Every finding on record at Riverstreet Manor

Based on a review of clinical records, facility policy, documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to implement abuse prevention procedures to protect one resident out of ten residents reviewed (Resident 7) following allegations of sexual abuse perpetrated by a facility employee (Employee 2, nurse aide). Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, or Misappropriation Prevention Program, last reviewed by the facility on May 1, 2026, revealed it is the facility policy that residents have the right to be free from abuse. The policy indicated the resident abuse prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from any further harm during investigations. A review of the facility policy titled Abuse, Neglect, Exploitation, or Misappropriation Reporting and Investigation, last reviewed by the facility on May 1, 2026, revealed it is the facility policy that all reports of resident abuse are thoroughly investigated by facility management. The policy indicated that upon receiving any allegation of abuse, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. The policy stated, Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic kidney disease (gradual loss of kidney function). A review of Resident 7's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 7, 2026, revealed that Resident 7 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). Employee 1, Nurse Aide (NA), documented that Resident 7 reported being involved in a sexual relationship with Employee 2, NA. Employee 1 documented that she immediately reported the allegation to Employee 3, Registered Nurse Supervisor (RNS). Employee 1 further documented that after Employee 2 was instructed to leave the facility, she observed Employee 2 enter Resident 7's room. A witness statement completed by Employee 3, Registered Nurse Supervisor (RNS), dated June 13, 2026, at 4:05 PM documented that Resident 7 reported she had been involved in a consensual intimate relationship with Employee 2, NA, for approximately two years and stated the encounters occurred during shower care. Employee 3 documented notifying the Assistant Director of Nursing (ADON). During an interview on June 24, 2026, at 2:10 PM the Assistant Director of Nursing (ADON) stated that on June 13, 2026, at approximately 4:19 PM, she was notified of Resident 7's allegation involving Employee 2, NA. The ADON stated she instructed Employee 3, Registered Nurse Supervisor (RNS), to call Employee 2 into a meeting. The ADON stated she participated in the meeting by telephone while Employee 3 informed Employee 2 that he was suspended immediately because of allegations of resident abuse. The ADON stated Employee 2 was instructed that he was not permitted to return to the facility until the investigation was completed. The ADON stated Employee 3 was responsible for implementing the abuse policy that day. The ADON further stated she was not physically present after the telephone call and did not observe events that occurred afterward. Employee 3, Registered Nurse Supervisor (RNS), was no longer employed by the facility and could not be reached for interview. During a telephone interview on June 25, 2026, at 9:25 a.m., Employee 1, Nurse Aide (NA), confirmed that after Resident 7 reported the allegation, Employee 2 entered Resident 7's room while carrying a black backpack. Employee 1 stated she observed Employee 2 enter the room while she was providing care to another resident across the hall. Employee 1 stated she could not determine how long Employee 2 remained inside the room. During an interview on June 24, 2026, at 1:50 PM Resident 7 stated that after reporting the allegation to staff, she was alone in her room crying when Employee 2 entered carrying a black backpack. Resident 7 stated Employee 2 told her he was going home to see his children, took hold of her hands, attempted to kiss her, and told her everything would be alright. Resident 7 stated she pulled her hands away, told him, No everything was not going to be alright, and Employee 2 then left the room. A nursing progress note dated June 13, 2026, at 7:38 PM documented that Resident 7 reported involvement in a consensual sexual relationship with Employee 2, NA. The note documented that the resident representative and on-call medical provider were notified. New physician's orders included laboratory testing for sexually transmitted infections (infections spread through sexual contact) and referral to a gynecologist (a physician specializing in women's reproductive health) if Resident 7 wished to proceed with further evaluation. The progress note documented that Resident 7 requested both the laboratory testing and gynecological referral and denied pain or discomfort. A psychiatry progress note dated June 15, 2026, at 1:00 AM, completed at the facility's request following Resident 7's allegation involving Employee 2, Nurse Aide (NA), documented that Resident 7 was interviewed in her room with privacy maintained. The psychiatric practitioner documented that upon entering the room, Resident 7 stated, Did they send you to talk about what happened? According to the psychiatry note, Resident 7 reported an ongoing sexual relationship with Employee 2 for approximately two years. The psychiatric practitioner documented that Resident 7 reported Employee 2 allegedly entered her room approximately 30 minutes before scheduled shifts to engage in sexual activity. The psychiatric practitioner documented that Resident 7 believed she would eventually marry Employee 2 and became emotionally distressed after learning Employee 2 reportedly had a relationship with another individual. The psychiatric practitioner documented mild symptoms of depression and anxiety and recommended continued non-pharmacological interventions (care approaches that do not involve medication, such as emotional support and reassurance) and supportive counseling. During an interview on June 24, 2026, at 8:50 AM Resident 7 stated that she had been involved in what she described as an ongoing consensual intimate relationship with Employee 2, Nurse Aide (NA), for approximately two years. Resident 7 reported that the relationship began while Employee 2 was providing her care and later became intimate. Resident 7 stated Employee 2 regularly spent time with her in her room before or during work shifts. Resident 7 further stated that Employee 2 asked her to keep the relationship a secret and that she disclosed the relationship to Employee 1, Nurse Aide (NA), after learning Employee 2 was reportedly involved in another relationship.During the interview on June 24, 2026, Resident 7 voluntarily presented social media communications that she identified as occurring between herself and Employee 2, Nurse Aide (NA). Resident 7 stated the social media account displayed a name and profile photograph that she believed belonged to Employee 2. The surveyor observed written messages initiated by Resident 7 expressing affection toward the account holder and audio call records reflecting multiple calls between Resident 7 and that account. The survey team did not independently verify ownership of the social media account or the content of the audio calls. During a telephone interview on June 24, 2026, at 10:04 AM, Employee 2, Nurse Aide (NA), denied engaging in any sexual relationship with Resident 7. Employee 2 acknowledged that after being notified on June 13, 2026, that he was suspended pending investigation of abuse allegations, he entered Resident 7's room to retrieve a documentation tablet that he stated had been left there earlier in the shift. Employee 2 stated no staff member accompanied him into the room. Employee 2 denied attempting to kiss or otherwise touch Resident 7 during that encounter. During a telephone interview on June 24, 2026, at 1:20 p.m., the investigating law enforcement officer reported that Resident 7 described the relationship as consensual and declined to pursue criminal charges. During an interview on June 24, 2026, at 2:20 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) reviewed the above information. Both confirmed that, under the facility's abuse policy, Employee 2, Nurse Aide (NA), should not have had any resident contact after being suspended pending investigation of the abuse allegation. The NHA and DON acknowledged that Employee 2 entered Resident 7's room after the suspension had been communicated and confirmed that this action was inconsistent with facility policy requiring an employee accused of resident abuse to remain on leave with no resident contact until completion of the investigation. The NHA and DON stated Employee 2's employment was subsequently terminated for failing to comply with facility policy. The facility failed to implement its abuse prevention procedures by allowing the alleged perpetrator access to Resident 7 after the allegation had been reported and the employee had been suspended pending investigation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of select facility policies, clinical records, resident assessments, grievance documentation, and staff interview, it was determined that the facility failed to develop and implement an individualized bowel and bladder incontinence management program for one of seven residents reviewed for the timely provision of staff assistance with toileting and management of urinary and bowel incontinence (Resident B2).Findings include: A review of facility policy titled Urinary Continence and Incontinence Assessment and Management reviewed by the facility on May 1, 2026, revealed the staff and practitioner will appropriately screen form, and manage individuals with urinary incontinence. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary incontinence. Periodically, as required and when there is a change in voiding, staff will define each individual's level of continence, referring to criteria in the Minimum Data Set (MDS). If the residents are incontinent, staff will initiate a toileting plan. Staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. Toileting programs will start with a three-to-five-day toileting assistance trial. The staff will document the results of the toileting trial in the resident's medical record. If the resident does not respond or does not try to toilet, or for those with such severe cognitive impairment, staff will use a check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and skin integrity. A clinical record review revealed that Resident B2 was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive brain disorder that impairs memory, thinking, reasoning, and the ability to perform daily activities) with behavioral disturbances (patterns of disruptive or inappropriate behaviors that interfere with daily functioning and emotional regulation). A review of the resident's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 29, 2026, revealed that Resident B2 had severe cognitive impairment with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) The assessment identified that Resident B2 was always incontinent of both bladder and bowel and was not receiving a toileting program to manage incontinence. A review of the resident's care plan revealed a urinary incontinence (involuntary loss of urine or inability to control bladder function resulting in loss of urine) care plan initiated on July 4, 2025, and last revised on May 19, 2026. The care plan identified urinary incontinence related to disease process, impaired mobility, physical limitations, severe cognitive impairment without perception to void (urinate), and recurrent UTIs (urinary tract infections, infections involving the urinary system, including the bladder and urethra). The care plan established goals for the residents to remain as clean, dry, and comfortable as possible, remain free from complications associated with incontinence, and remain free from skin breakdown. Planned interventions included providing toileting assistance or incontinent care as needed, providing incontinence care and comfort measures, using absorbent briefs as needed, and applying barrier cream after perineal care and as needed. A clinical record review revealed an Annual Resident Observation assessment dated [DATE], at 11:14 AM, documenting that Resident B2 utilized pads and briefs and was incontinent of bowel and bladder without awareness or perception of the need to urinate or defecate (bowel movement). A review of nursing documentation dated March 17, 2026, documenting an evaluation following reports of projectile vomiting on March 16, 2026, accompanied by increased abdominal discomfort and pressure. Diagnostic testing was ordered. A KUB (an abdominal x-ray used to evaluate the kidneys, ureters, and bladder) revealed no acute findings. However, a UA C&S (urinalysis with culture and sensitivity testing, used to identify urinary tract infections and determine effective antibiotic treatment) revealed a bacterial count of 50,000 to 100,000 colony-forming units per milliliter (CFU/mL) of Pseudomonas (a bacteria commonly associated with urinary tract infections commonly found in water, soil, and moist healthcare environments). The physician ordered Cipro (ciprofloxacin, an antibiotic used to treat bacterial infections) 500 milligrams twice daily for seven days to treat the UTI. A review of Resident B2's Medication Administration Record, (MAR legal record documenting medications administered to a resident), dated March 2026 revealed the resident received all 14 doses of Cipro 500 mg as prescribed by the attending MD for UTI. A review of the Documentation Survey Report v2 for March 2026 revealed nursing staff documented only that incontinence checks and care were completed during each shift, approximately every eight hours. The documentation identified Resident B2 as incontinent of both urine and bowel movements; however, the report contained 15 separate shifts with blank documentation regarding incontinence care. A review of the Documentation Survey Report v2 for April 2026 similarly revealed staff documented incontinence checks and care only once per shift. The report identified Resident B2 as always incontinent of urine and bowel movements and contained 18 separate shifts with blank documentation regarding incontinence care. Documentation Survey Reports for March and April 2026 reflected incontinence care documentation only once per shift, approximately