Every finding on record at Richfield Healthcare and Rehabilitation Center

Based on clinical record review, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for three of five residents reviewed for immunizations (Residents 1, 9, 12).Findings include: Clinical record review revealed the facility admitted Resident 1 on November 2, 2023. Documentation in Resident 1's clinical record revealed she received two pneumococcal vaccines prior to her admission (Pneumovax 23 and Prevnar 13). Review of Resident 1's pneumococcal consent dated November 2, 2023, revealed Resident 1's representative wanted the facility to administer Resident 1 the pneumococcal vaccine. Clinical record review revealed the facility admitted Resident 9 on April 17, 2023. Documentation in Resident 9's clinical record revealed she received two pneumococcal vaccines prior to her admission (Pneumovax 23 and Prevnar 13). Review of Resident 9's pneumococcal consent dated April 18, 2023, revealed Resident 9's representative wanted the facility to administer Resident 9 the pneumococcal vaccine. Clinical record review revealed the facility admitted Resident 12 on October 20, 2023. Documentation in Resident 12's clinical record revealed she received two pneumococcal vaccines prior to her admission (Pneumovax 23 and Prevnar 13). Review of Resident 12's pneumococcal consent dated October 21, 2023, revealed Resident 12's representative wanted the facility to administer Resident 12 the pneumococcal vaccine. According to the CDC (Centers for Disease Control and Prevention) guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Residents 1, 9, and 12 pneumococcal vaccinations would not be completed until they received PCV20 or PCV21 pneumococcal vaccines, five years after the last pneumococcal vaccine doses. There was no documented evidence to indicate that the facility offered Residents 1, 9, and 12 an updated pneumococcal vaccination. Interview with Employee 1, infection control preventionist, on January 22, 2026, at 10:30 AM confirmed the above findings for Residents 1, 9, and 12. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of 12 residents reviewed (Resident 5).Findings include: Clinical record review for Resident 5 revealed a diagnosis list that included essential hypertension (high blood pressure). Current physician orders for Resident 5 revealed an order dated September 11, 2025, at 8:00 PM for Metoprolol Tartrate (a medication that is used to treat high blood pressure and/or heartrate) oral tablet 25 milligrams (mg) give one tablet by mouth two times a day related to essential (primary) hypertension. The order indicated a blood pressure and heartrate hold: hold if heartrate less than 60; systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 100. A review of the Medication Administration Record (MAR) for January 2026 for Resident 5 revealed that facility staff were documenting the blood pressure, however the heartrate was not being documented. A review of the vital signs section of the electronic health record (EHR) for Resident 5 revealed the only documented heartrate / pulse for January was on January 9, 2026, at 10:09 AM; January 21, 2026, at 6:27 AM, and January 21, 2026, at 7:24 PM. There was no documented pulse to coincide with each administration of the resident's Metoprolol. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 21, 2026, at 11:30 AM. Further clinical record review for Resident 5 revealed an order revision dated January 21, 2026, for Resident 5 that now included an area on the MAR to document the resident's heartrate. 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding enhanced barrier precautions for two of 12 residents reviewed (Residents 25 and 31). Findings include: Review of the facility's current policy entitled, Enhanced Barrier Precautions (EBP), revealed it is the facility's purpose to reduce the transmission of multi-drug-resistant organisms (MDROs) through the appropriate and targeted use of enhanced barrier precautions while maintaining residents' quality of life. Further review of the policy revealed that EBP are used when contact precautions do not otherwise apply and involve the targeted use of gowns and gloves during high-contact resident care activities. The policy further noted that the presence of an indwelling medical device alone, including a foley catheter, does not automatically require enhanced barrier precautions. Clinical record review for Resident 25 revealed a diagnosis list that included benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate which may impede urine flow) and obstructive and reflux uropathy (blockage in the urinary tract which impacts the flow of urine). Current physician orders for Resident 25 included a foley catheter (indwelling medical tubing used to drain urine from the bladder) and associated catheter care. The current care plan for Resident 25 included a plan of care initiated on November 13, 2025, for use of an indwelling urinary catheter. Observation of Resident 25 on January 20, 2026, at 11:40 AM revealed that the resident was seated in a recliner in the common area living room of the facility. The resident had a foley drainage bag attached to the recliner. Concurrent observation of Resident 25's room revealed no evidence that the resident was on EBP due to having a foley catheter. There was no sign at the entrance to Resident 25's room indicating EBP precautions were in place, no personal protective equipment (PPE) in the room or at the doorway to don (put on), or any sign placed anywhere in the room that indicated staff or visitors were to see the nurse prior to care. In an interview with Employee 2, licensed practical nurse, on January 20, 2026, at 2:29 PM Employee 2 stated there were no residents in the hallway where Resident 25 resided that were currently on isolation or EBP. The above information for Resident 25 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 21, 2026, at 11:30 AM and the policy for isolation and enhanced barrier precautions was requested by the surveyor. Observation of Resident 31's room on January 20, 2026, at 11:55 AM revealed no EBP sign on or near the resident's door. Interview and observation of Resident 31 on January 20, 2026, at 2:00 PM, revealed the resident has a foley catheter which he has had since admission to the facility on December 12, 2025. The above information regarding Resident 31 was reviewed with the Director of Nursing on January 21, 2026, at 11:10 AM. The Director of Nursing indicated the facility only placed residents diagnosed with an MDRO on EBP and failed to implement the precautions for the above residents with an indwelling medical device. 483.80 Infection Prevention and ControlPreviously cited deficiency 2/6/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to promote resident involvement with care plan development for one of one resident reviewed (Resident 3). Findings include:In an interview with Resident 3 on January 20, 2026, at 1:25 PM, the resident stated she does not remember being invited to care plan meetings. Clinical record review for Resident 3 did not reveal any evidence that the resident was invited, attended, declined to attend, or was involved in her interdisciplinary care plan meetings in the last twelve months. During an interview with Employee 4, social worker, on January 21, 2026, at 2:37 PM, Employee 4 stated that she does not document when a resident is invited to their care plan meeting, or if they are present for the meeting. Employee 4 indicated there was no evidence to indicate Resident 3 was invited, attended, declined to attend, or involved in her care plan meeting over the prior twelve months. The Nursing Home Administrator and the Director of Nursing were made aware of the above findings on January 22, 2026, at 9:00 AM. 