Every finding on record at Rosewood Gardens Rehabilitation and Nursing Center

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for one of 27 residents reviewed. (Resident 11).Findings include:Review of Resident 11's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 11, 2025, revealed under section N0350 - Insulin, that the resident was not marked as receiving insulin medication.Review of Resident 11's physician's orders revealed that the resident has an order for insulin.Review of Resident 11's Medication Administration Record (MAR) revealed that the resident did receive insulin on two days of the seven days look back period, December 9th and 10th 2026. Interview with the licensed nursing staff, Employee E3, on February 5, 2026, at 10:40 a.m. confirmed that the resident's MDS assessment was marked incorrectly.483.20 Accuracy of AssessmentsPreviously cited 11/22/2024 28 Pa. Code 211.5(f) Clinical recordsPreviously cited 11/22/2024 28 Pa. Code 211.12(c) Nursing servicesPreviously cited 11/22/2024

Based upon clinical record review, it was determined the facility failed to ensure Minimum Data Set Assessments were completed accurately for two of 28 residents reviewed (Resident 46 and 106 Resident). Findings include: Review of Resident 46's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 4, 2024, revealed Resident 46 had a right foot pressure ulcer (opening of the skin caused by prolong pressure applied to an area). Review of Resident 46's clinical record revealed Resident 46 had a right foot wound as a result of an injury. Further review of Resident 46's clinical record failed to reveal evidence of a right foot pressure ulcer. Interview with the Director of Nursing on November 24, 2024 at 8:50 a.m. confirmed the MDS was inaccurately completed and further confirmed Resident 46 did not have a right foot pressure ulcer. A review of Resident 106's Annual Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated September 15, 2024, revealed resident was taking an Antipsychotic medication (Are prescription medications that treat certain disorders by changing how the brain works). A review of Resident 106's September 2024, Medication Administration Records revealed resident were on Lexapro and Remeron (A medication used for depression) and Lorazepam (A medication for anxiety). Clinical records failed to reveal that Resident was on Antipsychotic medication. An interview with licensed nurse Employee E3 was conducted on November 21, 2024, at 11:57 a.m. Employee E3 confirmed Resident 106 was not taking Antipsychotic mediation and that MDS was coded in error. The facility failed to ensure residents' assessments were completed accurately. 28 PA Code 211.5(a)(b)(f) Clinical Records

Based upon clinical record review, it was determined the facility failed to ensure resident records contained accurate documentation for one of 28 residents reviewed (Resident 46). Findings include: Review of Resident 46's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 4, 2024, revealed Resident 46 had a right foot pressure ulcer (opening of the skin caused by prolong pressure applied to an area). Review of Resident 46's clinical record revealed Resident 46 had a right foot wound as a result of an injury that occurred on July 3, 2024. Further review of Resident 46's clinical record failed to reveal evidence of a right foot pressure ulcer. Review of wound tracking documentation completed by the wound nurse from July 2024 through September 2024, revealed Resident 46 had a right foot pressure ulcer. Review of progress notes completed by the Nurse Practitioner from July 2024, through September 2024, further revealed Resident 46 had a right foot pressure ulcer. Interview with the Director of Nursing on November 24, 2024, at 8:50 a.m. confirmed Resident 46 did not have a right foot pressure ulcer and further confirmed that documentation in Resident 46's clinical record was inaccurate as Resident 46 did not have a right foot pressure ulcer. 28 PA Code 211.5(a)(b)(f) Clinical Records

Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of one residents reviewed (Resident 12). Findings include: Review of Resident 12's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of progress notes revealed that the resident had a planned discharge on November 8, 2024. Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview with the Nursing Home Administrator and Director of Nursing on November 22, 2024, at 11:30 a.m. confirmed that the recapitulation was not completed prior to discharge. 28 Pa Code 211.5 (f) Clinical records

