biologicals, as ordered by the prescriber, to meet the needs of resident ([NAME]) Based on observations, review of resident's clinical record and interview with staff, it was determined that facility failed to ensure timely reordering and availability of mediations from pharmacy for one of four residents reviewed (Resident R24)Findings include:Review of facility policy 'Reordering, Changing, and Discontinuing Medication Orders.' Revised February 2023, indicated that refills can be requested via facilities EMAR system; this is the most preferred method. Facility may also request refills by placing the 'refill' strip portion of the medication label on the Refill Order Form and faxing it to the pharmacy.Review of facility's policy 'Administering Medications,' revised April 2019, indicated that if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate on the MAR, and the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.Review of Resident R24's clinical record revealed the resident's diagnoses of paroxysmal atrial fibrillation (A-Fib, a type of heart rhythm disorder where the heart's upper chambers beat irregularly and rapidly for a short period of time), high blood pressure, hemiplegia/hemiparesis (paralysis to one side of the body) following cerebral infarction affecting right dominant side.Review of Resident R24's clinical record revealed a physician order for calcium + vitamin D3 oral tablet 600-5 mg-mcg supplement to be administered twice daily.Further review of Resident R24's clinical record revealed a physician order for Apixaban oral tablet 5 mg to be administered every 12 hours for A-FIB.During medication administration observation on September 10, 2025, at 10:40 am, Licensed nurse, Employee E8, did not administer supplement and Apixaban due to unavailability of medications; further indicating that Apixaban was untimely re-ordered on September 10, 2025.Review of Resident R24's nurses notes, dated September 10, 2025 at 10:03 am, revealed CRNP (Certified Registered Nurse Practitioner)/MD (physician) is aware of resident missed dose of Apixaban 5 mg, medication will be delivered from pharmacy.Review of Resident R24's medication administration record (e-MAR) revealed Employee E8 marked Apixaban 5 mg as given on September 10, 2025 at 10:56 am.Interview with facility's director of nursing on Thursday, September 11, 2025 at 1:30 pm, confirmed R24 missed dose of apixaban 5 mg on Wednesday, September 10, 2025, as well as inaccurate e-MAR documentation.28 Pa Code 201.18(b)(2) management28 Pa Code 211.9(a)(1)(k) pharmacy services28 Pa Code 211.12(d)(1)(3)(5) nursing services

Based on observations during medication administration, review of clinical records, facility policies and procedures, as well as interview with staff, it was determined that the facility did not ensure the medication error rate was less than five percent.Findings include: The facility's medication error rate was 8 percent based on observation of 25 medication opportunities with two medication errors observed.Review of facility policy 'Reordering, Changing, and Discontinuing Medication Orders,' revised February 2023, indicates that refills can be requested via facilities EMAR system; this is the most preferred method. Facility may also request refills by placing the 'refill' strip portion of the medication label on the Refill Order Form and faxing it to the pharmacy.Review of facility policy 'Administering Medications,' revised April 2019, indicates that medications are administered within one hour of their prescribed time, unless otherwise specified.Review of Resident R24's clinical record revealed the diagnoses of paroxysmal atrial fibrillation (A-Fib, a type of heart rhythm disorder where the heart's upper chambers beat irregularly and rapidly for a short period of time), high blood pressure, hemiplegia/hemiparesis following cerebral infarction affecting right dominant side.Further review of Resident R24's clinical record revealed a physician order for Apixaban oral tablet 5 mg to be administered every 12 hours for A-FIB, at 9 am and 9 pm.Review of Resident R24's clinical record revealed a physician order for calcium + vitamin D3 oral tablet 600-5 mg-mcg supplement to be administered twice daily.During medication administration observation on September 10, 2025, at 10:40 am, Licensed nurse, Employee E8, did not administer supplement and Apixaban due to unavailability of medications; further indicating that Apixaban was untimely re-ordered from pharmacy on September 10, 2025.Interview with facility's director of nursing on Thursday, September 11, 2025, at 1:30 pm, confirmed that Resident R24 did not receive Apixaban 5 mg and did not receive calcium + vitamin D3 oral tablet 600-5 mg-mcg supplement as prescribed.28 Pa Code 211.9(a)91) pharmacy services28 Pa Code 211.12(5) nursing services

Based on clinical record reviews, observations of care and services, interviews with residents and staff and reviews of policies and procedures, it was determined that for one of two residents reviewed for oral health services, the facility failed to provide prompt and routine dental care for each resident. (Resident R9) Findings include: A review of the facility's policy titled dental services dated December 2001, revealed that it was the responsibility of the facility to ensure that each resident had oral health examinations and assessments. The policy also said that it was the facility's responsibility to provide each resident with routine and emergency dental care. The policy indicated that the routine and emergency dental care would be provided by a contracted dental group. Observations of Resident R9 on September 8, 2025, revealed that this resident was in need of oral care. The need for dental cleaning of the resident's teeth was apparent upon speaking with the