Every finding on record at Rolling Hills Healthcare and Rehabilitation Center

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate transmission based precautions (TBP) for two of two residents reviewed on TBP (Residents 45 and 12) and ensure an environment free from the potential spread of infection with the storage of resident supplies on one of two nursing units (Annex; Residents 43 and 50).Findings include: Observation on September 15, 2026, at 11:35 AM of Resident 43's room revealed an uncovered toilet riser was sitting on the floor to the left of the toilet, leaning against the wall. Observation on September 16, 2026, at 8:00 AM of Resident 43's room revealed the uncovered toilet riser remained sitting on the floor to the left of the toilet, leaning against the wall. Observation on September 15, 2026, at 11:43 AM of Resident 50's room revealed an uncovered bed pan was sitting on the floor to the right of the toilet, leaning against the wall. Observation on September 16, 2026, at 8:03 AM of Resident 50's room revealed the uncovered bed pan remained sitting on the floor to the right of the toilet, leaning against the wall. During an interview with Employee 11, licensed practical nurse, on September 16, 2026, at 8:05 AM, they confirmed that the uncovered toilet riser and bed ban were sitting on the floor of the bathroom against the walls for both Residents 43 and 50. Employee 11 indicated they were unsure why those items were in those locations, as the residents in those rooms no longer utilized those items. The above information was reviewed with the Nursing Home Administrator and Employee 10, Assistant Director or Nursing on September 16, 2026, at 2:30 PM. Review of the facility's current policy entitled Isolation-Categories of Transmission-Based Precautions revealed in part that Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The individual on contact precautions is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material. Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Clinical record review for Resident 45 revealed a diagnosis of conjunctivitis (inflammation or infection of the transparent membrane that lines your eyelid and covers the white part of your eyeball) dated September 14, 2026. A physician order for contact precautions was initiated on September 15, 2026, at 9:22 AM. Observation of Resident 45's room on September 15, 2026, at 11:10 AM revealed a sign on the wall outside the resident's room for contact precaution isolation. The sign listed that everyone must clean their hands including before entering and when leaving. The sign also included that providers and staff must also put on gloves and a gown before room entry and discard before room exit. Further observation of Resident 45's room revealed Employee 7, licensed practical nurse, entered the room without wearing gloves or a gown. She talked closely with Resident 45 while touching his left shoulder. She then put her arms around the resident to slide him closer to the middle of the bed. Then she exited the room without performing hand hygiene. Interview with Employee 7 on September 15, 2026, at 11:13 AM revealed she was informed that morning that Resident 45 was on contact precautions. Observation of Resident 45's room on September 15, 2026, at 11:16 AM revealed Employee 8, nurse aide, and Employee 9, nurse aide, entered the room wearing gloves with no gown. They applied a lift sling under the resident and then used a mechanical lift to transfer him to a chair. Gloves were removed and hand hygiene performed prior to exiting the room. Concurrent interview with Employee 8 and 9 revealed they were not informed of Resident 45's conjunctivitis or contact precaution order. The facility failed to implement appropriate contact precautions for Resident 45. The above findings for Resident 45 were reviewed with the Nursing Home Administrator and Employee 10, assistant director of nursing, on September 16, 2026, at 11:30 AM. Clinical record review for Resident 12 revealed an order dated September 15, 2026, at 9:27 AM which noted Contact Precautions: Conjunctivitis 9/14/26. Observation of Resident 12's room on September 15, 2026, at 10:30 AM noted a sign on the door frame outside of Resident 12's room that indicated the resident was on contact precautions. The contact precautions sign instructed to STOP that providers and staff must put on gloves before room entry, put on a gown before room entry, and use dedicated and disposable equipment. Further observation of Resident 12's room on September 15, 2026, at 10:37 AM revealed a member of housekeeping staff sweeping the floor at the foot of Resident 12's bed. The staff member did not have a gown on. The above information was reviewed in a meeting with the Nursing Home Administrator on September 17, 2026, at 1:40 PM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner in the main kitchen in the facility and one of two nursing units (Main Unit).Findings include: Initial tour of the facility's main kitchen with Employee 2, dietary manager, on September 15, 2026, at 9:00 AM revealed the following: The walk-in cooler contained a one-gallon container of prepared yellow mustard with the expiration date of December 18, 2025. A four-ounce container of vanilla yogurt in the walk-in cooler past the use by date of September 9, 2026. The freezer contained a Styrofoam cup with a plastic lid and straw that contained an unidentified orange substance and no use by date. The above findings were reviewed with the Nursing Home Administrator and the Employee 10, assistant director of nursing, on September 16, 2026, at 11:30 AM. Observation of the Main Unit nursing station refrigerator on September 16, 2026, at 1:35 PM with Employee 3, LPN, revealed two containers of yogurt with the expiration date of September 9, 2026. The finding in the Main Unit nursing station refrigerator was reviewed with the Nursing Home Administrator on September 16, 2026, at 2:40 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of three residents reviewed for dementia care (Residents 13, 33, and 47). Findings include: Clinical record review for Resident 13 revealed a diagnosis list that included the need for assistance with personal care and vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety (dementia: a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons; vascular dementia: caused by a decrease in blood flow to certain parts of the brain). A physiatry (physical medicine and rehabilitation) progress note for Resident 13 dated September 10, 2026, at 3:09 PM revealed (in part) a chief complaint of mobility and activities of daily living (ADL) deficits secondary to vascular dementia. An admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 23, 2026, revealed that facility staff assessed Resident 13 as having a BIMS (Brief Interview for Mental Status) of 10, which indicated cognitive impairment. The Care Area Assessment Summary noted cognitive loss / dementia. A review of Resident 13's current care plan revealed that the resident has cognitive loss related to Alzheimer's Disease (a brain disease that causes progressive cognitive impairment) / Dementia that was created on July 24, 2026. The interventions / tasks associated with the care plan revealed generalized interventions such as allow adequate time to respond; approach / speak in a calm positive / reassuring manner; explain each activity/care procedure prior to beginning it; and provide cueing and prompting for such things as activities, personal care, or room location. There was no indication that the facility had implemented an individualized person-centered care plan to address the resident's specific dementia and cognitive loss needs. Clinical record review for Resident 33 revealed they had an active diagnosis of