Based on clinical record review and review of facility documentation, it was determined that the facility failed to ensure adequate supervision during a transfer for one of three residents reviewed for falls (Resident 86). Findings include: Review of Resident 86's clinical record revealed diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (stroke) affecting the resident's left non-dominant side and generalized muscle weakness. Review of Resident 86's quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated September 17, 2022, revealed the resident required extensive assistance of two staff persons for transfers during the lookback period. Review of Resident 86's care plan revealed a care plan initiated on September 30, 2020, identifying the resident as having a performance deficit in activities of daily living. An intervention was added the same date that the resident required extensive assistance of two staff persons for transfers. Review of Resident 86's progress notes revealed a nurse's note dated October 29, 2022, which stated: [nurse aide Employee E3] Called the nurse to the resident room .nurse found resident on the floor lying on his back. [Employee E3] stated when she was transferring the resident from bed to wheelchair. he slide on the floor. Found two skin tear on left arm 0.5x0.5cm. Review of facility documentation revealed a witness statement from nurse aide Employee E3 which revealed: When I try to transfer [him] from the bed to the wheelchair, he slide down on the floor. Interview with the Nursing Home Administrator and Director of Nursing on February 27, 2023 at 10:50 a.m. confirmed the above findings. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on the facility's policy review, CDC (Centers for Disease Control and Prevention) guidelines review, observation, and staff interview, it was determined that the facility failed to ensure infection control and prevention was implemented on one of three units observed (A Wing Unit). Findings include: Review of the facility's policy titled Clostridium Difficille (C-Diff- A bacterium that causes an infection of the large intestine) dated March 9, 2022, revealed that residents with diarrhea and suspected C-diff infection are placed on Contact Precaution (Refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment). The same policy also revealed that when caring for residents with C-diff infection, the staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to (ABHR-Alcohol-based hand rub) for the mechanical removal of C-diff spores from hands. Review of the CDC guidelines titled C-Diff dated July 20, 2021, revealed C-diff can live on people's skin. People who touch an infected person's skin can pick up the germs on their hands. Washing with soap and water is the best way to prevent the spread from person to person. Review of Resident 15's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 13, 2023, revealed resident had severe cognitive impairment. The same MDS also revealed that the resident was always incontinent of both bowel and bladder. Review of the nursing progress notes dated February 6, 2023, revealed resident's stool result was positive for C-diff, and an order of Vancomycin (antibiotic) 125mg four times daily was made by the physician. Review of the physician's order dated February 6, 2023, revealed an order for a contact precaution every shift related to C-diff. Review of the nursing progress notes dated February 22, 2023, at 10:55 p.m., revealed resident was on Vancomycin for C-diff, afebrile, and one loose stool this shift. Observation of medication administration conducted on February 23, 2023, with licensed nurse Employee E4 in Resident 15's room on the A-wing unit. During observation, a sign posted on the resident's door revealed the following: STOP, contact precautions, everyone must clean their hands, including before entering and when leaving the room. The sign also revealed that providers and staff must put on gloves and gown before room entry and discard before room exit. After preparing the resident's medication, Employee E4 entered Resident 15's room at 9:10 a.m., without wearing gloves and a gown. Employee E4 was observed placing a cup of water into the resident 's hand and guiding the resident's hands to drink the water after administering each pill. At 9:17 a.m., after the resident had taken the medications, Employee E4 took the resident's eaten breakfast meal tray and left the room without washing her/his hands. Employee E4 opened the tray truck and placed the tray inside. Employee E4 returned to the medication cart, cleaned her/his hand with a sanitizer then proceeded to prepare and administer medication to another resident. Interview with the Infection Preventionist, licensed nurse Employee E5 was conducted on February 27, 2023, at 10:45 a.m. Employee E5 confirmed that a contact precaution includes putting on gloves and a gown when entering the resident's room and disposing before leaving the room and washing hands with soap and water. The above information was conveyed to the Director of Nursing on February 27, 2023, at 10:47 a.m. The facility failed to ensure infection control and prevention was implemented on a resident with C-diff infection. 28 Pa. Code 211.5(f) Clinical Records Previously cited 2/11/22 28 Pa. Code 211.10(c) Resident Care Policies Previously cited 2/11/22 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 2/11/22