every eight hours. A review of a grievance filed on behalf of Resident B2 dated April 22, 2026, documented concerns that staff were not consistently completing incontinence checks, resulting in the resident remaining wet for extended periods of time. Despite the resident's documented severe cognitive impairment, continuous bowel and bladder incontinence, inability to perceive the need to toilet, recurrent urinary tract infections, and the facility policy directing implementation of a check-and-change program for such residents, the clinical record failed to reveal evidence that staff developed, implemented, monitored, or documented an individualized incontinence management program. Specifically, the record lacked evidence of a check-and-change protocol, scheduled toileting program, prompted voiding program, toileting trial, established toileting intervals, monitoring records, or evaluation of the effectiveness of any incontinence management intervention. Specifically, despite facility policy requiring implementation of a toileting plan for incontinent residents and a check-and-change program for residents with severe cognitive impairment, Resident B2's clinical record failed to contain evidence of a toileting assistance trial, scheduled toileting program, prompted voiding program, check-and-change protocol, established toileting intervals, monitoring records, documentation of program effectiveness, or individualized interventions directing staff regarding the frequency of incontinence care. The care plan failed to include specific individualized interventions directing staff regarding the frequency and method of toileting assistance or incontinence management necessary to address the resident's known continence needs. During an interview on May 28, 2026, at 2:00 p.m., the Director of Nursing reviewed the above findings and stated that Resident B2 was always incontinent of urine and bowel movements and should have been checked and changed every two hours. The Director of Nursing was unable to provide documented evidence demonstrating that two-hour check-and-change interventions were consistently implemented or documented for Resident B2. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interview, it was determined that the facility failed to ensure a timely and comprehensive skin assessment was completed upon readmission to identify and evaluate an existing pressure injury and guide treatment interventions for one of seven sampled residents reviewed for skin integrity concerns (Resident A1).Findings include:According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of a facility policy entitled Pressure Ulcers/Skin Breakdown -Clinical Protocol last reviewed May 1, 2026, indicated the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document/report the following: a full assessment of pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments including support surfaces; and all active diagnoses. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will assist the staff to identify the type (for example, arterial or stasis) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. Clinical record review revealed Resident A1 was originally admitted to the facility on [DATE], with diagnoses that included a history of transient ischemic attack (TIA, commonly referred to as a mini-stroke, which occurs when blood flow to part of the brain is temporarily blocked), cerebral infarction (an ischemic stroke caused by loss of blood flow to brain tissue), heart failure (a condition in which the heart cannot pump blood effectively enough to meet the body's needs), and occlusion and stenosis of the carotid arteries (narrowing or blockage of the major arteries that supply blood and oxygen to the brain). A review of the resident's care plan, initiated May 14, 2026, identified Resident A1 was at risk for altered skin integrity related to impaired mobility. The goal was to minimize skin breakdown and maintain skin integrity. Planned interventions included use of a pressure-relieving wheelchair cushion, consultation with wound care specialists, assistance with repositioning, use of a pressure-reducing mattress, administration of preventive skin treatments as ordered, and observation and reporting of changes in skin condition. Clinical record review revealed Resident A1 experienced a change in condition and transferred to the hospital on May 19, 2026. The resident was readmitted to the facility on [DATE]. A review of the hospital Discharge summary dated [DATE], at 2:09 PM documented the presence of a sacral wound (a type of pressure injury or ulcer that develops over the sacrum, the triangular bone at the base of the spine, due to prolonged pressure that impedes blood flow and damages tissue). A review of a nursing progress note dated May 24, 2026, at 4:46 PM documented the resident's return to the facility and indicated hospital discharge orders were reviewed with the attending physician. Review of physician orders revealed an order dated May 24, 2026, to cleanse a Stage 2 pressure ulcer (a partial-thickness skin loss involving the outer layers of skin and typically presents as a shallow open wound or blister) of the sacrum with normal saline solution, pat dry, apply hydrogel, a moisture-retaining wound treatment used to promote healing, and cover the wound with bordered gauze. Despite documentation from the hospital identifying the presence of a sacral pressure ulcer and physician orders directing wound treatment upon readmission, review of the clinical record failed to reveal documented evidence that licensed nursing staff completed a comprehensive skin assessment upon the resident's return to the facility on May 24, 2026. A review of the clinical record failed to reveal documentation identifying the wound's measurements, wound bed characteristics, presence or absence of drainage, condition of the surrounding tissue, pain assessment, or a comprehensive staging assessment upon readmission. Additionally, the clinical record failed to reveal documentation that nursing staff completed and recorded the assessment components required by facility policy to evaluate and monitor an existing pressure injury. A review of nursing documentation revealed a skin and wound evaluation completed by the contracted wound care specialist on May 27, 2026, at 2:36 PM. The wound care note documented that the coccyx/sacral wound contained 100 percent slough (a yellow or white nonviable tissue that can delay wound healing and increase the risk of infection). The wound was reclassified as an unstageable pressure injury, meaning the true depth of the wound could not be determined because the wound bed was completely covered with dead tissue. The wound measured 1.0 centimeters in length, 2.0 centimeters in width, and 0.5 centimeters in depth and contained exposed dermal tissue with a light amount of serous exudate a clear, thin, watery fluid produced by the body in response to tissue injury or inflammation). The wound care specialist recommended new treatment interventions including cleansing the wound with normal saline solution, applying Santyl (an enzymatic debridement medication used to remove dead tissue from chronic wounds) covering the wound with a bordered dressing, and changing the dressing daily. The wound characteristics documented by the contracted wound care specialist on May 27, 2026, had not been identified or documented by facility nursing staff upon the resident's readmission on [DATE]. During an interview with the Director of Nursing (DON) on May 28, 2026, at 2:15 PM, the above findings were reviewed. The Director of Nursing stated that skin assessments were expected to be completed and documented by licensed nursing staff upon readmission to identify existing skin impairments and facilitate timely treatment. The facility was unable to provide documentation demonstrating that licensed nursing staff completed the comprehensive skin assessment required by facility policy upon the resident's readmission on [DATE]. The facility failed to ensure a timely and comprehensive skin assessment was completed and documented upon readmission to identify existing skin impairment, evaluate wound characteristics, and guide appropriate interventions to promote healing in accordance with facility policy and accepted standards of practice. 8 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observation, review of select facility policy, and staff interviews, the facility failed to maintain sanitary conditions in the dietary department, including the main kitchen and a nursing unit pantry (Station 2), to ensure food was stored, prepared, and served in a manner that prevented contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of facility policies entitled Sanitation, last reviewed May 1, 2025, indicated that all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. The food services manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. An initial tour of the dietary department, conducted on April 14, 2026, at 9:15 AM with the facility's Certified Dietary Manager (CDM), revealed unsanitary conditions with the potential to contaminate food and increase the risk of foodborne illness (illness caused by consuming contaminated food).Observations revealed: The bottom shelves of multiple metal food preparation tables contained liquid stains and food debris. Several silver banquet trays stored on these shelves contained dried food residue and standing water. Multiple coffee cups identified as clean contained a white film and brown staining. Multiple cereal bowls contained dried food debris. The kitchen floor perimeter contained a sticky black substance, along with food, paper, and plastic debris. The floor behind the steamer unit contained a large accumulation of a sticky black and brown substance. The floor drain beneath the unit contained a buildup of the same black/brown material. The floor beneath the kitchen ice machine contained food debris and paper and plastic waste. A sticky black and brown substance was present on the floor and surrounding the drain. The ice machine drainpipe discharged directly into the floor drain without an air gap (an air gap is the open space between a drainpipe, and a sewer drain that prevents contaminated water from flowing back into equipment). The drainpipe contained a thick accumulation of dark residue extending from the pipe to the machine. Observation of the Station 2 pantry revealed additional unsanitary conditions. The ice machine drainpipe discharged directly into the floor drain with no visible air gap. A review of the facility menu for April 16, 2026, indicated portion-controlled serving requirements for the lunch meal which included 3 ounces of breaded chicken tenders, 4 ounces of tater tots, 4 ounces of seasoned green peas and 4 ounces of pears. During observation of the tray line on April 16, 2026, at 12:00 PM, the surveyor observed Employee 2 (cook) serve food items using gloved hands instead of using portion-controlled utensils (measured serving tools used to ensure consistent portions and sanitary handling). The employee handled chicken tenders and tater tots directly with gloved hands. During the same observation, the employee turned away from the serving line, handled a plate from a cart, placed it onto a meal tray, and then resumed serving food with the same gloves without performing hand hygiene or changing gloves. The surveyor observed this practice for multiple residents. During an interview on April 16, 2026, at 1:00 PM, the Certified Dietary Manager stated dietary staff are expected to use appropriate serving utensils to portion and serve food items from the tray line. During an interview on April 17, 2026, at 12:30 PM, the Nursing Home Administrator was informed of the above observations and acknowledged that the dietary department is required to be maintained in a clean and sanitary condition. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.6 (f) Dietary Services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on review of scheduled mealtimes, resident council meeting minutes, resident interviews, and staff interviews, the facility failed to ensure residents were consistently offered a nutritious evening snack when more than 14 hours elapsed between the substantial evening meal and breakfast the following day, for 5 of 5 residents reviewed who expressed a desire for a bedtime snack (Residents 10, 53, 9, 65, and 105).Findings include: A review of scheduled facility mealtimes revealed the interval between the substantial evening meal and breakfast exceeded 14 hours across multiple resident care areas. Dinner was served between 4:40 PM and 5:15 PM, and breakfast was served between 7:35 AM and 8:15 AM the following morning, resulting in overnight intervals ranging from 14 hours 55 minutes to 15 hours, as follows: Pine Hall: Dinner 4:40 PM, Breakfast 7:35 AM (14 hours 55 minutes)Oak Hall: Dinner 4:55 PM, Breakfast 7:50 AM (14 hours 55 minutes)Willow Hall: Dinner 5:05 PM, Breakfast 8:05 AM (15 hours)Spruce Hall: Dinner 5:15 PM, Breakfast 8:15 AM (15 hours) When more than 14 hours elapse between the substantial evening meal and breakfast the next day, the resident must be offered a nutritious snack (a food or beverage that provides calories and nourishment, such as milk, fruit, or a sandwich, rather than items with little nutritional value) at bedtime. A review of Food Committee meeting minutes revealed ongoing concerns regarding failure to provide evening snacks to residents: February 3, 2026: Residents reported snacks were not always being passed.March 3, 2026: Residents reported snacks were still not consistently passed.April 8, 2026: Residents reported snacks were not being offered despite snacks being delivered to the units and placed in the pantry. They stated that nursing puts the snacks in the pantry and no one passes them to the residents. During a resident council meeting conducted on April 14, 2026, at 10:30 AM, 5 of 5 residents interviewed (Residents 10, 53, 9, 65, and 105) reported they were not offered a snack in the evening and all residents reported that they do not receive a snack before bedtime. During an interview on April 15, 2026, at 2:00 PM, the Nursing Home Administrator was unable to provide documentation showing that evening snacks were consistently offered to residents. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (c) Resident Care Policies.

