Every finding on record at Rose View Rehab and Care Center

Based on a review of select facility policies and procedures, review of facility documents, and resident and staff interview, it was determined that the facility failed to implement effective corrective actions in response residents' grievance related to staff call bell response for two of eight residents reviewed (Residents 3 and 5).Findings include: The current facility policy entitled Grievance/Complaints, Recording and Investigating, revealed all grievances and complaints filed within the facility will be investigated and corrective actions will be taken to resolve the grievances. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. The facility's process to handling grievances reflects: The investigation and report will include, as applicable: a. the date and time of the alleged incident;b. the circumstances surrounding the alleged incident;c. the location of the alleged incident;d. the names of any witnesses and their accounts of the alleged incident;e. the resident's account of the alleged incident;f. the employee's account of the alleged incident;g. accounts of any other individuals involved (i.e. employee's, supervisor, etc.); andh. recommendations for corrective action. Review of Resident Concern form dated March 30, 2026, revealed Resident 3 filed a grievance regarding call bell wait time. Review of the steps taken revealed a call bell audit was initiated. Summary of the findings revealed call bell audits to be completed and will be done randomly. Random audits were provided for: March 31, 2026, and April 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27, 2026, in correlation to the March 30, 2026, grievance filed. Clinical review of the audit call bell response time forms noted along the bottom of each sheet stated The goal is to answer the bell within eight minutes. If this is not accomplished, please explain why and follow-up provided in the comments section. Clinical review of the call bell audits provided by the facility revealed Resident 3 waited more than eight minutes on the following dates and times recorded with no comment noted in the comments section of the audit form: April 7, 2026, 10:20 - 10:45 AM, 25 minutesApril 16, 2026, 4:00 - 4:10 PM, 10 minutesApril 19, 2026, 5:30 - 5:45, 15 minutes and 8:45 - 8:55, 10 minutes (AM or PM not noted)April 20, 2026, 7:00 - 7:10, 10 minutes (AM or PM not noted) Interview with Resident 3 on August 4, 2026, at 10:14 AM, revealed that resident has timed the call bell on occasions leading to a wait of 45 minutes to an hour and a half for staff to respond to her call bell. Resident 3 reported that almost every weekend she waits an hour for staff to address her call bells and feels it is due to being short-staffed. Interview with the Director of Nursing on August 4, 2026, at 3:05 PM, confirmed the above findings for Resident 3 and indicated there was no further documentation that the facility implemented any additional interventions, other than audits to promptly resolve Resident 3's grievance related to call bells. Clinical record review revealed the facility admitted Resident 5 on July 7, 2026. Review of Resident Concern form dated July 12, 2026, revealed Resident 5 filed a grievance with call bell and dietary concerns. Review of steps taken revealed Resident 5 was educated on ordering alternate meal choices two hours in advance. The summary of pertinent findings revealed facility staff talked to Resident 5 and went over her dislikes. There were no documented steps taken, or conclusion relating to Resident 5's call bell concern. Interview with Resident 5 on August 4, 2026, at 11:53 AM revealed that she frequently has to wait 45 minutes to an hour for staff to respond to her call bell. Resident 5 stated that staff have never addressed her call bell concerns. The surveyor reviewed the above concerns for Resident 5 with the Director of Nursing and Employee 1 (assistant nursing home administrator) on August 4, 2026, at 3:05 PM. The facility failed to resolve Resident 3 and 5's grievances related to staff response call bells. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure influenza immunization for one of five residents reviewed for immunization concerns (Resident 127) and failed to ensure pneumococcal immunization for one of five residents reviewed for immunization concerns (Resident 108).Findings include: Review of the CDC (Centers for Disease Control) Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2025-26 Influenza Season, revealed that vaccination should ideally be offered during September or October. However, vaccination should continue after October and throughout the influenza season as long as influenza viruses are circulating and unexpired vaccine is available. Clinical record review for Resident 127 revealed that the facility admitted her on [DATE]. An Influenza Vaccination Informed Consent form (document the facility utilizes to obtain informed consent for vaccination) revealed that Resident 127 initialed consent to the influenza vaccine on [DATE]. Review of immunization data in Resident 127's electronic medical record revealed the most recent influenza vaccine received by Resident 127 was dated [DATE] (for the 2024 to 2025 influenza season). Staff documented on [DATE], that Resident 127 was not eligible for the influenza vaccine because she was not due, that she had it previously. There was no evidence that Resident 127 received the influenza vaccine for the 2025 to 2026 influenza season. Interview with the Nursing Home Administrator on [DATE], at 2:30 PM and [DATE], at 9:15 AM and 12:14 PM revealed that the facility had no evidence that Resident 127 received this season's influenza vaccine that she was both eligible for and consented to. Current CDC recommendations to help prevent pneumococcal disease in adults note that there are two types of vaccines recommended: Pneumococcal conjugate vaccines (PCVs: PCV15, PCV20, and PCV21) andPneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) CDC recommends the administration of the PCV15, PCV20, or PCV21 for all adults [AGE] years old or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. Clinical record review for Resident 108 revealed that the facility admitted her on [DATE]. Her date of birth was [DATE]. Review of immunization information for Resident 108 revealed that she received the following pneumococcal immunizations: Pneumovax on [DATE] (before her admission to the facility at age [AGE]) Pneumovax 23 on [DATE] (before her admission to the facility at age [AGE]) Resident 108's medical record contained no evidence that she ever received a PCV immunization. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 9:15 AM confirmed the above findings for Resident 108. 