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain professional dental services for one of two residents reviewed for dental concerns (Resident 12).Findings include: Observation of Resident 12 on January 20, 2026, at 12:01 PM revealed Resident 12 was sitting in her personal chair in her room. Resident 12 was unable to answer any questions related to her dental history due to her current cognitive status. Resident 12 appeared to have her own teeth. Clinical record review the facility admitted Resident 12 on October 20, 2023. The surveyor requested evidence of professional dental care services provided for Resident 12 in the past year during an interview with the Director of Nursing and the Nursing Home Administrator on January 21, 2026, at 11:30 AM. Interview with the Director of Nursing on January 22, 2026, at 9:22 AM confirmed that Resident 12 consented to services from the facility's contracted provider for dental services on March 18, 2024. Resident 12 became eligible for Medicaid-provided services on September 25, 2025. The facility had no evidence that the contracted provider provided services since Resident 12's admission to the facility. 483.55 (b)(1)(2) Dental ServicesPreviously cited 2/6/2528 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to assess and implement individualized interventions to promote bowel and bladder continence for one of two residents reviewed for incontinence (Resident 1).Findings include: Observation of Resident 1 on October 20, 2026, at 10:54 AM revealed Resident 1 was seated in a chair in the hallway. Resident 1 stated to the surveyor that she was having a bowel movement and needed staff assistance. Clinical record review for Resident 1 revealed an annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 9, 2025, in which facility staff assessed Resident 1 as continent of her bowel, and occasionally incontinent of her bladder. Further review of Resident 1's clinical record revealed an MDS assessment completed on October 31, 2025, noting staff assessed Resident 1 as now frequently incontinent of bowel and bladder. Further review of the MDS revealed Resident 1 is dependent on staff for toilet transfers. Further review of Resident 1's clinical record revealed the last assessment of Resident 1's bowel and bladder status was on November 11, 2025, and it did not address Resident 1's decline in her bowel and bladder continence or implement interventions to address the declines. The facility failed to assess and implement individualized interventions to promote Resident 1's bowel and bladder continence. The findings were reviewed with the Director of Nursing on January 22, 2026, at 11:57 AM, and she was unable to provide any further documentation addressing Resident 1's bowel and bladder decline. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding constipation for one out of 18 residents reviewed (Resident 31). Findings include: During an interview with Resident 31 on January 20, 2026, at 2:03 PM, the resident stated he was having some constipation for the last day or two. Clinical record review for Resident 31 revealed that the resident was diagnosed with constipation on December 12, 2025, upon admission. Review of Resident 31's active physician's orders revealed the resident was prescribed routine Senna S Oral (a laxative medication that acts to soften stool and stimulate the bowels to produce bowel movements). Further review revealed that the resident was also prescribed a three-step bowel protocol (a series of medical interventions that are initiated sequentially when the resident does not have a bowel movement independently, and the previous step was ineffectual). Review of Resident 31's current comprehensive plan of care (a summary of a resident's personal health, nursing, and psychological well-being needs and how they can be met) revealed no evidence Resident's 31's constipation diagnosis was addressed on the resident's plan of care. An interview with the Nursing Home Administrator and the Director of Nursing on January 22, 2026, at 12:40 PM, it was confirmed that facility staff did not address the resident's medical diagnosis of constipation in the resident's comprehensive plan of care. 28 Pa. Code 211.10. (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to establish clear end of life directives for one of four residents reviewed (Resident 4).Findings include: Clinical record review for Resident 4 revealed an active physician's order dated [DATE], that indicated the resident was a DNR (do not resuscitate, do not attempt CPR (cardiopulmonary resuscitation) when the person has no pulse and is not breathing). Clinical record review for Resident 4 revealed a social services note dated [DATE], at 2:17 PM that noted the resident's code status was changed to DNR with comfort measures. Review of Resident 4's current plan of care last revised on [DATE], revealed the resident expressed the desire to be a DNR. A review of the Resident 4's paper clinical record kept at the nurse's station on [DATE], at 12:45 PM revealed a POLST (Pennsylvania Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) for the resident dated [DATE], which indicated in the event the resident has no pulse and is not breathing to perform CPR. The above information regarding Resident 4's wishes to be a DNR not matching the resident's POLST was concurrently reviewed with the Nursing Home Administrator on [DATE], at 12:45 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of resident personal fund accounting, clinical record review, and resident, family, and staff interview, it was determined that the facility failed to provide a personal fund quarterly statement for two of two residents reviewed for personal funds concerns (Residents 3 and 13). Findings include: Interview with Resident 3's sister on February 4, 2025, at 11:00 AM indicated that the facility automatically receives Resident 3's social security check monthly. Resident 3's sister stated that she did not know what is done with the personal allowance (now 60 dollars) that Resident 3 is permitted to keep each month. Resident 3's sister stated that she does not receive a statement accounting for Resident 3's money. Interview with Resident 3 on February 4, 2025, at 1:50 PM revealed that Resident 3 could not answer if she had a personal fund, where the accounting statement goes, or how much money she had in the account to spend. Review of an accounting statement dated April 1, 2024, to February 13, 2025, revealed that Resident 3 had no debits (withdrawals) from the account with a resulting balance of $1,772.28. Clinical record review for Resident 13 revealed a, Resident Fund Management Service, authorization (form the facility utilized to document a resident's desire to establish a resident fund account and have social security payments forwarded directly to the facility) signed by Resident 13 on September 11, 2024. The authorization stipulated that Resident 13 would receive a statement of her account at least quarterly. Interview with Resident 13 and her husband on February 4, 2025, at 12:32 PM revealed that Resident 13's social security payment is forwarded to the facility automatically. The interview confirmed that Resident 13 and her husband understood that Resident 13 is allowed to have an amount monthly for a personal allowance and her husband is afforded a spousal support payment each month. Neither Resident 13 nor her husband recalled receiving an accounting statement at least quarterly. Resident 13's husband named Employee 2 (business office manager/human resources director) as the person he would contact for any issues regarding finances. Interview with Employee 2 on February 5, 2025, at 1:26 PM revealed that she did not provide residents with quarterly statements; however, she would have that person speak to the survey team. No facility staff indicated to the survey team that they provided residents their quarterly personal fund statements. Interview with the Nursing Home Administrator on February 5, 2025, at 2:38 PM confirmed that the facility did not have evidence of providing Residents 13 or 3, or their responsible parties, personal fund statements at least quarterly. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies and procedures, observation, and staff interview, it was determined that the facility failed to store food in a manner to prevent potential food borne illness in the facility's main kitchen. Findings include: The facility policy entitled, Food Storage, last reviewed without changes on December 31, 2024, revealed that scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers but are kept covered in a protected area near the containers. The Guidelines for Storage, instructed staff to, Date your products with Use by Dates. Observation of the facility's kitchen on February 4, 2025, at 9:50 AM with Employee 3, dietary manager, revealed the following observations: A reach-in refrigerator with the following items: A 46-ounce carton of orange juice labeled as opened on January 4, 2025, and a use by date of January 11, 2025. A portioned serving of applesauce labeled with a use by date of February 1, 2025 A portioned serving of mixed fruit with a use by date of February 2, 2025 A shelf below a food preparation table contained a 25-pound bin with a white substance identified by Employee 3 as sugar. The scooping utensil used by staff to obtain the food item was stored within the bin in contact with the food product. Interview with Employee 3 on February 4, 2025, at 9:54 AM confirmed that staff are not to store the scooping utensils with food products after use. A food preparation area stored a 20-pound bin of a white substance labeled, thickener. The scoop used by staff to obtain the food product was stored inside the bin in contact with the food product. Observation of a reach-in refrigerator on February 4, 2025, at 10:00 AM revealed a one-gallon container of pickle relish dated December 15, 2024. Interview with Employee 3 at the time of the observation revealed that the date would indicate staff opened the container on that date, and that the item did not have a use by date indicated; however, the item should have been discarded in one month. Kitchen staff referred to the Guidelines for Storage document, which indicated that pickles stored in the refrigerator were good for one month. The surveyor reviewed the above facility kitchen concerns during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 11:00 AM. 483.60(i) Food safety requirements Previously cited 3/1/24 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of two nursing units (first floor; Residents 13, 18, 2, 14, 20, and 16). Findings include: The facility policy entitled, Handwashing Policy, last reviewed without changes on December 31, 2024, indicated that the purpose of the policy was to reduce the risk of infection and ensure a safe and hygienic environment throughout the facility. Staff are to use a disposable towel to turn off the faucet as the last step of the handwashing technique. Observation of a medication administration pass on February 4, 2025, at 11:35 AM revealed Employee 1 (licensed practical nurse, LPN) administered medications to Resident 13. Employee 1 washed her hands at a sink in Resident 13's room but used the back of her arm to turn off the faucet. Continued observation of the medication administration pass on February 4, 2025, at 11:44 AM revealed Employee 1 began to prepare medications for administration to Resident 18. Employee 1 stated that she was going to choose to wear a mask, gown, and gloves to enter Resident 18's room because he was experiencing symptoms of potential gastrointestinal infection. After administering Resident 18's medications, Employee 1 removed her mask, gown, and gloves, and washed her hands at a sink in the hallway. Employee 1 used the back of her arm to turn off the faucet after washing her hands. Continued observation of the medication administration pass for Resident 2 on February 4, 2025, at 11:57 AM revealed that Employee 1 donned gloves to obtain a blood glucose assessment (small sample of blood obtained via a finger prick is placed on a test strip and read by a glucose meter device). Employee 1 removed her gloves and washed her hands at a sink in the hallway. Employee 1 used the back of her arm to turn off the faucet after washing her hands. Employee 1 prepared Resident 2's medications, donned gloves, and administered an insulin (injectable hormone used to lower blood sugar) injection into Resident 2's right arm. Employee 1 removed her gloves and washed her hands at a sink in the hallway. Employee 1 used the back of her arm to turn off the faucet after washing her hands. Observation of the medication administration pass on February 4, 2025, at 1:17 PM revealed Employee 1 administered medications to Resident 14. Employee 1 washed her hands in Resident 14's room sink but used the back of her arm to turn off the faucet. Observation of a medication administration pass on February 4, 2025, at 1:31 PM revealed Employee 1 administered medications to Resident 20. Employee 1 washed her hands at a sink in Resident 20's room but used the back of her arm to turn off the faucet. Observation of a medication administration pass on February 4, 2025, at 1:39 PM revealed Employee 1 administered medications to Resident 16. Employee 1 washed her hands at a sink in Resident 16's room but used the back of her arm to turn off the faucet. Interview with Employee 1 on February 4, 2025, at 2:25 PM confirmed that she did not use a disposable towel to turn off the faucet after washing her hands multiple times during the medication administration passes. The surveyor reviewed the concerns regarding handwashing observations during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 12:31 PM. 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for two of three residents reviewed (Residents 4 and 13). Findings include: Clinical record review for Resident 4 revealed that he was transferred to the hospital from December 3 to 9, 2024, after a change in his condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Interview with Employee 4 (registered nurse supervisor) on February 5, 2025, at 11:49 AM confirmed the above findings for Resident 4. Interview with Resident 13 and her husband on February 4, 2025, at 12:51 PM indicated that she was admitted to the hospital within the past month. Resident 13's husband could not recall if he received a written notice that included the required contents (e.g., reasons for Resident 13's transfer). Resident 13's husband indicated that he is in the facility four days a week on the days that Resident 13 is not out of the facility for hemodialysis (treatment for kidney failure; a machine filters extra fluid and waste products from the blood). Clinical record review for Resident 13 revealed census information that documented Resident 13 began a hospitalization leave of absence on January 22, 2025. Nursing documentation dated January 29, 2025, at 3:57 PM revealed that Resident 13 returned to the facility from the hospital. A Notice of Transfer or discharge date d January 23, 2025, indicated that the contracted dialysis provider sent Resident 13 to the hospital due to a low blood pressure and confusion on January 22, 2025. There was no evidence that the facility provided Resident 13's husband this notice. The signature line designated for the resident's or resident's representative's acknowledgement of the notice was blank. The surveyor reviewed the above findings regarding Resident 13 during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 12:31 PM. 