resident. An accumulation of food debris was observed between the teeth when resident was expressing a smile. Clinical record review revealed that Resident R9 had been evaluated by the dental hygienist on July 18, 2025. The hygienist assessment indicated that Resident R9 had moderate to severe calculus, moderate to severe plaque and moderate to severe gum bleeding. The hygienist indicated that Resident R9 was not tolerating the cleaning and needed to be examined by a dentist. The dental assessment dated [DATE], indicated that Resident R9 complained of teeth pain and asked to be examined by a dentist. Interview with the licensed practical nurse, Employee E3 at 9:30 a.m., on September 9, 2025, revealed that this nurse was familiar with the oral care needs of Resident R9. The licensed nurse, Employee E3, confirmed that there were no routine dental services scheduled to treat the oral needs (teeth pain, plaque, calculus and bleeding gums) of Resident R9. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to maintain accurate medication administration records for one of 23 residents reviewed. (Resident R24)Findings include:Review of Resident R24's clinical record revealed the resident's diagnoses of paroxysmal atrial fibrillation (A-Fib, a type of heart rhythm disorder where the heart's upper chambers beat irregularly and rapidly for a short period of time), high blood pressure, hemiplegia/hemiparesis (paralysis to one side of the body) following cerebral infarction affecting right dominant side.Review of Resident R24's clinical record revealed a physician order for calcium + vitamin D3 oral tablet 600-5 mg-mcg supplement to be administered twice daily.Further review of Resident R24's clinical record revealed a physician order for Apixaban oral tablet 5 mg to be administered every 12 hours for A-FIB.During medication administration observation on September 10, 2025, at 10:40 am, Licensed nurse, Employee E8, did not administer supplement and Apixaban due to unavailability of medications; further indicating that Apixaban was untimely re-ordered on September 10, 2025.Review of Resident R24's medication administration record (e-MAR) revealed Employee E8 marked Apixaban 5 mg as given on September 10, 2025 at 10:56 am.Interview with facility's director of nursing on Thursday, September 11, 2025 at 1:30 pm, confirmed R24 missed dose of apixaban 5 mg on Wednesday, September 10, 2025, as well as inaccurate e-MAR documentation.28 Pa. Code 201.18(b)(2) Management28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for nine of nine months reviewed (January, February, March, April, May, June, July, August, and September). Findings include: The facility was asked for evidence that the facility was notifying the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for the last six months including the months of April, May, June, July, August, and September, 2024. On October 3, 2024 1 at 1:11 a.m. the Nursing Home Administrator, Employee E1 stated that there was no evidence of the transfers and discharges being sent to the Office of the State Long-Term Care Ombudsman due to the social worker being new to the facility. Employee E1 was asked to provide evidence that the notices were sent during the month of January, February, and March, 2024. Employee E1, the Nursing Home Administrator was not able to provide these notices. Resident R11 was transferred to the hospital and admitted with a diagnosis of pneumonia on May 15, 2024. An interview on October 3, 2024 at 11:10 a.m. with Employee E1, Nursing Home Administrator, confirmed that no ombudsman notification was available for review. Resident R8 was transferred to the hospital on December 18, 2024 and admitted through December 21, 2023. An interview on October 3, 2024 at 11:10 a.m. with Employee E1, Nursing Home Administrator, confirmed that no ombudsman notification was available for review. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on review of facility policy, observation, and interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that grievance or complaint forms were available to residents or their representatives without asking for two of two units reviewed. (First floor and Second floor) Findings include: Review of the facility policy titled, Grievances/Complaints, Filing with a revision date of April 2017 states, Policy Statement- Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). Further review of the facility policy revealed, Policy Interpretation and Implementation .5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 13. If the grievance was filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps will be taken to investigate that grievance(s)v and report the findings. The grievance officer will reiterate to the resident that is it against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility, and that his or her rights to be free of discrimination or reprisal will be protected. On October 1, 2024 at 11:00 a.m. a facility tour was conducted with the Director of Social Services, Employee E7 to observe where grievance forms and grievance boxes were located on the first floor and second floor units. The tour of the first and second floor revealed there were no forms readily accessible for residents or their representatives available without having to ask. Further observation revealed there was no locked grievance box available on the first floor or second floor units allowing for residents or their representatives to turn in grievance forms anonymously. On October 1, 2024 at 11:05 a.m. an interview held with the Director of Social Services Employee E7 revealed the only place that grievances form were located was currently in the social services office. Employee E7 stated that if a resident or resident's representative has a concern or a grievance, they have to come to her for her to fill out and file a grievance for them. Employee E7 confirmed there are no grievance forms readily accessible and there is currently no way for the grievance forms to be turned in anonymously. Resident Council held on October 2, 2024 at 10:00 a.m. with ten awake, alert, and oriented residents. When asked about grievance forms five out of ten of the residents (R97, R74, R3, R29, and R72) stated they were not aware of where to access grievance forms in the facility. 28 Pa code 201.18(b)(2)(3) Management 28 Pa code 201.29(a) Resident rights