Based on review of facility documentation and staff interview, the facility failed to ensure it conducted required quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings and failed to ensure the attendance of the Medical Director or a physician designated by the Medical Director at required quarterly QAPI meetings for two of four quarters reviewed (Quarters 3 and 4 of 2025).Findings include: A review of the facility policy titled Quality Assurance Performance Improvement, last reviewed May 1, 2025, revealed the facility established a QAPI program (a facility-wide program that uses ongoing review of data and care practices to identify problems, correct them, and improve the quality and safety of services provided to residents). The policy indicated the program would be comprehensive, ongoing, and address the full range of services and departments. However, the policy did not specify the required participation of the Medical Director or a physician designated by the Medical Director and did not outline expectations for attendance or accountability for participation in quarterly QAPI meetings. A review of available QAPI committee meeting sign-in sheets and supporting documentation revealed the facility was unable to provide documented evidence that required quarterly QAPI committee meetings were conducted during the period of August 2025 through December 2025. In addition, the facility was unable to provide documentation that the Medical Director or a designated physician representative attended QAPI meetings conducted during the period of July 2025 through December 2025. The absence of documentation of required quarterly QAPI committee meetings and the absence of documentation of Medical Director or designated physician participation demonstrated the facility did not ensure the implementation of its QAPI program on a quarterly basis with required physician involvement in quality review activities. An interview conducted on April 17, 2026, at 10:30 AM, with the Director of Nursing and the Nursing Home Administrator included review of the above findings. During the interview, they acknowledged the facility was unable to provide documentation to support that required quarterly QAPI committee meetings were conducted for the identified time period and acknowledged that the Medical Director or designated physician representative had not attended the identified QAPI meetings. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to develop an individualized baseline care plan that addressed a resident's immediate needs and documented treatment preferences, including comfort-focused care and avoidance of hospital transfer when appropriate, for one of 24 residents reviewed (Resident 56).Findings include: A review of the facility's policy, Care Plans -Baseline last updated on May 1, 2025, revealed that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. The policy indicated the immediate needs to be addressed in the baseline care plan include but are not limited to initial goals, physician orders, and interventions to meet the resident's needs. Resident 56 was admitted to the facility on [DATE], with diagnosis which included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and decreased awareness). A review of Resident 56's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 14, 2026, revealed that Resident 56 was cognitively impaired with a BIMS score of 6 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment, suggesting significant difficulties with memory, orientation, and daily functioning). A review of the Physician Orders for Life Sustaining Treatment (POLST, a medical order documenting a resident's treatment preferences for life-sustaining care) signed February 11, 2026, indicated the resident's wishes for Do Not Attempt Resuscitation and Comfort Measures Only (care focused on relieving pain and suffering rather than prolonging life). The POLST specified the resident should remain in the facility and not be transferred to the hospital unless comfort needs cannot be met. A review of the baseline care plan initiated on February 11, 2026, indicated that Resident 56's advance directives would be followed and that the resident wished to allow a natural death and did not want resuscitation (Do Not Resuscitate). However, the baseline care plan did not include specific, person centered details about the resident's wishes to remain in the facility, avoid hospital transfer when possible, or specific measures to provide comfort such as symptom management or interventions to relieve pain and suffering A review of the clinical record revealed a change in condition on February 13, 2026, including altered responsiveness, inability to follow commands, and facial drooping. Documentation indicated the physician assistant and family were present, and the decision was made to continue comfort-focused care in the facility. During an interview on April 16, 2026, at 11:48 AM, the Director of Nursing (DON) confirmed the baseline care plan did not include individualized interventions addressing the resident's treatment preferences and immediate comfort care needs as required by facility policy. The DON also confirmed that the facility did not have a policy addressing comfort measures. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(iii) Medical records.

Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure appropriate duration and clinical rationale for an as-needed (PRN) psychotropic medication order and failed to document the use of non-pharmacological interventions prior to administration for one of 24 residents reviewed (Resident 56). Findings include: Federal requirements for the use of psychotropic medications expect that psychotropic medications are used only when necessary to treat a specific, documented condition. The requirements further limit PRN psychotropic medication orders to 14 days unless the prescriber documents a clinical rationale for continued use and specifies the duration of the extended order. Non-pharmacological interventions are approaches that do not involve medications, such as verbal reassurance, redirection, environmental adjustments, or comfort measures, and are expected to be attempted and documented when clinically appropriate prior to the use of a PRN psychotropic medication. A review of the facility's policy titled Psychotropic Medication Use, last updated May 1, 2025, indicated that PRN psychotropic medication orders are limited to 14 days. The policy further indicated that if the medication is to continue beyond 14 days, the prescriber must document the reason for the extended use and specify the duration. Resident 56 was admitted to the facility on [DATE], with diagnosis which included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered awareness). A review of Resident 56's (admission) Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 14, 2026, revealed that Resident 56 was cognitively impaired with a BIMS score of 6 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment, suggesting significant difficulties with memory, orientation, and daily functioning). A review of the clinical record revealed a physician order dated February 13, 2026, for Lorazepam (a medication used to treat anxiety by slowing activity in the brain and nervous system) 2 milligrams per milliliter, administer 0.5 milliliters orally every six hours as needed for terminal agitation (a condition characterized by restlessness, confusion, or distress that may occur near the end of life). The clinical record did not indicate Resident 56 was receiving hospice services (specialized care focused on comfort rather than curing a terminal illness). A review of the electronic medication administration record (eMAR, an electronic system used to document medication administration) revealed Lorazepam was administered on February 13, 2026, at 3:48 PM; April 3, 2026, at 6:58 PM; and April 8, 2026, at 6:00 PM. Review of the February 13, 2026, physician order did not identify documentation of a clinical rationale or a specified duration to support continuation of the PRN psychotropic medication beyond 14 days. The clinical record confirmed the medication remained active and was administered beyond the 14-day limit without required prescriber documentation. Review of the eMAR and supporting documentation did not identify evidence that non-pharmacological interventions were attempted prior to administration of the medication on the above dates. Additionally, documentation dated February 13, 2026, did not indicate the presence of agitation at the time the medication was administered. During an interview on April 16, 2026, at 11:48 AM, the Director of Nursing confirmed the clinical record did not contain documentation specifying the duration or clinical rationale for continuation of the PRN psychotropic medication beyond 14 days. 28 Pa. Code 211.2(d)(3)(5) Medical Director. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of observations, clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide adequate supervision to prevent a resident from exiting the facility without authorization (elopement) for one of 24 residents reviewed (Resident 28).Findings include: A review of the facility policy entitled Wandering and Elopements, last reviewed May 1, 2025, revealed it was the policy of the facility to identify residents who are at risk of unsafe wandering and will strive to prevent harm while maintaining the least restrictive environment for residents. The policy defined elopement as a resident leaving the premises or a safe area without authorization. Clinical record review revealed Resident 28 was admitted on [DATE], with diagnoses including localization-related symptomatic epilepsy (a seizure disorder that begins in one area of the brain and may spread) and essential thrombocythemia (a condition in which the body produces too many platelets, increasing the risk for blood clots or bleeding). Review of a quarterly Minimum Data Set assessment (MDS, federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 6,2026, revealed Resident 28 had a BIMS score of 13 (Brief Interview for Mental status, a tool to assess the resident's cognition, orientation, and ability to register and recall new information). A score of 13-15 indicates that cognition is intact. Information provided to the Department during the survey revealed that on April 14, 2026, at 7:00 PM, Resident 28 approached the front desk and requested to leave the facility. The receptionist asked if he was a resident, and the resident stated he was not. The receptionist then allowed the resident to exit the building. During an interview on April 16, 2026, at 9:30 AM, Resident 28 stated he intentionally provided incorrect information to the receptionist in order to go outside. The resident reported he walked toward the corner of the property before a nurse found him and returned him to the building. before being located by staff and returned to the building. Clinical record review revealed no documentation of the resident exiting the facility, and no evidence the physician or responsible party (an individual legally authorized to receive information or make decisions on behalf of the resident) was notified. A review of external medical (hospital record) documentation indicated Resident 28 reported to a physician on April 15, 2026, that he had left the facility with the intention of going to a pizza establishment. A review of the elopement risk assessment dated [DATE], indicated Resident 28 was not identified as being at risk for elopement. The care plan, initiated the same date, did not address elopement risk or include interventions related to supervision for leaving the facility. Nursing documentation indicated the resident was independently mobile with the use of a rollator walker (a wheeled walking aid that provides support and stability). During an interview on April 16, 2026, at 10:15 AM, the Nursing Home Administrator and Director of Nursing stated the resident was cognitively intact, frequently ambulated throughout the facility, and was not considered an elopement risk. They indicated the event was not considered an elopement because the resident remained close to the building. An interview with Employee 4 Receptionist, conducted via telephone on April 16, 2026, at 10:00 AM revealed Resident 28 approached the front desk requesting to be let out of the building. Employee 3 stated she asked the resident if he was a resident of the facility, and he replied No, stating he just needed fresh air. Employee 4 indicated she allowed the resident to exit the building. She further stated that after the resident exited and began walking toward the left side of the building, she observed him stumbling and felt something was not right. Employee 4 reported she immediately went to Nursing Station 1 to notify the nursing supervisor. She stated the nursing supervisor showed her a picture of a resident, and she confirmed it was the same individual she had allowed to leave. Employee 4 indicated the nursing supervisor then initiated a Code [NAME] (a facility-wide overhead announcement used to alert staff of a missing resident) on April 14, 2026, at 7:05 PM. An interview with Employee 3 Licensed Practical Nurse, conducted via telephone on April 16, 2026, at 10:24 AM revealed she heard a Code Green announced overhead and responded by searching for Resident 28. Employee 3 stated she exited the building and located Resident 28 walking on the sidewalk along the side of the facility closest to the cemetery (located near the road). She indicated it was still light outside and warm, approximately 76 degrees Fahrenheit, and the resident was wearing a shirt, sweatpants, and sneakers. Employee 3 reported she escorted the resident back into the facility at approximately 7:10 PM. On April 17, 2026, at 10:15 AM, the above findings were reviewed with the Nursing Home Administrator and Director of Nursing. The facility did not ensure adequate supervision to prevent Resident 28 from exiting the building without authorization.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) (2.1) (3) Management. 28 Pa. Code 211.10 (d) Resident care policies.