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to residents or the residents' responsible parties for one of three residents reviewed for hospitalization concerns (Resident 4). Findings include: Clinical record review revealed that Resident 4 was transferred to the hospital from December 3 to 9, 2024, after he had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Interview with Employee 4 (registered nurse supervisor) on February 5, 2025, at 11:49 AM confirmed the above findings for Resident 4. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 12 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed a nursing note dated December 22, 2023, indicating that the facility readmitted her from a hospital stay where she was diagnosed with aspiration pneumonia (infection in the lungs) and sepsis (a bloodstream infection). A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 30, 2024, indicated the facility assessed her as having pneumonia, septicemia (a bloodstream infection), and a multidrug resistant organism (MDRO, an infection susceptible to certain antibiotics). There was no documented evidence in Resident 1's clinical record to indicate that she had a current pneumonia infection, septicemia, or an MDRO. MDS Assessments dated August 1, 2024, August 30, 2024, and November 27, 2024, indicate that the facility continued to assess Resident 1's as having pneumonia, septicemia, and an MDRO. There was no documented evidence in Resident 1's clinical record to indicate that she had a current pneumonia infection, septicemia, or an MDRO since December of 2023. Interview with the Administrator on February 5, 2025, at 12:50 PM confirmed that Resident 1's MDS's dated May 30, 2024, August 1, 2024, August 30, 2024, and November 27, 2024, were coded in error regarding having pneumonia, septicemia, and an MDRO. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent future falls or accidents for one of three residents reviewed for falls (Resident 5). Findings include: Clinical record review revealed the facility admitted Resident 5 on November 9, 2017. The facility initiated a care plan noting Resident 5 was at risk for falls on November 27, 2020, due to decreased safety awareness. Nursing documentation dated October 10, 2024, at 5:40 PM noted Resident 5 had an unwitnessed fall. Review of the facility investigation into Resident 5's fall noted he fell out of bed. Resident 5 was found on his right side with his blanket wrapped around him and a 1.8 centimeter (cm) by 0.6 cm abrasion above his ear. The investigation noted no new interventions and indicated staff will discuss at interdisciplinary team meeting (IDT). Nursing documentation dated October 17, 2024, at 2:35 AM noted Resident 5 was found on floor on the left side of his bed, between his bed and closet. Review of the facility investigation into Resident 5's fall revealed the immediate action the facility took was for staff to place a pillow behind Resident 5's upper body while he was in bed to prevent further falls. Nursing documentation dated December 20, 2024, at 1:59 AM revealed Resident 5 was observed laying on his backside on the floor beside his bed. Documentation noted Resident 5 was assisted back to bed and blanket rolls were placed on bilateral sides of his mattress to remind him of the edges of the mattress. Nursing documentation noted Resident 5's care plan was updated. Further review of Resident 5's care plan revealed the nursing staff never updated his care plan with the intervention of placing a pillow behind Resident 5's upper body while in bed, or the blanket rolls on the bilateral sides of Resident 5's mattress while in bed. The only documentation the facility was able to provide related to the IDT meeting regarding Resident 5's fall was noted January 8, 2025, after three falls from his bed occurred. Interview with the Director of Nursing on February 6, 2025, at 11:19 AM confirmed the above findings for Resident 5, and was unable to provide any further documentation that Resident 5's care plan was updated to prevent further falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the consultant pharmacist reported irregularities to the attending physician, and that these reports were acted upon, for one of five residents reviewed for medication concerns (Resident 13). Findings include: Consultant pharmacist reports dated July 2, 2024, and October 4, 2024, listed numerous residents who were reviewed during the visits but did not require any recommendations. Resident 13 was not listed in either report. Resident 13's clinical record did not include evidence that a consultant pharmacist reviewed her medication regimen in July 2024, or October 2024. Resident 13's clinical record did not contain a report from the consultant pharmacist for July 2024, or October 2024. Interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 3:16 PM revealed that the facility did not have a report of the consultant pharmacist's recommendations for July 2, 2024, or October 4, 2024. The interview confirmed that since Resident 13's name was not listed among the residents on the available July 2024, or October 2024 reports, she should have had a recommendation forwarded to her physician for those months. The facility failed to ensure that the consultant pharmacist documented on a separate, written report that was sent to the attending physician, and that the physician documented in Resident 13's medical record that the identified irregularity was reviewed, and what, if any, action was taken to address it, for the months of July 2024, and October 2024. 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 2 and 14). Findings include: The facility's medication error rate was eight percent based on 25 medication opportunities with two medication errors. The facility policy entitled, Administering Medications, last reviewed without changes on December 31, 2024, indicated that medications are administered in accordance with prescriber orders. Each nurses' station has a current Physician's Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance for pharmacy services available. Manufacturer's instructions or users' manuals related to any medication administration devices are kept with the devices or at the nurses' station. The facility policy entitled, Insulin Administration, last reviewed without changes on December 31, 2024, revealed the nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. There was no reference to the administration of insulin via single-patient-use prefilled pens that would include the appropriate technique for priming the disposable needle before use. Clinical record review for Resident 2 revealed an active physician's order for staff to administer two units of Insulin Aspart with Niacinamide (Fiasp FlexTouch, a disposable single-patient-use prefilled pen containing insulin, an injectable hormone used to lower blood sugar) before meals when the blood glucose assessment (small sample of blood obtained via a finger prick is placed on a test strip and read by a glucose meter device) is within the range of 151 to 200 mg/dL (milligrams per deciliter). Manufacturer's instructions for the Fiasp FlexTouch pen stipulate that the user is to prime the pen before each injection. After application of a disposable needle, step seven of the instructions notes to turn the dose selector to select two units. Step eight instructs to hold the pen with the needle pointing up and tap the top of