Based on review of clinical records, review of facility policy, review of facility investigation reports, hospital record review, and staff interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) reviewed was free from physical abuse and neglect which resulted in actual harm to Resident R1 who sustained a head injury, hematoma to the right side of the face, lip laceration and required transfer to the hospital. This deficiency was identified as past non-compliance. (Resident R1) Findings Include: A review of the facility policy, titled Lifting Machine, Using a Mechanical, dated July 2017 stated, the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General Guidelines: at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 1. Mechanical lifts may be used for tasks that require: 2. Lifting a resident from the floor; a. Transferring a resident from bed to chair; c. Lateral transfers; d Lifting limbs; Toileting or bathing; or f. Repositioning. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Review of Resident R1's clinical record revealed that the resident was admitted to the facility, with diagnoses that included osteoarthritis of knee (a degenerative joint disease, in which the tissues in the joint break down over time), hammer toes (a foot condition in which the toe has an abnormal bend in the middle joint) right and left foot and muscle weakness. A review of Resident R1's quarterly Minimum Data Set (MDS-a periodic review of a resident's assessment and care needs), dated May 3, 2024, revealed that Resident R1 was dependent on staff for transfer to move between surfaces including to and from bed, chair, wheelchair or the assistance of 2 or more helpers is required for the resident to complete the activity. A review of Resident 1's current care plan dated May 11, 2018, revealed that Resident R1 had the potential for falls related to deconditioning, decreased mobility, and history of falls. The care plan intervention included Resident R1 transfers via a Hoyer lift (allow a person to be lifted and transferred with a minimum of physical effort) with 2 persons assist. A review of Resident R1's physician order summary on October 10, 2019, revealed an order to transfer with a Hoyer lift with 2 person assist. A review of the facility investigation for June 4, 2024, revealed Resident R1 was found with facial injuries which included swelling to the resident's right jaw, right forehead and some bleeding was noted to the resident's lip/mouth. New order received to send the resident to the emergency room for evaluation. Further review of the facility investigation revealed that on June 4, 2024, around 7:00 p.m., Employee E3, Nurse aide was taking Resident R1 to her room to put her to bed. According to the employee, she transferred Resident R1 to her bed by herself. According to Nurse aide, Employee E3, due to the resident being very combative and swinging the bed control remote, she left the resident in bed and closed the door. A few moments later, resident was heard screaming by Nurse aide, Employee E4, Help me. Help me. They're beating me up.' Upon entry into the residents' room, Employee E4 observed facial injuries to Resident R1. Employee E4 then got the Charge nurse, Employee E5, who also noticed the injuries. Charge nurse, Employee E5 then informed the Employee E6, Supervisor. Resident R1 had a lump on her forehead, swelling to the right lower jaw, and blood on her lips. Resident was sent to the hospital as ordered by the physician. Review of a statement by the Charge nurse, Employee E5 dated June 4, 2024, revealed that while he was passing out the medication he saw one of the aides taking Resident R1 to her room. When he approached Resident R1's room from a distance he saw the aide struggling with the resident. He asked the aide what was going on and the aide stated the resident was trying to hit her. He advised the aide to leave the resident alone since she was already in the bed. Fifteen minutes later another aide called the nurse to Resident R1's room immediately. When he entered the resident's room he saw a lump on her forehead, swollen right jaw and bleeding from mouth. Resident was in pain. Facility investigation also revealed an interview with Nurse aide, Employee E3 which indicated Upon interview of [Employee E3], she stated that she was taking [Resident R1[ to her room. Upon entering the room, [Nurse aide, Employee E3] rolled resident's wheelchair to bedside. [Nurse aide, Employee E3], by herself then picked up the resident from the wheelchair and placed her on the bed, sideways. Once the resident was in bed, [Nurse aide, Employee E3] stated that she then tried to change the resident, but the resident was swinging the bed control remote. [Nurse aide, Employee E3] said she left the residents room due to her being combative and closed the door. [Nurse aide, Employee E3] admitted that she did not use a Hoyer lift (mechanical lift) or have another staff member present during the transfer which was part of the resident's care plan. [Nurse aide, Employee E3] denies hitting the resident and said the injuries were caused by the resident swinging the bed remote Continued review of the investigation revealed that Charge nurse, Employee E5 did not see Resident R1 swinging