Based on facility policy review, clinical record review, and staff and resident interviews, it was determined the facility failed to monitor and manage hydration status in accordance with a physician-ordered fluid restriction to ensure proper fluid balance for one of 24 residents reviewed (Resident 39).Findings include: A review of the facility policy titled Fluid Restriction Policy, last reviewed May 1, 2025, indicated the facility will provide an appropriate amount of fluid to residents who have a prescribed physician order for fluid restriction. The policy further stated that when a fluid restriction (a medical order that limits the total amount of liquids a resident may consume within a specified time period, usually over 24 hours, to prevent complications such as fluid overload, which is excess fluid in the body, or worsening heart or kidney conditions) is ordered by the physician, the clinical nutrition staff will coordinate with nursing for a 24-hour distribution of the daily allowance of fluids for meals, supplements, and medication administration. The procedure dictated that fluid preferences will be reviewed with the resident by the clinical nutrition staff and residents with fluid restriction orders will be reviewed for adherence by the clinical nutritionist. A clinical record review revealed Resident 39 was admitted on [DATE], with diagnoses including Parkinsonism (a neurological condition that causes slowed movement, muscle stiffness, and tremors) and hypertensive heart and chronic kidney disease with heart failure (a condition in which long-standing high blood pressure has caused damage to the heart and kidneys, leading to reduced ability to pump blood effectively and remove excess fluid from the body, which can result in fluid buildup). These conditions place the resident at risk for fluid overload (a condition in which the body retains more fluid than it can safely manage, potentially causing swelling, breathing difficulty, and strain on the heart). A review of Resident 39's quarterly Minimum Data Set (MDS, a federally required standardized assessment used to evaluate a resident's condition and guide care planning) dated March 5, 2026, revealed a Brief Interview for Mental Status (BIMS, a structured interview used to assess memory, attention, and orientation) score of 9, indicating moderate cognitive impairment (some difficulty with memory and decision-making a score of 08-12 indicates moderate cognitive impairment). A clinical record review identified a physician order dated August 1, 2025, for a 1500 milliliter (mL) daily fluid restriction including 900 mL with meals and 600 mL during nursing care, including medication administration. A care plan addressing nutritional risk identified the need for fluid restriction due to fluid overload (condition in which the body has more fluid than it can effectively manage), along with a history of noncompliance (not consistently following a prescribed treatment plan) and a history of weight loss and gain. The goal indicated the resident would consume appropriate amounts of food and fluids to maintain nutritional status. An interview with Resident 39 on April 15, 2026, at 10:30 AM revealed the resident was unaware of the fluid restriction order and did not recall involvement in care planning related to fluid intake. A review of a nutrition evaluation completed by the clinical nutritionist dated March 9, 2026, documented the presence of the 1500 mL fluid restriction; however, the record did not include evidence of resident education regarding the restriction, review of fluid preferences, or monitoring of adherence to the ordered fluid limit, as required by facility policy. A clinical record review, including documentation of fluid intake during meals and medication administration, showed that Resident 39 exceeded the prescribed 1500 mL daily fluid restriction on multiple occasions, including:April 2, 2026: 1560 mLApril 10, 2026: 1920 mLApril 11, 2026: 1680 mLApril 15, 2026: 1660 mLAn interview was conducted on April 16, 2026, at 2:15 PM with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) to review the above information. The NHA and DON confirmed that the facility failed to monitor Resident 39's hydration status and adherence to the prescribed fluid restriction and failed to involve the resident in the plan of care regarding the fluid restriction as required by facility policy. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on observation, select facility policy review, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications in two of two medication rooms (Station 1 Medication Room, and Station 2 Medication Room).Findings include: A review of the facility policy titled Medication Labeling and Storage last reviewed by the facility on May 1, 2025, revealed it is the policy of the facility that if a multidose vial ( container of medication intended for use in more than one dose for multiple administrations, which contains a preservative to reduce bacterial growth and requires labeling with the date opened and adherence to manufacturer storage and beyond-use guidelines) of injectable medication has been opened or accessed (e.g., needle puncture) the vial should be dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the opened vial. An observation of the medication room in Station 2 Med Room on April 15, 2026, at 8:53 AM, in the presence of Employee 3 (Licensed Practical Nurse ) of the medication stored in the medication refrigerator revealed one (1) multi-dose vial of Tuberculin Purified Protein Derivative, Diluted Aplisol (used primarily in the tuberculin skin test, also known as a Mantoux test, used to determine whether a person has been infected with Tuberculosis ) that had been opened and available for use, but not dated when initially opened. An interview with Employee 3(LPN) on April 15, 2026, at 8:54 AM confirmed the multidose vial of Tuberculin Purified Protein Derivative was opened and available for use, was not dated when initially opened. An observation of the medication room in Station 1 Med Room on April 15 , 2026, at 9:02 AM, in the presence of the Assistant Director of Nursing ( ADON) of the medication stored in the medication refrigerator, revealed two multi-dose vials of Tuberculin Purified Protein Derivative, Diluted Aplisol, that had been opened and available for use, but not dated when initially opened. An interview with the ADON on April 15, 2026, at 9:04 AM confirmed the two multidose vials of Tuberculin Purified Protein Derivative were open and available for use but were not dated when initially opened. Review of manufacturer safety information revealed the multidose vials of Tuberculin Purified Protein Derivative, Diluted Aplisol should be discarded within 30 days of opening. An interview was conducted on April 15, 2026, at 1:30 PM with the Director of Nursing (DON) to review the above findings related to the facilities failure to adhere to acceptable storage and use-by dates for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a review of select facility policies, clinical records, grievances filed with the facility, and staff interviews, it was determined that the facility failed to make prompt and adequate efforts to resolve a resident grievance in accordance with facility policy, for one of ten residents sampled (Resident 1).Findings Include: A review of facility policy entitled Grievance Process Procedure last reviewed by the facility on May 2, 2025, revealed it is the policy of the facility to make prompt efforts to resolve resident grievances to the satisfaction of the resident and or resident representative. The policy indicated a resolution of the concern is desired within five (5) working days from the date the concern was filed. The policy indicated routine follow up on concerns that are outstanding will be completed through the morning process meeting. The policy further identified the grievance official as the Nursing Home administrator (NHA). A grievance is defined as a formal or informal complaint or concern expressed by a resident or resident representative regarding care, services, or conditions at the facility. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], at 5:20 PM, with diagnoses to include frequent falls and chronic pain syndrome (a condition characterized by persistent pain lasting longer than three months) and was discharged from the facility on November 15, 2025. A review of a Grievance/Concern Form filed by Resident 1 on November 7, 2025, revealed the resident reported that he did not receive his prescribed oxycodone 10 mg (a narcotic analgesic medication prescribed for the treatment of moderate to severe pain and requires timely administration as ordered to manage pain) upon admission to the facility. Further review of the grievance form indicated the grievance was assigned to the Director of Nursing and Unit Manager for follow up. A review of Resident 1's Medication Administration Record and progress notes revealed the resident's ordered narcotic pain medication was not administered until November 8, 2025, at 4:56 PM, following admission to the facility. Further review of the grievance documentation revealed social services met with Resident 1 to discuss the concern on November 10, 2025. Review of the grievance resolution section indicated the grievance was closed with the notation that the resident was discharged prior to resolution. The grievance form was signed by the Nursing Home Administrator, identified by policy as the grievance official. Review of the timeline revealed the resident remained in the facility for eight days following the filing of the grievance, exceeding the facility's stated five working day timeframe for grievance resolution. There was no documented evidence that the facility timely evaluated the resident's grievance regarding the failure to receive prescribed narcotic pain medication upon admission. There was no documented evidence of attempts to resolve the grievance within five working days, as required by facility policy, nor was there documentation of corrective action, findings, or communication of a resolution to the resident prior to discharge. An interview with the Nursing Home Administrator on December 30, 2025, at 1:00 PM, revealed that the Director of Nursing printed the resident's Medication Administration Record in response to the grievance; however, the Nursing Home Administrator confirmed no further action was taken to resolve the grievance. An interview with the Nursing Home Administrator on December 30, 2025, at 1:40 PM, reviewed the above findings and confirmed the facility did not resolve Resident 1's grievance regarding the receipt of prescribed oxycodone prior to discharge. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of resident clinical records, select facility policy, and staff interview it was revealed that the facility failed to assure that one of 10 residents reviewed were free of significant medication errors. (Resident 1)Findings include: A review of a facility policy, entitled Reconciliation of Medications on Admission last reviewed by the facility on May 2, 2025, defined the medication reconciliation process as the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescriptions. The policy further detailed the steps in completing a medication reconciliation which included gathering the information needed to reconcile the medication list by using the approved medication reconciliation form, the discharge summary from the referring facility, the admission order sheet, and all prescription and supplement information obtained from the resident/family during the medication history. The policy further explained that the medication reconciliation process is used to ensure that all medications, routes, and dosages on the list are appropriate for the resident and his/her condition. The policy explained that medication reconciliation helps to ensure the medications, routes and dosages have been accurately communicated to the Attending Physician and care team. The steps portion of the policy directed staff to ask the resident or responsible party to list all physician and pharmacies from which he or she obtained medications. The policy revealed that if there was a discrepancy between documentation, the staff member was to contact the nurse from the referring facility, contact the physician from the referring facility, discuss the findings with the resident/family, contact the residents outside provider and pharmacies for an accurate list of current medications. The policy then directed staff to document any discrepancy on the medication reconciliation form, what actions were taken by the nurse to resolve the discrepancy, and document whether the discrepancy was resolved or not. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include hypertension (a condition blood pushes too forcefully against artery walls) and hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone). A review of Resident 1's clinical record revealed that upon admission, records were obtained from the referring facility which included a current medication list dated November 3, 2025. The list included the following medications:Sennoside 8.6mg-1 tablet by mouth twice a day for constipation.Pantoprazole 40mg- 1 tablet by mouth daily for acid reflux.Tiotropium 2.5mcg- 2 inhalations by mouth daily for breathing.Bacitracin 500units/gm ointment- apply moderate amount topically twice a day for skin infection.Aspirin 81mg- take one tablet by mouth daily every day for heart health.Oxybutynin 5mg- take one tablet by moth twice a day for overactive bladder.Levothyroxine 175mg- take one tablet by mouth every day at 6am for thyroid hormone replacement.Fluticasone/Salmeterol- inhale 1 puff by mouth twice a day for breathing. Semaglutide 0.25mg/0.375ml- Inject 0.5mg subcutaneously once weekly for diabetes.Hydrophilic cream- apply small amount topically every day for dry skin.Oxycodone 10mg- Take one tablet every 4 hours for pain.Losartan 50mg- Take one half tablet by mouth daily for blood pressure.Gabapentin 300mg- take one capsule by mouth three times a day for pain.Magnesium oxide 400mg- take one tablet by mouth daily for low magnesium.Famotidine 20mg- take one tablet by mouth twice daily.Finasteride 5mg- take one tablet by mouth daily for prostate.Apixaban 5mg- take 1 tablet every 12 hours for atrial fibrillation (an irregular heartbeat).Acetaminophen 325mg- take one tablet every 4 hours as needed for pain.Allopurinol 300mg- take one tablet by mouth daily for gout (an inflammatory disease). Ferrous Gluconate 324mg- take one tablet every other day for iron replacement.Furosemide 40mg- take one tablet by mouth daily for swelling and blood pressure.Tamsulosin 0.4mg- take one capsule by mouth twice a day for enlarged prostate (male reproductive gland).Further review of Resident 1's clinical record revealed the facility failed to ensure an accurate and complete medication reconciliation was completed upon admission, resulting in the resident being placed on medications that had been previously discontinued.A review of Resident 1's clinical record revealed that upon admission, the resident was placed on the following medications that were not included on the current medication list provided by the referring facility:Methimazole 10 mg, administer one half tablet by mouth every Saturday and Sunday for hyperthyroidism (a condition in which the thyroid gland produces excessive thyroid hormone), despite referring facility documentation indicating the resident was being treated with levothyroxine 175 mcg for hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), representing conflicting thyroid therapies.Simvastatin 40 mg, one tablet by mouth in the evening for high cholesterol, despite the medication not being included on the current medication list from the referring facility.Lisinopril 20 mg, one tablet by mouth every morning for hypertension, despite the most recent medication list documenting the resident was being treated with losartan for blood pressure control.A review of the referring facility's clinical documentation revealed that lisinopril 20 mg was discontinued on May 22, 2024, due to an episode of hyperkalemia (a condition in which potassium levels in the blood are abnormally elevated, which can interfere with heart rhythm and muscle function and may result in life-threatening complications). The referring documentation further confirmed that methimazole and simvastatin were also discontinued at that time. A review of Resident 1's progress notes revealed a nursing entry dated November 11, 2025, at 4:38 PM, documenting that the provider ordered laboratory testing to be completed on November 12, 2025, and directed that lisinopril be discontinued. A review of Resident 1's laboratory results dated [DATE], at 7:35 AM, revealed the resident's potassium level was elevated at 5.2 mmol/L (normal range 3.5-5.1mmol/L).A review of Resident 1's progress notes revealed a note dated November 12, 2025, at 12:21 PM, documenting that the provider was notified of the elevated potassium level, reviewed the laboratory results, and issued a new order to administer Kayexalate, a medication used to treat hyperkalemia by lowering potassium levels in the blood. An interview with the Nursing Home Administrator conducted on December 30, 2025, at 1:00 PM, revealed that a medication list dated May 22, 2024, was utilized during the admission medication reconciliation process, despite the referring facility's clinical record containing an updated medication list dated November 3, 2025. The Nursing Home Administrator confirmed the facility failed to reconcile medications in accordance with facility policy, resulting in Resident 1 receiving multiple discontinued medications, including lisinopril, which contributed to another episode of hyperkalemia. An additional interview with the Nursing Home Administrator on December 30, 2025, at 1:40 PM, confirmed the above findings and acknowledged that the medication reconciliation process was not completed as required by facility policy, resulting in the facility's failure to ensure the resident was free from a medication error. 28 Pa. Code 211.10 (c) Resident Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy Services.

Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members as planned to ensure safety and prevent major injuries. As a result, one resident (Resident 1) sustained multiple subdural hematomas and closed nasal fracture requiring hospital evaluation, representing actual harm for one resident out of one sampled for abuse prohibition.Findings include: A review of the facility's policy entitled Abuse and Neglect Clinical Protocol, last reviewed by the facility on May 2, 2025, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is the policy of the facility, as part of the strategy to prevent abuse, neglect, mistreatment, and exploitation of residents, that volunteers, employees, and contractors hired by the facility are expected to be able to identify neglect as it may occur against residents and prevent resident neglect as a priority throughout all levels of the organization. A review of the facility's policy entitled Managing Falls and Fall Risks, last reviewed by the facility on May 2, 2025, revealed it is the policy of the facility that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (severe weakness or paralysis on one side of the body) due to cerebral infarction (brain tissue damage caused by interruption of blood flow). A Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 1, dated September 18, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) and indicated the resident was dependent (relying on someone for physical support) for rolling side to side in bed. Review of Resident 1's care plan for risk of falls, initiated December 28, 2021, indicated the resident was at risk for falls due to impaired balance, poor coordination, and a history of falls. Interventions included the use of a bariatric bed (type of bed used to accommodate overweight or larger individuals) and mattress and encouragement to change positions slowly. Continued review of Resident 1's current comprehensive person-centered care plan indicated the resident had an ADL (activities of daily living) self-care performance deficit related to physical limitations. Planned resident-centered interventions revealed the resident required two-staff assistance with bed mobility initiated on May 6, 2024, with revision on September 29, 2025. A clinical record review for Resident 1 revealed a form titled Lift, Transfer, and Reposition, dated September 12, 2025, that revealed Resident 1 required two staff members for repositioning in bed. A nurse's progress note written by Employee 1 (Registered Nurse Supervisor) dated October 10, 2025, at 2:25 AM, documented that on October 9, 2025, at 10:20 PM, Employee 1 received notification from the nurse assigned to Resident 1 that Resident 1 had been found lying on the floor on their back after a fall from bed. Upon assessment, Resident 1 was noted to have a superficial laceration (wound) on the bridge of the nose measuring 1.2 centimeters (cm) in length and two additional superficial cuts on the forehead measuring 0.5 cm and 0.8 cm, accompanied by mild swelling. Resident 1 complained of right shoulder pain. The bleeding was controlled, the physician was notified of the incident, and orders were received to transfer Resident 1 to the emergency department for further evaluation. Resident 1 was subsequently transported to the hospital for medical assessment and treatment. A nurse's progress note written by Employee 1 (RN Supervisor) dated October 10, 2025, at 2:53 AM revealed that an in-service was conducted with the assigned aide for Resident 1 regarding proper two-person assist for dependent residents, and emphasizing stabilization during turning and hygiene care A review of outside hospital records provided by the facility, dated October 10, 2025, revealed that Resident 1 presented to the emergency department after a fall at the facility that occurred while an aide was rolling Resident 1 during routine care. The documentation indicated that Resident 1 fell onto his right shoulder and forehead, resulting in an abrasion (a scrape or rubbing away of the skin) and a hematoma (a localized collection of clotted blood outside the blood vessels) extending from the nasal bridge into the forehead. A CT scan (computed tomography imaging test that uses X-rays and a computer to create detailed cross-sectional images of the body) of the head revealed multiple subdural hematomas (collections of blood between the brain and its protective covering), with the largest on the left side, as well as intraparenchymal hemorrhage (bleeding within the brain tissue), bleeding between the scalp and skull, swelling of the right frontal scalp, and mild bilateral paranasal (pertaining to the air-filled cavities within the skull bones around the nasal cavity) soft tissue swelling. Imaging also raised suspicion of a non-displaced fracture (a bone break without separation of the bone fragments) of the left nasal bone. Hospital documentation noted that Resident 1 was receiving hospice services at the facility, and the resident's family elected for discharge from the emergency department with return to the facility following evaluation. A nurse's progress note written by Employee 2, Licensed Practical Nurse (LPN), dated October 10, 2025, at 9:16 AM revealed that Resident 1 returned from the emergency room post-fall with a diagnosis of subdural hematoma and closed fracture of the nasal bone. The facility's investigative documentation initiated October 10, 2025, by Employee 1 (RN Supervisor) revealed that Employee 3 (Nurse Aide, NA) had rolled Resident 1 onto his side in bed by herself to provide incontinence care. Resident 1 slowly fell out of bed to the floor. Further review revealed that Employee 4, LPN, was called to the room by Employee 3, NA, and Resident 1 was on the floor between beds laying on his right arm and shoulder, and bleeding was noted from his face. The investigation determined that Employee 3 was aware that two-person assistance was required but provided care alone. The facility substantiated neglect based on failure to follow the resident's plan of care. A written statement from Employee 4 (LPN), dated October 9, 2025 (no time indicated), confirmed they responded to the call and found Resident 1 was on the floor between the beds, lying on his right arm and shoulder, and bleeding was noted from his face, and Employee 3 was next to the resident. A written witness statement completed by Employee 3, Nurse Aide, dated October 10, 2025 (no time indicated), revealed that while completing rounds after dinner, Employee 3 entered Resident 1's room to change the resident's brief. Employee 3 rolled Resident 1 onto the resident's side in bed without assistance, despite being aware that Resident 1 required the assistance of two staff members for bed mobility. The statement indicated that Resident 1 occasionally flinched during care. While reaching to retrieve a clean brief, Employee 3 maintained one hand on Resident 1, who then began to roll toward the window side of the bed. Employee 3 climbed onto the bed in an attempt to control the movement and assisted Resident 1 to the floor; however, Resident 1's face struck the oxygen concentrator positioned beside the bed. Employee 3 then placed a bath blanket under Resident 1's head and immediately called for help. A telephone interview conducted with Employee 3, Nurse Aide, on October 21, 2025, at 1:30 PM revealed that on October 9, 2025, at 10:20 PM, Employee 3 provided personal care for Resident 1. During care, Employee 3 rolled Resident 1 onto the resident's side to clean the resident. After reaching for a clean brief, Resident 1 continued rolling toward the window on the left side of the bed. Employee 3 reported being unable to prevent the movement but was able to grasp Resident 1 and control the descent to the floor. Before reaching the floor, Resident 1's head struck an oxygen concentrator situated next to the bed. Following the incident, Resident 1 was observed on the floor between both beds with facial bleeding. Assistance was obtained, and Resident 1 was lifted back into bed with the use of a mechanical lift. Employee 3 confirmed awareness that Resident 1 required the assistance of two staff members for bed mobility during care. A review of human resources documentation revealed Employee 3 was hired on August 27, 2025, and completed initial in-service training on that date, including abuse prevention education. Employee 3 was suspended on October 9, 2025, pending investigation and was terminated on October 14, 2205. There was no documented evidence that Employee 3 followed the resident's care plan, which required two staff members for safe bed mobility. Employee 3 rolled Resident 1 in bed by herself at 10:20 PM on October 9, 2025, and turned her back to grab a brief, resulting in Resident 1 rolling out of bed onto the floor and sustaining a forehead laceration and subdural hematoma. An interview with the Director of Nursing on October 21, 2025, at 3:00 PM revealed that facility documentation reflected the internal investigation substantiated neglect related to the failure to provide care with two-person assistance as required by the plan of care. The substantiated neglect resulted in actual physical harm to Resident 1, including multiple subdural hematomas, a facial laceration, and a closed nasal fracture. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observation and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 resident shower areas in the facility and maintain a clean and safe outdoor smoking area Findings include: On October 21, 2025, at 1:00 P.M., observations of the Area 145 shower/bathroom revealed multiple items stored inappropriately within resident bathing areas, including two shower chair buckets, a mechanical lift sling, a pair of sneakers, and an open plastic bag of briefs placed inside the bathtub. The bathtub's waterspout was coated with a thick layer of dried white residue. In the first shower stall, the perimeter of the floor was coated with a black, sticky substance. The floor surface showed visible soil and buildup. A stainless-steel soap dispenser on the wall exhibited visible streaks and brown discoloration, and the ceiling vent was layered with lint. The air conditioning/heating ceiling unit also had visible accumulations of dust and debris. The shower bed in the second shower stall was observed with a white powdery film and areas of dried residue. In the Area 158 shower room, the perimeter of the flooring contained a similar black, sticky buildup. A large rust stain was visible on the wall beneath the handrails. Two ceiling cuts were noted, and the ceiling vent displayed significant lint accumulation. A shower chair within this area was stained with brown discoloration. The wheelchair scale had visible buildup and liquid residue, and the stand-up mechanical lift showed dried deposits and surface staining. The bathtub in the same area contained a pair of wheelchair leg rests. The floors throughout the shower room exhibited visible debris, including plastic and paper materials, and the edges contained black adhesive-like residue. An observation of the outdoor smoking area near the laundry entrance revealed extensive cigarette litter across the concrete surface, including ashes and cigarette butts. Three white plastic patio chairs were coated with black residue consistent with cigarette ash. The patio table contained ashes and cigarette debris. Four surrounding fabric chairs appeared worn and soiled, with several burn holes noted on the seat fabric. During an interview on October 21, 2025, at 3:00 P.M., the Nursing Home Administrator acknowledged that all facility areas are expected to be always maintained in a clean and sanitary condition.28 Pa. Code 201.18 (e)(1) (2.1) Management

