Every finding on record at Saint Mary's Villa Nursing Hom

Based on a review of clinical records, physician orders, select facility policy, observations, and staff interviews, it was determined that the facility failed to provide the necessary care and services to maintain skin integrity by failing to implement physician-ordered skin protection interventions for one of 21 residents reviewed (Resident 14).Findings include: A review of the facility policy titled Pressure Ulcer Protocol Assessment/Prevention, last reviewed February 26, 2026, revealed it is the facility's policy that residents will not develop a pressure ulcer (an injury to the skin and underlying tissue caused by prolonged pressure that reduces blood flow) unless the individual's clinical condition demonstrates the injury was unavoidable. The policy indicated residents identified as being at risk will receive preventive interventions and residents with existing skin impairment will receive an individualized treatment plan to address their specific needs. Clinical record review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease with dyskinesia (a progressive neurological disorder that affects movement and may cause involuntary movements). A review of Resident 14's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 9, 2026, revealed that Resident 14 had severe cognitive impairment with a BIMS score of 99 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 99 indicating the assessment could not be completed because the resident was unable to participate). Clinical record review revealed a Braden Scale assessment (a standardized tool used to evaluate a resident's risk for developing pressure injuries) dated July 9, 2026, identified Resident 14 as having a score of 13, indicating a moderate risk for pressure injury. The assessment identified impaired sensory perception (the ability to recognize and respond to physical sensations), inability to ambulate or bear weight independently, limited ability to reposition without assistance, and very poor nutritional status. A review of the clinical record included a Wound Assessment Report dated July 21, 2026, completed by the wound care Nurse Practitioner. The assessment identified incontinence-associated dermatitis (skin irritation and breakdown caused by prolonged exposure to urine or stool) involving the sacrum (the triangular bone located at the base of the spine) and an abrasion (an area where the skin has been scraped or rubbed away) to the right knee. Clinical record review revealed a physician order dated July 7, 2026, directing staff to apply bilateral heel bows (protective padded heel devices designed to offload pressure from the heels) at all times, removing them only for care. Additional clinical record review revealed physician orders dated July 10, 2026, directing staff to apply bilateral leg protectors (padded protective sleeves designed to reduce skin injury from friction or impact) at all times, removing them only for care, and bilateral heel lift boots (protective boots designed to elevate the heels and reduce pressure) at all times, removing them only for care. During an observation conducted on July 28, 2026, at 11:34 AM, Resident 14 was seated in a Broda chair (a specialized positioning chair designed to provide support and pressure redistribution). Resident 14 was wearing pants, white socks, and sneakers. The resident was not wearing the physician-ordered bilateral leg protectors, bilateral heel lift boots, or bilateral heel bows. Employee 4 Licensed Practical Nurse (LPN) was present during the observation and acknowledged the physician-ordered protective devices were not in place. During an interview, the Nursing Home Administrator and Director of Nursing were informed of the findings on July 29, 2026, at 11:30 AM and acknowledged nursing staff failed to follow the physician order. 28 Pa Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to consistently monitor resident weights and implement nutritional interventions after significant weight changes were identified to promote and maintain residents' nutritional status for two of 21 residents reviewed (Residents 43 and 87).Findings include: A review of the facility policy titled Weight Resident Policy, last reviewed February 28, 2026, revealed all residents will be weighed upon admission, reweighed the following day for accuracy, and then weighed weekly for four weeks. If weights remain stable, residents will then be weighed monthly or as ordered by the physician. The policy revealed residents with a weight gain or loss of three pounds or more will be reweighed within 24 hours to verify the weight. If the weight change is confirmed, nursing staff will notify the physician and the dietary manager or registered dietitian. Clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (a condition in which the kidneys become damaged and are unable to adequately filter waste and excess fluid