the bed remote at any time this shift. There was no evidence in the clinical record that the resident had the injuries prior to Resident R1 was transferred to the bed. Staff statement revealed that the resident had no injuries to the face prior to the transfer to the bed. Review of a statement by Nurse aide, Employee E3 dated June 4, 2024, revealed that the resident was in the bed. She was yelling and holding on to the bed remote and swinging it, so she left the room. Continued review of the statement revealed no evidence that Nurse aide, Employee E3 saw Resident R1 hitting herself with the remote. Nurse aide, Employee E3 was suspended by the facility and did not allow an interview when called over the phone or returned the message left by the State Agency. Review of facility investigation revealed that several attempts were made to contact Nurse aide, Employee E3 to complete a formal statement. Nurse aide, Employee E3 did not respond to any of the attempts. Review of the conclusion of the facility investigation revealed that based on interviews, there was no definitive way to determine how resident sustained her injuries. It was unlikely that the injuries were sustained by the resident swinging the bed control remote. What was known was that by Employee E3's own admission, she did an inappropriate transfer and did not follow the resident plan of care that required two-person transfer with a Hoyer lift. Due to this fact, Employee E3's employment has been terminated. Review of clinical record and resident's care plan did not reveal any evidence that the resident had any behaviors of self-harm such as swinging the bed remote and hurting herself. Interview with Unit manager, Employee E7, on June 27, 2024, at 12:00 p.m. stated most days, she was with her doll baby, she was mostly quiet, she sometimes screams, and throw stuff like water or milk at others. She never hurt anyone or never hurt herself. Interview with Licensed Practical Nurse, Employee E8, on June 27, 2024, at 10:39 a.m. stated she heard someone transferred the resident incorrectly, her lips were swollen, bruise on face under eye, bruise on her head, sometimes she the resident was combative, but never seen her hurting herself. Licensed Practical Nurse, Employee E8 stated the resident was able to make her needs known. Resident was always transferred using a Hoyer. A review of hospital records for Resident 1 dated June 4, 2024, revealed that a [AGE] year-old female with history of osteoarthritis of bilateral knees and unable to ambulate, dementia was sent from nursing home with head injury and questionable assault. Clinical Impression included head injury, Hematoma and lip laceration. An interview with the Director of Nursing and Administrator on June 27, 2024, at 1:00 p.m., confirmed that Nurse aide, Employee E3 did not follow Resident R1's care plan for transfers. Resident R1 was subsequently found with injuries possibly obtained during transfers. This deficiency was cited as past non-compliance. Review of facility Action plan/Follow up documentation revealed the following: The facility was investigating an allegation of Abuse/Neglect that occurred on 6/4/2024 with Resident R1. The resident was seen in the emergency room and returned to the facility. The residents who Nurse aide, Employee E3, had taken care of on the evening of 6/4/24 were evaluated by the Nursing Supervisor on 6/4/24 and were found without injuries. Employee E3 involved in the incident did violate the care plan/Kardex as the resident is a two person Hoyer lift transfer which was also noted on the care plan/Kardex. Current residents in the facility have had their care plan/Kardex reviewed to ensure that the appropriate transfer status is indicated. All current staff are being re-in serviced by the Director of Staff Development, or designee, regarding the Abuse Prevention Policy. Current RN, LPN and Nurse Aide (N.A). staff are being re-in serviced by the Director of Staff Development, or designee, regarding resident transfers and the need to check the resident's care plan/Kardex for the resident's transfer status prior to performing a transfer. Current RN, LPN and N.A staff are being re-in serviced by the Director of Staff Development, or designee, regarding dealing with combative residents and the need to stop and ensure resident safety, report the behavior to the charge nurse and re-approach the resident at a later time. Re-in servicing has been completed as of 6/7/24 and the facility has determined compliance as of 3 pm Auditing- The Director of Nursing or designee, will audit the RN, LPN and N.A. randomly as they transfer residents to ensure that resident transfers are being performed as indicated on the residents' care plan/Kardex. Audits will be completed weekly x 4 weeks and then monthly for 90 days. Results of the audits will be forwarded to the QAPI Committee for review and additional recommendations. The Director of Nursing, or designee, will randomly audit the resident care plan/kardexes to ensure that appropriate transfer status is indicated. The Social Services Department will conduct random audits to rule out Abuse/Neglect via visits with the residents to ensure there are no Abuse/Neglect concerns weekly x 4 weeks and then monthly. Results of the audits will be forwarded to the QAPI Committee for additional review/recommendations. The facility alleged compliance with their plan of correction as of June 7, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on observations of resident care, clinical record reviews, interviews with residents and staff, and the review of facility policies and procedures, it was determined that for one of fourteen residents reviewed, the facility failed to provide adequate supervision, staff assistance and assistive devices to ensure an environment that was