Based on clinical record review, staff and resident interview, and facility policy and procedure review it was determined the facility failed to provide services for residents to maintain and restore bladder and bowel continence to the extent possible for one of two residents reviewed. (Resident 70) Findings Include: Review of facility policy and procedure titled Urinary and Bowel Incontinence- Evaluation and Management, effective January 2023, revealed Resident shall have their continence status evaluated within five days of admission, re-admission and re-evaluated at least quarterly by a licensed nurse as part of the comprehensive assessment and care planning process. As part of the initial and ongoing assessments, the nursing staff will initially screen for information related to urinary and bowel continence utilizing the Bowel and Bladder evaluation. Upon completion of the Bowel and Bladder Evaluation, should the bowel or bladder history indicate anything other than continent, a voiding diary will be implemented for admission/readmission. Upon evaluation of the data collection from the voiding diary, a decision will be made to determine if a toileting program is appropriate for the individual resident. Interview with Resident 70 on February 27, 2023, at 9:30 a.m. revealed they are alert and oriented and incontinent of bowel and bladder and wear incontinence briefs. Resident 70 also stated they can go to the bathroom with out the assistance of staff. Review of Resident 70's Quarterly Minimum Data Sets (MDS-periodic assessment of resident needs), dated October 31, 2022, and January 31, 2023, revealed the resident is occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident 70's Quarterly Bowel and Bladder Evaluations, dated November 11, 2022, and February 21, 2023, revealed the resident is continent of both bowel and bladder. Review of Resident 70's bladder continence task from January 24, 2023, to February 23, 2023, revealed the resident had incontinence episodes on 15 shifts. Review of Resident 70's bowel continence task from January 24, 2023, to February 23, 2023, revealed the resident had incontinence episodes on 8 shifts. Review of Resident 70's clinical record revealed there was no voiding diary completed after the quarterly assessments of November 11, 2023, and February 21, 2023. Review of Resident 70's care plan revealed there was no care plan for bowel incontinence and the bladder care plan did not include intervention for the resident to maintain or improve their bowel and bladder continence. Interview with the Director of Nursing and the Nursing Home Administrator on February 27, 2023, at 10:30 a.m. confirmed the Quarterly Bowel and Bladder Evaluations, dated November 11, 2022, and February 21, 2023, were incorrect and there was no voiding diary completed per policy and there were no interventions develop to help Resident 70 maintain or improve their bowel and bladder incontinence. 28 Pa. Code 211.5 (f) Clinical record 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to monitor and address weight loss in a timely manner for two of 11 residents reviewed for nutrition (Resident 19 and Resident 111). Findings include: Review of facility policy titled Weight Management revised January 2022 revealed; Each resident will be weighed upon admission, readmission and as ordered by a physician .All weights are to be documented in the electronic medical record. Inaccurate weights/errors will be struck out of the electronic medical record once the accuracy of a weight has been verified .Weight variances will be reviewed by dietician and [interdisciplinary team.] Review of Resident 19's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 19's clinical record including progress note of January 2, 2022, revealed that the resident was identified with a stage 3 pressure ulcer (full thickness skin loss and subcutaneous fat may be visible) to the right hip. Review of Resident 19's clinical record including vital signs record revealed that the resident weighed 119.2 pounds on December 28, 2021. Review of nutrition note dated January 10, 2022, indicated that the January 2022 weight had not yet been obtained and a recommendation was made to obtain the weight. Review of resident's weight of January 19, 2022, revealed a weight of 118.7 pounds. Review of resident's weight of January 26, 2022, revealed a weight of 110.0 pounds, a loss of 8.7 pounds or 7.3% in one week. There was no evidence that a reweight was obtained. Next recorded weight of 108.6 pounds was obtained on February 9, 2022 (14 days later). Interview with Employee E3, Registered Dietitian, on February 11, 2022, at 12:00 p.m. revealed Employee E3 was aware of the weight loss recorded on January 26, 2022, and awaiting a reweight to be obtained. Employee E3 indicated that the expectation was that the reweight would have been obtained sooner than February 9, 2022. Review of Resident 111's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 111's weights revealed that on January 18, 2022, the resident weighed 109.9 pounds (lbs.) On January 26, 2022, the resident weighed 103.8 lbs., which is a 5.55% weight loss in eight days. Further review of the resident's weights failed to reveal a reweight following the January 26, 2022 weight, or any weights obtained since January 26, 2022. Interview with the dietitian, Employee E3, on February 11, 2022 at 11:54 a.m. indicated that the dietitian was aware of Resident 111's weight loss and was waiting for a reweight to confirm accuracy. Review of Resident 111's clinical record failed to reveal any documented evidence that the dietitian was made aware of the weight loss or awaiting a reweight for Resident 111. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observation, clinical records review, and staff interviews, it was determined that the facility failed to timely notify the physician regarding the resident's inability to bear weight and pain on the resident's left lower extremity for one of 26 residents reviewed (Resident 79). Findings include: Review of Resident 79's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 79's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated October 21, 2021, revealed resident required supervision with ambulation and limited with one person assistance with transferring. The same MDS revealed resident had severe cognitive impairment. Interview was conducted with the Rehabilitation Director, Employee E4 on February 11, 2022, at 11:00 a.m. Employee E4 stated that Resident 79 was on rehabilitation caseload from October 15, 2021, until November 9, 2021. Review of the Physical Therapy Treatment Notes dated October 20, 2021, revealed Resident 79 performed gait training to increase safety and performance with functional ambulation on the unit. The same note revealed that the resident actively participated in skilled interventions and was compliant with skilled interventions. Review of the