unspecified dementia, and their annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) completed on May 20, 2026, indicated that the facility assessed Resident 33 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed. The facility developed a care plan for Resident 33 noting they had cognitive loss and a diagnosis of dementia on December 23, 2022. Interventions listed included allowing adequate time to respond, provide consistent routine/caregivers, and to identify self when speaking with the resident. A review of Resident 33's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 47 revealed they had an active diagnosis of unspecified dementia, and their annual MDS completed on July 7, 2026, indicated that the facility assessed Resident 47 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed. The facility developed a care plan for Resident 47 noting they had cognitive loss related to a diagnosis of dementia on August 26, 2022. Interventions listed included allowing adequate time to respond, approach/speak in a calm manner, and to identify self when speaking with the resident. A review of Resident 47's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The above findings for Residents 33 and 47 were reviewed with the Nursing Home Administrator and Employee 10, Assistant Director of Nursing, during a meeting on September 16, 2026, at 1:05 PM. They confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 33 and 47's dementia. The above information for Resident 13's care plan was reviewed with the Nursing Home Administrator on September 17, 2026, at 1:40 PM. The facility failed to develop an individualized and person-centered dementia care plan to support the dementia care needs to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents 13, 33, and 47. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of three residents reviewed for range of motion concerns (Resident 7).Findings include: Clinical record review for Resident 7 revealed a diagnosis list that included muscle weakness, age-related cognitive decline, need for assistance with personal care, and muscle wasting and atrophy. A review of the current care plan for Resident 7 included an activity for daily living (ADL) self-care deficit related to physical limitations, obesity, decline in mobility, and decline in self-care awareness. Further review of Resident 7's care plan revealed a maintenance restorative passive range of motion left ankle related to decline in range of motion; requires some assistance that was created on December 3, 2024, and revised on August 5, 2025. Interventions include the following: left ankle move ankle in all planes, right / left / up and down; ten reps (repetitions) x two created on December 3, 2024, and revised on March 9, 2026. A Physical Therapy Discharge Summary for Resident 7 dated July 7, 2026, at 10:01 AM noted a restorative program not indicated at this time. Functional maintenance program established / trained = range of motion program; range of motion program established / trained: maintenance RNP - PROM maintenance program. The prognosis to maintain current level of functioning (CLOF) was noted to be good with consistent staff follow-through. The documentation noted a discharge reason that included patient refuses / non-compliant with treatment. A review of the task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 7 revealed a Maintenance RNP (Restorative Nursing Program) - PROM (passive range of motion) program dated March 31, 2026. The frequency noted was days, evenings, and nights as needed. Review of the task documentation for this program for Resident 7 for the last 30 days revealed no data found. There was no documentation to indicate that facility staff were documenting the task as being completed, attempted, the resident refused, or unable to complete (i.e. due to an underlying condition; review of the progress notes revealed the resident has a wound on the left calf per medical provider documentation dated July 28, 2026, at 8:23 PM; and a post event nursing note dated July 31, 2026, at 1:25 AM noted an open area to the left outer ankle). The range of motion program / missing documentation for Resident 7 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 16, 2026, at 11:30 AM. An interview with Employee 12, Director of Rehab, on September 17, 2026, at 1:19 PM revealed it was unclear whether the resident was still on the program or not. The facility provided no further documentation related to Resident 7's range of motion program. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to properly store resident medication on one of two nursing units (Main Unit).Findings include: The policy entitled Storage of Medications, last reviewed on March 31, 2026, with no changes, revealed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Observation of the Main nursing unit on September 15, 2026, at 2:57 PM revealed an unattended and unlocked medication cart in front of the nursing station. The first drawer of the medication cart included resident specific medication. The second drawer contained medication including insulin pens. The third drawer included house stock medications. The fourth drawer contained house stock medications and eye drops. Continued observation of the unattended medication cart until September 15, 2026, at 3:02 PM revealed no staff returned to the medication cart until Employee 1 (licensed practical nurse). Employee 1 acknowledged that she did not lock the medication cart prior to walking away. The above medication security concern was reviewed with the Nursing Home Administrator and Employee 10 (assistant director of nursing) on September 16, 2026, at 11:30 AM. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations and staff interview, it was determined that the facility failed to properly contain and dispose of garbage at the facility trash dumpsters.Findings include: Observation of the facility's outside trash dumpsters on September 15, 2026, at 9:25 AM revealed the following: There were two observed trash dumpsters. Each of the dumpsters had a side door open with bagged trash visible inside. The ground surrounding the dumpsters had nine scattered pieces of glass. A second observation on September 16, 2026, at 7:58 AM revealed one dumpster with a side door open with bagged trash visible inside. The nine pieces of glass remain visible on the ground. The above information was reviewed in a meeting with the Nursing Home Administrator on September 16, 2026, at 11:30 AM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to provide timely notification to a resident's representative of changes in payment coverage and liability for one of three residents reviewed (Resident 1).Findings include: Clinical record review for Resident 1 revealed that the facility admitted her on January 15, 2026. Review of hospital documentation obtained by the facility for pre-admission review, dated January 12, 2026, revealed that Resident 1 presented with reported dementia (an acquired mental disorder characterized by a decline in intellectual abilities, memory, judgment, etc., that is sufficient to interfere with social functioning), lived at home with her husband with home care, and was, sent to the emergency department by power of attorney for placement as there is concern patient is not safe at home any longer. Additional documentation on the report noted, Spoke briefly with (Resident 1's niece's name) niece and POA. The documentation entry included Resident 1's niece's telephone number. Review of a Consent to Treat form signed by Employee 4 (registered nurse) on January 15, 2026, indicated that the staff obtained verbal consent to treat Resident 1 from her niece. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 20, 2026, revealed that staff assessed Resident 1 as usually understood, usually understood others, that she always needed someone to help her read instructions or other written material from her doctor or pharmacy, her BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment) score was five which indicated severe cognitive impairment, and that her diagnoses included unspecified dementia. Interview with Employee 1 (business office manager) on July 15, 2026, at 9:20 AM revealed that the facility had a change in ownership on February 9, 2026, and an increase in the daily room rate effective April 1, 2026. Employee 1 stated that she mailed letters to residents' families on February 25, 2026, to make them aware of the anticipated new room rate. Review of a list of names and addresses provided by Employee 1 that documented where she addressed letters for mailing on February 25, 2026, indicated that Resident 1's letter was addressed to Resident 1 at her home address. There was no indication that a letter was addressed to Resident 1's niece/representative. Review of Resident 1's facility financial ledger revealed that the cost for her daily room and board increased on March 12, 2026, and April 1, 2026. Interview with Employee 1 and Employee 3 (social services director) on July 15, 2026, at 10:30 AM confirmed that a room move completed on March 12, 2026, from a semi-private to a private room resulted in an increase in cost for Resident 1. There was no evidence in Resident 1's medical record that the room move on March 12, 2026, was discussed with Resident 1's niece/responsible party or that she received written notification. The interview confirmed that the change in Resident 1's charges on April 1, 2026, was a result of the facility's increase in the daily room rate. Interview with Employee 1 on July 15, 2026, at 11:49 AM confirmed that the February 24, 2026, letter regarding the facility's planned daily room rate increase was addressed to Resident 1 and mailed to Resident 1's home address despite Resident 1 had an established power of attorney (niece) who was identified as such in documentation received by the facility as part of Resident 1's admission to the facility on January 15, 2026. The interview indicated that on March 25, 2026, Resident 1's niece/power of attorney was in the facility to provide additional supplemental insurance information and was made aware of the daily room rate increase that would take effect April 1, 2026 (one week later). Employee 1 confirmed that March 25, 2026, was the first time Resident 1's power of attorney was made aware of the planned room rate increase. Employee 1 stated that she was unaware that Resident 1 had an established power of attorney before that time. The surveyor reviewed the hospital documentation and facility face sheet that listed Resident 1's niece as her first contact person and that the hospital documentation stipulated that Resident 1 had a power of attorney. Employee 1 indicated that she scanned Resident 1's power of attorney documentation into her electronic medical record on April 22, 2026, after the documentation was received from Resident 1's niece. Review of Power of Attorney documentation available in Resident 1's medical record confirmed that on May 21, 2004, Resident 1 named her niece as her Attorney-in-Fact. Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055) is issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Key elements of compliance with the provision of the notice include that the facility notified an eligible resident in writing of the items and services which are/are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services as soon as reasonably possible when a change in coverage occurs. The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. Clinical record review for Resident 1 revealed census information that the facility admitted her on January 15, 2026, for services primarily paid for by Medicare A. The census information indicated that Resident 1's payment source changed to private pay on January 30, 2026, as Resident 1 continued to reside in the facility. Review of a CMS-10055 form for Resident 1 indicated that beginning on January 30, 2026, Resident 1 could be responsible for an estimated cost per day. The notice included no documentation that facility staff discussed the notice and the change in payment coverage with Resident 1's responsible party; and there was no evidence that the facility mailed the notice to Resident 1's responsible party. The notice was not signed by Resident 1's responsible party. Interview with Employee 2 (registered nurse assessment coordinator) on July 15, 2026, at 9:36 AM confirmed that Resident 1's last Medicare A covered day was January 29, 2026, and that she could not provide evidence of attempts to obtain a signed CMS-10055 from Resident 1's responsible party. The surveyor reviewed the above concerns related to notification of Resident 1's responsible party of an increase in the daily room rate as well as the changes in her personal payment liability after the discontinuation of her Medicare A benefits during an interview with the Nursing Home Administrator and the Director of Nursing on July 15, 2026, at 2:30 PM. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to provide written notice to a resident's responsible party before the resident's room change for one of three residents reviewed (Resident 1).Findings include: Clinical record review for Resident 1 revealed that her diagnoses list included unspecified dementia (progressive brain disorder that destroys memory and thinking skills); and that she resided on the secured annex nursing unit for residents with dementia-type diagnoses. Census information in Resident 1's medical record indicated that the facility moved her from her room on the main nursing unit to another room on the annex nursing unit on February 2, 2026. Social services documentation by Employee 3 (social services director) dated February 2, 2026, at 9:36 AM revealed that Employee 3 spoke with Resident 1's family regarding a room change. Employee 3 explained that due to increased behaviors that the facility was, looking to move the resident to Annex. The move was scheduled to occur that afternoon. Resident 1's census information indicated that the facility moved her room again on March 12, 2026, from a semi-private room on the annex nursing unit to a private room on the annex nursing unit. There was no progress note documentation by facility staff regarding moving Resident 1's room on March 12, 2026. Interview with Employee 1 (business office manager) and Employee 3 on July 15, 2026, at 10:30 AM indicated that the facility had no evidence that written notice was provided to Resident 1's responsible party for either of the room moves (February 2, 2026, or March 12, 2026). The interview confirmed that the room move completed on March 12, 2026, from a semi-private to a private room resulted in an increase in cost for Resident 1. There was no evidence in Resident 1's medical record that the room move on March 12, 2026, was discussed with Resident 1's responsible party. The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and the Director of Nursing on July 15, 2026, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure resident privacy for one of four residents reviewed (Resident 3).Findings include: Clinical record review for Resident 3 revealed a quarterly MDS assessment dated [DATE], that assessed Resident 3 as having a memory problem and that he had severe cognitive impairment (never or rarely made decisions). Review of an incident investigation dated September 5, 2025, revealed that Employee 3 (nurse aide) reported to the Director of Nursing that Employee 5 (nurse aide) sent an electronic private message with a picture attachment of Resident 3. Resident 3's face was obscured by a filtering program; however, Employee 3 was able to identify that it was a facility resident. Statements obtained by the facility during the investigation determined that Employee 5 sent the same photo to Employee 4 (nurse aide). The facility substantiated that Employee 5 took and disseminated a photo of Resident 3 who was incapable of giving consent to be photographed. Interview with the Nursing Home Administrator on September 16, 2025, at 3:15 PM confirmed the above findings. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and services for an indwelling urinary catheter as ordered by the physician for one of one resident reviewed for urinary catheter concerns (Resident 1).Findings include: Clinical record review for Resident 1 revealed physician orders to maintain a coude foley catheter (flexible tubing inserted into the bladder to drain urine; a coude catheter is equipped with a bent tip to allow passage beyond obstructions such as the prostate gland) for obstructive uropathy (blockage in the urinary system that hinders urine flow; commonly an enlarged prostate) as follows: 24 French (scale where one French unit corresponds to approximately 0.33 millimeters in diameter) coude foley with 10 cc (cubic centimeters, one cc equals one milliliter) balloon changed monthly every 30 days and as needed for blockage or obstruction. This may only be changed by the registered nurse (dated May 31, 2025, to August 29, 2025). 24 French coude foley with 30 cc balloon changed monthly every 30 days and as needed for blockage or obstruction. This may only be changed by the registered nurse (dated August 29, 2025). Review of Resident 1's treatment administration record dated July 2025 revealed that Employee 1 (licensed practical nurse) documented that he changed Resident 1's coude catheter on July 30, 2025 (although Resident 1's physician order stipulated that the registered nurse complete the treatment). Review of Resident 1's treatment administration record dated August 2025 revealed that Employee 6 (registered nurse) changed Resident 1's coude catheter on August 8, 2025. Nursing documentation by Employee 6 dated August 8, 2025, at 10:02 PM indicated that changing Resident 1's coude catheter was effective for blockage/obstruction. Nursing documentation dated August 29, 2025, at 9:59 AM revealed that the Director of Nursing changed Resident 1's catheter for monthly change. Resident 1's clinical record did not contain evidence of a complication (e.g., blockage or obstruction) that warranted changing the indwelling catheter sooner than 30 days from the previous change (that occurred on August 8, 2025). Nursing documentation by Employee 2 (licensed practical nurse) dated April 30, 2025, at 2:03 PM reiterated that a registered nurse changed Resident 1's coude catheter on August 29, 2025. The facility failed to ensure that Resident 1's physician ordered treatment for his indwelling urinary catheter was completed by the appropriate licensed staff at the appropriate schedule. Interview with the Nursing Home Administrator on September 16, 2025, at 3:15 PM confirmed the above findings. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide professional dental services for two of two residents reviewed for dental concerns (Residents 27 and 46). Findings include: Observation of Resident 27 on July 30, 2025, at 10:32 AM revealed she was edentulous (without natural teeth). Interview with Resident 27 on the date and time of the observation revealed that she once had a full denture for her upper and lower jaws; however, Resident 27 alleged that staff took her lower denture, and she did not know when or where they took them. Review of Resident Evaluation documentation dated June 1, 2024, at 4:00 AM for a quarterly review revealed that she was mentally oriented to person and place; however, was noted to have current and a history of behaviors. Staff assessed Resident 27 as having a full upper denture plate and a full lower denture plate. and Resident 27 preferred her dentures only removed at night. An annual MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated August 2, 2024, indicated that the care area related to dental concerns triggered as Resident 27 had full upper and lower dentures during the review of July 27, 2024, to August 2, 2024. The annual MDS dated [DATE], and a quarterly MDS dated [DATE], revealed that Resident 27 was dependent on staff for oral hygiene. Oral hygiene is defined as the ability to use suitable items to clean teeth; dentures (if applicable). The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment. An electronic document entitled, Resident Evaluation V6, dated October 31, 2024, indicated that lower dentures were not applicable for Resident 27 (she did not have a lower denture at that time). A plan of care initiated by the facility on December 23, 2022, to address Resident 27's self-care deficit related to activities of daily living stipulated that Resident 27 required staff to Assist with daily hygiene, grooming, dressing, oral care and eating as needed. A plan of care to address Resident 27's edentulous condition (revised April 16, 2025) noted that Resident 27 had a full upper denture but no lower denture. The plan of care intervention for staff to assist with oral hygiene and dentures as needed was initiated December 27, 2022. The surveyor requested any documentation that the facility identified and addressed Resident 27's missing lower denture during interviews with the Nursing Home Administrator, Director of Nursing, and Employee 1 (registered nurse, director of clinical operations) on July 30, 2025, at 1:45 PM and July 31, 2025, at 2:00 PM. Interview with the Nursing Home Administrator on July 31, 2025, at 2:48 PM indicated that the Nursing Home Administrator confirmed that Resident 27 had an upper and lower denture; however, at some point, lost the bottom dentures but the facility did not know when. The Nursing Home Administrator indicated that there was no incident investigation or progress note to evidence when Resident 27 no longer had her lower denture between the dates of August 2, 2024, and October 31, 2024. The Nursing Home Administrator stated that Resident 27 exhibited a behavior of throwing her dentures at staff. Documentation by the facility's consultant professional dental provider dated January 6, 2025, indicated that Resident 27 was not a candidate for a lower ridge denture. Interview with Employee 1 on July 31, 2025, at 3:26 PM confirmed that the first assessment that indicated Resident 27 no longer had a lower denture was on October 31, 2024, and the facility had no evidence of an attempt to obtain professional dental services to replace the denture until January 6, 2025 (more than two months after). The facility was unable to provide a determination of when Resident 27 lost her lower denture within the three-month time between August 2, 2024, and October 31, 2024, despite Resident 27's dependence on staff for her oral hygiene daily. It was determined that the facility did not obtain timely professional dental services for a resident who lost their denture. Clinical record review for Resident 46 revealed that the facility admitted him on October 6, 2024, with Medicaid as a payment source for his admission to the facility. Observation of Resident 46 on July 30, 2025, at 10:58 AM revealed he had his fingers in his mouth pinching a tooth on his lower right jaw while repeating, can you take it out? Observation of Resident 46's mouth revealed he had missing and discolored teeth. Clinical record review for Resident 46 revealed no evidence of professional dental services provided since his admission to the facility (almost eight months). The surveyor requested any evidence of professional dental services for Resident 46 during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 1 on July 30, 2025, at 1:45 PM. An admission MDS assessment dated [DATE], assessed Resident 46 has having no obvious or likely cavities or broken natural teeth. A plan of care initiated by the facility on March 27, 2025, indicated that Resident 46 had a dental or oral cavity health problem related to broken and missing teeth. Interventions listed in the plan of care included that the facility would refer Resident 46 to the dentist/hygienist for evaluation/recommendations regarding denture realignment, new fitting, teeth extraction, and repair of carious teeth. Interview with the Director of Nursing, the Nursing Home Administrator, and Employee 1 on July 31, 2025, at 2:00 PM confirmed that the facility had no evidence that Resident 46 received professional dental services since his admission in October 2024. The facility provided no evidence that Resident 46 or Resident 46's responsible party refused services from the facility's contracted dental provider. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15 Dental services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist reported any irregularities to the attending physician (and the facility's medical director if applicable) and the Director of Nursing on a separate, written report; and that the attending physician documented a review and actions taken to address the identified irregularity in the resident's medical record for one of five residents reviewed for medication regime concerns (Resident 27).Findings include: Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on July 30, 2025, at 1:45 PM revealed that the facility's contracted consulting pharmacist reviews each resident's medication regime monthly and, unless listed on the document entitled, Listing of Residents Reviewed with No Recommendations, a resident has a separate report of the identified potential medication irregularity on which the attending physician documents a review and response. The interview indicated that the separate report would be scanned into the resident's electronic medical record under the miscellaneous section. Clinical record review for Resident 27 revealed that her name did not appear on the Listing of Residents Reviewed with No Recommendations, report for November 2024, December 2024, and March 2025. Resident 27's electronic medical record did not include a separate report from the consultant pharmacist for those months. Interview with the Director of Nursing on August 1, 2025, at 12:24 PM confirmed that upon her review of Resident 27's physical chart, there were no separate reports from the consultant pharmacist for November 2024, December 2024, or March 2025. Interview with the Director of Nursing on August 1, 2025, at 12:38 PM indicated that the consultant pharmacist included recommendations for Resident 27 to nursing staff on November 3, 2024, that read, Please update the Seroquel (antipsychotic medication) order to 25 mg (milligrams) daily. Per GDR (gradual dose reduction) in October it was decreased from 50 mg to 25 mg daily, within a list that included other residents' information. Although it is not in the scope of practice for licensed nursing staff to update a physician's order for a medication, the consultant pharmacist did not refer this recommendation to Resident 27's physician. The consultant pharmacist also did not document this information on a separate report for documentation of the monthly review in Resident 27's medical record. Interview with the Director of Nursing on August 1, 2025, at 12:38 PM indicated that the consultant pharmacist included recommendations for Resident 27 to nursing staff on December 8, 2024, that read, The resident is receiving Cholestyramine (medication that lowers fats, like cholesterol, in the blood). Please ensure periodic labs are conducted to monitor. Documentation of results should be accessible for review, within a list that included other residents' information. The list included a second entry that repeated, Please update the Seroquel order to 25 mg daily. Per GDR in October, it was decreased from 50 mg to 25 mg daily. Although it is not in the scope of practice for licensed nursing staff to generate orders for laboratory testing or update medication dosages, the consultant pharmacist did not refer these findings to Resident 27's physician on a separate report for documentation of the monthly review in Resident 27's medical record. A consultant pharmacist report dated February 3, 2025, requested that Resident 27's physician review Resident 27's use of Hydroxyzine (antihistamine that reduces the symptoms of itching, or hives, on the skin; it can also be used as a sedative to treat anxiety and tension) 50 mg at HS (hour of sleep) for a possible GDR or discontinuation. The physician did not document a review and response to this recommendation until more than a month later (dated March 5, 2025), which agreed to decrease the medication to 25 mg at HS. Due to the time lapse between the February 2024 consultant pharmacist review and Resident 27's physician's response in March 2025, the consultant pharmacist repeated the request for the facility to review Resident 27's Hydroxyzine medication for a possible GDR per a Consultant Pharmacist's Medication Regimen Review Recommendations Pending a Final Response, report generated for Outcomes Entered Between March 1, 2025, and March 5, 2025; however, the consultant pharmacist did not document these findings to Resident 27's physician on a separate report for documentation of the March 2025 monthly review in Resident 27's medical record. Interview with the Director of Nursing on August 1, 2025, at 1:20 PM confirmed that the only evidence a consultant pharmacist reviewed Resident 27's medication regime in March 2025, was the above-mentioned report, which listed several other residents' information and did not generate a separate report to a physician although the entry noted, Routed to: MD. A physician's order dated March 5, 2025, instructed staff to decrease Resident 27's Hydroxyzine medication to 25 mg at bedtime (after the consultant pharmacist's March 2025 review). Resident 27's physician did not complete a timely review and response to the consultant pharmacist's February 3, 2025, reported irregularity. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide a dependent resident assistance with nail hygiene for one of three residents reviewed for activities of daily living concerns (Resident 46). Findings include: Observation of Resident 46 on July 30, 2025, at 11:47 AM revealed his fingernails were long (extending beyond the tips of his fingers) with darkened material under them. Clinical record review for Resident 46 revealed that the facility developed a plan of care to address Resident 46's risk for alteration in skin integrity related to poor self-care and history of picking at skin (initiated October 4, 2024). A plan of care initiated by the facility on October 4, 2024, noted Resident 46's self-care deficit regarding activities of daily living that listed interventions that included staff assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Resident 46 required the extensive assistance with staff for hygiene and grooming. Review of quarterly MDS assessments (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 27, 2025, and July 28, 2025, indicated that Resident 46 needed substantial/maximal assistance with personal hygiene. Observation of Resident 46 again on August 1, 2025, at 9:38 AM with Employee 2 (licensed practical nurse) revealed that the fingernails of his bilateral hands continued to extend beyond the tips of his fingers, darkened substances remained underneath several fingernails, and a red substance (presenting as dried blood) was