free of accident hazards. The lack of supervision, assistance and assistive devices caused an incident of actual harm for Resident R8 (Resident R8). Findings include: The facility policies related to safety with hot beverages indicated that beverages were to be served at a palatable temperature while maintaining appropriate practices for resident safety. The policy indicated that hot liquids were to be served in the proper container, lids were to be removed at the point of service to the resident, except those identified as an adaptive feeding device and all coffee equipment must be in a secure area or under constant visual surveillance by staff. The comprehensive assessment MDS (an assessment of care needs) dated (MONTH) 12, 2019, for Resident R8 indicated that this resident had severely impaired vision (no vision or sees only light, colors or shapes: eyes do not appear to follow objects). The BIMS (a brief screener that aids in detecting cognitive impairment) score for Resident R8 revealed that this resident was cognitively intact. The assessment also indicated that the functional status of Resident R8 for eating (how the resident eats and drinks regardless of skill) was extensive assistance of one person physical assist for eating. The occupational therapist evaluated Resident R8 on (MONTH) 25, 2019. The evaluation indicated that Resident R8 required a two handled cup with lid and straw, food placed in bowls and regular utensils for all meals with supervision. The speech language pathologist evaluated Resident R8 on (MONTH) 19, 2019 and indicated that this resident required full feeding assistance during meals. There was no person centered care plan developed and documented related to Resdient R8's functional abilities/level of assistance and supervision needed for eating. This lack of person centered care plan development and implementation was confirmed during an interview with the director of nursing, Employee E2, at 2:00 p.m., on (MONTH) 10, 2019. Nursing progress notes and physician progress notes [REDACTED]. There was no documentation to indicate that this resident was provided a two handled cup with lid and straw as assessed by the occupational therapist for the eating/drinking and safety needs of this resident. There was no documentation to indicate that Resident R8 was provided adequate supervision and one person physical assistance with eating and drinking as assessed by the occupational therapist and the speech language pathologist, to meet this resident's care needs for eating and drinking. An interview with Resdient R8 at 2:30 p.m., on (MONTH) 10, 2019 revealed that the resident was given a cup of coffee on (MONTH) 25, 2019. The resident reported that he screamed when the incident happened, because the scalding, with the hot beverage was painful. An interview with the registered nurse responsible for the care of Resident R8 on (MONTH) 25, 2019 revealed that during this interview at 3:00 p.m., on (MONTH) 10, 2019, that the registered nurse was not in the dining room at the time the incident happened. The registered nurse reported being in the hallway outside the dining room and went into the dining room to assess the resdient's skin condition. The facility failed to indicate how Resident R8 obtained a cup of hot coffee in the dining room on (MONTH) 25, 2019. This was confirmed during an interview with the nursing home administrator at 3:30 p.m., on (MONTH) 10, 2019. The wound care specialist evaluated Resdient R8 on (MONTH) 29, 2019 and diagnosed the resident with trauma having a full thickness ulceration of the chest 23.0 by 36 cm measurement. Wound base localized area 70% fluid filled blister. A third degree burn was a burn that has penetrated the epidermis and dermis and extended into the subcutaneous fat of the hypodermis. On (MONTH) 5, 2019 the wound specialist documented the anterior chest wall as a full thickness wound, measuring 20cm by 34cm by .1 cm area. An observation of Resident R8's anterior chest at 2:30 p.m. on (MONTH) 10, 2019 revealed an ulceration on the chest wall. The registered nurse, Employee E6, who was present during this observation and reported that Resident R8 was being treated with [MEDICATION NAME] and [MEDICATION NAME] every day and that the anterior chest was then covered with ABD pad and ABD binder. The facility failed to ensure a safe environment for Resident R8. The resident was not provided with adequate supervision, physical assistance, and assistive devices to prevent accidents, and this lack of care resulted in actual harm to Resident R8. 28 P[NAME] Code: 201.18(a)(b)(1)(3) Management 28 P[NAME] Code: 211.10(a)(b)(c)(d) Resident care policies 28 P[NAME] Code: 211.11(a)(b)(c)(d) Resident care plan 28 P[NAME] Code: 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations of resident care, clinical record reviews, interviews with residents and staff, and the review of facility policies and procedures, it was determined that for one of fourteen residents reviewed, the facility failed to provide adequate supervision, staff assistance and assistive devices to ensure an environment that was free of accident hazards. The lack of supervision, assistance and assistive devices caused an incident of actual harm for Resident R8 (Resident R8). Findings include: The facility policies related to safety with hot beverages indicated that beverages were to be served at a palatable temperature while maintaining appropriate practices for resident safety. The policy indicated that hot liquids were to be served in the proper container, lids were to be removed at the point of service to the resident, except those identified as an adaptive feeding device and all coffee equipment must be in a secure area or under constant visual surveillance by staff. The comprehensive assessment MDS (an assessment