Physical Therapy Treatment Notes dated October 26, 2021, revealed, Resident 79 ambulated three feet with moderate handheld assistance. A review of the same note revealed resident guarded the left lower extremity due to a pain scale of 7 out of 10 (moderate pain). Response to treatment revealed limited standing activity due to pain. Clinical records review failed to reveal that nursing staff was notified of resident's moderate pain to left lower extremity while ambulating in therapy. There was no documented evidence that the pain on the left lower extremity was addressed. Review of the Physical Therapy Treatment Notes dated October 27, 2021, revealed transfer training, chair pushing from the armrest, maximum assist the first trial to moderate assist of two with poor initiation task due to pain. A review of the same note revealed nurse made aware patient is still in pain on LLE (left lower extremity). Review of the nursing progress notes failed to reveal information regarding the reported pain of the resident's LLE pain while in therapy on October 27, 2021. There was no documented evidence that the pain on the left lower extremity was addressed. Interview conducted with Employee E4 on February 11, 2022, at 11:00 a.m., revealed that the resident's pain on LLE was identified on therapy on October 26, 2021. Employee E4 was unable to answer if it was communicated with nursing. Employee E4 confirmed that Resident's LLE pain was communicated with nursing on October 27, 2021. Review of the Physicians' note dated October 29, 2021, at 12:55 p.m., revealed Resident 79 had right foot pain, appeared right bunion (bony bump that forms on the joint at the base of the big toe) was inflamed, continue Tylenol (medication to treat mild pain) and follow up with Podiatry (medical professional devoted to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the same physician's note failed to reveal information regarding the resident's left lower extremity pain during therapy. Review of the Podiatry consults dated October 29, 2021, revealed that a length discrepancy was noted with the left lower extremity shorter than the right. The same note revealed that the resident would not get up to walk, unable to determine if pelvic tilt was contributing to the discrepancy, recommended a consult with Physical therapy (PT) and Occupational therapy (OT) for further evaluation and treatment and a level up attachment for the left shoe. Review of the Physical Therapy (PT) Treatment Notes dated November 1, 2021, revealed the patient appears to be limited by pain on the left lower extremity with the patient grimacing in pain at times. Review of the Physical Encounter notes signed on November 1, 2021, revealed transfer from wheelchair to wall bar with maximum assist with patient appearing to avoid weight-bearing on left lower extremity due to pain with a grimace on her/his face. Response to treatment revealed the patient was resistant at times and appeared to be in increased pain on the left lower extremity during transfers, nursing was aware. Review of the nursing progress notes failed to reveal information regarding reported pain and avoiding bearing weight on the left lower extremity during November 1, 2021, therapy. There was no documented evidence that the pain on the left lower extremity was assessed and treated. Review of the Physical Therapy Treatment Notes dated November 2, 2021, revealed multiple attempts to have the resident stand were unsuccessful: stand at the table; at wall bar; and a rolling walker. The same note revealed spoke with nursing and reported that the resident was not walking anymore. Review of the nursing progress notes failed to reveal that the physician was notified of the resident's change in condition with ambulation. Review of the Physical Therapy Discharge Summary revealed resident was discharged from therapy on November 9, 2021, due to achieving the highest practical level. A review of the same note revealed the following: Gait-baseline (October 15, 2021) was supervision or touching assistance; October 21, 2021, substantial maximal assistance; Discharge (November 9, 2021) dependent. Ambulation on October 27, 2021 not treated due to pain, November 9, 2021 unable (to ambulate) due to safety, the patient demonstrated a decline in ambulation requiring the use of a wheelchair for locomotion. Further review of the Physical Therapy Discharge Summary revealed: Patient had been making consistent progress with mobility but recently demonstrated decline due to left lower extremity pain, treatment results were communicated to Interdisciplinary Team. Discharge recommendation revealed, Assist needed two transfers and locomotion, use a wheelchair for locomotion on the unit. Clinical records review failed to reveal documented evidence that the physician was notified of the resident's ambulation decline due to left lower extremity pain. An interview conducted on February 11, 2022, at 1:45 p.m wi revealed . th the resident's attending physician, takes care of a lot of patients and receives a lot of phone calls and therefore would not be able to remember any calls received on the above dates. Review of the nursing progress notes dated November 9, 2021, at 9:10 a.m., revealed resident's family called the facility enquiring about the resident's poor transfer status and then informed that the facility was waiting for the level-up lift shoe. Clinical records review revealed resident had a fall on November 16, 2021, at 2:50 a.m., facility documentation revealed resident was found on the floor with feet in bed, the resident was assessed but no injury noted. the attending physician and family were notified of the fall. Review of the nursing progress notes dated December 2, 2021, at 2:20 p.m., revealed that the (PCP) primary care physician was notified of Resident 79's weight loss and not ambulating or putting left leg down to bear weight on. An x-ray was ordered for bilateral hips and pelvis. Review of clinical records revealed portable x-ray findings suggestive of age-indeterminate left hip x-ray. The physician ordered the resident to be transferred to the hospital for further evaluation. Review of the progress notes dated December 2, 2021, at 9:24 p.m., revealed CT scan result indicated a comminuted displaced sub capital fracture of the left hip with subacute chronicity (A break or splinter of the bone into more than two fragments). Additional review of the nursing progress notes dated December 3, 2021, at3:20 a.m., revealed that the resident was admitted to the hospital for a left hip fracture. The above information was conveyed to the Nursing Home Director and Director of Nursing on February 11, 2021, at 2:00 p.m. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 4/26/19, 6/27/19 28 Pa. Code 211.5(f) Clinical records Previously cited 4/26/19, 6/27/19 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services Previously cited 4/26/19, 6/27/19