483.80(d)(1)(2) Influenza and Pneumococcal Immunizations Previously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to obtain proper treatment to maintain vision for one of one resident reviewed for vision concerns (Resident 41). Findings include: An interview with Resident 41 on December 17, 2024, at 11:06 AM revealed that she saw the eye doctor a long time ago, and Resident 41stated that she never received her new glasses. Observation of Resident 41's overbed table at this time revealed there was a pair of broken eyeglasses with one of the lenses missing. Review of Resident 41's clinical record revealed see saw Health drive eye care group on June 7, 2024. Health drive recommended new glasses for Resident 41 and to deliver them upon arrival. Interview with the Nursing Home Administrator on December 20, 2024, at 10:52 AM confirmed Resident 41 never received the new glasses ordered on June 7, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel protocol medication administration for one of 23 residents reviewed (Resident 48). Findings include: Clinical record review for Resident 48 revealed a medical provider progress note dated November 4, 2024, at 2:17 PM that indicated she was having difficulty passing stool. Review of Resident 48's bowel elimination records revealed that staff documented no bowel movements for November 27, 28, 29, and 30, 2024, and December 7, 8, 9, 10, or 11, 2024. Clinical record review for Resident 48 revealed the following physician orders to promote bowel movements: Milk of Magnesia Suspension 400 MG (milligrams) per 5 ML (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth as needed (PRN) for constipation if no BM (bowel movement) on day four give with the 7-3 shift morning medication pass. Bisacodyl Suppository 10 MG (Dulcolax, stimulant laxative medication administered via suppository form into the rectum to treat constipation by increasing fluid/salts in the intestines) Insert one suppository rectally PRN for constipation if MOM is ineffective on day five. Give with the 7-3 shift morning medication pass. Fleet's Enema 7-19 GM (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation) Insert 1 applicator rectally PRN for constipation if Dulcolax is ineffective administer on day six. Administer with the 7-3 shift morning medication pass. There was no documentation on Resident 48's medication administration record (MAR) indicating that staff initiated her bowel protocol, or that she refused her bowel protocol medications, for the dates noted above. Interview with the Director of Nursing on December 20, 2024, at 9:55 AM confirmed the above noted findings that the facility failed to provide the highest practicable care related to Resident 48's bowel protocol medication administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to maintain the food preparation and dishwashing area in a safe and sanitary manner in the facility's main kitchen. Findings include: An observation of the facility's main kitchen with Employee 1, dietary manager, on December 17, 2024, at 8:25 AM revealed the following: Flooring tiles surrounding the dish machine area were absent of grout with observed liquid and food debris buildup in between the tiles. Multiple vinyl tiles in the kitchen entrance area outside the dish room, surrounding the ice machine and production area inside the entrance area were broken and cracked with dirt and debris buildup. The broken and cracked tiles are susceptible to harboring food/dirt debris presenting sanitation concerns in a food preparation area. The flooring where the tile meets the wall and transition strip from the kitchen to the dish machine room was observed with significant black buildup. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 19, 2024, at 2:30 PM. 483.60 (i)(2) Food storage safe and sanitary Previously cited 1/29/24 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 identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of two residents reviewed for PTSD (Resident 57). Findings include: Clinical record review for Resident 57 revealed that the facility admitted him on March 1, 2023. Clinical record review for Resident 57 revealed that he had a current diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health disorder that is caused by an extremely stressful or terrifying event). Review of Resident 57's current care plan revealed a care plan problem entitled, has a mood problem related to PTSD and Adjustment disorder and may display moods of being withdrawn from people. Some triggers include not able to go home independently or to be at home with family. The goal and interventions were noted as follows: Resident 57 will have improved mood state through the review date Administer medications as ordered. Monitor/document for side effects and effectiveness. Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Discuss with resident, if appropriate about long term care and needing assistance. Provide active listening and support when feeling overwhelmed or upset. Interview with the Nursing Home Administrator on December 19, 2024, at 11:30 AM revealed that Resident 57 was admitted with the diagnosis of PTSD. She stated that they spoke to Resident 57's wife yesterday and that she did not know what triggers him but indicated that he would wake up and go out into another room when he would have issues related to his PTSD, but he would not talk about it. She confirmed that the facility did not ask Resident 57's wife about his PTSD until after the surveyor brought it to their attention on December 18, 2024, at 2:50 PM. The facility failed to identify care plan triggers that may retraumatize Resident 57 related to his diagnosis of PTSD. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received the pneumococcal immunization for one of five residents reviewed for immunization concerns (Resident 5). Findings include: Clinical record review revealed that the facility admitted Resident 5 on December 3, 2018. Review of Resident 5's immunization history revealed no evidence of a recommended pneumococcal vaccine. Review of a Pneumococcal Immunization Informed Consent dated November 18, 2024, revealed Resident 5's responsible party gave the facility permission to administer the pneumococcal vaccination. During an interview with the Nursing Home Administrator on December 20, 2024, at 11:53 AM it was confirmed that there was no documented evidence that Resident 5 was offered the pneumococcal immunization after the facility received the November 18, 2024 consent. 483.80(d)(1)(2) Influenza and Pneumococcal Immunizations Previously cited deficiency 12/1/23 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 complete and accurate Minimum Data Set (MDS) assessments for two of 23 residents reviewed (Residents 102 and 108). Findings include: Review of Resident 102's clinical record revealed that the facility admitted her with a diagnosis of pneumonia (an infection in the air sacs in one or both lungs) on September 6, 2024. Review of Resident 102's resolved diagnosis list indicated that her pneumonia infection was resolved on October 10, 2024. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 15, 2024, indicated the facility assessed her as still having pneumonia. There was no documented evidence in Resident 102's clinical record to indicate that she had a pneumonia infection. Interview with the Administrator on December 19, 2024, at 9:11 AM confirmed that Resident 102's November 15, 2024, MDS was coded in error regarding having pneumonia. Review of Resident 108's closed clinical record revealed an MDS assessment dated [DATE], that indicated Resident 108 was discharged from the facility to a hospital setting. Physician progress note documentation dated November 11, 2024, at 11:29 AM indicated that Resident 108 was discharged home. Interview with the Nursing Home Administrator on December 20, 2024, at 10:58 AM confirmed Resident 108 was discharged home and the November 11, 2024, MDS was coded in error. S483.20(g) Accuracy of Assessments Previously cited 12/1/23 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident 4). Findings include: Clinical record review for Resident 4 revealed nursing documentation dated October 26, 2024, at 1:38 PM, noting Employee 1 (licensed practical nurse) went into the resident room to administer medications to Resident 3 in bed A. Documentation revealed Resident 3 was being assisted to the bathroom by staff. Documentation further noted Employee 1 put Resident 3's medications on her bedside table when Resident 4 (resident in bed B) requested a pain pill, and she left the room to obtain the pain medication from the medication cart. When Employee 1 returned with the pain medication, Resident 4 had ingested the medications she put on Resident 3's bedside dresser. The registered nurse notified the on call provider and received a new order to check vital signs every shift for 24 hours. Nursing documentation dated October 26, 2024, at 3:52 PM noted the registered nurse supervisor was notified of Resident 4's most recent blood pressure reading of 74/34 mmHg (millimeters of mercury). The registered nurse was in the room and took a manual blood pressure with systolic (pressure in the arteries when the heart beats) pressure of 76 and she was unable to hear diastolic (pressure in the arteries when the heart is at rest between beats). Documentation revealed the on-call provider was notified immediately and the facility received a new order to send Resident 4 to the emergency department for further evaluation. Review of Resident 4's Minimum Data Set (an assessment completed at specific intervals to determine resident care needs) dated October 24, 2024, noted staff assessed Resident 4 as independent in his wheelchair. The assessment indicated that Resident 4's BIMS (Brief Interview for Mental Status, which indicates cognition) score was 15, which indicated he was cognitively intact. Review of facility documentation revealed Resident 4 took the following medications in error: Amlodipine (medication to treat high blood pressure) 10 milligram (mg), one tablet Ferrous Sulfate (iron supplement) 325 mg, one tablet Lisinopril (medication used to treat high blood pressure) 20 mg, two tablets Magnesium Oxide (medication to treat heart burn) 400 mg, one tablet Risperdal (antipsychotic medication) 0.5 mg, one tablet Amitriptyline (antidepression medication) 10 mg, two tablets Baclofen (muscle relaxant) 5 mg, one tablet Benztropine Mesylate (medication to treat tremors) 0.5 mg, two tablets Carvedilol (medication used to treat high blood pressure) 25 mg, one tablet Famotidine (medication to treat heart burn) 20 mg, one tablet Metformin (antidiabetic medication) 1000 mg, one tablet Review of hospital documentation dated October 26, 2024, revealed Resident 4 presented to the emergency department for hypotension (low blood pressure) and altered mental state secondary to accidental medication administration. Resident 4 was treated with intravenous fluids and observed in the emergency department for four hours. Further review of Resident 4's clinical record revealed nursing documentation dated October 27, 2024, at 12:29 AM noting Resident 4 was hypotensive again so on call provider was called and ordered intravenous fluids. Attempts to gain intravenous access was unsuccessful, and Resident 4's blood pressure was rechecked and was 104/59 mmHg. The physician was notified and ordered a subcutaneous button (a small needle inserted into the fatty tissue beneath the skin) access for fluids. Documentation revealed access was obtained and fluids running. During an interview with Employee 1 on October 30, 2024, at 12:05 PM confirmed she left Resident 3's medications unattended on her bedside table while Resident 3 was in the bathroom. Employee 1 stated she left the room to obtain a pain pill for Resident 4 and when she reentered the room, she noticed that Resident 4 had taken all Resident 3's medications. Employee 1 confirmed Resident 4 is independent in his wheelchair and able to wheel himself in the room. The facility failed to ensure that Resident 4 was free of a significant medication error. 28 Pa Code:211.12(d)(1)(2)(5) Nursing Services

Based on observation and staff interview, it was determined that the facility failed to store and prepare food in a safe and sanitary manner to prevent the potential for food borne illness in the main kitchen. Findings include: A tour of the facility's main kitchen on November 28, 2023, at 8:25 AM revealed the following: Two three-tiered red plastic carts in the dish room had a build-up of a black removable substance on the storage surface. The attached trash receptacles had a build-up of splatter on the inside and outside surfaces. Concurrent interview with Employee 1, dietary manager, revealed these carts were power washed on a regular basis and the carts are used to pick up dirty dishes on the units after meals. The perimeter of the floor edges in the main kitchen had a build-up of debris. A metal dish caddy was uncovered, exposing the upright stored dishes to contaminants. There were crumbs and debris on the dish surfaces. The drain in front of the ice machine had a rusty build-up and had water pooling around the drain. In the standup refrigerator near the ice machine was a serving bowl of lettuce that was uncovered, a covered bowl of lettuce labeled with a use by date of November 25, and two undated containers of salad dressing, two individual serving bowls of undated oatmeal, and a container of peanut butter and jelly sandwiches that were dated as made on November 26. Although, these sandwiches were acceptable for eating by the date, the crust was hard. On a three-tiered metal rack were two trays of pear crisp dated November 27. Employee 1 confirmed the pear crisp would be served at supper and should be refrigerated until the staff were ready to plate them. A container of plastic utensils was uncovered and had specks of debris. In the rolling refrigerator was a covered container of lettuce in which the lid was not tight, and the lettuce was wilted. Two trays of unfrosted chocolate cake dated November 26 were on a cart. Although the cake was within the acceptable date range for serving, the edges were hard. The cake was partially covered with parchment paper; however, the edges were not covered. Employee 1 indicated the cake would be frosted and served for lunch on this date. A build-up of food splatter was on the outside of the double oven, gas range, tilt skillet, and steamer. Two containers of margarine were undated and uncovered on top of the range and the range was not in use. A two-tiered cart containing mixing bowls were stored upright and uncovered. Crumbs were present in one bowl. A utility cart had rusty wheels and a build-up of splatter on the surface. On the cook's prep area was a container of thickener that was not labeled or dated. During a meeting with the Nursing Home Administrator on November 30, 2023, at 11:15 AM the surveyor reviewed the findings for the kitchen. 