from the blood). Weight records revealed Resident 43 weighed 103.8 pounds on May 15, 2026. Following hospitalization, the resident returned to the facility on June 1, 2026, weighing 96 pounds, representing a 7.5 percent weight loss over 16 days. Weight records further revealed the resident weighed 92.4 pounds on June 16, 2026, reflecting an additional 4-pound weight loss over the following two weeks. Clinical record review revealed the resident should have been placed on weekly weights following the significant weight loss in accordance with facility policy. However, the clinical record contained no documented evidence that staff obtained a weekly weight during the week of June 8, 2026. A dietary progress note dated June 16, 2026, at 10:16 AM documented that Resident 43 experienced an unplanned significant weight loss. The registered dietitian noted the resident was receiving Ensure (a high-calorie, high-protein oral nutritional supplement) twice daily with good acceptance and recommended increasing the supplement to three times daily. Clinical record review failed to reveal documented evidence that the dietary recommendation to increase Ensure to three times daily was implemented. During an interview on July 30, 2026, at 11:00 AM, Employee 1, Certified Dietary Manager (CDM), confirmed residents who experience significant weight loss are placed on weekly weights in accordance with facility policy and acknowledged Resident 43 was not weighed weekly during June 2026. Employee 1 further confirmed the registered dietitian's recommendation to increase Ensure to three times daily was not implemented and could not provide a reason why. Clinical record review revealed Resident 87 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive brain disorder that causes worsening memory, thinking, and behavior) and dysphagia (difficulty swallowing that increases the risk for poor nutrition, dehydration, choking, and aspiration). On May 6, 2026, Employee 1, a Certified Dietary Manager (CDM) completed a Mini Nutritional Assessment (MNA is a validated nutrition screening and assessment tool that can identify geriatric residents age [AGE] and above who are malnourished or at risk of malnutrition based on numeric scoring. A score of 12 -14 points is normal nutritional status, 8 - 11 points is at risk of malnutrition, and 0 - 7 points is malnourished) that revealed Resident 87 scored five points reflecting malnutrition. A review of the resident's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 8, 2026, , revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) because of severe cognitive impairment. A progress note completed by the Director of Nursing (DON) dated July 17, 2026, at 11:46 AM documented discussion with Resident 87's spouse and responsible party regarding the resident's declining appetite and weight loss. The DON reviewed meal intake and weight trends and explained oral nutritional supplements, including Ensure and Two Cal (a high-calorie, high-protein oral nutritional supplement), would be initiated if the resident continued to lose weight. The resident's spouse requested weekly weights. Weight records revealed Resident 87 weighed 142.3 pounds on July 18, 2026, at 9:48 AM and 137.8 pounds on July 25, 2026, at 10:19 PM, representing a 4.5-pound weight loss in one week. Clinical record review failed to reveal documented evidence that staff obtained a reweigh within 24 hours to verify the significant weight loss as required by facility policy. Clinical record review also failed to reveal documented evidence that staff notified the resident's physician or responsible party after the significant weekly weight loss.The above findings were reviewed during an interview on July 30, 2026, at 12:15 PM, with the Director of Nursing and confirmed the facility did not obtain a reweight and could not provide documented evidence that the physician or responsible party had been notified of the weight loss. 28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on a review of controlled medication shift-to-shift count records, facility policy, and staff interviews, it was determined the facility failed to consistently implement procedures to ensure accurate accountability and documentation of controlled medication counts for three of four medication carts reviewed.Findings include: A review of the facility policy titled Narcotic Control, last reviewed February 26, 2026, revealed the purpose of the policy is to establish procedures for the administration and control of controlled medications (prescription medications regulated by federal and state law because they have the potential for misuse or dependence) and to ensure the safety of residents. The policy required the nurse coming on duty and the nurse going off duty to perform the controlled medication count together, document the count, and immediately report any discrepancies to the Director of Nursing Services. Unit 33 Long