Based on observations and staff interviews, it was determined that the facility failed to maintain an environment that was hazard-free during lunch and activities, during two of the five days of the survey. Findings include: Observations during lunch meal pass, on B wing, Dementia Unit, on October 19, 2020, at approximately 12:40 p.m., revealed that Employee E3, Licensed Nurse, was in a resident's room. The medication cart was in the hallway at the nursing station. The cart was observed at that time to be unattended and unlocked. Residents were observed in the direct area of the cart. This was confirmed by Employee E3 at approximately 1:00 p.m. Observation made during return visit to the B wing, Dementia Unit, on October 22, 2020, at approximately 1:35 p.m. revealed Employee E4, Licensed Nurse, was in a resident's room. The medication cart was located outside of the nursing station. The cart was observed at that time to be unattended and unlocked. Resident R16 was noted at the nursing station in the area of medication cart. Employee E4 returned to medication cart at approximately 1:45 p.m,. and it was confirmed with Employee E4 that the medication cart was unlocked and unsupervised. Interview with the Director of Nursing, Assistant Director of Nursing and the Unit Manager on October 23, 2020, at 11:15 a.m., revealed the medication cart should have been locked or attended by a licensed nurse. The staff failed to ensure that residents were safe and failed to maintain an environment that was hazard-free. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, and interviews with staff, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of the clinical record for Resident R68 revealed [DIAGNOSES REDACTED]. the tissues of the body). Review of Resident R68's physician orders [REDACTED].> (greater than) 3 lbs (pounds), every day shift. Review of Resident R68's electronic medical record, vital sign section, revealed for the month of August 2020, there were only six weights recorded. August 7, 2020- 151.8 lbs, August 8, 2020- 146.4 lbs, August 10, 2020- 146.6 lbs, August 17, 2020- 146.0 lbs, August 24, 2020- 145.4 lbs, and August 31, 2020- 144.6 lbs. Review of Resident R68's electronic medical record, vital sign section, revealed for the month of September, 2020, there were only four weights recorded. September 1, 2020- 143.4 lbs, September 7, 2020- 142.4 lbs, September 14, 2020- 145.6 lbs, and September 25, 2020- 155.0 lbs. Review of Resident R68's electronic medical record revealed on September 7, 2020, Resident R68's weight was 142.2 pounds. The next documented weight was September 14, 2020, for 145.6 pounds. Resident R68 had a 3.4 pound weight gain, and there was no documentation of physician notification, per the physician's orders [REDACTED].>Review of Resident R68's electronic medical record, vital signs section, revealed for the month of October, 2020, there were eight weights recorded. October 1, 2020- 145.4 lbs, October 3, 2020- 144.0 lbs, October 6, 2020 - 145.0 lbs, October 7, 2020- 146.0 lbs, October 9, 2020- 145.5 lbs, October 14, 2020- 141.6 lbs, October 16, 2020 - 142.5 lbs, and October 19, 2020- 145.0 lbs. Interview with Resident R68's physician and the Director of Nursing on October 23, 2020 at approximately 1:30 p.m. revealed that Resident R68's daily weights had not been completed as ordered. The facility failed to follow a physician's orders [REDACTED]. 28 Pa. Code 201.18(a)(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure accurate assessments for one of 25 residents reviewed (Resident 79). Findings include: Review of Resident 79's Quarterly Minimum Data Set (MDS- periodic assessment of the resident's condition) dated September 4, 2020, revealed under section P-Restraints and Alarms, that the resident was coded as using a trunk restraint in a chair, or out of bed less than daily. Observations of Resident 79 throughout the survey failed to reveal that the resident was restrained at any time. Review of Resident 79's clinical record failed to reveal evidence that the resident was utilizing a trunk restraint. Interview with the Director of Nursing on October 21, 2020, at 2:20 p.m. confirmed that Resident 79's MDS was coded incorrectly and that Resident 79 never utilized restraints. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and interviews with staff and family it was revealed that the facility did not ensure that the baseline care plan was established and reviewed with family for one of three residents reviewed (Resident R1) in a timely manner. Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on (MONTH) 21, 2019, with a primary [DIAGNOSES REDACTED]. Further review of Resident R1's clinical record revealed a baseline care plan that did not address the primary [DIAGNOSES REDACTED]. Resident R1's family was interviewed on (MONTH) 27, 2019, at approximately 9:00 a.m., and revealed that the facility did not address the resident's weight loss [DIAGNOSES REDACTED]. An interview with Licensed Employee E3 on (MONTH) 27, 2019 at approximately 1:35 p.m. revealed that the base line care plan did not address the abnormal weight loss [DIAGNOSES REDACTED]. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.11(c)(d) Resident Care Plan 28 Pa. Code 211.12(c) Nursing Services Previously cited 4/26/2019 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.12(d)(3) Nursing Services