483.60(i)(1)(2) Food Procurement, store/prepare/serve-Sanitary Previously cited 1/10/23 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for three of 25 residents reviewed (Residents 6, 40, and 83). Findings include: Clinical documentation review for Resident 40 revealed a Fall Risk Evaluation dated November 27, 2023, at 2:52 AM that indicated the resident was documented as having one to two falls in the past three months under the history of falls section. A review of clinical documentation for Resident 40 revealed no evidence of any falls within the past three months as the above Fall Risk Evaluation noted. A request by the surveyor for any fall investigations for Resident 40 during a meeting with the Nursing Home Administrator and Director of Nursing on November 29, 2023, at 2:30 PM revealed no evidence of any falls as indicated. An interview with the Director of Nursing on December 1, 2023, at 9:51 AM confirmed the resident did not have any falls as the Fall Risk Evaluation had indicated. The Director of Nursing further believed the documentation was an error in staff assessment. Clinical documentation for Resident 6 revealed a diagnoses list that included Type 2 Diabetes Mellitus (a condition where the body does not use insulin well, which results in elevated blood glucose levels). The current care plan for Resident 6 revealed the resident has diabetes and one of the interventions included Diabetes medication as ordered by doctor. A review of the physician orders for Resident 6 revealed the resident was ordered Humalog Insulin Lispro (a type of medication used to lower the blood sugar) and Insulin Glargine (a type of medication used to lower the blood sugar). Clinical documentation for Resident 6 revealed the resident was transferred to the hospital on November 21, 2023, and returned to the facility on [DATE]. Physician documentation dated November 29, 2023, at 3:38 PM revealed the resident was readmitted to the facility from the hospital. Multiple medications were ordered, which included Insulin Lispro (concentration of 100 units per milliliter injectable solution) administer five units beneath the skin before meals and at bedtime. Review of the current orders by the surveyor on November 30, 2023, at 2:00 PM revealed an order dated November 30, 2023, at 12:22 AM. The order was for Humalog Solution (concentration 100 units per milliliter) Insulin Lispro inject 100 units subcutaneously at bedtime for diabetes. The upcoming start date of the medication was noted as November 30, 2023, at 9:00 PM. An interview with the Nursing Home Administrator and Director of Nursing on November 30, 2023, at 2:30 PM revealed that this was most likely an error with the documentation and will be corrected immediately. Further review on November 30, 2023, at 3:30 PM revealed the order was changed. An interview with the Director of Nursing on December 1, 2023, at 9:45 AM confirmed the initial order to inject 100 units of insulin was a documentation error and it was corrected immediately upon the surveyor findings. Clinical record review for Resident 83 revealed a Fall Risk Evaluation dated November 8, 2023, at 1:41 AM that indicated the resident was documented as having one to two falls in the past three months under the history of falls section. A review of clinical documentation for Resident 83 revealed no evidence of any falls within the past three months as the above Fall Risk Evaluation noted. A request by the surveyor for any fall investigations for Resident 83 during a meeting with the Nursing Home Administrator and Director of Nursing on November 29, 2023, at 2:30 PM revealed no evidence of any falls as indicated. An interview with the Director of Nursing and Nursing Home Administrator on December 1, 2023, at 9:51 AM confirmed Resident 83 did not have any falls as the Fall Risk Evaluation had indicated. They indicated the documentation was an error in staff assessment. 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of six residents reviewed (Residents 3 and 102). Findings include: The policy entitled Psychotropic Medication Use, last reviewed January 18, 2023, indicates that residents will not receive medications that are not clinically indicated to treat a specific condition. Non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. The policy does not include measures the facility will implement to monitor the target behaviors for the as needed use of a psychotropic medication. Review of Resident 3's clinical record revealed a physician's order dated October 27, 2023, that indicated nursing staff were to monitor Resident 3's behaviors and make a progress note regarding her behaviors and interventions every shift. The order did not specify what behaviors nursing staff were monitoring. The behavioral monitoring order was discontinued on November 17, 2023, despite Resident 3 continuing to receive an as needed psychotropic medication for anxiety or agitation. A physician's order dated October 30, 2023, indicated that nursing staff can administer Ativan (a medication used to treat anxiety) 0.5 mg (milligrams) half a tablet every 12 hours as needed for anxiety. A physician's order dated November 4, 2023, indicated that nursing staff can administer Ativan 0.5 mg one tablet every 12 hours as needed for anxiety. A physician's order dated November 7, 2023, indicated that nursing staff can administer Ativan 0.5 mg one tablet every day at 2:00 PM as needed for anxiety or agitation. A physician's order dated November 13, 2023, indicated that nursing staff can administer Ativan 0.5 mg one tablet every eight hours as needed for anxiety or agitation. Review of Resident 3's MAR (Medication Administration Record, a form used to document the administration of medications) dated November 2023, indicated that nursing staff administered the Ativan to Resident 3 12 times, according to the physician orders listed above. There was no documented evidence in Resident 3's clinical record to indicate that nursing staff attempted non-pharmacological interventions or documented behavioral monitoring when administering the Ativan twice on November 4, 2023, twice on November 5, 2023, once on November 6, 2023, once November 10, 2023, twice on November 15, 2023, once on November 18, 2023, once on November 20, 2023, once on November 24, 2023, and once on November 25, 2023. Interview with the Director of Nursing on December 1, 2023, at 10:35 AM acknowledged the above findings for Resident 3. Clinical record review for Resident 102 revealed that she was seen by a consultant specializing in psychogeriatrics (mental health treatment for older people for the purpose of improvement in functional status, behavior, and quality of life) on July 25, 2023, and September 13, 2023. The resident was diagnosed with major depressive disorder (depression), unspecified dementia (loss of memory, language, problem solving that interfere with daily life) with anxiety, and anxiety disorder. A physician's order for Resident 102 dated September 28, 2023, indicating the nurse can administer Ativan 0.5 mg one tablet every 12 hours as needed for anxiety/agitation for 14 days. A physician's order for Resident 102 dated October 27, 2023, indicating the nurse can administer Ativan 0.5 mg one tablet every 12 hours as needed for anxiety/agitation for 14 days. A physician's order for Resident 102 dated November 15, 2023, indicating the nurse can administer Ativan 0.5 mg one tablet every 12 hours as needed for anxiety/agitation for 14 days. Review of Resident 102's MAR for October 2023, revealed nursing staff administered Ativan three times according to the physician orders above. Review of Resident 102's MAR for November 2023, revealed nursing staff administered Ativan eight times according to the physician orders above. There was no documented evidence in Resident 102's clinical record to indicate that nursing staff attempted non-pharmacological interventions prior to administering the Ativan on October 3, 10, and 27, 2023 (three of three times), and on November 9, 17, 19. 