of care needs) dated (MONTH) 12, 2019, for Resident R8 indicated that this resident had severely impaired vision (no vision or sees only light, colors or shapes: eyes do not appear to follow objects). The BIMS (a brief screener that aids in detecting cognitive impairment) score for Resident R8 revealed that this resident was cognitively intact. The assessment also indicated that the functional status of Resident R8 for eating (how the resident eats and drinks regardless of skill) was extensive assistance of one person physical assist for eating. The occupational therapist evaluated Resident R8 on (MONTH) 25, 2019. The evaluation indicated that Resident R8 required a two handled cup with lid and straw, food placed in bowls and regular utensils for all meals with supervision. The speech language pathologist evaluated Resident R8 on (MONTH) 19, 2019 and indicated that this resident required full feeding assistance during meals. There was no person centered care plan developed and documented related to Resdient R8's functional abilities/level of assistance and supervision needed for eating. This lack of person centered care plan development and implementation was confirmed during an interview with the director of nursing, Employee E2, at 2:00 p.m., on (MONTH) 10, 2019. Nursing progress notes and physician progress notes [REDACTED]. There was no documentation to indicate that this resident was provided a two handled cup with lid and straw as assessed by the occupational therapist for the eating/drinking and safety needs of this resident. There was no documentation to indicate that Resident R8 was provided adequate supervision and one person physical assistance with eating and drinking as assessed by the occupational therapist and the speech language pathologist, to meet this resident's care needs for eating and drinking. An interview with Resdient R8 at 2:30 p.m., on (MONTH) 10, 2019 revealed that the resident was given a cup of coffee on (MONTH) 25, 2019. The resident reported that he screamed when the incident happened, because the scalding, with the hot beverage was painful. An interview with the registered nurse responsible for the care of Resident R8 on (MONTH) 25, 2019 revealed that during this interview at 3:00 p.m., on (MONTH) 10, 2019, that the registered nurse was not in the dining room at the time the incident happened. The registered nurse reported being in the hallway outside the dining room and went into the dining room to assess the resdient's skin condition. The facility failed to indicate how Resident R8 obtained a cup of hot coffee in the dining room on (MONTH) 25, 2019. This was confirmed during an interview with the nursing home administrator at 3:30 p.m., on (MONTH) 10, 2019. The wound care specialist evaluated Resdient R8 on (MONTH) 29, 2019 and diagnosed the resident with trauma having a full thickness ulceration of the chest 23.0 by 36 cm measurement. Wound base localized area 70% fluid filled blister. A third degree burn was a burn that has penetrated the epidermis and dermis and extended into the subcutaneous fat of the hypodermis. On (MONTH) 5, 2019 the wound specialist documented the anterior chest wall as a full thickness wound, measuring 20cm by 34cm by .1 cm area. An observation of Resident R8's anterior chest at 2:30 p.m. on (MONTH) 10, 2019 revealed an ulceration on the chest wall. The registered nurse, Employee E6, who was present during this observation and reported that Resident R8 was being treated with [MEDICATION NAME] and [MEDICATION NAME] every day and that the anterior chest was then covered with ABD pad and ABD binder. The facility failed to ensure a safe environment for Resident R8. The resident was not provided with adequate supervision, physical assistance, and assistive devices to prevent accidents, and this lack of care resulted in actual harm to Resident R8. 28 PA. Code: 201.18(a)(b)(1)(3) Management 28 PA. Code: 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code: 211.11(a)(b)(c)(d) Resident care plan 28 PA. Code: 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to follow and obtain physician's orders related to radiology studies and medication administration for one resident of 32 residents reviewed resulting in actual harm (Resident R20). Findings include: Review of facility policy titled Medication Administration, dated (MONTH) (YEAR), revealed that medications are administered in accordance with written orders of attending physicians. Review of the clinical record for Resident R20 revealed that the resident was admitted to the facility from an acute care hospital on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED].). Review of a Certified Registered Nurse Practitioner (CRNP) comprehensive physical assessment, dated (MONTH) 19, (YEAR), revealed that Resident R20 was complaining of new right groin/hip pain since yesterday (September 18, (YEAR)), and an X-ray would be obtained to rule out fracture (broken bones). Review of a physician's order, dated (MONTH) 19, (YEAR), instructed staff to obtain a right hip X-ray. Review of a physician comprehensive physical assessment, dated (MONTH) 20, (YEAR), at 12:31 p.m. revealed that Resident R20 was complaining of new right groin/hip pain, and that the X-ray of the right hip to rule out fracture was pending. Review of a Physical Therapy (PT) Evaluation and Plan of Treatment, dated (MONTH) 20, (YEAR), indicated that Resident R20 was now with new rt (right) hip pain, X-ray ordered. Review of nursing progress notes revealed on (MONTH) 21, (YEAR), at 3:27 p.m. the facility was notified by the [MEDICAL TREATMENT] center where Resident R20 was receiving treatment that the resident had an episode of unresponsiveness while receiving his [MEDICAL TREATMENT] treatment, and was sent to the hospital directly from the [MEDICAL