the pen gently a few times to let any air bubbles rise to the top. Step nine instructs to hold the pen with the needle pointing up and press and hold in the dose button until the dose counter shows zero. Step ten, dose selection, instructs to check to make sure the dose selector is set at zero and turn the dose selector to select the number of units you need to inject. Observation of a medication administration pass on February 4, 2025, at 11:57 AM revealed Employee 1 (licensed practical nurse, LPN) prepared medications for administration for Resident 2. Employee 1 obtained a blood glucose assessment of 199 mg/dL. Employee 1 obtained a Fiasp Flextouch insulin pen and a disposable needle from the medication cart. Employee 1 applied the needle to the tip of the Fiasp Flextouch pen and dialed one unit to prime the needle (returning the reading on the window of the pen to zero). Employee 1, then, dialed two units for administration to Resident 2. Employee 1 did not prime the needle with two units of insulin before preparing the physician ordered dose of two units. Employee 1 entered Resident 2's room and administered the insulin medication into Resident 2's right upper arm. Clinical record review for Resident 14 revealed an active physician's order for staff to administer Polyethylene Glycol (laxative to stimulate bowel movements), 3350 oral powder, 17 grams per scoop; give one scoop by mouth in the afternoon for constipation, mix in four to eight ounces of fluid. Instructions on the Polyethylene Glycol container inform the user to use the cap of the container, fill powder to the top of the cap, to obtain a dose of 17 grams. Continued observation of the medication administration pass on February 4, 2025, at 1:10 PM, revealed Employee 1 prepared Polyethylene Glycol for Resident 14. Employee 1 used a plastic medication cup to determine how much of the medication powder to administer. Employee 1 stated that her goal was to fill the medication cup to just over 15 milliliters. Employee 1 did not use the cap of the Polyethylene Glycol container to measure the dose. Employee 1 mixed the powder in water, entered Resident 14's room, and administered the medication to Resident 14. Interview with Employee 1 on February 4, 2025, at 2:25 PM confirmed that she primed Resident 2's insulin needle with only one unit of insulin. Employee 1 did not have a Fiasp FlexTouch pen package insert or the manufacturer's instructions to know that the proper priming technique required two units. Observation of Resident 14's Polyethylene Glycol container instructions with Employee 1 confirmed that the user is to use the container cap to measure 17 grams of the medication. Employee 1 verified that if she used the medication container cap versus a plastic medication cup, Resident 14 would have received more of the medication powder. The surveyor reviewed the concerns regarding the above medication pass observations during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 12:31 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure medication was labeled in accordance with accepted professional standards for one of 16 residents reviewed for medication administration (Resident 14). Findings include: The facility policy entitled, Administering Medications, last reviewed without changes on December 31, 2024, indicated that medications are administered in accordance with prescriber orders. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Clinical record review for Resident 14 revealed an active physician's order for staff to administer Clonazepam (used to control and prevent seizures) oral disintegrating tablet 0.5 milligrams (mg), one tablet by mouth two times a day and two tablets by mouth in the afternoon. Observation of the medication administration pass on February 4, 2025, at 1:10 PM revealed Employee 1 (licensed practical nurse) prepared the Clonazepam 0.5 mg medication for Resident 14. Employee 1 poured two tablets of the Clonazepam medication for administration. The label on the medication instructed staff to administer one tablet by mouth twice daily; and two tablets by mouth at bedtime. Interview with Employee 1 on February 4, 2025, at 2:25 PM confirmed that the Clonazepam label instructed staff to administer one tablet twice a day and two tablets at bedtime; however, that did not agree with the active physician's order for Resident 14. Employee 1 confirmed that the label indicated that the pharmacy filled 30 tablets of this medication on January 24, 2025, and there were 23 tablets available on the date and time of the observation (seven tablets had been administered from this medication supply before Employee 1 removed two additional tablets). The surveyor reviewed the concerns regarding the above medication labeling during an interview with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 12:31 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assist residents to obtain routine dental care for two of two residents reviewed (Residents 4 and 3). Findings include: Observation of Resident 4 on February 4, 2025, at 11:42 AM revealed he had several broken and missing teeth. Resident 4 was unable to be interviewed due to his cognitive status. Clinical record review revealed the facility admitted him on February 23, 2024. Review of Resident 4's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated February 29, 2024, revealed staff assessed Resident 4 as having no obvious or likely cavity or broken natural teeth. Further review of Resident 4's clinical record revealed nursing documentation dated January 26, 2025, at 1:54 PM noting Resident 4 reports that he broke a tooth today in the right upper front of his mouth. A tooth was noted to be broken in the front side of Resident 4's mouth. Nursing documentation dated January 27, 2025, at 7:15 AM revealed the Director of Nursing assessed Resident 4's mouth due to the broken tooth. The Director of Nursing noted Resident 4's teeth were obviously decayed. Nursing documentation dated January 30, 2025, at 9:47 PM revealed the registered nurse spoke to Resident 4's wife about his broken tooth. Resident 4's wife stated it was in Resident 4's upper left side of his mouth. His wife stated he does have a tooth on the right side that is broken off, but his wife stated that wasn't new. Further review of Resident 4's clinical record revealed he saw the dentist for a comprehensive assessment on October 7, 2024. There was no documentation that Resident 4 received any prophylactic cleanings of his teeth by a dental hygienist since admission. The facility provided no evidence that Resident 4 received routine prophylactic dental cleanings in the past year as covered under the State plan. Interview with the Director of Nursing on February 6, 2025, at 12:45 PM confirmed these findings. Observation of Resident 3 on February 4, 2025, at 1:51 PM revealed that she had discolored, possibly broken, and missing teeth. Interview with Resident 3 on the date and time of the observation revealed that she believed that she had a tooth that needed pulled (extracted). Clinical record review for Resident 3 revealed progress note documentation by the facility's consultant dentist dated July 29, 2024, that indicated Resident 3 had two non-restorable teeth that was recommended for extraction as needed, and Resident 3 had partial dentition. Progress note documentation by the facility's consultant dental hygienist dated September 4, 2024, indicated that Resident 3 received adult prophylaxis (professional dental cleaning). An annual MDS dated [DATE], identified that Resident 3 had obvious, or likely, cavities or broken natural teeth, and the assessment triggered the need for a care plan. A plan of care initiated