22, 23, and 29, 2023 (six of eight times). Interview with the Director of Nursing on December 1, 2023, at 1:00 PM acknowledged the above findings for Resident 102. 483.45 Psychotropic Medications Previously cited 1/10/23 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(2)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the administration of a pneumococcal vaccine for one of five residents reviewed for immunization concerns (Resident 6). Findings include: Clinical record review for Resident 6 revealed that the facility admitted him on December 3, 2018. Review of Resident 6's immunization history revealed no evidence of a recommended pneumococcal vaccine. Review of a Pneumococcal Immunization Informed Consent dated November 6, 2023, revealed Resident 6's responsible party gave the facility permission to administer the pneumococcal vaccination. During an interview with Employee 4 (infection preventionalist) on December 1, 2023, at 1:57 PM it was confirmed that there was no documented evidence that Resident 6 was offered the pneumococcal immunization. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Second Floor Nursing Unit). Findings include: Observation of the Second Floor Nursing Unit medication cart with Employee 7 (licensed practical nurse) on November 30, 2023, at 8:40 AM revealed an accumulation of debris and dirt in the bottoms of the drawers on the cart. There were multiple unsecured and unidentified medication tablets on the bottom of several of the drawers that included: a small blue oblong pill, a large white capsule, two round white pills, an oblong white pill, half of a white tablet, two oblong pills, and two beige round pills. The above findings were discussed in a meeting with the Nursing Home Administrator and Director of Nursing on November 30, 2023, at 2:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 56). Findings include: Review of a physician's order for Resident 56 dated August 21, 2023, indicated staff to administer oxygen 2 liters per minute (lpm) via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) continuously. Review of a nursing progress note for Resident 56 dated November 5, 2023, at 6:13 AM revealed the resident had an oxygen saturation (percentage of oxygen in the blood, normal usually is 95-100 percent) of 64 percent. Resident 56's oxygen was bumped up to 4 lpm and his oxygen saturation came up to 90 percent. Review of the treatment administration records for Resident 56 dated November 2023, revealed that the oxygen was administered continuously at 2 lpm. Observation of Resident 56 on November 28, 2023, at 1:45 PM revealed that the resident's oxygen was set at 3.5 lpm. Concurrent interview with Employee 2, licensed practical nurse, confirmed the oxygen was set at the incorrect level and decreased the oxygen to 2 lpm minute and that Resident 56 is unable to change the oxygen level. Review of the current plan of care for Resident 56 revealed that the use of oxygen was not addressed. The surveyor reviewed the incorrect oxygen flow rate for Resident 56 during an interview with the Nursing Home Administrator and Director of Nursing on November 29, 2023, at 2:10 PM and the lack of oxygen being addressed in the care plan on December 1, 2023, at 1:30 PM. 483.25(i) Respiratory/Tracheostomy care and Suctioning Previously cited 1/10/23 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of active nurse aides and staff interview, it was determined that the facility failed to complete a performance evaluation of every nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 5 and 6). Findings Include: Review of the facility's list of nurse aide staff revealed Employee 5 with a hire date of June 1, 2007, and Employee 6 with a hire date of July 7, 2015. A request to review the annual performance evaluations for Employees 5 and 6 revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with the Nursing Home Administrator on December 1, 2023, at 10:24 AM confirmed that performance evaluations were not completed. 28 Pa. Code 201.19 Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of two residents reviewed (Resident 30). Findings include: A clinical record review revealed the facility admitted Resident 30 on July 21, 2021. Further review of Resident 30's clinical record revealed the following weight assessments: July 18, 2023, 137 pounds August 14, 2023, 127.4 pounds (a 9.6 pound, a 7.1 percent significant weight loss) A nutrition progress note dated August 15, 2023, recommended staff monitor Resident 30's weights weekly, and administer Ensure Clear (a nutrition drink that contains high-quality protein and essential nutrients) three times a day with her meals. Further review of Resident 30's weight assessments revealed staff did not complete weekly weights as recommended by the registered dietician. A review of Resident 30's MAR (Medication Administration Record, a form utilized by the facility to document the administration of medications) dated August 2023, revealed no evidence the facility implemented the Ensure Clear as recommended by the registered dietician to address Resident 30's significant weight loss. Further review of Resident 30's September 2023 MAR revealed the facility did not start Resident 30's Ensure Clear until September 7, 2023, (24 days after identified weight loss) An interview with the Nursing Home Administrator on December 1, 2023, at 11:23 AM confirmed these findings and stated the facility had no further documentation addressing Resident 30's significant weight loss. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate completion of assessments for three of 25 residents reviewed (Residents 4, 30, and 66). Findings include: Clinical record review for Resident 4 revealed a Level I PASRR (Preadmission Screen and Resident Review, assessment used to identify evidence of serious mental illness and/or intellectual or developmental disabilities in all individuals seeking admission to Medicaid- or Medicare-certified nursing facilities) dated November 16, 2018, that indicated Resident 4 had a positive screen for serious mental illness in Section II-D and Section VII indicated that Resident 4 was in a Target Group requiring approval from the Program Office prior to admission. A letter from Office of Mental Health Department of Human Services program offices dated November 20, 2018, determined that Resident 4 had evidence of a mental health condition that met the criteria for a Program Office review and the resident may be admitted or continue to reside in a nursing facility. An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 15, 2023, assessed Resident 4 as not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The surveyor reviewed the above findings for Resident 4 during a meeting with the Nursing Home Administrator and Director of Nursing on November 29, 2023, at 2:15 PM. During an interview with Employee 3, licensed practical nurse, on November 30, 2023, at 11:23 AM who completed the above section of the MDS confirmed that the annual assessment was incorrect, and Resident 4 was considered by the State Level II PASRR process to have a serious mental illness. Clinical record review for Resident 30 revealed a MDS (Minimum Data Set, an assessment tool completed at specific interval to determine care needs) dated July 15, 2023, indicating staff assessed Resident 30 as having no lower extremity impairment. Further review of Resident 30's clinical record revealed an MDS dated [DATE], noting staff assessed Resident 30 as having lower extremity impairment on both sides. Interview with the Nursing Home Administrator and Director of Nursing on November 30, 2023, at 2:42 PM confirmed there was no evidence of a decline in Resident 30's range of motion in her lower extremities. The Director of Nursing and Nursing Home Administrator confirmed Resident 30's August 29, 2023, MDS was inaccurate. Clinical record review for Resident 66 revealed MDS assessments dated May 25, and July 21, 2023, indicating staff assessed Resident 66 as having no lower extremity impairment. Further review of Resident 66's clinical record revealed an MDS dated [DATE], noting staff assessed Resident 66 as having lower extremity impairment on both sides. Interview with the Nursing Home Administrator and Director of Nursing on November 30, 2023, at 2:42 PM confirmed there was no evidence of a decline in Resident 66's range of motion in her lower extremities. The Director of Nursing and Nursing Home Administrator confirmed Resident 66's November 8, 2023, MDS was inaccurate. 28 Pa. Code 211.5(v) Medical records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview it was determined the facility failed to store food and maintain the equipment in a sanitary manner in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on [DATE], at 8:30 AM, revealed the following: A metal sink located in the coffee station area was covered in brown stains. A garbage can located under the sink had dried brown spills covering the lid. The garbage cans have a foot pedal mechanism for opening that was non-functional. Two light green colored wash racks were observed sitting on a shelf below the coffee station. The racks contained debris, dried brown spills, and a buildup of a white flaky substance on several areas of the racks. The racks contained several empty clear pitchers and lids that contained significant brown staining. Dried brown splatter was observed on the wall behind the shelf. The lower shelf of a metal stand with wheels located by the condiment/silverware station, holding metal beverage carafes on the lower shelf was observed dirty with dust and debris and sticky to touch. A two-door upright cooler beside the coffee station contained debris buildup on the interior tray slides. The interior base of the cooler contained dried debris, sheet trays sitting directly on the bottom interior of the cooler with plastic containers of food stored on them, contained dried food debris. The interior of the right-side door was observed with dried substance, which appeared to have run down the door. The metal base and frame of the bread rack contained a buildup of dust and debris. The white plastic covering on the lower shelf of a wire metal shelving unit located beside the bread rack contained dust and debris. A table mounted can opener in the food preparation area contained dried food buildup on the blade and area surrounding the blade. Two food preparation tables were observed with white paper sheets on the lower shelves acting as a cover on the shelf with books, pans, and other equipment sitting on top of them. The exposed shelf area on the tables contained visible dust and were sticky to touch. A juice dispensing machine located in the preparation area was observed on a table with a metal rack below. The metal rack below was observed with dust build up throughout the rack itself. Two boxes of juice concentrate were observed on the metal rack with plastic tubing attached and connected to the juice machine. Three additional tubes were observed coming from the machine and were hanging from the metal rack. The ends were not connected to any juice product. All the tubing was sticky to touch and observed with multiple colors of dried substance on the tubing, and dust stuck on the tubes. The connector ends were hanging, soiled, not in use, and not covered. One of the tubes not connected to any juice product was observed with a brownish colored liquid filling the tube. Concurrent interview with Employee 10, dietary manager, revealed he was not sure what juice was in the tube, and when the last time a box of juice was connected to the exposed ends. A wire metal rack shelf with pots and pans stored on it in next to the steamer area was sticky to touch and covered with dust stuck on the metal spokes. A ceiling vent directly above the pan rack was observed with dust hanging from it. The tilt kettle was observed with chunks of dried food and dried spills on the right side of the kettle. A roll-a-way cooker stationed by the prep table contained a dried tan colored substance splattered all over the interior base of the cooler. Two three tier metal carts were observed in the dry storage area holding recipe books, trash bags, case of oats, case of corn bread mix, and some canned items. The shelves of both carts contained dust and debris. The walk-in cooler located outside the building, contained a speed rack with several sheet tray pans stored on it. One empty tray sitting on the rack contained dried spills and debris. A pan was filled with a tan colored meat, of which Employee 10 identified as sliced turkey was observed on a tray on the rack. There was no evidence as to what the product was, when it was placed there, or when it expired. A tray at the top of the rack contained three pieces of meat, covered in saran wrap, and labeled roast beef ,d+[DATE]. Employee 10 stated they were cooked prior and now pulled from the freezer to use. Review of a cool down log revealed an entry for roast beef dated [DATE]. There was no evidence to indicate when the roast beef cooked on [DATE], that Employee 10 identified in the cooler was frozen, and if so when it was pulled from the freezer, or when it needed used by, as nine days had already passed since it was cooked. The dish room was observed with dried spills and debris covering the flooring area by the clean out station. There were no staff working in the dish room and Employee 10 indicated no washing had been done yet that morning. The baseboard and walls of the dish room including under the clean out station area were observed with dried splatter throughout the dish room. Fifteen dishwashing racks lined up on the clean end of the dish