Based on observation, review of clinical records, facility policy, and resident and staff interviews, it was determined the facility failed to implement its established smoking policy to ensure resident safety. The facility failed to post the smoking policy in a conspicuous and legible manner, failed to ensure that required smoking safety equipment was available in the designated smoking area, and failed to ensure smoking materials were properly secured for nine residents who smoke (Residents 2, 3, 4, 5, 6, 7, 8, 9, and 10).Findings include: A review of the facility's policy titled Facility Smoking Policy, last reviewed May 2, 2025, revealed that smoking be permitted only in designated areas that are separate from resident care areas, well ventilated, and equipped with portable fire extinguishers. The policy identified the designated smoking location as the courtyard accessible through the door near the laundry and outside the Station 1 dayroom, prohibited oxygen use in smoking areas, and required that residents be evaluated for smoking safety upon admission and re-evaluated quarterly and with a change in condition. The policy required that residents be supervised until evaluated as safe to smoke independently, that smoking times be scheduled at 10:30 AM, 1:30 PM, 4:00 PM, and 7:00 PM, and that each resident's smoking status be reflected in the care plan. In addition, the policy required smoking supplies, including cigarettes, matches, and lighters, to be labeled with the resident's name and room number, maintained by staff, and stored at the reception desk. Residents were not permitted to keep their own lighters, lighter fluid, or matches. During the entrance conference on October 21, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility permits smoking in designated areas. A list of smoking residents provided by the facility included Residents 2, 3, 4, 5, 6, 7, 8, and 9. Resident 10 was observed smoking during the survey but was not included on the list provided to the survey team. An observation conducted on October 21, 2025, at approximately 10:15 AM, revealed Residents 3 and 4 smoking on the patio outside the laundry room without staff supervision. Each resident possessed their own cigarettes and lighter and independently lit their cigarettes. Resident 2 was observed entering a door code into the keypad outside the smoking entrance door. Resident 2 was interviewed at that time and stated that she knew the door code and went to the smoking area independently in her wheelchair whenever she wished. She stated she did not wear a smoking apron and kept her cigarettes and lighter at her bedside. Further observation of resident areas and lobby spaces on October 21, 2025, revealed that the facility's smoking policy was not posted in any resident area or common space. At approximately 10:20 AM the same day, Residents 3 and 4 were interviewed and stated that they knew the door code to the smoking area and went out to smoke without notifying staff. They reported they kept their smoking materials and smoked independently. An observation on October 21, 2025, at 10:53 AM revealed Resident 10 in her wheelchair in the first-floor A hallway with a pack of cigarettes and a lighter in her lap. She wheeled herself to the smoking area door, entered the key code, went outside to the patio, lit her cigarette, and began smoking without staff supervision. Resident 2 was admitted [DATE], with a diagnosis of emphysema (a chronic, progressive lung disease that causes shortness of breath). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated April 18, 2024, directed staff to check her room for smoking materials, secure smoking materials at the front-lobby reception desk, and educate family and visitors not to leave smoking items in her room. Resident 3 was admitted to the facility on [DATE], with diagnosis to include Chronic Obstructive Pulmonary Disease (COPD). A quarterly MDS (Minimum Data Set, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 8, 2025, revealed a BIMS score of 15 (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents a score of 13 to 15 indicates intact cognition). A smoking assessment dated [DATE], identified him as an independent smoker. His care plan, dated August 19, 2025, directed staff to educate family and visitors not to leave smoking materials in his room and to store such materials at the front-lobby desk. Resident 4 was admitted [DATE], with a diagnosis of COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified him as an independent smoker. A care plan initiated May 21, 2025, and revised June 24, 2025, instructed staff to check his room for smoking materials, secure them at the reception desk, educate family and visitors about smoking policies, and ensure oxygen was removed before smoking and replaced after. Resident 5 was admitted [DATE], with COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 3, 2024, included, remove oxygen to smoke, reapply when done smoking, check resident room for smoking materials (cigarettes, matches, lighters, etc.) at the lobby reception desk. Educate family and visitors not to leave smoking materials in resident room, educate resident to interventions and facility smoking policy and procedures and to secure smoking materials (cigarettes, matches and lighters at the front lobby desk. Resident 6 was admitted on [DATE], with emphysema. An annual MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. Her care plan, initiated September 13, 2023, instructed staff to check her room for smoking materials, secure them at the reception desk, and educate residents and visitors regarding smoking procedures. Resident 7 was admitted [DATE], with a diagnosis of hypertension (elevated blood pressure). An annual MDS dated [DATE], revealed a BIMS score of 14 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 12, 2024, instructed staff to check her room for smoking materials, secure them at the reception desk, and educate the resident and family on smoking policy expectations. Resident 8 was admitted [DATE], with COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 14 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 12, 2024, directed staff to remove oxygen before smoking, reapply it after, check for smoking materials in her room, and secure them at the reception desk. Resident 9 was admitted [DATE], with COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 14, 2025, directed staff to remove oxygen before smoking, reapply after, check her room for smoking materials, and secure them at the reception desk. Resident 10 was admitted [DATE], with chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide). A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated July 9, 2025, directed staff to check her room for smoking materials, secure them at the reception desk, educate family and visitors not to leave smoking materials in the room, and ensure adherence to the smoking policy. An interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on October 21, 2025, at 2:00 PM, revealed that residents maintained smoking materials such as cigarettes and lighters in their rooms and that the smoking policy was posted only outside the smoking-area exit door. The DON and NHA indicated that the facility's current practices for securing smoking materials and posting the policy were not consistent with the facility's written smoking policy. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 209.3 (a) Smoking. 28 Pa Code 211.10 (c) (d)Resident care policies

Based on observation and staff interview, it was determined the facility failed to maintain food delivery equipment in a clean and sanitary condition to prevent potential food contamination for four of four food delivery carts observed (Pine, Oak, Willow, and Spruce hallways).Findings include: Safe food handling and sanitation standards established by the United States Department of Agriculture (USDA) and Food and Drug Administration (FDA) require all equipment and utensils used in the storage, preparation, and delivery of food to be kept clean and in good repair. Equipment must undergo a two-step process consisting of cleaning (removal of visible soil and debris) and sanitizing (application of heat or chemical solution to reduce microorganisms that may cause illness). Harmful bacteria that cause foodborne illness cannot be seen, smelled, or tasted; therefore, strict adherence to cleaning and sanitizing procedures is required to prevent contamination. On October 21, 2025, the following observations were made during meal service: At 11:45 AM, the stainless-steel food delivery cart on the Pine hallway had a large amount of dried food and liquid residue on the top, sides, and doors. The interior floor of the cart contained accumulated food particles, paper debris, and visible dirt. At 11:55 AM, the stainless-steel food delivery cart on the Oak hallway had dried food residue, liquid stains, and visible dirt on the exterior and interior surfaces. At 12:10 PM, the stainless-steel food delivery cart on the [NAME] hallway had dried food and liquid residue on the top, sides, and doors, with paper debris and dirt on the floor of the cart. At 12:30 PM, the stainless-steel food delivery cart on the Spruce hallway had dried food and liquid residue on the top and doors, with accumulated food debris and dirt on the floor of the cart. The metal shelving unit on the left side of the cart was broken, and the detached metal brackets were resting inside the cart. During an interview on October 21, 2025, at 3:15 PM, the Nursing Home Administrator, the above observations were reviewed. 28 Pa code 201.18(b)(1) Management

Based on a review of clinical records, resident and staff interviews, and facility documentation, it was determined the facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living (ADLs) consistently received necessary care and services to maintain personal hygiene and dignity for two residents out of 24 sampled residents (Residents 25 and 60). Findings include: A review of Resident 25's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease (a movement disorder of the nervous system that cause symptoms of tremors, rigidity, and postural instability), and muscle weakness. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 12, 2025, indicated the resident required substantial/maximal assistance from staff for showering/bathing. The resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 13-15 indicates the resident is cognitively intact). During an interview with Resident 25 on June 25, 2025, at 9:59 AM, the resident reported that staff were not consistent with providing showers on scheduled days, stating, Mondays and Fridays are my shower days, usually at night. I got one this week, but I have gone almost three weeks sometimes without getting a shower. A review of Resident 25's Kardex (a quick-reference summary for staff to guide delivery of care) documented that Resident 25 was scheduled to receive showers on Mondays and Fridays during the evening shift. A review of the Documentation Survey Report v2 for May 2025 revealed that on multiple scheduled shower dates (May 5, May 9, May 12, May 19, May 23, May 26, and May 30, 2025), showers were either not documented as provided or coded as not done (code 09) or not attempted due to medical condition (code 88). There was no supporting documentation indicating a change in condition that would have precluded showering. Similarly, a review of the Documentation Survey Report v2 for June 2025 revealed continued inconsistencies in shower provision and documentation for Resident 25. On June 2, 2025, the log recorded a code of 07 indicating the resident refused the shower. For June 6, 2025, the log recorded a code of 88, indicating the shower was not attempted due to a medical condition or safety concerns; however, there was no documentation showing any change in condition that would have prevented the resident from receiving a shower. Further review showed no documentation for June 13, 2025, to confirm that a shower was provided. The log for June 16, 2025, showed NA (not applicable), and there was no documentation to show that a shower was provided on June 20, 2025, as scheduled. During an interview with the Nursing Home Administrator (NHA) on June 26, 2025, at approximately 11:00 AM, the NHA acknowledged that Resident 25 was scheduled to receive showers on Mondays and Fridays and confirmed that showers should have been provided as scheduled. The NHA could not explain why showers were not consistently provided or documented. A review of Resident 60's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include paralytic syndrome (a term for complete loss of strength in an affected limb or muscle group. It can be caused by damage to the brain, spinal cord, or peripheral nerves), hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain. The excess fluid increases the size of the ventricles and puts pressure on the brain), and muscle weakness. A review of Resident 60's comprehensive resident centered plan of care initiated on August 2, 2023, identified urinary incontinence and included goals to maintain the resident in as clean and dry as possible. Planned interventions required staff to provide toileting assistance at established times and to perform timely incontinence checks and changes, remind resident that it was time to use toilet, adjust toileting times to meet the resident's needs, and place urinal/bedpan within reach. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 3, 2025, indicated the resident required extensive assistance of two-plus staff for bed mobility, transfers, and toilet use. Additionally, the MDS indicated the resident was always of incontinent of urine and bowel without a toileting plan. During an interview with Resident 60 on June 24, 2025, at 9:54 AM, the resident reported that after dinner on Saturday, June 21, 2025, he made requests for his soiled incontinence brief to be changed after dinner but was not changed until 6:00 AM on June 22, 2025. Also, the resident stated he often had to wait long periods of time for staff to change his soiled briefs. A review of the resident's task survey report (an electronic report that summarizes care activities completed by nurses 'aides) dated June 2025, revealed that on Saturday June 21, 2025, staff recorded NA (not applicable) at 6:59 AM on 11PM-7AM shift, a blank (no documentation) on 7AM-3PM shift, and was incontinent of urine and changed at 10:59 PM on 3PM-11PM shift and on Sunday June 22, 2025, the resident was record to have been incontinent at 1:38 PM and no further record of incontinence care recorded by staff. During an interview with the Director of Nursing (DON) on June 26, 2025, at approximately 11:30 AM, the DON confirmed Resident 60 should have been on a every two-hour check and change program due to urinary and bowel incontinence and staff were required to record completion of these tasks in the electronic record. The facility could not provide documented evidence that Resident 60's plan of care addressed his individualized incontinence needs or documentation of staff consistently completing incontinence checks on each shift in efforts to keep the resident's skin clean and dry. The above findings were reviewed in an interview with the DON on June 6, 2025, at approximately 2:00 PM. The facility could not provide documented evidence that Resident 60's incontinence needs were assessed, and care planned to meet his individualized needs or that he received timely care and services to manage his incontinence 28 Pa. Code 211.12 (c)(d)(5) Nursing services.