Hall Medication Cart (Rooms 214 through 228) A review of the facility's Shift-to-Shift Count Record on July 29, 2026, at 9:10 AM revealed: July 28, 2026: The incoming day shift Licensed Practical Nurse (LPN) did not sign the Shift-to-Shift Count Record to verify the controlled medication count. During an interview on July 29, 2026, at 9:13 AM, Employee 2, LPN, confirmed the incoming nurse did not sign the Shift-to-Shift Count Record on the identified date. Unit 33 Short Hall Medication Cart (Rooms 200 through 213) A review of the facility's Shift-to-Shift Count Record on July 29, 2026, at 9:17 AM revealed: July 28, 2026: The incoming day shift LPN did not sign the Shift-to-Shift Count Record to verify the controlled medication count. During an interview on July 29, 2026, at 9:19 AM, Employee 3, LPN, confirmed the incoming nurse did not sign the Shift-to-Shift Count Record on the identified date. Unit 30 Long Hall Medication Cart (Rooms 246 through 263) A review of the facility's Shift-to-Shift Count Record on July 29, 2026, at 9:25 AM revealed: July 28, 2026: The off-going day shift LPN did not sign the Shift-to-Shift Count Record to verify the controlled medication count. During an interview on July 29, 2026, at 9:29 AM, Employee 5, LPN, confirmed the off-going nurse did not sign the Shift-to-Shift Count Record on the identified date. During an interview on July 30, 2026, at 11:00 AM, the Director of Nursing acknowledged the identified omissions in the Shift-to-Shift Count Records and confirmed the facility policy required both the incoming and off-going nurses to complete the controlled medication count and sign the record. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service.28 Pa Code 211.9 (c)(k) Pharmacy services.28 Pa Code 211.5(f)(x) Clinical records.28 Pa. Code 211.10(a) Resident Care Policies.

Based on review of select facility policy, controlled drug records, clinical records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled drug records and failed to implement pharmacy procedures for timely disposition of resident medications to prevent misuse, diversion (unauthorized use or theft), or accidental exposure for one of three closed records reviewed (Resident 93).Findings include: Review of facility policy entitled, Disposition of Medications last reviewed by the facility on February 27, 2025, revealed guidance regarding disposition of medications. The policy explained a process to implement safe and responsible disposition practices of discontinued medications to protect residents and staff from improper diversion or accidental exposure. Further it is indicated medications discontinued by the prescriber order, residents' death, or discharge are either to be destroyed on site or return to the pharmacy for destruction. Controlled substances must be destroyed in the facility using the drug disposal system containing the instant chemical digestion solution. Review of clinical record for Resident 93, revealed the resident was discharged to the hospital on July 31, 2025, at 11:59PM with no anticipation of return. Review of a progress note dated July 31, 2025, at 11:39 PM revealed staff documented that two controlled substances, Tramadol (a narcotic pain medication) and Diazepam (a controlled anxiety medication), were secured in the Director of Nursing's (DON) office. The note indicated 39 Tramadol tablets, and 38 Diazepam tablets were placed in the DON's office. Review of the controlled substance log revealed the medications were destroyed by the DON on August 19, 2025, indicating the medications were stored in the DON's office for 20 days prior to proper disposition. Observation of the DON's office revealed a locker designated for controlled substance storage. The locker had one lock with only one key, which was in the possession of the DON. An interview with the DON on September 11, 2025, at 12:30 PM revealed that when she was not available, staff placed controlled medications in her office, but staff did not have access to the locker. The interview further revealed that staff members had access to her office, creating an opportunity for staff to access controlled substances without appropriate oversight. The DON indicated she had been on vacation during the beginning of August, which left the Tramadol and Diazepam unsecured in her office for an extended period of time. The facility was unable to produce a narcotic log for the medications stored in the locker in the DON's office. The facility confirmed there was no plan in place for proper accounting of narcotics awaiting disposition. An interview with the Nursing Home Administrator (NHA) and the DON on September 12, 2025, at 2:30 PM confirmed the facility was unable to provide documentation of procedures to ensure accurate controlled drug records and timely disposition of resident medications. 28 Pa Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)(j.1)(1)(2)(3)(4)(5)(k) Pharmacy services.