noted under the fingernails of his right hand. A skin injury one and 1.5 inches long was observed with dried, smeared, blood on Resident 46's left forearm. The surveyor reviewed the concern regarding hygienic care of Resident 46's fingernails during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on August 1, 2025, at 1:50 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure the highest practicable care regarding a pacemaker for one of 18 residents reviewed (Resident 44). Findings include: Clinical record review for Resident 44 revealed that the facility admitted him on April 4, 2023. Diagnoses listed for Resident 44 upon his admission to the facility included the presence of a cardiac pacemaker (surgically inserted medical device with wires attached to the heart for the purpose of administering electrical impulses to regulate the heart rate). Review of Resident 44's clinical record revealed a current care plan for cardiac disease related to coronary artery disease (a condition where the arteries supplying blood to the heart narrow due to plaque buildup restricting blood flow), congestive heart failure (the heart does not pump blood well enough causing fluid to accumulate), hypertension (high blood pressure), and a pacemaker. The listed interventions included instructions to perform pacemaker checks; however, there was no intervention related to a pacemaker machine or method used to perform pacemaker checks. Clinical record review for Resident 44 revealed no evidence of a current physician's order for pacemaker monitoring until July 31, 2025, after the surveyor brought it to the facility's attention during a meeting with the director of nursing, nursing home administrator, and Employee 1, (registered nurse, director of clinical operations) on July 30, 2025, at 2:30 PM. Interview with the Director of Nursing and Nursing Home Administrator on July 31, 2025, at 2:20 PM confirmed that there was no order for Resident 44's pacemaker checks prior to the surveyor bringing it to their attention on July 30, 2025. They also confirmed that they had no evidence that pacemaker checks were being completed for Resident 44. The facility failed to provide the highest practicable care regarding Resident 44's pacemaker. 28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.3(a)(e)(2) Verbal and telephone orders28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess a resident's bed system for potential accident hazards for one of 18 residents reviewed (Resident 15). Findings include: The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The FDA is using a head breadth dimension of 120 mm (4.75 inches) as the basis for its dimensional limit recommendations. To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become trapped. FDA is recommending 60 mm (two and three-eighths inches) as an appropriate dimension for neck diameter. The openings in a bed system should be wide enough not to trap a large chest through the opening between split rails. The FDA concurs with the dimension of 318 mm (12.5 inches) to represent chest depth for the population vulnerable to entrapment and has used this dimension as the basis for its recommended dimensional limits. This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Zone seven is the space between the inside surface of the headboard or foot board and the end of the mattress. This space may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. FDA recognizes this area as a potential for entrapment and encourages facilities and manufacturers to report entrapment events at this zone. Observation of Resident 15's room on July 30, 2025, at 10:17 AM revealed he was in his bed. Observation of Resident 15's bed system revealed that there were assist bars bilaterally at the head of his bed, a trapeze device mounted in the center of his bed, and there was a gap of six to eight inches between the top of his mattress and the headboard. Resident 15's bed system did not include a footboard. Clinical record review for Resident 15 revealed a GUAR-In Bed Positioning / Side Rail Evaluation dated July 10, 2025. The facility assessed Resident 15's bed positioning for safety. The document stipulated that the Gaps between head/foot boards and bed rails are within the FDA dimensional limits (<2-1/3 inches) and do not represent a risk for entrapment. (Devices may be used to decrease gaps/spaces); however, the document did not address the potential spatial concerns between the mattress and the headboard. Observation of Resident 15's room on August 1, 2025, at 9:32 AM with Employee 2 (licensed practical nurse) revealed he was in his bed. Employee 2 measured the space between the top of Resident 15's mattress to his headboard for a measurement of 10 inches. There was no footboard on Resident 15's bed and the mattress appeared to have slid distally within the bed system. The surveyor reviewed the above concern regarding the Zone seven gap within Resident 15's bed system during an interview with the Director of Nursing, the Nursing Home Administrator, and Employee 1 (registered nurse/director of clinical operations), on August 1, 2025, at 1:50 PM. The Director of Nursing indicated that Resident 15 may have had a footboard at one time on his bed; however, the facility was unable to provide documentation of when this bed system change occurred. The facility was unable to provide evidence of an assessment of Resident 15's bed system that included a review of the stability of the mattress positioning to ensure that potential sliding of the mattress did not present a gap size that presented a potential risk for entrapment. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that medical records were readily accessible to individuals performing health oversight activities for one of 18 residents reviewed (Resident 27). Findings include: The state survey agency entered the facility on July 29, 2025, at 9:00 AM and provided the Nursing Home Administrator the federal Entrance Conference Worksheet, which included the form entitled, Electronic Health Record (EHR) Information. Instructions on the form direct the provider to, Provide specific instructions on where and how surveyors can access the following information in the EHR (or in the hard if using split EHR and hard copy system) for the initial pool record review process. Surveyors require the same access staff members have to residents' EHRs in a read-only format. Clinical record review for Resident 27 revealed that the surveyor was unable to view three months of nurse aide documentation of the completion of tasks necessary for Resident 27's care (e.g., bathing, toileting assistance, bowel elimination records, incontinence care, behavior monitoring, oral hygiene, application of medical devices, etc.). Email communication to the Nursing Home Administrator on August 1, 2025, at 9:17 AM requested instructions regarding how the surveyors could independently review a month of nurse aide documentation (as reports run for licensed staff completion of treatments or medications) for a resident. The Nursing Home Administrator email response on August 1, 2025, at 11:05 AM indicated that she would print the nurse aide documentation that the surveyor requested. Interview with Employee 3 (licensed practical nurse) on August 1, 2025, at 12:50 PM revealed that he could view and print a Documentation Survey Report, that provided documentation by nurse aide staff of the care and services provided to Resident 27 for any month requested. Employee 3 printed this report for the surveyor at that time. The state agency surveyor was unable to view the same information independently without the intervention of facility staff. The facility failed to ensure that surveyors were provided the same medical record access staff members had to residents' EHRs in a read-only format. The surveyor reviewed the above concern with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on August 1, 2025, at 1:50 PM. 28 Pa. Code 211.5(b)(1)(2)(f)(i)-(xi)(i) Medical records