Based on review of facility temperature log guidelines, observation and staff interview, it was determined that the facility failed to maintain the minimum standard holding temperature for hot food items in the main kitchen during tray line. Findings include: Review of the facility temperature log guidelines, undated, revealed that the minimum standard holding temperature for hot food items is indicated to be between 140 and 155 degrees Fahrenheit. Observation of the tray line for the noon meal on (MONTH) 25, 2019 at 12:30 p.m., when food temperatures were taken by the Director of Dining Services, revealed chicken breasts at a holding temperature of 130 degrees Fahrenheit which was below the minimum standard holding temperature indicated on the facility temperature log guidelines. The internal temperature of the chicken breast was confirmed by the Director of Dining Services at the time of the observation. The facility failed to maintain the holding temperature of chicken breasts at the minimum standard holding temperature. 28 PA Code 201.14(a) Responsibility of licensee Previously cited 3/19/2018 28 PA Code 201.18(b)(1)(3)(e)(1) Management Previously cited 3/19/2018 28 PA Code 211.6(d) Dietary services Previously cited 3/19/2018

Based on review of the National Fire Protection Agency's (NFPA), observation and staff interview, it was determined that the facility failed to provide an environment free of accident hazards in the main kitchen. Findings include: Review of NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations states that open flames are not permitted in health care settings. Observation of the kitchen tray line on (MONTH) 25, 2019 at approximately 12:15 p.m., revealed chafing dishes (portable food warmers) being heated by sterno (fuel made from denatured and jellied alcohol) with an open flame used on the tray line. Interview with the Director of Dining Services at the time of the observation confirmed that the chafing dishes had been used on the tray line since (MONTH) 22, 2019. The Director of Dining Services further stated that the use of the chafing dishes was temporary as the steam table was broken and the replacement would not be available until later on (MONTH) 25, 2019. 28 PA Code 201.18(b)(1) Management Previously cited 3/19/2018 28 PA Code 207.2(a) Administrator's responsibility

Based on review of the Resident Assessment Instrument User's Manual and clinical records and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for 23 of 58 residents reviewed (Residents 1, 3, 8, 9, 11, 12, 15, 16, 17, 19, 20, 21, 22, 27, 35, 37, 38, 39, 44, 45, 46, 47, and 56). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated (MONTH) (YEAR), indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date. Review of Resident 1's clinical record revealed that the last assessment was completed on (MONTH) 3, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 3's clinical record revealed that the last assessment was completed on (MONTH) 1, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 8's clinical record revealed that the last assessment was completed on (MONTH) 3, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 9's clinical record revealed that the last assessment was completed on (MONTH) 11, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 11's clinical record revealed that the last assessment was completed on (MONTH) 19, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 12's clinical record revealed that the last assessment was completed on (MONTH) 20, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 15's clinical record revealed that the last assessment was completed on (MONTH) 21, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 16's clinical record revealed that the last assessment was completed on (MONTH) 28, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 17's clinical record revealed that the last assessment was completed on (MONTH) 29, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 19's clinical record revealed that the last assessment was completed on (MONTH) 3, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 20's clinical record revealed that the last assessment was completed on (MONTH) 5, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 21's clinical record revealed that the last assessment was completed on (MONTH) 6, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 22 ' s clinical record revealed that the last assessment was completed on (MONTH) 6, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 27's clinical record revealed that the last assessment was completed on (MONTH) 7, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 35's clinical record revealed that the last assessment was completed on (MONTH) 11, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 37's clinical record revealed that the last assessment was completed on (MONTH) 14, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 38's clinical record revealed that the last assessment was completed on (MONTH) 14, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 39's clinical record revealed that the last assessment was completed on (MONTH) 15, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 44's clinical record revealed that the last assessment was completed on (MONTH) 19, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 45's clinical record revealed that the last assessment was completed on (MONTH) 20, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 46's clinical record revealed that the last assessment was completed on (MONTH) 20, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 47's clinical record revealed that the last assessment was completed on (MONTH) 21, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 56's clinical record revealed that the last assessment was completed on (MONTH) 20, (YEAR). There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on (MONTH) 26, (YEAR), at 9:55 a.m. confirmed that a quarterly MDS assessment should have been completed for Residents 1, 3, 8, 9, 11, 12, 15, 16, 17, 19, 20, 21, 22, 27, 35, 37, 38, 39, 44, 45, 46, 47, and 56 within 92 days of the completion of their previous assessment. 28 Pa Code 211.5(f) Clinical records Previously cited 3/19/18 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 10/11/17