by the facility on March 24, 2020, to address Resident 3's dental or oral cavity health problem related to possible carious/broken teeth listed interventions that included refer to the dentist/hygienist annually and as needed. Resident 3's clinical record did not provide evidence that the facility provided routine dental services to the extent covered under the State plan (e.g., every six months). The surveyor reviewed the above findings regarding Resident 3 with the Director of Nursing on February 5, 2025, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, dining area, and food storeroom. Findings include: Observation of the facility's main kitchen on February 27, 2024, at 9:20 AM with Employee 1, cook, revealed the following: A large garbage can in the food preparation area across from the dishwasher was observed with visible dried food and dried liquid runs on the exterior of the can and the lid was not present. The lid was on top of the garbage can next to the handwashing sink. The cook's refrigerator contained a plastic bag of sliced onions, that were not dated. Employee 1 indicated that nursing staff had leftovers and gave them to the kitchen in case they were needed but they were not used. Also in the refrigerator were the following food items that were not dated with a use-by date or expiration date: six slices of bread, two plastic squeeze bottles of Italian dressing, two sticky plastic squeeze bottles of sauce that was identified as barbeque sauce and two plastic squeeze bottles that was identified as liquid butter by Employee 1, two containers of mustard, two cartons of orange juice, and a partial pack of hamburger rolls. Employee 1 indicated that the items in the squeeze bottles were taken from the original containers to make it easier for resident use at the tables. In addition, in the refrigerator was an open container of beef broth that was not dated with the open date and the label indicated to use within 14 days of opening, a container of tomato sauce with a use-by date of February 25, 2024, a container of tapioca pudding with use-by date of February 26, 2024, a partial tray of yellow cake with chocolate icing that was dated as made on February 23, 2024, and a container of cheesy broccoli soup with use-by date of February 24, 2024. Employee 1 indicated that cooked food is good for three days after making. The plastic shelving unit contained an open container of drink thickener with the expiration date of February 25, 2024, and a spray bottle labeled as a sanitizer that was stored with the food items. The shelving unit near the coffee machine contained three bags of homemade cookies with no use-by date, a container of individual coffee creamers without a use-by date or expiration date, bins of single serve condiments (ketchup, mustard, honey, jelly, barbeque sauce, salad dressing, mayonnaise, and syrup) without expiration dates, and a bottle of coconut syrup that was labeled for staff use with a best-by date of December 14, 2023. The cupboard on the bottom of the steam table housed single serve condiments without expirations dates. The corner shelf next to the cook's refrigerator contained an open jar of peanut butter with the expiration date of November 6, 2023, a 22-pound container of chocolate icing with a use-by date of January 16, 2024, and a container of flour, two bags of cake mix, and a bag of rice pilaf that were not dated with expiration dates. The drink refrigerator contained a pitcher of honey-thick lemonade with a use-by date of February 24, 2024, and an open container of Thick and Easy drink without a use-by date. The Thick and Easy label indicated to use the product within 10 days of opening. Tour of the facility's food storage area was done after the tour of the main kitchen with Employee 2, dietary aide, and revealed the following: The shelving unit contained the following food items without expiration dates: a bin of flour, a box of graham crackers, three boxes of cookies, and two boxes of oatmeal pies. In addition, a box of cookies was on the shelf with an expiration date of October 24, 2023. Another shelving unit contained the following food items without expiration dates: brownie and cake mixes, chicken and beef bases, packs of rice pilaf, packs of potato pearls, and #10 cans of food. The walk-in freezer contained bags of chicken and hamburger without any expiration dates. The stand-up refrigerator contained the following items without expiration dates: 12 cartons of orange juice and seven packs of luncheon meat. A bag of lettuce that had browning and wilting had a use-by date of February 24, 2024. The emergency food section contained numerous cans of evaporated milk with an expiration date of January 20, 2024. The canned goods were labeled with [NAME] dates (dates according to the [NAME] calendar, that represents the date the food as manufactured or packaged). Employee 2 did not know how to read the [NAME] dates and determine the use-by dates of the emergency canned food. The surveyor reviewed the findings for the kitchen and storage area with Employee 3, dietary manager, on February 27, 2024, at 1:45 PM. The surveyor reviewed the above findings with the Nursing Home Administrator on February 27, 2024, at 2:15 PM. Observation on February 29, 2024, at 12:10 PM of the facility's ice machine that is in a room in the main dining room revealed there was no visible air gap from the ice machine between the indirect waste pipe and the flood level rim of the waste receptor as indicted in International Plumbing Code 802.3.1 and 802.3.2 of 2018. The above findings were reviewed with the Nursing Home Administrator on February 29, 2024, at 12:15 PM. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on review of closed clinical records, staff interviews, and select facility policies and procedures, it was determined that the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) for one of one resident reviewed who had requested that CPR be administered if they became unresponsive with no pulse resulting in harm and the resident's death (Resident CR28). Findings include: Review of the facility policy entitled, Emergency Procedure, Cardiopulmonary Resuscitation, last reviewed without changes in [DATE], indicated that if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR (Cardiopulmonary Resuscitation) will initiate CPR unless it is known that a Do Not Resuscitate (DNR) order specifically prohibits CPR or there are signs of irreversible death (e.g. rigor mortis). The policy further indicated that if an individual is found unresponsive, staff are to briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR, instruct the staff member to activate the emergency response system, and call 911. Closed clinical record review for Resident CR28 revealed that the facility admitted her on [DATE]. A current physician order dated [DATE], indicated that her code status was per her Pennsylvania Order for Life-Sustaining Treatment (POLST, form used to stipulate provision of health care if a resident becomes incapacitated), and that CPR or attempt at resuscitation should be initiated if she has no pulse or is not breathing. Review of Resident CR28's POLST dated [DATE], indicated in Section A that if she is found with no pulse and is not breathing, CPR and resuscitation should be initiated. Resident CR28's POLST was discussed, completed, and signed by her in the presence of a licensed physician and her brother. Resident CR28's POLST dated [DATE] was faxed from a discharging hospital to the facility again on [DATE], after she was readmitted from a hospital stay. Review of Resident CR28's closed clinical record revealed Minimum Data Set Assessments (MDS, an assessment completed at