machine were observed worn, and with white flaky buildup covering several spots on the racks. A cart containing what Employee 10 identified as clean equipment observed in the dish room was observed with eight tan colored resident meal trays. The trays were discolored and stained, and one tray contained a broken corner. Three brown dollies were observed lined up along the dish room wall, which Employee 10 indicated were also clean. Two of the dollies contained several racks stacked on them with plastic coffee mugs. The dish racks were also worn and contained a flaky white debris in several areas of the rack. The bases of the dollies contained dried noodles, and other dried food debris, and dried liquid spills. The above observations of the main kitchen were reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:45 PM. 42 CFR 483.60(i) (1)-(3) Food Procurement, Store-Sanitary Previously cited [DATE] 28 Pa. Code 211.6 (c) Dietary services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure documentation of what the resident and/or their responsible party received pertaining to the written notice of the facility bed hold policy at the time of transfer for five of six residents reviewed for hospitalization concerns (Residents 6, 38, 169, 105, and 116). Findings include: Clinical record review revealed nursing documentation dated October 27, 2022, at 1:47 AM noting the facility received a call from the lab indicating Resident 6 had a critical result of her potassium levels. Nursing staff obtained her vitals and notified the nurse practitioner and received an order to send Resident 6 to the emergency room for evaluation and treatment. Nursing documentation revealed that Resident 6 left the facility via an ambulance at 2:15 AM. Social service documentation dated October 28, 2022, at 6:58 AM revealed notified HCR (health care representative) that a copy of the facility's bed hold policy and resident's transfer notice were sent to her today. Clinical record review revealed nursing documentation dated December 2, 2022, at 11:44 AM noting Resident 38 left the facility at 9:30 AM via emergency medical services to the emergency department for evaluation of her altered mental status. Documentation revealed HCR is aware of her transfer to the emergency room , and a copy of the facility's transfer notice and bed hold agreement were sent with the resident. Resident 38 remained in the hospital until December 19, 2022. Clinical record review revealed nursing documentation dated January 2, 2023, at 1:57 PM that noted Resident 169 was sent to the emergency department from dialysis due to seizure like activity. Social service documentation dated January 3, 2023, at 8:35 AM noted the facility notified HCR that a copy of the facility's bed hold policy and resident's transfer notice was sent home to him. Interview with the Nursing Home Administrator and Director of Nursing on January 9, 2023, at 2:47 PM confirmed the facility did not keep a copy of Resident 6, Resident 38, or Resident 169's bed hold notice sent to the responsible party. The surveyor requested the facility's policies pertaining to the provision of a bed-hold notice upon the transfer of a resident to the hospital or therapeutic leave during interviews with the Nursing Home Administrator on January 9, 2023, at 2:30 PM, and via email communication January 11, 2023, at 9:32 AM. The facility policy entitled, Bed Hold Policy, last reviewed without changes on January 22, 2022, revealed that residents who are transferred or discharged to the hospital may have their beds held for them in accordance with federal, state, and facility policy. The policy did not include the facility's obligation, or process, to ensure that the resident and the resident representative received written information that specifies the duration of the state bed-hold policy or the reserve bed payment (e.g., expected costs) for a non-covered bed-hold. Clinical record review for Resident 105 revealed nursing documentation dated September 11, 2022, at 1:45 PM that Resident 105 was exhibiting a decreased level of consciousness and increased oxygen demand and required supplemental oxygen administration. Resident 105's heart rate was irregular. Staff contacted the physician's assistant and obtained an order to transfer Resident 105 to the emergency department for evaluation and treatment. Nursing documentation dated September 11, 2022, at 6:06 PM revealed that the hospital admitted Resident 105 for a urinary tract infection and dehydration. Interview with the Nursing Home Administrator and the Director of Nursing on January 8, 2023, at 2:30 PM, and January 9, 2023, at 2:30 PM, revealed that the facility could not provide a copy of the bed-hold notice provided to Resident 105 and her responsible party. The facility provided the one-page policy referenced above; however, could not provide an individualized notice for Resident 105 at the time of her transfer to the hospital. Closed clinical record review for Resident 116 revealed a physician's order dated October 28, 2022, at 2:00 AM to send Resident 116 to the emergency department for evaluation and treatment for a low oxygen level and unresponsiveness. Nursing documentation dated October 28, 2022, at 1:30 AM revealed that Resident 116 left the facility with emergency management services to the hospital emergency department; and that a copy of the facility's transfer notice and bed hold agreement was sent with the resident. Social services documentation dated October 28, 2022, at 9:13 AM revealed, Notified HCR (health care representative) that a copy of the facility's bed hold policy and resident's transfer notice were sent home today. The surveyor requested a copy of the bed-hold notice provided to Resident 116 and her responsible party in response to her transfer to the hospital during interviews with the Nursing Home Administrator and the Director of Nursing on January 8, 2023, at 2:30 PM, and January 9, 2023, at 2:30 PM; however, the facility failed to provide this evidence. The facility provided the one-page policy referenced above; however, could not provide an individualized notice for Resident 116 at the time of her transfer to the hospital. Interview with the Nursing Home Administrator on January 9, 2023, at 10:13 AM revealed that the facility has no individualized notice pertaining to the resident's bed-hold rights. The facility could only provide the one-page policy referenced above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights

Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to identify, assess, and provide interventions to prevent pressure sore development for one resident reviewed (Resident CR1). Findings include: The policy entitled Skin Integrity Management, identified by the Acting Director of Nursing as the most recent policy, 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. The purpose of this plan is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Staff is to complete a comprehensive evaluation of the resident upon admission/re-admission to the facility. The Braden Scale, a tool for assessing a pressure ulcer risk, indicates the following: severe risk 10, high risk 10-12, moderate risk 13-14, and mild risk 15-18. Closed clinical record review for Resident CR1 revealed that the facility admitted him on July 25, 2015, for rehabilitation for intractable (constant, severe that is not curable by any other means) back pain and then return home. Review of the Initial (Admission) Nursing Assessment, dated July 25, 2015, indicated that his skin was rarely moist usually dry, his skin color was normal, and the skin condition was warm. The identified skin conditions included: left antecubital (elbow) bruise, scab at the middle of the abdomen, moisture associated to right and left groin diffuse, an open area on the back of the right leg, and a blotch rash to the back and back of the thighs. No other skin issues were noted. Review of the Braden Scale assessment dated [DATE], revealed the nursing staff assessed Resident CR1 at a score of 19, at no risk for developing a pressure sore. Resident CR1 was hospitalized from August 4 through 7, 2015. Review of the hospital records failed to indicate any skin issues. Review of the nursing assessment upon his return from the hospital revealed that his skin was occasionally moist due to daily incontinence but had infrequent exposure. It was mainly at night and staff was using a padding system. His skin color was normal and warm. He had a left antecubital bruise and a bruise on his right inner wrist. No other skin issues were noted. Nursing staff did not update the Braden scale to re-assess Resident CR's potential for developing a pressure ulcer. Nursing documentation dated August 8, 2015, at 2:10 PM revealed that Resident CR1 had a sacral (base of the spine) deep tissue injury. Nursing staff notified his physician and received orders to cleanse with soap and water and apply [MEDICATION NAME] (used to protect wounds) every other day. The Wound Management Tracking Tool (a listing of the residents in the facility with skin issues), dated August 2015, revealed that Resident CR1 had an area on his right buttocks due to incontinence. The measurements dated August 7, 2015, week one, revealed no length or width and a depth of less than 0.1. There were two other weekly measurements, week two (no date) 6 centimeters (cm) long and 3.5 cm wide and 0.2 deep with light drainage. Week 3 (no date) 11 cm long and 4 cm wide and 0.2 deep with light drainage. There was no other description or tracking of this skin issue. Resident CR1's plan of care dated August 11, 2015, revealed staff is to assist him in repositioning every two hours, observe his skin condition with daily care, report abnormalities, pressure redistribution surfaces to his bed and chair, and a weekly skin assessment by a licensed nurse. Nursing documentation dated August 12, 2015, revealed that the physician changed the sacral wound treatment. He discontinued the [MEDICATION NAME] and implemented a skin paste (barrier) twice daily. Nursing documentation dated August 13, 2015, indicated that Resident CR1 was cooperative with medications and treatments. Nursing documentation dated August 25, 2015, indicated that Resident CR1 had a new onset/change in skin integrity, two Stage III (full thickness tissue loss) pressure ulcers on the right buttocks. Pressure ulcer one measured 5.3 cm long, 3.0 cm wide, and 0.4 cm deep. Pressure ulcer two measured 4.0 cm long, 2.0 cm wide, and 0.3 cm deep. Review of the Skin Integrity Report, confirms the above pressure description and includes further description. Both pressure ulcers had minimal drainage and the surrounding tissue was inflamed. An interview with the Nursing Home Administrator and Acting Director of Nursing on November 12, 2015, at 3:00 PM confirmed that staff assessed Resident CR1 upon admission as not being at risk for developing a pressure ulcer. There were no pressure areas or open areas on his sacrum or buttocks at that time. Staff did provide him with a pressure reducing mattress and cushion for his chair, which is standard for all admissions. During the same interview, they confirmed that Resident CR1 was hospitalized from August 4-7, 2015. Review of his hospital record and readmission nursing assessment failed to indicate any skin issues on his sacrum or buttocks. Nursing documentation dated August 8 indicated a deep tissue injury on his sacrum. The only description and/or tracking for this deep tissue injury is documented on the Wound Management Tracking Tool as noted above. The Nursing Home Administrator and Acting Director of Nursing indicated that nursing staff revealed that Resident CR1 had two Stage III pressure ulcers on his buttocks due to refusal of treatments. Review of Resident CR1's Treatment Administration Records (a form used to document treatments provided to the resident) indicated there were no resident refusals from August 8 through and including August 24, 2015. Review of the POC Resident Response Rate Report (documentation of resident's turning and repositioning revealed that Resident CR1 did not refuse to be turned from August 8 through August 31, 2015. The facility failed to identify, assess, and implement interventions to prevent two Stage III pressure ulcers on Resident CR1's right buttocks. 483.25(c) Treatment/Services to Prevent/Heal Pressure Sores. Previously cited 6/12/15 28 Pa. Code 211.10(a)(d) Resident care policies. Previously cited 6/12/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/12/15

Based on clinical record review, staff interview, and review of select facility policies, it was determined that the facility failed to implement interventions to prevent an accident for one of 24 sampled residents (Resident 44). Findings include: The policy entitled "Accidents, Incidents, and Adverse Events," last reviewed February 12, 2014, revealed an adverse event is defined as an unexpected occurrence involving death, serious physical injury, or psychological injury, or the risk thereof. Clinical record review for Resident 44 revealed that her care plan indicated that she was at risk for falls, had a history of [REDACTED]. Review of nursing documentation dated March 22, 2014, revealed that Employee 5 (nurse aide) responded to Resident 44's sounding alarm. Employee 5 indicated that Resident 44 was walking in her room without her walker or anything on her feet. Employee 5 assisted Resident 44 into the bathroom and onto the toilet. Employee 5 exited the bathroom leaving Resident 44 alone. Resident 44 attempted to stand without assistance and fell . Resident 44 was transferred to the emergency room with complaints of right hip and back pain. The hospital x-ray at the emergency room revealed a right hip fracture. Resident 44 was admitted to the acute care hospital for surgery. The facility's investigation into Resident 44's March 22, 2014, fall revealed that Employee 5 left Resident 44, who was confused and at risk for falls, in the bathroom unattended, when she fell fracturing her right hip. The facility determined that neglect was the cause of Resident 44's fall and terminated her employment. An interview with the Director of Nursing on March 19, 2014, at 3:00 PM confirmed the above findings. 483.25(h) Accidents. Previously cited 6/14/1328 Pa. Code 201.18(e)(1) Management. Previously cited 6/14/13 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/14/13 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 6/14/13