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 4, 42, and 49). Findings include: Clinical record review for Resident 4 revealed the facility admitted her on September 9, 2021, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of a significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 21, 2023, indicated that the facility assessed Resident 4 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 4's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 42 revealed the facility admitted her on March 12, 2021, with diagnosis including Dementia. A review of Resident 42's Minimum Data Set assessment dated [DATE], indicated that the facility assessed Resident 42 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 42's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 49 revealed the facility admitted her on February 25, 2022, with diagnosis including Dementia. A review of Resident 49's Minimum Data Set assessment dated [DATE], indicated that the facility assessed Resident 42 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 49's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Director of Nursing, Nursing Home Administrator, and Employee 1 (consultant) on October 12, 2023, at 11:30 AM. Further interview with Employee 1 on October 13, 2023, at 9:35 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 4, 42, and 49's dementia and cognitive loss. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan

Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for three of three residents reviewed (Residents 13, 37, and 46). Findings include: Review of Resident 13's clinical record revealed that the facility transferred him to the hospital on August 8, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 13's transfer to the hospital. Review of Resident 37's clinical record revealed that the facility transferred him to the hospital on June 20, 2023, and again on September 17, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 37's transfers to the hospital. Review of Resident 46's clinical record revealed that the facility transferred the resident to the hospital on August 31, 2023, at 7:50 AM. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 46's transfer to the hospital. Interview with Employee 3, social worker, on October 12, 2023, at 1:04 PM confirmed the above findings and indicated that she had not sent any transfer notices to the Office of the State Long-Term Care Ombudsman for any resident transfers. Employee 3 indicated that she was faxing the local Ombudsman office, but also could not provide documented evidence that it occurred. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for one of 14 residents reviewed (Resident 39) Findings include: Clinical record review for Resident 39 revealed a diagnoses list that included a history of muscle weakness. Resident 39's current care plan noted the resident was at risk for falls due to weakness. An intervention included having the call bell in reach. Observation of Resident 39 on October 11, 2023, at 11:28 AM revealed the resident was in bed. The resident's call bell was observed draped over a recliner that was positioned next to the bed. The call bell was four feet from the resident and not easily accessible. Observation of Resident 39 on October 13, 2023, at 10:44 AM revealed the resident was in bed. The resident's call bell was observed coiled up on the right arm of the recliner that was positioned next to the bed and not easily accessible. Interview with Employee 4, licensed practical nurse, on October 13, 2023, at 10:44 AM confirmed the finding and placed the call bell within Resident 39's reach and advised the call bells should always be on the residents. The above findings for Resident 39 were reviewed with the Nursing Home Administrator on October 13, 2023, at 12:45 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of one resident reviewed (Resident 3). Findings include: The policy entitled Abuse Policy, last reviewed on August 29, 2023, indicates that the facility describes an injury of unknow origin as an injury that was not observed by any person, cannot be explained by the resident, and a suspicious location not generally vulnerable to trauma. The policy does not specify how the facility will specifically rule out abuse when an injury of unknown origin occurs. Review of Resident 3's clinical record revealed a nursing care plan indicating that she needs the help of two staff members to use a mechanical lift to transfer her out of bed. Resident 3 is not self-ambulatory. A nursing note dated October 6, 2023, at 6:30 PM indicated that staff noted a bruise to the top of Resident 3's left foot measuring 5 cm (centimeters) by 4 cm. The note further described the bruise as green and blue (indicating an older bruise up to five days). Review of the facility's investigation into Resident 3's bruised left foot revealed a witness statement form indicating that for investigations regarding a bruise, the facility is to collect staff statements from the previous three days prior to its discovery. The facility only collected two staff members on the same shift it was discovered, one who reported it and another who didn't see it. There was no documented evidence to indicate the facility collected staff statements for the three days prior to Resident 3's discovery of her bruise. There was also no other documented evidence to indicate the facility thoroughly investigated the possible cause of the bruise to rule out the potential for abuse and/or neglect. Interview with Employee 1, consultant, on October 13, 2023, at 11:00 AM confirmed the above findings for Resident 3. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide a physician ordered assistive device to prevent an accident that resulted in harm (right femur fracture) for one of three residents reviewed (Resident 6). Findings include: The policy entitled Falls-Clinical Protocol, last reviewed without changes on (MONTH) 14, (YEAR), indicates that for an individual who has fallen, nursing staff will attempt to define possible causes within 24 hours of the fall, and based on that assessment will identify pertinent interventions to try to prevent subsequent falls. Review of Resident 6's fall care plan, initiated on (MONTH) 7, (YEAR), revealed that the facility identified her as being at risk for falls due to a previous history of falls and poor safety awareness. Nursing documentation dated (MONTH) 2, 2019, at 7:51 AM revealed that Resident 6 rolled out of bed. Resident 6 stated she hit her right forehead. Nursing staff noted no other injuries at that time. A physician order [REDACTED]. Nursing documentation dated (MONTH) 5, 2019, at 12:30 AM revealed that the nurse was notified that Resident 6 fell out of bed. The fall was unwitnessed, and Resident 6 appears to have fallen out of the left side of her bed and landed on her right side. Nursing staff noted a contusion (bruise) to Resident 6's right temple and that Resident 6 was complaining of a headache and severe pain to her right leg. The facility transferred Resident 6 to the hospital. Nursing documentation dated (MONTH) 5, 2019, at 1:30 PM revealed that the facility received a call from the hospital indicating that Resident 6 sustained a horrible femur fracture and that since Resident 6 is not a surgical candidate, the hospital attempted a reduction (fixing a fracture without surgery) with little improvement. Resident 6 was sent back to the facility with a splint to her right lower extremity. Review of the facility's investigation revealed two nursing staff witness statements dated (MONTH) 5, 2019, indicating that the physician ordered bilateral wedges were not in place on Resident 6's bed when she was in bed, and that they were actually still in a bag and not being used. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 11, 2019, at 2:30 PM acknowledged the above findings. The facility failed to provide Resident 6 with needed supportive assistive devices for her bed to prevent an accident that caused a severe injury resulting in harm. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 3/23/18, 2/16/17 28 Pa. Code 201.18(e)(1) Management Previously cited 3/23/18, 2/16/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 3/23/18, 2/16/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 3/23/18, 2/16/17