Based on clinical record review, facility policy review, observations, and staff and resident interviews, it was determined the facility failed to honor and incorporate the resident's expressed preferences and choices into the care planning process for one of 18 sampled residents (Resident 5). Findings include: A review of Resident 5's clinical record revealed Resident 5 was admitted to the facility August 13, 2013, with diagnoses to include lobar pneumonia (infection that inflames the air sacs in one or both lungs). A review of a Resident 5's quarterly Minimum Data Set Assessment (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care), dated August 8, 2025, revealed Resident 5 was cognitively intact with a BIMS score of 13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 indicates intact cognition). A review of the comprehensive care planning policy last reviewed by the facility on February 27, 2025, revealed the facility will develop a comprehensive person-centered care plan for each resident. The policy further described the plan will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. A clinical record review revealed multiple instances of electronic health record documentation of Resident 5's choice to not participate in aspects of care including: BiPap machine (type of noninvasive ventilation that helps you breathe), occupational therapy (treatment that helps people overcome physical, emotional and social challenges), nebulizer treatments (device that turns liquid medicine into a mist), blood pressure readings, meals, weights, skin treatments, and bathing. A review of Resident 5's care plan in effect at the time of the survey did not address the resident's specific choices as described above nor did the care plan accurately reflect resident specific interventions tailored to meet the Resident 5's specific needs related to electing to refrain from participation in various aspects of care. An interview with the Nursing Home Administrator and Director of Nursing on September 12, 2025, at 11:10 AM confirmed the Resident 5's expressed choice was not accurately reflected in the care plan at the time of the survey. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to fully develop and implement procedures to fully screen four employees out of five to ensure they were eligible for employment in a long term care nursing care facility. (Employees 1, 2, 3, and 4). Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility February 27, 2025, revealed the requirement for screening potential employees included obtaining references from the most recent or previous employer. Review of employee personnel files revealed the following: Employee 1 (Porter): Hired on May 19, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Employee 2 (Licensed Practical Nurse): Hired on July 7, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 3 (Licensed Practical Nurse): Hired on July 21, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 4 (Nurse Aide): Hired on July 28, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Interview with the Nursing Home Administrator (NHA) on September 11, 2025, at 10:15 a.m. the NHA verified there was no evidence the facility attempted to obtain information from previous employers and/or current employers for information regarding the employees past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous/current employment for four out of five new hires. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, resident observation, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for two of 18 residents sampled (Resident 4 & Resident 8).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses to include Pneumonia, an unspecified organism (infection that inflames the air sacs in one or both lungs) and Acute Kidney Failure (kidneys suddenly can't filter waste products from the blood). The quarterly MDS dated [DATE], section J (section related to health conditions including fall history) documented Resident 4 experienced no falls since admission/ readmission or prior assessment. Upon clinical review, Resident 4 experienced a fall on February 2, 2025, which was not reflected on the MDS dated [DATE]. A review of the clinical record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses to include Monoplegia of the upper limb (one limb, an arm or a leg, has lost complete voluntary muscle movement). Further clinical record review revealed a quarterly MDS dated [DATE], for Resident 8, Section J, (section related to health conditions including fall history) documented Resident 8 did not experience any falls since admission/ readmission or prior assessment. Upon further clinical record review, Resident 8 experienced a fall May 4, 2025, which was not reflected on the June 24, 2025, quarterly MDS. An interview with the Director of Nursing and Nursing Home Administrator on September 11, 2025, at 11:10 AM confirmed the MDS coding for both Resident 4 and Resident 8 was inaccurate regarding fall history. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the toileting needs of one of 18 sampled residents (Resident 5).Findings include: A review of facility policy titled 'Bowel & Bladder Toileting Plan' reviewed on February 27, 2025, revealed that all residents will be assessed on admission, readmission and change of condition according to the bowel and bladder patterning criteria. Upon completion of the assessment, individualized bowel and bladder program(s) will be initiated for each resident as indicated. A review of the policy titled ‘Foley Catheter Procedure When a Resident is admitted With Foley in Place' describes a facility policy stating any resident who enters the facility with a catheter will be evaluated upon admission for the necessity of maintaining or removing the catheter. A review of Resident 5's clinical record revealed Resident 5 was admitted to the facility August 13, 2013, with diagnoses including lobar pneumonia (an infection causing inflammation of the air sacs in one or both lungs). A quarterly Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care), dated August 8, 2025, described Resident 5 as cognitively intact with a BIMS score of 13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 indicates intact cognition). The assessment indicated Resident 5 required staff assistance for toileting hygiene and transfers. A review of the clinical record revealed Resident 5 returned to the facility on August 4, 2025, following an acute care stay from July 25, 2025, to August 4, 2025. Resident 5 returned with an indwelling catheter in place. Review of an MDS dated [DATE], showed that prior to hospitalization Resident 5 was incontinent and did not use an indwelling catheter (tube inserted into the bladder to drain urine). No documentation in the clinical record justified the presence of the catheter upon return from the hospital. Clinical records further indicated Resident 5 developed Moisture Associated Skin Damage (MASD inflammation and skin erosion caused by prolonged exposure to moisture such as urine or feces) on the right gluteal fold (the skin crease beneath the buttocks) and Incontinence Associated Dermatitis (a type of MASD caused specifically by urine exposure) upon return from acute care on August 4, 2025. The MASD was documented as measuring 14 cm in length by 8 cm in width. Further review of Resident 5's clinical record described the removal of the indwelling catheter on August 13, 2025. A review of the 72-hour resident voiding pattern illustrated Resident 5 had episodes of incontinence during the evaluation period from August 13, 2025, until August 16, 2025. Resident 5 was incontinent at 9:00 PM August 13, August 14, and August 15, 2025, according to the 72-hour resident voiding pattern record, which evaluated Resident 5's incontinence/ continence levels hourly.A review of the resident's person-centered care plan, initiated May 5, 2021, included focus areas for potential skin breakdown due to incontinence. A care plan revision on August 14, 2025, noted Resident 5's frequent incontinence and included goals for Resident 5 to remain free from skin breakdown. Interventions included two-hourly incontinence checks, cleansing, barrier cream, pull-up briefs per Resident 5's request, and monitoring for infection. However, the care plan did not specify the type of incontinence, did not include a structured toileting schedule, and did not incorporate individualized interventions targeted to the consistent 9:00 PM incontinence episodes documented in the voiding pattern record. A Bladder Review note dated August 19, 2025, documented Resident 5 was 100% incontinent since catheter removal, required assistance of two for transfers, and was at risk for incontinence related to diuretic use, difficulty walking, and muscle weakness. Despite these findings, there was no evidence of individualized interventions such as scheduled toileting times to reduce episodes of incontinence and support skin healing. There was no evidence the facility evaluated and implemented an individualized plan for Resident 5's toileting needs based on voiding patterns or habits, nor was there documentation to justify the presence of an indwelling catheter for nine days following return from acute care. An interview with the Director of Nursing and the Nursing Home Administrator on September 12, 2025, at 1:35 PM confirmed that the facility had not developed or implemented an individualized incontinence management plan for Resident 5. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(a)(d) Resident care policies.