TREATMENT] center to evaluation. Review of nursing progress notes dated (MONTH) 23, (YEAR), indicated that Resident R20 was admitted to the hospital from (MONTH) 21-23, (YEAR). Further review of the clinical record revealed no documentation that the right hip X-ray was obtained from when it was ordered on (MONTH) 19, (YEAR), to when the resident was sent to the hospital from [MEDICAL TREATMENT] on (MONTH) 21, (YEAR). Review of a nursing progress note dated (MONTH) 23, (YEAR), revealed that Resident R20 was readmitted back to the facility from the acute care hospital at 5:30 p.m., and the resident had moderate pain upon arrival. Review of readmission physician's orders, dated (MONTH) 23, (YEAR), instructed staff to administer [MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) 2 milligrams (mg), one tablet orally every six hours, as needed for pain. Review of a nursing progress note dated (MONTH) 24, (YEAR), at 10:00 p.m. revealed Resident R20 was complaining of moderate right hip pain and that [MEDICATION NAME] was administered per physician's order. Review of a physician comprehensive physical assessment, dated (MONTH) 25, (YEAR), revealed that Resident R20 was complaining of right groin/hip pain, the resident was noted to have pain with internal rotation of R (right) hip, the physician was wondering about the X-ray results, and the physician was Attempting to get results of R (right) hip imaging (X-ray report). Review of a PT treatment encounter note dated (MONTH) 25, (YEAR), revealed that Resident R20 was complaining of right hip pain, the pain was described as sharp, aching, and the resident's right hip pain was documented as a complexity/barrier impacting the resident's ability to perform during the therapy session. Review of a nursing progress note dated (MONTH) 26, (YEAR), at 9:20 a.m. revealed that Resident R20 was noted with complaint of pain to the resident's right side, and the pain medication was administered per the physician's order. Review of a PT treatment encounter note dated (MONTH) 26, (YEAR), revealed Resident R20 was experiencing right hip pain with movement rated as a 7/10 (pain scale of 1 being little to no pain and 10 being the worst pain), specifically, Lot of pain when I stand, but then it goes down when I stop. Review of an Occupational Therapy (OT) treatment encounter note dated (MONTH) 26, (YEAR), revealed Resident R20 had pain in the right hip rated as a 5/10 at rest, described as aching, and pain in the right hip with movement rated as an 8/10, with the resident describing the pain as saying, Ouch. Further review of the clinical record for Resident R20 revealed that on (MONTH) 26, (YEAR), at 6:59 p.m. Resident R20 returned from a [MEDICAL TREATMENT] treatment with a moderate complaint of pain, and a [MEDICATION NAME] (medicated patch applied to the skin to numb pain) placed on right hip. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record revealed no physician's order for a [MEDICATION NAME] to be applied to the resident's right hip. Review of a nursing progress note dated (MONTH) 26, (YEAR), revealed at 9:02 p.m. an X-ray order number (insurance precertification) was confirmed by the facility. Review of an OT treatment encounter note, dated (MONTH) 27, (YEAR), revealed a Q[NAME] (Quality of Care - plan of care meeting) meeting was conducted with Resident R20 and members of the facility's interdisciplinary team (IDT) including physical therapist, occupational therapist, speech therapist, registered nurse assessment coordinator, social services and nursing to discuss the resident's current level of functioning, plan of care, goals and progress towards those goals. The OT treatment encounter note indicated that the occupational therapist educated the IDT regarding progress made towards goals with pain barriers of Resident R20's right hip pain, and that members of the IDT verbalized understanding. Review of PT treatment encounter notes revealed on (MONTH) 28, (YEAR), Resident R20 was experiencing increased pain in the right hip rated as 4/10 at rest, described by the resident as intense, and rated as 9/10 during movement. The PT treatment encounter note additionally indicated that the resident did receive pain medication prior to therapy, and the physical therapist reported the resident's increased right hip pain to the charge nurse for further assessment. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record revealed no documentation that [MEDICATION NAME] was administered to Resident R20 again on (MONTH) 28, (YEAR), and no documentation that the charge nurse or any other licensed nurse assessed the resident related to the physical therapist's concern about the resident's complaint of increasing pain in the right hip. Review of the MAR indicated [REDACTED]. Review of a nursing progress note dated (MONTH) 29, (YEAR), at 12:30 a.m. revealed the [MEDICATION NAME] was administered due to the resident complaining of right hip pain. Review of a nursing progress note dated (MONTH) 29, (YEAR), at 6:59 p.m. revealed that Resident R20 received an X-ray that day and results showed that a right [MEDICAL CONDITION] is present, a CRNP was notified of the results of the X-ray and a report was called in to an acute care hospital where Resident R20 was to be evaluated. Review of a radiology report, dated (MONTH) 29, (YEAR), at 6:23 p.m. revealed the report indicated a Concern for a new subcaptial (type of fracture) fracture right femur (thigh bone). Review of a nursing progress note dated (MONTH) 30, (YEAR), at 6:25 a.m. revealed that the nurse called staff at the acute care hospital for status on Resident R20 and revealed the resident was admitted to the hospital with [REDACTED]. Review of a hospital discharge summary note, dated (MONTH) 13, (YEAR), revealed Resident R20 was diagnosed with [REDACTED]. Review