Based on a review of the facility's scheduled mealtimes, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by seven of seven residents participating in a group interview (Residents 8, 11, 80, 67, 37, 44, and 50). Findings include: A review of facility policy titled Snacks, last reviewed by the facility on May 2, 2025, revealed it is the facility policy that snacks and beverages will be provided as identified in residents' individual plans of care. Bedtime (HS- hour of sleep) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. During a resident group interview conducted on June 25, 2025, at 10:00 AM, seven residents in attendance (Residents 8, 11, 80, 67, 37, 44, and 50) stated that snacks are not routinely offered to them in the evenings, and they would like to receive an evening or bedtime snack. Residents 11 and 67 reported that, in the past, a kitchen staff member would come around to offer snacks in the evening; however, currently, the snack cart is delivered to the nurses' station and nursing aides are responsible for delivering snacks. Resident 11 reported, the aides don't have time to do that; we have to come to the station if we want a snack. Resident 73 expressed disappointment that staff only allow residents to take one snack, stating, it's sometimes not enough. The bag of chips you get is small and only gives you a couple in it. During an interview on June 26, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) was unable to explain why residents were not consistently offered snacks as desired. The NHA acknowledged awareness of the issue and stated that residents should be provided a snack at bedtime. These findings were reviewed with the Nursing Home Administrator on June 26, 2025. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, select facility policy and staff interviews it was determined the facility failed to develop and implement individualized pain management programs, consistent with professional standards of practice, to meet the pain management needs and attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for two residents out of 24 reviewed (Resident 37 and Resident 98). Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. A review of a facility policy last reviewed by the facility on May 2, 2025, revealed the physician will order appropriate non-pharmacologic and medication interventions to address a resident's pain. The policy further revealed staff will provide the elements of a comforting environment and appropriate physical and complementary interventions including heat or ice, repositioning, massages, and the opportunity to discuss their management of chronic pain. A review of Resident 98's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included Parkinson's Disease (a progressive neurological disorder that primarily affects movement, causing tremors, stiffness, and balance difficulty), and chronic pain. A review of a physician order initially dated March 28, 2025, revealed the resident was ordered Oxycodone (a narcotic pain medication) 10MG give 1 tablet via PEG-Tube (a tube inserted into the stomach to administer nutrition and medication) every 6 hours as needed for a pain level of 4 to 10 (0 indicates no pain and 10 indicates the worst pain) with Non-Pharmacological Interventions (healthcare strategies that don't involve medication but instead focus on other approaches to improve health and well-being) including 1. Reposition 2. Back rub 3. Music 4. Warm/cool compress 5. Diversional activity. A review of the resident's March 2025 Medication Administration Record (MAR) revealed staff administered the as needed Oxycodone 5 times for the month of March. Of the five doses given, 5 doses were administered with no non-pharmacological interventions attempted prior to giving the pain medication, despite the order indicating the need for the non-pharmacological interventions. A review of the residents May 2025 MAR revealed staff administered the as needed Oxycodone on May 2, 2025, for a pain scale of 0, indicating the resident was not experiencing any pain, revealing the pain medication was administered outside of the physician order indicating the as needed medication is to be administered for pain severity on a scale of 4 to 10. A review of the residents June 2025 MAR revealed staff administered the as needed Oxycodone 42 times in the month of June. Of the 42 doses administered, 42 doses were administered with no non-pharmacological interventions attempted prior to giving the pain medication. A review of Resident 37's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease and osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage, this breakdown causes pain). A review of a physician order initially dated June 12, 2025, revealed the resident was ordered Tramadol 50mg every 8 hours as needed for pain for 14 days. A review of the resident's June MAR revealed staff administered the as needed tramadol 15 times with no non-pharmacological interventions attempted prior to each administration of the medication. An interview with the Director of Nursing on June 26, 2025, at approximately 10:00AM revealed the facility was unable to supply supporting documentation that nonpharmacological interventions were attempted prior to the administration of the as needed pain medication for resident 98 and resident 37. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and information submitted by the facility and staff interviews, it was determined that the facility failed to provide sufficient staff assistance and utilize safe technique during care to prevent an accident resulting in severe injury (fractured humerus (upper arm)) to one resident (Resident 79) out of 24 residents reviewed. Findings include: A review of the clinical record revealed that Resident 79 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of a 30-day Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 9, (YEAR), revealed that the resident's cognition was intact and that he required extensive assistance with two persons for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture) and for transfers between surfaces. The resident's care plan, dated (MONTH) 11, (YEAR), revealed a problematic area of the resident's risk for falls related to impaired mobility with a care planned intervention for the assist of two attendants (staff) for bed mobility and transfers. A nurses' note dated (MONTH) 22, (YEAR), at 11:44 AM indicated that the resident fell from bed on 5/22/18 (May 22, (YEAR)). Later that day at 2:18 PM, nursing noted that an order was received for an x-ray of the right arm. Results from the x-ray revealed a non-displaced acute [MEDICAL CONDITION] humeral neck (the humerus is the long bone in the upper arm. It is located between the elbow joint and the shoulder) with a clinical correlation suggesting an orthopedic (branch of medicine concerned with conditions involving the musculoskeletal system) consultation. A review of a Pennsylvania Department of Aging, Act 13 Mandatory Abuse Report, (a state mandated report form for investigation of alleged abuse) dated (MONTH) 24, (YEAR), and a Pennsylvania Bulletin PB22 (a state mandated report form for investigation of alleged abuse, neglect and misappropriation) also dated (MONTH) 24, (YEAR), both revealed that on (MONTH) 22, (YEAR), at approximately 10:30 AM, Employee 3 (nurse aide) went into the resident's room to wash and dress Resident 79 while the resident was in bed. Employee 3 was standing at the left side of the resident's bed while changing the resident's brief with the resident positioned on his right side when the resident started to cough and slid out of his bed onto the floor. Further review of the two aforementioned reports revealed the resident is an assist of 2 for bed mobility per his plan of care and that the employee (Employee 3) did not follow his care plan by having another person assist her with the resident's care, resulting in this resident's fall and fracture. Review of an attached witness statement (a description of the event/incident by staff) signed by Employee 3, revealed that the nurse aide wrote that the resident is an assist of two for bed mobility and transfers; however, I was the only aide providing care to him at the time of the incident. Review of a facility Follow-Up Question Report dated (MONTH) 22, (YEAR), pertaining to Bed Mobility-Support Provided revealed that on 19 occasions, from (MONTH) 1, (YEAR), through (MONTH) 22, (YEAR), nursing staff documented that the resident was assisted in bed mobility by only one staff, not two as care planned. An interview with Director of Nursing (DON) on (MONTH) 23 10, (YEAR), at approximately 2:10 PM confirmed that the nursing staff failed to consistently provide sufficient activities of daily living assistance as planned for this resident and failed to use safe nursing technique when rolling and a re-positioning the resident in bed. The nurse aide rolled the resident away from the nurse aide, without additional staff assistance at the bedside, during the provision of personal care, and the resident slipped out of bed and sustained a fracture. 483.26(d)(1)(2) Free of Accidents Previously cited 8/5/16 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services. Previously cited 9/29/17, 7/17/17, 8/5/16 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/29/17, 8/5/16

Based on review of clinical records, select facility policy and resident incident reports, observation, and staff interview, it was determined that the facility failed to timely identify changes/declines in skin integrity to prevent pressure sore development for three out of 23 residents sampled (Residents 20, 65, and 113). Findings include: A review of the facility Skin Integrity Management Policy reviewed by the facility January 2, 2014, revealed that the implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Practice standards included: to identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Determine the need for support surface for bed and chair, determine the need for heel protectors and heel lift devices. A review of the facility policy for Accidents\Incidents (including injuries of unknown origin) reviewed by the facility May 15, 2014, indicated that if the incident is an injury of unknown origin, interview all staff assigned to the customer (resident) for the preceding 48 hours. A review of the clinical record revealed that Resident 20 had diagnoses, which included diabetes mellitus and [MEDICAL CONDITION]. A significant change Minimum Data Set assessment (MDS process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated, May 21, 2014, revealed that the resident required staff assistance for ADLs (Activities of Daily Living), had limited range of motion of the lower extremity on one side, and was at risk for developing pressure sores. A review of the resident's current plan of care indicated that the resident was at risk for skin breakdown. Interventions to prevent skin breakdown included weekly skin assessments by the licensed nurse, to turn and reposition the resident every two hours and keep the heels elevated off the bed. The means as to how the resident's heels were to be elevated off the bed were not identified on the plan of care. There was also no plan for more frequent skin checks based on the resident's [DIAGNOSES REDACTED]. Review of the resident's Follow Up Question Report revealed that the resident refused to keep her heels elevated on July 1, 4, 7, 20, and 22, 2014. A Task History Report dated, March 26, 2014, indicated that the resident was to have a Prevalon boot (specialty boot used to relieve pressure) to the bilateral extremities when in bed. Resident refusals of this intervention were noted on July 1,4, 7,8,9,10, 12, 14, 15, 16,18, 19, 20, 22, 24, and 25, 2014. There was no indication of the reason for the resident refusal or if education was provided to the resident on the reason for measure or if alternative approaches to relieve pressure on the resident's heels were attempted. A Physical Therapy Evaluation dated, July 18, 2014, noted that the resident had a decline in lower extremity strength, an increase in swelling of the bilateral extremities and had developed a pressure area over the right lower leg from the use of a MAFO (a molded ankle foot orthotic). A nurses note dated, July 13, 2014, at 3:13 a.m., noted that the resident complained of lower extremity pain. [MEDICATION NAME] (pain medication), prescribed on an as needed basis, was given as ordered with positive effect. There was no documented evidence that a skin assessment was performed by nursing at this time. A nurses note dated, July 14, 2014, at 10:30 AM noted that a 1.5 cm x 0.5 cm x 0.3 cm abrasion was present on the resident's right ankle, which was described as 50 % necrotic and 50% granulation and painful. The physician was notified and the MAFO was discontinued until the area resolved. A physician order was also received to cleanse the abrasion of the right ankle with wound spray cleanser, pat dry, and apply Hydrogel (cut to size) to wound bed with non sting skin prep to periwound and cover with 2 x 2 Border gauze and change everyday and as needed. Review of the related incident report dated July 14, 2014, noted that the resident had stated that her ankle gets sore from wearing the brace and that it was hurting and rubbing her ankle. A nurses note dated July 26, 2014, at 10:31 p.m., indicated that the resident had a deep tissue injury to the left heel, which measured 4 cm x 5 cm. A deep tissue injury to the right heel measuring 2 cm x 3.5 cm was also noted. Review of the corresponding incident report dated, July 26, 2014, at 10:00 PM indicated that these areas were in-house acquired pressure ulcers. Observation