Based on review of clinical records, select facility policy, and staff interviews, the facility failed to develop and implement an individualized pain management program consistent with professional standards of practice, including the use of non-pharmacological interventions prior to administering as-needed narcotic pain medication, and failed to follow physician orders for one of 22 residents reviewed (Resident 6).Findings include: According to the U.S. Department of Health and Human Services, Interagency Task Force, Pain Management Best Practices Final Report (May 6, 2021), effective pain treatment plans should be individualized and patient-centered, with measurable outcomes focusing on quality of life (QOL), improved functionality, and the ability to perform activities of daily living (ADL's basic self-care tasks such as bathing, dressing, eating, and toileting). Best practice emphasizes multimodal approaches (the use of multiple methods including medications, physical therapy, and other interventions) and recommends attempting non-pharmacological interventions (pain relief strategies that do not involve medication. These approaches are often the first step in pain management and are intended to reduce discomfort, improve function, and minimize the need for narcotics or other drugs. Examples include repositioning a resident, applying heat or cold, relaxation or breathing techniques, massage, distraction, exercise, or use of supportive devices such as pillows or braces) when clinically appropriate. A review of a facility policy last reviewed by the facility on February 27, 2025, revealed the physician will order appropriate non-pharmacologic and medication interventions to address a resident's pain. The policy further revealed non-pharmacological interventions will be attempted prior to the administration of PRN (as needed) pain medications If non-pharmacological interventions failed, PRN narcotic medications could then be administered. The policy also required staff to use a verbal numeric pain scale (0 = no pain; 1-4 = mild pain; 5-7 = moderate pain; 8-10 = severe pain). A review of Resident 6's clinical record revealed the resident was admitted on [DATE], with diagnoses including osteoarthritis (most common form of arthritis when the protective cartilage that cushions the ends of the bones wears down over time and causes pain) of the right knee and muscle spasms. A physician order dated May 21, 2025, directed staff to administer Hydrocodone-acetaminophen 5/325 mg (a narcotic pain medication) by mouth every 6 hours as needed for moderate pain (pain scale 5-7). A review of the resident's May 2025 Medication Administration Record (MAR) revealed staff administered the PRN Hydrocodone five times. On all five occasions, staff documented no attempt of non-pharmacological interventions prior to administering the narcotic pain medication, contrary to facility policy. Further review of the May MAR revealed that on May 28, 2025, at 10:02 PM, staff administered the narcotic for a reported pain scale of 8 (severe pain), outside of the physician's order, which specified use only for moderate pain (5-7). A review of the June 2025 MAR revealed Hydrocodone was administered once. Again, no non-pharmacological interventions were documented prior to administration. A review of the July 2025 MAR revealed Hydrocodone was administered three times, each without documented use of non-pharmacological interventions. On July 6, 2025, at 5:37 PM, Hydrocodone was administered for a pain scale of 3 (mild pain). On July 13, 2025, at 4:50 PM, Hydrocodone was administered for a pain scale of 4 (mild pain). Both administrations were inconsistent with the physician's order, which required moderate pain (5-7) before administration. A review of the August 2025 MAR revealed Hydrocodone was administered once again without documentation of attempted non-pharmacological interventions. An interview with the Director of Nursing (DON) on September 12, 2025, at 11:10 AM confirmed that the facility was unable to provide documentation showing that staff attempted non-pharmacological interventions before narcotic administration or justification for administering the narcotic medication outside the parameters of the physician's order. 28 Pa. Code 211.10 (C)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of one resident reviewed (Resident 77). Findings include: Review of clinical record of Resident 77 revealed diagnoses to include Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is typically associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features. The average IQ of a young adult with Down syndrome is 50, equivalent to the mental ability of an 8- or 9-year-old child). Further review of Resident 77's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated September 23, 2024, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated September 26, 2024, indicated that, You have evidence of an Intellectual Disability. The Office of Developmental Programs, Department of Human Services has reviewed your information for nursing facility placement and the possibility that you are a person with an ID. Additional ID specialized services are available for individuals who are in a nursing facility. These services can include training, treatments, therapies and related services to help people function as independently as possible. Based on the review of your information the departments determination appears below: You do require ID/MR specialized services. Review of Resident 77's current care plan conducted during the survey ending November 15, 2024, revealed the care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's intellectual disability and PASARR II. An interview with the Nursing Home Administrator on November 15, 2024 at 11:00 a.m. confirmed the PA-PASARR-ID II form completed had identified Resident 77 as requiring the need for special services and was unable to provide evidence of coordination of services including care planning. There was no evidence at the time of the survey the facility had timely identified and coordinated the provision of specialized services for this resident with the potential to adversely affect the resident's ability to achieve and maintain their highest practicable physical, mental and psychosocial well-being 28 Pa. Code 211.5(f)(iv)(vi) Medical records.