of the information dated (MONTH) 29, (YEAR), submitted by the facility, revealed that upon investigation into the circumstances surrounding Resident R20's right [MEDICAL CONDITION], an X-ray of the resident's hip was ordered to rule out fracture by the physician on (MONTH) 25, (YEAR), but was not done primarily due to his being out of the facility at appointments or [MEDICAL TREATMENT]. Further review of the clinical record revealed no documentation that the right hip X-ray, initially ordered on (MONTH) 19, (YEAR), was obtained until (MONTH) 29, (YEAR), ten days later. The clinical record revealed no documentation that nursing staff acted upon the physical therapist's concern about the resident's complaint of increasing pain in the right hip on (MONTH) 28, (YEAR), and no documentation that nursing staff adequately assessed, monitored and notified the physician of the resident's increasing complaints of pain. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 29, (YEAR), at approximately 10:15 a.m. confirmed the original order for a right hip X-ray was on (MONTH) 19, (YEAR), had not been obtained prior to readmission to the hospital on (MONTH) 21, (YEAR); confirmed that documentation indicated upon readmission to the facility on (MONTH) 23, (YEAR), Resident R20 was complaining of right hip pain; and confirmed documentation indicated the resident continued to complain of right hip pain until the X-ray of the right hip was obtained on (MONTH) 29, (YEAR). The facility failed to follow and obtain physician's orders related to radiology studies and medication administration for one resident resulting in actual harm. Quality of Care CFR(s): 483.25 Previously cited 02/15/17, 04/01/16 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 02/15/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/15/17, 04/01/16

Based on review of a clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to provide the appropriate equipment for the safe transfer of a resident, using a full mechanical lift for one of 25 residents, resulting in actual harm to the resident (Resident Cl1). Findings include: Review of Resident Cl1's clinical record revealed that resident's most recent admission to the facility was September 15, 2014, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- assessment of needs) dated June 17, 2015, indicated that Resident Cl1 was totally dependent on staff for transfers and required the physical assistance of two staff members. Review of Resident Cl1's nursing care plan, dated as initiated on November 14, 2011, noted that the resident had impaired physical mobility due to deconditioning, with the goals of not developing further complications related to immobility, and remain free from falls and injury. An intervention to achieve these goals, dated November 14, 2011, was that Resident Cl 1 required the use of mechanical lift for transfers out of bed, and the assist of two for the transfers. Review of the nursing progress notes of August 26, 2015, at approximately 11:15 a.m., Resident Cl 1 was observed by the licensed nurse, laying on the floor, positioned to the left floor of her bed, with both legs across the base of the mechanical lift. Resident's posterior neck was on top of the other base of the lift. The resident was found to have pain, swelling and tenderness, in the right hip area. Resident Cl1's physician ordered the resident to be transferred, 911, to the emergency room for an evaluation. emergency room documentation, dated August 26, 2016, revealed that Resident Cl1 had sustained fractures (break of a bone) of the right femur (thigh bone), tibia (shin bone of the lower leg) and fibula (smaller bone of lower leg) from the fall. Resident Cl1's right leg was splinted, and the resident was admitted to the hospital for planned surgical repair of the right leg. Further review of hospital documentation, dated August 28, 2016, revealed that the resident was diagnosed with [REDACTED]. Review of the hospital discharge documentation, dated September 9, 2015, noted that resident was transferred from the hospital to an inpatient hospice unit in poor condition. Review of the facility documentation revealed that on August 26, 2015, at 11:15 a.m., two staff members were attempting to transfer Resident Cl1 from the bed to a shower chair, using the full mechanical lift, when three of the four straps, attached to the transfer sling, popped and the resident fell to the floor. An interview with Employee E5, certified nursing assistant (cna), on April 1, 2016, at approximately 11:10 a.m., revealed that the employee was assigned for care to Resident Cl1 on August 26, 2016, and when attempting to transfer the resident with Employee E4, cna, assisting, with the full mechanical lift to the shower chair, the strap on the sling broke, and resident fell . Employee E4 also stated that the strap on the sling broke, and resident fell . During the survey March 29 - April 1, 2016, the sling used to transfer Resident Cl1 on August 26, 2015, was not available for inspection. Interview with the director of nursing on March 30, 2016, at 10:40 a.m., confirmed that Resident CL1 had sustained a fall from a hoyer lift while at the facility. Further interview with the director of nursing revealed that the facility had conducted an internal investigation into the fall and determined that staff had not used the appropriate manufacturer's sling for the lift when transferring the resident. The facility failed to ensure that resident's environment was free of accident hazards by not providing safe, appropriate and the correct equipment for resident transfers with a mechanical lift resulting in multiple fractures an actual harm to one resident. 28 Pa. Code: 201.18(a)(1) 28 Pa. Code:211.11(a)(c) Resident care plan. 28 Pa Code: 211.12(d)(5) Nursing services.