specific intervals to determine care needs) dated [DATE] and [DATE], indicating that the facility assessed her as having a BIMS (Brief Interview for Mental Status) of 15, which indicates that her cognitive responses are intact. Nursing documentation dated [DATE], at 1:40 AM indicated that the resident made a statement of wanting to go to the hospital. There was no documented evidence in Resident CR28's closed clinical record to indicate that the facility attempted to assess or interview Resident CR28 to ascertain why she felt she needed to go to the hospital. Nursing documentation dated [DATE], at 10:00 PM indicated that Resident CR28 expired at 8:25 PM this evening, and that she was without an apical pulse (heartrate) for one minute. Licensed staff made Resident CR28's on call physician aware and released her body to the funeral home. There was no documented evidence in Resident CR28's closed clinical record to indicate that licensed staff initiated CPR or an attempt at resuscitation, as per Resident CR28's documented wishes in her POLST. Further clinical record review revealed no documentation in the closed clinical record that Resident CR28 had irreversible signs of death (Rigor mortis- stiffening of the body, lividity- pooling of blood to an area that is in contact with a hard surface or the lowest points of the body, or decapitation- separation of the head from the body, transection, or decomposition). There was no documentation in Resident CR28's closed clinical record to indicate that death was imminent or expected. During an interview with the Administrator and the Director of Nursing on [DATE], at 11:30 AM, the surveyor provided all the above information and concerns regarding Resident CR28 and her code status. No further information or documentation was identified or provided to this surveyor during the survey process to contradict the above findings. The facility failed to initiate CPR in accordance with Resident CR28's wishes and professional standards of nursing to a resident who had requested CPR and had a physician's order for CPR, when finding the resident unresponsive, without a pulse or breathing, and without clear irreversible signs of death, causing actual harm to Resident CR28. 483.24(a)(3) Cardio-Pulmonary Resuscitation (CPR) 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(3) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited [DATE] 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on review of clinical records, incident reports and dietary meal tickets, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were not served foods they were allergic to for one of 12 residents reviewed (Resident 38), which resulted in harm with an allergic reaction, requiring [MEDICATION NAME] (an injection used to treat life-threatening allergic reactions), [MEDICATION NAME] (allergy medication) and transfer to the hospital for difficulty with swallowing and breathing and failed to accommodate each resident's food preferences for two of 12 residents reviewed (Residents 10 and 28). Findings include: Review of Resident 10's clinical record revealed [DIAGNOSES REDACTED]. behavior). Review of Resident 10's current physician orders [REDACTED]. Review of Resident 28's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 28's physician orders [REDACTED]. An observation in the 1st floor dining room, during the noon meal at approximately 12:30 p.m. on (MONTH) 13, (YEAR), revealed Residents 10 and 28 were served a pureed stuffed pepper in a bowl. An interview with the FSD 1, on (MONTH) 13, (YEAR), upon completion of the noon meal service, in the 1st floor dining room at approximately 1:00 p.m. revealed that staff utilize the food preference book in the kitchen to determine food preferences for residents. Review of the Preference book/sheets revealed Residents 10 and 28, who received pureed stuffed peppers, had a dislike for stuffed peppers. FSD 1 revealed that the residents don't know any better, so they served them the main entrée anyway. An interview with the Nursing Home Administrator on (MONTH) 14, (YEAR), at approximately 3:00 p.m. revealed resident preferences should be followed. Review of the physician orders [REDACTED]. Further review of the physician orders [REDACTED]. On (MONTH) 10, (YEAR), Resident 38 filed a grievance that she was being served milk products from dietary and that she is allergic to milk. The action taken was to communicate the concern to the FSD 1 and the Director of Nursing to provide education to appropriate staff. Review of the education included a typed paper that stated, Resident 38 stated she was receiving items of food that contained milk products. Please make sure that we do not send her food with milk products in them (Milk allergy is a true food allergy, involves the immune system, caused by an allergic reaction to one of the many proteins in milk. Food allergy reaction to milk can begin within minutes or can be delayed for several hours and symptoms may include; stomach pain, nausea, diarrhea, skin rash, swelling of the lips or throat, and trouble breathing). The education was dated (MONTH) 10, (YEAR), and the only signature on the paper was FSD 1, indicating that only the FSD 1 had been educated. Review of the current care plan revealed a care area initiated on (MONTH) 16, (YEAR), that Resident 38 required assistance for eating, related to inability to use utensils. The intervention included that the resident is totally dependant on staff for eating. A nursing note written on (MONTH) 10, (YEAR), at 4:22 p.m. stated that the resident complained of her mouth and tongue feeling funny after taking one bite of noodles and two bites of carrots that had butter on them and the resident is allergic to milk. The physician was contacted and ordered [MEDICATION NAME]. The resident complained of the inside of her mouth feeling itchy and dry. Resident 38 denied feeling improvement after the [MEDICATION NAME] was given. Physician contacted again and ordered [MEDICATION NAME] (medication used for treating allergic reactions). The resident voiced difficulty with swallowing and breathing and insisted on going to the hospital. Emergency Medical Services was contacted and the resident left the facility at 1:10 p.m. Review of the tray ticket for Resident 38 revealed milk listed under allergy, and one of the beverage preferences for breakfast, lunch and dinner was [MEDICATION NAME] milk (cows' milk treated with the enzyme [MEDICATION NAME] to breakdown the milk sugar lactose, which isn't digested by someone with a lactose intolerance). Review of the recipes for Noodles and California blend vegetables (a mix of broccoli, carrots and cauliflower), which were two items served as part of the noon meal on (MONTH) 10, (YEAR), revealed both recipes contained margarine. During an interview with FSD 1 on (MONTH) 13, (YEAR), at approximately 3:00 p.m. it was revealed that butter was used in place of margarine to prepare both of the aforementioned menu items. Review of the packaging for butter, revealed that it contained milk. During an interview with the FSD 1 on (MONTH) 13, (YEAR), at approximately 3:00 p.m. it was revealed that usually the cook removes a serving/one portion of the food item prior to adding butter or margarine for Resident 38, however, that didn't occur on (MONTH) 10, (YEAR). During an interview with the Nursing Home Administrator on (MONTH) 14, (YEAR), at 3:05 p.m. he stated that he would expect that all the staff members who received education would sign off on the education. He also would expect that Resident 38 would not be served milk products. The facility failed to ensure that residents were not served foods they were allergic to for one of 12 residents reviewed (Resident 38), which resulted in harm with an allergic reaction, requiring [MEDICATION NAME] and transfer to the hospital for difficulty with swallowing and breathing 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/31/18, 6/15/17, 7/8/16 28 Pa. Code 211.11(d) Resident care plan. Previously cited 1/31/18 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/31/18, 11/14/17, 6/15/17 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/31/18, 11/14/17, 6/15/17, 4/6/17, 7/8/16