of the resident on August 21, 2014, at 10:30 a.m., revealed that the facility was treating the resident for Moisture Associated Skin Damage to the left and right buttock. According to the resident's Skin Integrity Report the damaged area was not incontinence related. Observation of the area revealed that the resident also had breakdown to her gluteal folds, which were not being treated by the facility. Interview with the director of nursing in training on August 21, 2014, at 11:30 a.m., failed to provide documented evidence that the facility implemented effective interventions to prevent pressure sore development and to timely identify and assess changes in skin integrity to prevent worsening and promote healing. A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment indicated that the resident required staff assistance for activities of daily living (ADLs), had limited range of motion to the lower extremity on one side, and was at risk for developing pressure ulcers. A Skin Integrity Report dated, March 13, 2014, indicated that the resident had a deep tissue injury to the right heel, which was described as purple and measured 3 cm x 4 cm. Observation of the resident on August 19, 2014 , at 12:30 p.m., revealed that the resident had her heels directly on the pillow. The resident was also crossing her feet. Interview with Employee 3 (a nurse aide) confirmed that the resident frequently crosses her feet. Further review of the clinical record revealed no documented evidence that the facility had identified that the resident's habit of crossing her feet may place additional pressure to the resident's heels/feet. After the deep tissue injury was identified on March 13, 2014, an order for [REDACTED]. A review of the clinical record revealed that Resident 113 was severely, cognitively impaired with [DIAGNOSES REDACTED]. An quarterly Minimum Data Set assessment dated [DATE], revealed that the resident required assistance with her ADLs (Activities of Daily Living) and was at risk for developing pressure areas. A review of physician's orders and plan of care dated December 2, 2013, revealed approaches to keep the resident's heels elevated off the bed, turn and reposition every 2 hours, the resident was to be out of bed with overlay, and out of bed to a Broda chair (a recline positioning chair (wheelchairs) for long term care) with bilateral leg rests at all times and nonskid slippers, no shoes. Review of a Nursing Department Skin Integrity Report form dated June 4, 2014, revealed a DTI, pressure area on the resident's right lateral heel, measuring 0.7 cm x 0.5 cm (deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin) with intact skin, deep purple in color. A review of a pressure ulcer worksheet dated June 4, 2014, no time indicated, revealed that Resident 113 had a new, in-house acquired DTI, measuring 0.7 cm x 0.5 cm. The new interventions planned by the facility to prevent further skin breakdown included lengthening the foot rests on the broda chair and a prevalon boot (a protective boot). A wound care specialist initial evaluation dated June 9, 2014, indicated that Resident 113 had an unstageable DTI of the right, lateral foot, measuring 0.8 cm x 0.5 cm. The wound care specialist physician indicated that this resident had diabetes and behaviorally sits in a chair with required footrests for long periods. An observation on August 20, 2014, at 11:45 AM revealed that Resident 113's right lateral heel DTI pressure area measured 0.5 cm x 0.5 cm and had a black center with red blanchable area surrounding. There were large amounts of flaking skin surrounding the area and all over the foot. During an interview on August 21, 2014 at 1:30 PM the Director of Rehabilitation stated that after the discovery of the right lateral heel DTI, therapy was consulted to evaluate the residents seating. She further stated that the longer foot rests were placed on the Broda chair to improve the resident's positioning in the chair and not for pressure relief. An observation of the resident's seating (Broda chair with padded leg rests) revealed that the padded leg rests were surrounded by unpadded metal. The Director of Rehabilitation confirmed that Resident 113's foot could possibly have pressed on the metal causing the pressure area. A review of computer generated nurse aide documentation dated May 22, 2014 through June 4, 2014, indicated that staff documented that this resident was turned and repositioned every 2 hours and that his heels were elevated off the bed. However, during an interview on August 20, 2014 at 11 AM, the Director of Nursing in training confirmed that the computer generated nurse aide documentation from May 30, 2014 through June 8, 2014 did not reflect the actual interventions in place at that time. There was no evidence to support the consistent application of adequate preventative measures to prevent pressure sore development or of the actual preventative interventions that were implemented prior to the discovery of the heel pressure areas. There was no identification of the length of time this resident was out of bed in the broda chair. The Director of Nursing in training was unable to explain the lack of documented evidence of the consistent application of preventative measures to deter pressure development. A review of an incident report dated July 22, 2014 at 9:30 PM revealed that Resident 113 was severely cognitively impaired resident and always incontinent of urine. The resident was found with a 7 cm x 0.5 cm bruise to the right groin, a 5 cm x 0.5 cm bruise to the left groin with a 1 cm x 1 cm abrasion to the right groin. The facility's investigative conclusion dated July 28, 2014, revealed that the resident's incontinence brief was too tight and rubbing. A review of an employee witness statement dated July 23, 2013 (no time) indicated that Employee 5 (nurse aide) noted "I did resident in bed to check him around 5 pm. He was dry so there was no need for me to take off his pants, so I did not see anything." A review of an employee witness statement dated July 23, 2014, (no time) indicated that Employee 6 (nurse aide) stated when doing PM care the employee noticed bruises and an abrasion. and it to the employee's nurse. The resident was in bed sleeping at the time. A review of an employee witness statement dated July 22, 2014, (no time) indicated that Employee 4 (LPN) stated that the employee was called into the resident's room by a nurse aide. Employee 4 observed a 7 cm x 0.5 cm bruise to the resident's right groin, 5 cm x 0.5 cm bruise to the resident's left groin and a 1 cm x 1 cm abrasion to right groin. The resident's adult brief was too tight and lined up with bruising. A review of electronic nurse aide documentation failed to identify the actual times this resident was toileted prior to the discovery of the bruises and abrasion. During an interview on August 20, 2014 at 1 PM the Director of Nursing in training confirmed that Employee 7 (nurse aide) was the last employee to toilet Resident 113 on July 22, 2014 on the 7 AM to 3 PM shift. The DON-in-training confirmed that Employee 7 did not document that point on the employee's witness statement. The DON-in-training stated that Resident 113 was to be checked and changed by staff for incontinence every 2 hours. She confirmed that there was no indication as to when the improper sized brief was placed on this resident and verified that every 2 hour checks for incontinence were not completed as planned to timely identify skin impairment. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 9/26/13 28 Pa Code 211.10 (a)(c)(d) Resident care policies Previously cited 9/26/13

Based on a review of clinical records and Resident/Patient Incident Report, staff and resident interview, it was determined that the facility failed to ensure that safety interventions planned to prevent falls and resident injury, by assuring staff assistance and supervision are provided when needed, were effectively utilized for two of eight sampled residents (Residents 60 and 89). Findings include: Clinical record review revealed that Resident 60 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (assessment completed at periodic intervals to identify care resident care needs) dated September 12, 2011, indicated that the resident had highly impaired vision, had some cognitive impairment, required extensive assistance of two staff for transfers, locomotion on and off unit and had unsteady balance when walking and moving from a seated to standing position. A review of an August 15, 2011, physician's orders [REDACTED]. A review of a nurse's note and Resident/Patient Incident Report dated November 4, 2011, at 9:50 p.m., revealed that the resident was found on the floor of his room after an un-witnessed fall. The incident report indicated that staff was summoned to the room of Resident 60 by a call light, which was activated outside the resident's room. Upon responding to the call light, staff noted that Resident 60 was on the bedroom floor. It was noted that Resident 60's roommate had activated the call light in their room to request staff to respond to Resident 60's fall. The facility's investigation revealed that the last time the resident was seen by staff was approximately 9:00 p.m., when staff had provided care to the resident. At the time of the fall, the resident's bed was to have a pressure alarm in place on the bed to notify staff of potential unsafe acts upon the resident's rising from bed. The incident report indicated that although the pressure alarm was in place, it failed to function correctly thus an audible alert to notify staff of Resident 60's unsafe acts went undetected by staff. Staff interviews conducted by the facility after the incident revealed that nursing staff confirmed that the audible pressure alarm was in place and failed to function correctly thus resulting in the resident's unsafe act and eventual fall. Staff also confirmed that they responded to the call light (call light pushed by roommate) lit outside the resident's room not to the sound of calling out or the sound of someone falling onto the floor. The resident was last seen at 9 PM and subsequently found on the floor at 9:50 PM , but it was not determined how long the resident was out of bed before his fall. Interview with Resident 60's roommate, (Resident 31) on November 18, 2011, at approximately 10:05 a.m., confirmed that he pushed the call bell for staff to come to the room after Resident 60 had fallen. Resident 31 stated that when the resident fell , it was a very loud bang. Resident 31 also stated that prior to the fall the resident yelled out very loudly. There was no evidence that the facility had interviewed the resident's roommate as part of their investigation into the resident's fall. The facility's incident investigation indicated that staff noted it was not uncommon for this resident to attempt to get out of bed and that this particular behavior had occurred in the past. Upon staff finding the resident on the floor, it was observed that he had a bruise above the right eye and complained of right shoulder pain. Facility staff notified the physician and obtained orders to send the resident to the emergency room . It was at this time that the resident was noted to have fractures of the eighth through tenth ribs on the right chest area, a fracture of the right arm (right proximal humerus bone) and a right subdural hematoma all which required medical and/or surgical treatment. Interview with the director of nursing on November 18, 2011, at approximately 12:30 p.m., failed to provide evidence that Resident 60 was provided with adequate supervision or effective intervention to prevent this unsafe act and fall with subsequent serious injuries. Clinical record review revealed that Resident 89 had [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively intact, required staff assistance for transfers, walking and toilet use. A care plan in effect from March 27, 2011, indicated that staff was to ensure that the call light was in reach at all times when in the room. Physician orders [REDACTED]. Review of a nurse's note and Resident/Patient Incident Report dated November 1, 2011, at 8:55 p.m., revealed that the resident was observed sitting on the floor of her room after an unwitnessed fall. The facility's investigation noted that staff were summoned to the resident's room by the resident screaming for assistance. The investigation indicated that the resident ' s call light was on and when staff questioned the resident as to why she attempted to get out of bed by herself, the resident stated that she had to go to the bathroom. Interview with the resident on November 18, 2011, at approximately 10:50 a.m., confirmed that the resident had activated the call light prior to her fall on November 1, 2011. The resident stated that staff informed her that when she needs to get out of bed for any reason, she was not to do it unassisted. The resident stated that she had to go to the bathroom and had waited for assistance in excess of fifteen minutes and did not want to " have an accident." The resident stated that she had no other option, but to take herself to the bathroom. Interview with the director of nursing on November 18, 2011, at approximately 12:30 p.m., failed to provide evidence that the facility had attempted to ascertain the timeliness of call bell response when investigating Resident 89's fall or evidence that Resident 89 was interviewed regarding how long she had to wait for assistance after activating the call bell. Call bell audits conducted during the 3 PM to 11 PM shift were unavailable for review at the time of the survey 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 12/29/10