Based on review of clinical records and controlled drug records, and staff interview, it was determined the facility failed to implement procedures to promote accurate accounting of controlled medications for one resident of 18 residents sampled (Resident 48). Finding include: A review of the clinical record revealed Resident 48 had a physician's order dated October 18, 2024, for Tramadol HCl oral tablet 50 mg (an opioid pain medication), give one tablet by mouth every 8 hours as needed for moderate pain identified by a scale of 5-7 (pain scale, 1-10, 1 least amount of pain and 10 most amount of pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on October 19, 2024, at 9:00 AM, and October 23, 2024, at 2:40 PM, nursing staff signed out a dose of the resident's supply of Tramadol 50 mg. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. A physician order dated October 28, 2024, was noted for Hydrocodone-Acetaminophen oral tablet 5-325 mg (an opioid pain medication combined with a non-opioid pain reliever used to treat moderate to severe pain), give one tablet by mouth every 6 hours as needed for moderate pain (scale 5-7). A review of the controlled substance record accounting for the above narcotic medication revealed that on November 3, 2024, at 1:00 PM, November 6, 2024, at 2:30 PM, November 9, 2024, at 8:15 AM, and November 12, 2024, at 1:00 PM nursing staff signed out a dose of the resident's supply of Hydrocodone-Acetaminophen 5-325 mg. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. During an interview on November 14, 2024, at approximately 11:05 AM, the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medication for Resident 48 and indicated the controlled substance record be documented clearly and accurately. 28 Pa Code 211.5 (f)(x) Medical records. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.9(a)(1)(k) Pharmacy services

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of four resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of the resident food pantry located on the second floor, Extension 31, on November 13, 2024, at 10:50 AM, revealed that inside the refrigerator there was one opened 46-ounce container of mildly thick/nectar consistency lemon flavored water dated October 21, 2024, two opened 46-ounce containers of moderately thick/honey consistency lemon flavored water dated October 23, 2024, one opened 46-ounce container of mildly thick/nectar consistency lemon flavored water dated November 5, 2024, and one opened 46-ounce container of moderately thick/honey consistency lemon flavored water dated November 5, 2024 (manufacturers label noted that after opening, the drinks may be kept up to seven (7) days under refrigeration). Interview with Employee 1 (registered nurse) on November 13, 2024, at 11:00 AM confirmed the observation of the resident food pantry on Extension 31. Observation of the resident food pantry located on the second floor, Extension 33, on November 13, 2024, at 11:05 AM, revealed inside the refrigerator there was one opened 46-ounce container of moderately thick/ honey consistency lemon flavored water dated October 16, 2024, and one opened 46-ounce container of mildly thick/nectar consistency lemon flavored water without an open date. Interview with Employee 2 (registered nurse) on November 13, 2024, at 11:15 AM confirmed the observations of the resident food pantry on Extension 33. Interview with the Nursing Home Administrator and the Director of Nursing on November 14, 2024, at approximately 1:00 PM confirmed the food and beverages in the resident pantry were to be dated when opened and discarded according to manufactures instructions.