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent accidents for two of 6 residents (Resident 3 and 6) reviewed resulting in harm for one resident (Resident 6). Findings include: Review of the clinical record for Resident 6 revealed [DIAGNOSES REDACTED]. Resident 6's care plan revealed a focus area last revised on April 12, 2017, related to the inability to ambulate independently. Staff were to transfer the resident with a rolling walker and one assist. The care plan focus area for alteration in skin integrity dated March 20, 2017, indicated that staff would apply dermasavers (loose-fitting tubes that stays in place to protect the skin) to both legs when out of bed and during transfers. Review of the facility's incident report dated January 22, 2018, revealed that staff was transferring Resident 6 from her wheelchair to her bed when she obtained a 5 cm by 2 cm laceration on her right lower leg. She was sent to the emergency room and required 20 sutures (a row of stitches holding together the edges of a wound). Review of the information submitted to the Department of Health field office dated January 23, 2018, revealed that Resident 6 was unable to pivot for the transfer and caught her leg on the wheelchair resulting in a skin tear. Further review of the facility's incident report dated January 22, 2018, revealed that Nurse Aide 2 did not follow the proper transfer interventions. Nurse Aide 2 did not use a walker when transferring Resident 6 from the wheelchair to the bed. Resident 6 was not wearing the dermasaver on her right leg. During an interview with the Nursing Home Administrator on January 31, 2018, at 3:00 p.m. he confirmed that the interventions should have been in place. Review of Resident 3's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 3's current fall care plan revealed an intervention for a chair alarm, with an initiation date of July 13, 2016. Review of Resident 3's current physician orders [REDACTED]. Review of the facility's investigation into Resident 3's fall on January 10, 2018, revealed that Resident 3 transferred from her wheelchair to a recliner, resulting in a fall with no injury. Further review of the incident report revealed that there was no alarm on Resident 3's wheelchair at the time of the fall. During staff interview on January 31, 2018, at approximately 1:00 p.m. the Director of Nursing stated she was unsure why the alarm was not in place. The facility failed to ensure interventions were implemented with each resident's written plan of care resulting in harm to Resident 6, which required the resident to be sent to the hospital and receive 20 sutures to a laceration of the lower leg. 42 CRF 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/15/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/15/17, 7/8/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/15/17. 28 Pa. Code 211.5(f) Clinical record. Previously cited 11/14/17. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 11/14/17, 6/15/17, 4/6/17, 7/8/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/14/17, 6/15/17

Based on review of hospital records, clinical record and incident report, and staff interviews it was determined that the facility failed to provide ordered medication for pain resulting in the resident having severe pain, after a fall for one out of three residents reviewed (Resident 2). Findings include: Review of the clinical record for Resident 2 revealed [DIAGNOSES REDACTED]. Review of Resident 2's clinical record including incident reports revealed that on September 8, 2017, Resident 2 had a fall from her bed at 3:15 p.m. A statement written by Registered Nurse (RN 1), time and date not indicated, revealed at approximately 3:15 p.m. Resident 2 was found lying on the floor on her L (left) side with her head resting on the heater. Resident was assessed. Bump noted to back of head, forehead above eyebrow and R (right) hand and base of thumb. Resident denied having any pain in these areas at this time. Resident just kept c/o (complaining of) her R leg. Resident stated her whole leg hurts when asked and pointed to her hip. There was no evidence Resident 2 was medicated for pain. A Hoyer lift (mechanical device used to move a resident from the floor to the bed) was brought into the room and the resident was then assisted to her bed with 5 (five) staff. Resident 2 was assessed again while lying in bed and a bump was noted to the top of her L (left) shoulder. The resident denied pain to that area. At approximately 3:45 p.m. RN 1 called the physician and the mobile X-ray company, for an X-ray of the right leg. At approximately 6:30-6:45 p.m., RN 1 checked on the resident and she complained of severe pain in her right leg. There is no evidence that the physician was notified of Resident 2 having severe pain. At approximately 9:15 p.m. the mobile X-ray company called the facility to confirm that they received the X-ray results. At that time, the report was being received through the FAX machine. The X-ray results revealed a right [MEDICAL CONDITION]. RN 1 called the physician and received an order to send Resident 2 to the emergency room . Review of Resident 2's plan of care for pain management dated December 6, 2015, revealed an intervention dated April 18, 2016, for meds (medications) as ordered, monitor the effectiveness and adverse reactions of the medication. Review of Resident 2's Medication Administration Record [REDACTED]. Resident 2's Medication Administration Record [REDACTED]. Review of the hospital records revealed that Resident 2 had a right femoral neck (which is located near the top of the femur (thigh) bone), left clavicle (collar bone) fracture and a subdural hematoma (when blood collects on your brain's surface beneath the skull). During an interview with the Director of Nursing on October 30, 2017, at 1:10 p.m. she stated that she was not aware that the resident was in severe pain or she would have sent her to the ER (emergency room ). During another interview with the Director of Nursing on October 30, 2017, at 3:45 p.m. she confirmed that the resident was not given pain medication. The Director of Nursing provided education to licensed staff on October 11, 2017, stating that if a resident falls and there is a possibility they have an injury such as fracture or head injury, notify the physician and send to ER, start neurological checks and vital signs and notify family. They were also educated that if it is known that a resident hit their head, there is evidence of any bumps, bruises ect, call the physician and have then sent to the ER and notify family. During an interview with the Nursing Home Administrator on November 14, 2017, at 10:30 a.m. it was revealed that licensed staff was educated on October 11, 2017, related to resident falls and a possibility they have an injuries, such as fractures or head injuries, notifying the physician and sending to the ER, at the recommendation of the Area Agency on Aging, 33 days after the fall to Resident 2 occurred. 42 CFR 483.24 Provide Care/Services for Highest Well-Being Previously cited 7/8/16 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/15/17, 4/6/17, 7/8/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 6/15/17