Based on observations, record review and staff interview, the facility failed to ensure residents dignity in one out of four units observed. (E wing) Findings include: On (MONTH) 23, 2019, at 1:38 p.m., Resident #84 was observed in her bed. There was an uncovered urinary bag with yellow urine visible hanging from the side of the bed. At 5:02 p.m., urinary bag of Resident #84 was still observed uncovered. Observations conducte on (MONTH) 24, 2019, at approximately 11:03 am, revealed Resident #84 was in her bed, the urinary bag still uncovered with yellow urine, hanging from the side of the bed. Interview with Employee E3 on (MONTH) 24, 2019, at 11:07 am indicated that the catheter bag should be covered with a dignity bag and proceeded to place a dignity cover for the urinary bag of Resident #84. Observation of the evening meal on (MONTH) 23, 2019 revealed at 5:10 p.m. revealed the meals trays arrived on the [NAME] unit. Further observation revealed that by 5:15 p.m. all of the trays were delivered to the resident in the dining room. Residents #65 and Resident #124 sat with the meals in front of them from 5:15 p.m. until they were assisted by staff members to eat at 5:34 p.m. Further observations between 5:10 p.m. and 5:34 p.m. revealed three instanced where the residents who required help with eating were referred to as feeders by the staff and once when a clothing protector was referred to as a bib. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 26, 2019 at 1:30 p.m. confirmed that the residents were provided care without ensuring their dignity during meal time. Observation of Resident #62 during all days of the survey revealed a bright neon pink sign posted above the bed stating, honey thick liquids only provide all liquids by spoon. Interview with Licensed Nursing Employee E6 on (MONTH) 25, 2019 at 9:20 a.m. confirmed that the sign should not have been posted. Observation of Resident #111 during all days of the survey revealed a sign posted above the bed stating, position pillow under Resident 111's left shoulder for extra support - wear splint on left hand 8-10 hours a day - OT (occupational therapy) Dept. Interview with Licensed Nursing Employee E6 on (MONTH) 25, 2019 at 9:20 a.m. confirmed that the sign should not have been posted. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(j) Resident's rights

Based on staff interviews and record review, the facility failed to provide care and services related to diabetes (a disease characterized by long-term high blood sugar) on one out of 24 residents reviewed (Resident #104). Findings include: Interview conducted with Resident #104 on (MONTH) 24, 2019, at 9:30 a.m. revealed that Resident # 104 went to [MEDICAL TREATMENT] (manual removal of waste and toxins from the body) every Monday, Wednesday and Friday. Resident #104 reported that her [MEDICAL TREATMENT] took approximately 3-4 hours. Further interview with Resident #104 revealed that there were times that she reminded staff to check her blood sugar, especially on [MEDICAL TREATMENT] days. Review of Resident #104 [DIAGNOSES REDACTED].). Review of Resident #104 Minimum Date Set (MDS- assessment of resident care needs) dated (MONTH) 5, 2019 identified the resident with a BIMS ((Brief interview for mental status) score of 15 out of 15 which place the resident as cognitively intact. Review of Resident #104's physician's orders [REDACTED].<70 or >400 notify MD; 201-250, 2 units; 251-300, 3 units; 301-350, 4 units; 351-400, 5 units three times daily (timed at 9:00 am, 1 pm, and 5 pm). Review of (MONTH) 2019 Medication Administration Record [REDACTED]. On (MONTH) 16, 2019 the blood sugar result was missing for 1:00 p.m. Reviewof (MONTH) 2019 MAR indicated [REDACTED] Interview with Director of Nursing on (MONTH) 26, 2019 at approximately 1:30 p.m. confirmed that Resident #104's blood sugar monitoring for the 5:00 p.m. on (MONTH) 11, 19, 20, 25, 26, 31, 2019; (MONTH) 3, 10, 15, 17, 18, 21, 22 and on (MONTH) 16, 2019, at 1:00 p.m. was not completed. 28 Pa Code 211.5(f) Clinical records Previously cited 3/19/18 28 Pa Code 211.12(c)(d)(1) Nursing services Previously cited 3/19/18

Based on observations, interview and record review, the facility failed to ensure that infection prevention and control program was maintained in one of four residents reviewed for infection control (Resident #84). Findings include: Review of Resident #84's care plan revealed that a care was developed on (MONTH) 10, 2019 for urinary tract infection. Observation conducted on (MONTH) 23, 2019, at 1:38 p.m. of Resident #84 revealed that the resident was in her bed with an uncovered urinary bag hanging from the side of the bed, touching the floor. Further observation conducted on (MONTH) 23, (YEAR) at 5:02 p.m. revealed the urinary bag was still observed touching the floor. On (MONTH) 24, 2019, at approximately 11:03 a.m., Resident #84 was observed in her bed, the urinary bag still hanging from the side of the bed touching the floor. Interview with Employee E3 on (MONTH) 24, 2019, at 11:07 am confirmed that urinary bag of Resident #84 should not be touching the floor. 28 Pa. Code 201.18 (b)(1) Management

Based on policy review, clinical record review and staff interview, it was determined the facility failed to ensure that clinical records were complete and accurate for one of 24 residents reviewed (Resident 136). Findings include: Review of facility policy Weight Assessment and Intervention, effective date (MONTH) 2019, revealed that when obtaining a resident's weight, staff would reweigh the resident if there was a 5 pound or more difference noted to verify the resident's weight before documenting it in the resident's record. Review of Resident 136's weights revealed that on (MONTH) 9, 2019, the resident was documented as weighing 207.4 pounds. On (MONTH) 23, 2019, the resident was documented as weighing 262.2 pounds, a difference of 54.8 pounds. Further review of Resident 136's record failed to reveal that the resident was reweighed following the (MONTH) 23, 2019 weight. Interview with licensed nurse Employee E3 on (MONTH) 26, 2019 at 9:30 a.m. confirmed that Resident 136's weight of 262.2 pounds on (MONTH) 23, 2019 was documented in the clinical record incorrectly. 28 Pa. Code 211.5 (f) Clinical records Previously cited 3/18/18 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 3/18/18