Based on clinical record review, review of select policy and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel continence management and preliminary testing for infectious disease for two of 14 residents sampled (Residents CR1 and 49). Findings include: The policy entitled [MEDICAL CONDITION] Screening-Administration and Interpretation of [MEDICATION NAME] Skin Test, last reviewed without changes on February 29, 2016, indicates that test results should always be read in mm (millimeters) and that a positive reaction would be considered to be an area of induration (palpable hardness) around the injection site. An induration greater than 10 mm is considered positive for residents in a long term setting and should be referred for further diagnostic studies. The policy entitled [MEDICAL CONDITION], Screening for Residents, last reviewed without changes on February 29, 2016, indicates that the facility would screen all residents for [MEDICAL CONDITION] infection. If a [MEDICAL CONDITION] skin test is positive, nursing staff will contact the physician to obtain orders for a chest x-ray. Review of Resident CR1's closed clinical record revealed that the facility admitted her on December 19, 2015. A Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated December 26, 2015, indicated that the facility assessed her as having the ability to make herself understood and the ability to understand others. Nursing documentation dated December 20, 2015, at 4:07 AM, indicated that Resident CR1 was alert and oriented, and able to make wants and needs known. Resident CR1's medication review report dated and signed by her physician on December 22, 2015, indicated that Resident CR1 had no known allergies [REDACTED].>Review of Resident CR1's closed clinical record revealed documentation dated December 21, 2015, at 1:15 PM, that indicated nursing staff administered the first step of the [MEDICATION NAME] skin test. Nursing documentation dated December 24, 2015, indicated that nursing staff interpreted the first step of Resident CR1's [MEDICATION NAME] skin test as negative. Nursing staff did not document if any induration in millimeters was present at the site of Resident CR1's first [MEDICATION NAME] skin test. Nursing documentation dated December 29, 2015, at 10:52 AM indicated that nursing staff assessed Resident CR1's left forearm, the site of the first [MEDICATION NAME] skin test, as having a 2 cm (centimeters) by 1.8 cm indurated area. This area of induration would be almost double the size of a positive result. The documentation also indicated that a fax was sent to Resident CR1's physician to make him aware. Interview with the Director of Nursing on March 4, 2016, at 11:20 AM confirmed that the documentation of notification to Resident CR1's physician could not be found. A prescriber fax notification form dated December 29, 2015, at 11:00 PM indicated that nursing staff observed Resident CR1 with red, dry legs. Resident CR1 indicated, They itch and she scratches them a lot. Resident CR1's physician responded to the fax notification with a physician's orders [REDACTED]. A prescriber fax notification form dated December 30, 2015, at 12:28 PM indicated that nursing staff observed Resident CR1 as having bilateral lower extremity reddened skin. Resident CR1 complained of skin burning and itching and admits to rubbing her heels down her shins all night long. Resident CR1's physician responded to the fax notification with a physician's orders [REDACTED]. A prescriber fax notification form dated December 31, 2015, with no time noted, indicated that nursing staff observed Resident CR1 as having a red right eye. Resident CR1's physician provided no new orders. Nursing documentation dated January 3, 2016, at 7:12 PM indicated that nursing staff administered the second step [MEDICATION NAME] skin test in Resident CR1's right forearm. Nursing documentation dated January 5, 2016, at 1:06 PM indicated that nursing staff noted that both Resident CR1's eyes are blood shot (inflamed or red). Nursing documentation dated January 6, 2016, at 11:40 AM indicated that Resident CR1 was transferred to the hospital for face and throat swelling. There was no evidence in Resident CR1's closed clinical record to indicate what events occurred leading up to her face and throat swelling or her transfer from the facility. emergency room documentation dated January 6, 2016, at 11:24 AM indicated that medics needed to administer the epi-pen twice. The documentation also indicated that Resident CR1's swelling started in the morning, is allergic to chocolate, and that some was found in her room, but Resident CR1 denied eating any. History and physical documentation dated January 6, 2016, at 12:38 PM indicated that Resident CR1 was admitted to the intensive care unit with a diffuse papular rash over her body, a round [DIAGNOSES REDACTED]tous patch on her right arm with 15 mm of induration (site of second [MEDICATION NAME] test), and a [DIAGNOSES REDACTED]tous patch on her left arm with 12 mm of induration (site of first [MEDICATION NAME] test). A physician's progress note dated January 14, 2016, indicated that Resident CR1 was readmitted to the facility following a likely adverse reaction to the [MEDICATION NAME] skin test. A physician order [REDACTED]. Review of the Incontinence Management/Function Guideline, last reviewed without changes on February 29, 2016, revealed that the purpose of the bowel management program is to avoid bowel incontinence whenever possible, prevent skin problems such as pressure areas and excoriation, improve the morale of the resident, restore resident's dignity, manage bowel incontinence, and restore or maintain as much normal function as possible. The resident will be assessed/evaluated on admission and with a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) significant change. The bowel management program's effectiveness will be reviewed with the resident's quarterly MDS assessment. Clinical record review for Resident 49 revealed that the facility completed a significant change MDS assessment on March 26, 2015, indicating that she is continent of bowel. On November 3, 2015, the facility completed a quarterly MDS assessment. They note that her BIMS score (Brief Interview for Mental Status) is 11 (in the high range of moderately impaired cognition) and that she is now frequently incontinent of bowel. There was no documentation in November 2015 indicating that the facility evaluated Resident 49 after her change in bowel continence or implemented a toileting plan to help maintain and/or improve her continence status. Interview with the Director of Nursing on March 4, 2016, at 9:15 AM confirmed the above findings. 483.25 Quality of Care Previously cited 4/10/15 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 4/10/15 28 Pa. Code 211.10(a) Resident care policies. Previously cited 4/10/15 and 6/11/15 28 Pa. Code 211.12(c)(d)(3) Nursing services. Previously cited 4/10/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/10/15 and 6/11/15