Based on interviews with the resident and facility staff, review of facility and other agency documentation, and clinical record review, it was determined that the facility failed to provide sufficient preparation and orientation for a resident transfer resulting in the transfer being aborted and placing the resident in an unsafe environment, for one of one resident reviewed. (Resident R1). Findings include: Review of Resident R1's admission assessment related that the resident was admitted [DATE], with a cognitive assessment score of 14, indicating that the resident was cognitively intact. The resident required extensive assistance, requiring one person physical assist with bed mobility (how the resident moves to and from a lying position), transfer (how the resident moves between surfaces such as bed to chair), locomotion (how the resident moves to and returns from locations), dressing and hygiene. The resident uses a walker and a wheelchair. The resident is frequently incontinent of bowel and bladder. [DIAGNOSES REDACTED]. difficile - an internal bacteria that causes chronic diarrhea). Review of the facility's admission packet included an acknowledgement of notice for a short-term stay provided to residents upon admission indicating that every resident admitted for short-term rehabilitation is permitted to reside in the facility for a short-term stay. This means residents admitted for short-term stays are not accepted for long-term care residence and that a discharge plan will be established based on the resident's rehabilitation and care plan goals upon admission. In order to be considered for long-term residency, the resident or his/her designee must contact the social services department or the admissions department. The applicant must also complete and submit the long-term care application. The admissions department will notify the resident or his/her designee of the community's ability to accept the resident on a long-term basis. If the facility is unable to accept the resident for long-term care admissions, the social services department will assist the resident or his/her designee in developing an appropriate discharge plan. Review of the social service notes, dated January 29, 2013, related that the resident was admitted from the hospital on January 28, 2013, for generalized weakness, hematuria (blood in urine) and has little informal support and that the resident had been receiving home care prior to hospitalization . Social service notes dated January 30, 2013, related that the resident was provided home care through Protective Services with home health agency visits twice a week. The Protective Services Caseworker felt that the resident needed long-term care placement due to safety issues in the home setting. The Social Worker informed the Caseworker that Resident R1 was at the facility for short-term rehabilitation only and the resident was opposed to long-term care placement. A social service note dated February 1, 2013, indicated that the home health representative had spoken to Protective Services and the resident's primary care physician in the community. The resident's primary care physician did not feel the resident could go home due to unsafe conditions and Protective Services agreed. Social service notes dated February 4, 2013, related that the resident was aware of not returning home and was disappointed, but expressed an understanding. The resident inquired about staying at the facility on a long-term basis. The facility Social Worker was to speak with the other facility Social Worker and admissions regarding the resident's interest for long-term care placement. The facility Social Worker also made the resident aware of possibly needing to send referrals to other nursing care facilities. Social service notes dated February 7, 2012, related that the resident accepted a transfer to another facility but wanted to return home. The Social Worker explained the safety concerns and explained AMA (leaving the facility against medical advice). Social service notes dated February 11, 2013, related that if the resident chose to go home after the conclusion of his therapy, the facility would not be able to arrange transportation or home care. The "Social Worker cannot participate in arranging a discharge that could be unsafe. Resident expressed understanding." Social service notes dated February 19, 2013, related that the resident was discharged to the hospital on February 18, 2013, due to chest pain and returned to the facility on [DATE]. Social service notes dated February 27, 2013, related, "due to declined condition resident appears appropriate for long-term care placement. The Social Worker informed the resident that this is the opinion of the team and told him that it would be wise to find placement where he can transition from rehab to long-term care. Resident prefers to stay at facility but says he feels he has no choice." Resident was admitted for short-term rehab and the long-term care application was not completed. Social service notes dated March 6, 2013, related that the resident accepted another nursing home for long-term care and stated, "Resident became upset and walked away. Resident stated he doesn't think he could make it at home right now. Resident agreed to give it a try." Social service notes dated March 7, 2013, related the resident left the original facility on March 7, 2013, at approximately 10:15 a.m., via transport with his belongings. The Social Worker received a call approximately 1/2 hour later from the second nursing care facility. The second nursing care facility indicated that the resident was refusing to be admitted because the room was a semi-private room, rather than a private room. The resident was returned to the van and sent back to the original nursing care facility. When he returned to the original facility, the resident remained in the van. Per the facility Social Worker's note, the transport worker stated, "he (transport van driver) would not take the resident to his home or the emergency room due to liability issues." The supervisor from the transport company informed the Social Worker that the dispatcher would call 911 for the police to handle the situation. When the police arrived, the Social Worker explained the story to them and informed them that the resident is his own guarantor. The Social Worker explained the AMA (against medical advice) process, but did not think this would be a solution as the resident was already discharged . The police spoke to the resident about his wishes. The resident did not want to return to the facility, but wanted to return home. The police officer informed the Social Worker and the Director of Nursing that the resident had requested to return home and that the police would accompany him through the door. Nursing notes dated March 5, 2013, at 12:30 p.m., related that the resident used a walker with assistance for ambulation and one person assist with ADL's (activities of daily living). Nursing notes dated March 7, 2013, at 2:15 a.m., related that the resident was a one person assist with care and was occasionally incontinent of urine. Nursing notes dated March 7, 2013, related that the resident was discharged to another nursing home at approximately 10:00 a.m., by transport van. A physician's note dated March 7, 2013, stated, "the resident discharged to another nursing home on March 7, 2013." Review of documentation from the second nursing home dated March 7, 2013, read, "At approximately 10:15 a.m., resident arrived to facility via transport from original facility." The resident related to the charge nurse of the second nursing care facility that he was promised a private room and he was not going to stay at the facility. The charge nurse of the second facility refused to sign a release form from the transport van company because the resident stated he "was not staying at the facility at time of arrival". The resident stated, "he wanted to either go back to where he came from or be taken home to his apartment." The resident was escorted back into the van. The van exited the property at approximately 10:30 a.m. There was no paperwork presented to, or signed by, the resident or any responsible party. The Nursing Home Administrator (NHA) of the original facility called the NHA of the second nursing care facility at 12:00 p.m., to relate that the original facility would not accept the resident back to their facility and that he was discharged and admitted to the second nursing care facility. Review of the transport company's report dated March 11, 2013, identified that when the resident arrived at the second nursing care facility at 10:53 a.m., on March 7, 2013, the resident was taken to a multibed (four bed) bedroom and stated, "the Social Worker of the original facility promised him he would be going into a private room." The nurse explained to the resident that there were no private rooms and the resident related he was not staying. The dispatcher told the transport worker to return the resident to the original facility. Resident R1 left the second facility at 11:31 a.m., and arrived back at the original facility at 11:53 a.m. Review of the transport driver's written statement obtained March 11, 2013, at 1:00 p.m., revealed that when the transport van arrived at the original facility, four staff members met the van in the driveway and told the driver not to remove the resident from the van because he was discharged and was not their patient. The van driver called the police. The police arrived and talked to the facility staff and then told the van driver to take the resident to his home. The van driver left the original facility enroute to the resident's home at 12:15 p.m., and arrived at the resident's home with a police escort at 12:24 p.m. Review of the police report dated March 7, 2013, related: Responded to customer dispute in progress. Van had resident in wheelchair in back of transport. Resident was discharged from original facility to second facility and when he arrived, he was under the impression he was to be placed in a single room. When he saw a four bedded room, he declined to be admitted and demanding to return to the original facility. Original facility denied his re-admittance to the home. Police asked resident what he wanted to do. Resident stated he wanted to go home. (Denied access into the original nursing home and kept in van). After working out arrangements, transport van driver took resident to his home and was escorted by police and van driver into his home. The police reported that resident's "home is very cluttered and not fit for an elder with a walker and wheelchair". The police contacted Protective Services. Nursing notes dated March 7, 2013, at 9:00 p.m., revealed that the resident was readmitted to the original facility, at 7:00 p.m., was unsteady on his feet, ambulated via wheelchair with assist, received extensive assist with ADL's (activities of daily living), and redness at the rectum area was noted. Interview with the original facility's NHA on March 8, 2013, at 8:55 a.m., indicated that the resident was originally admitted for short-term rehabilitation, but it was determined that he would need long-term placement. Options were discussed with the resident and he indicated that he would go to the other facility, but upon arrival at the second facility he did not like the room because it was a multibed (four bed) bedroom. The NHA indicated that there was not an appropriate bed available for the resident at the original facility because the only available private beds were on the dementia unit. The NHA stated that the facility could have placed him in a room that was set for construction, but the resident would have to be moved again when construction started. Construction was scheduled to begin on March 18, 2013. Another interview at 1:00 p.m., with the NHA indicated that when the resident inquired about staying at the facility, he was told that bed availability was an issue because there were no beds on the long-term care unit. Review of the facility census sheet dated March 7, 2013, indicated that three private rooms on the dementia unit and three private rooms on the rehab unit were available. The resident was readmitted to a private room on a secured dementia unit. Interview with the NHA on March 8, 2013, at 1:00 p.m. confirmed the room availability. Interview with the Social Worker on March 7, 2013, at 10:30 a.m., revealed that the resident could not stay at the facility because he was accepted for short-term rehabilitation. An additional interview at 12:25 p.m., with the Social Worker, indicated that the resident did not express that he wanted to stay at the facility long-term; he wanted to finish rehabilitation and return home. The Social Worker confirmed that a long-term care application was not completed for the resident to remain at the facility. Interview with Resident R1 on March 8, 2013, at 12:30 p.m., revealed that he went to the other facility and they did not have a private room and that he had specifically asked for a private room. He stated, "I was brought back to the facility and they refused to let me come back, so I went home for approximately five hours until the facility relented and let me return." The resident also stated, " I do not know what is going to happen, I guess I'll stay here, but in a different room. I would prefer to go home, but this facility is a good option." The original facility failed to allow Resident R1 to return to the facility after the resident went to another facility and refused to stay at the second facility. The original facility barred the transport company driver from assisting the resident into the facility by having four staff meet the van in the driveway whereby the resident was kept in the transport van when it arrived at 11:53 a.m. The police were contacted and the resident was transported to his home and left alone in an unsafe environment as documented by the police, Protective Services and the home care agency. The resident was not permitted back into the original facility on March 7, 2013, upon return from the second facility, and remained in the transport van from 11:53 a.m., until 12:24 p.m., when he was transported to his home. The resident remained in an unsafe home environment from 12:24 p.m. until 7:00 p.m. on March 7, 2013. The only alternative given to the resident was to return home to an unsafe environment. There was no assurance that the resident had medications or food in his home or was able to provide self-care when the facility had deemed that the resident required the assistance of one person with ADLs. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(2)(3) Management. 28 Pa. Code 201.18(b)(1) Management. Previously cited 03/04/11, 05/17/11, 10/18/12. 28 Pa. Code 201.18(e)(1) Management. Previously cited 03/04/11, 05/17/11. 28 Pa. Code 201.25 Discharge policy. 28 Pa.Code 201.29(f)(g) Resident rights.