Based on review of clinical records, select facility policy, and grievances lodged with the facility and staff interview, it was determined that the facility failed to immediately notify the resident's interested representative of a significant change in condition for one resident out of seven sampled (Resident A1). Findings include: A review of the facility policy entitled notification of the responsible party on hospital transfers, dated as reviewed by the facility January 2024, revealed that the the facility will notify a resident's responsible party of a hospital transfer once the order has been obtained from the physician to transfer. The facility will initiate transfer when it is determined that the cannot provide services required for the resident and or if the resident and or the responsible party requests the hospital transfer be initiated The corresponding procedures were noted as: The facility will notify the incapable residents responsible party of an upcoming transfer to the hospital and or a change in condition and reason they are being sent out for evaluation. If the resident is capable and requests to not notify the family the facility will follow their wishes. If the change occurs in the off hours at night and the resident is deemed stable by a physician and or a nurse assessment the facility may wait to notify the family during waking hours, unless specified other by family member. If the resident is deemed unstable immediate notification will occur. Documentation of transfer and notification date and time shall be documented in the residents medical record. A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses, which included chronic obstructive pulmonary disease, dementia, and hypertension. Review of nursing documentation dated May 21, 2024, at 11:06 AM, indicated that Resident A1 had a moist productive cough, had expectorated yellow mucous, the resident's lung sounds were noted to have some rhonchi and expiratory wheezing, temperature was 98.4 degrees Fahrenheit, and her oxygen saturation was 90% on room air. A physician order was received from the physician to complete a chest x-ray. According to nursing documentation at 1:14 PM on May 21, 2024, the resident's son (representative) was made aware of new MD [physician] orders and resident's condition. Nursing documentation dated May 22, 2024, at 4:32 AM, revealed that the resident vomited a large amount of maroon liquid with some coffee ground residual noted. According to the nursing documentation, the resident's abdomen was distended (large) but soft and non-tender, the resident's temperature was 100.5 degrees Fahrenheit (elevated), blood pressure was 86/50 mmHg (low) , her heart rate was 64, and her oxygen saturation was 79% on room air (normal is 98-100%). There was no documented evidence that the resident's respiratory rate was evaluated at that time. Nursing documentation further noted that oxygen was immediately applied via nasal cannula to increase oxygen saturation up 89-90%. A call was placed to the on-call physician who instructed the facility to continue to monitor resident for any worsening symptoms and update her physician in the AM [morning] and to update family in the AM. The facility did not notify the resident's son, her designated representative, at the time the resident had experienced a significant change in medical condition on May 22, 2024, at approximately 4:32 AM. There was no indication that the facility had ascertained if this resident's family wished to be notified of significant changes during non-waking hours, according to the facility policy indicating that the facility may wait to notify the family during waking hours, unless specified other by family member. Physician documentation dated May 22, 2024, at 10 AM, revealed that the changes in the resident's condition that occurred at 4:30 AM that morning were reviewed, current condition evaluated, and a chest x-ray and KUB (x-ray of abdomen) were ordered. Nursing documentation dated May 22, 2024, at 4:23 PM, revealed that the resident's temperature was 99.1 degrees Fahrenheit, her oxygen saturation was 90% with oxygen on via nasal cannula at 2 liters/min, no complaints of pain/discomfort were offered, no vomiting/nausea. Resident observed to have a wet, congested cough with thick yellow mucus produced. Resident in good spirits otherwise. Nursing notes dated May 22, 2024, at 5:10 PM, revealed that the KUB results indicated that the resident had Cholelithiasis (gallstones in the gallbladder). New physician orders were obtained to send the resident to the emergency room for evaluation and treatment of Cholelithiasis, abdominal distention, vomiting, pain, nausea, and elevated white blood cell count. Review of grievance submitted to the facility on [DATE], at 11:32 PM via email from the resident's representative, revealed that the resident's family expressed a concern that they were not notified of the resident's significant change in condition that occurred at 4:30 AM on May 22, 2024, and that the facility waited until approximately 6:20 PM on May 22, 2024, to send the resident to the emergency room for evaluation and treatment. An interview with the Nursing Home Administrator on July 2, 2024, at approximately 11:00 AM confirmed that the facility had not previously ascertained if this resident's family wanted to be notified during non-waking hours and verified that the facility did not immediately notify the resident's designated representative of the resident's change in condition identified on May 22, 2024, at approximately 4:30 AM. 28 Pa. Code 201.29 (a)(b) Resident rights 28 Pa. Code 211.12 (d)(3) Nursing services 28 Pa. Code 211.10 (a) Resident care policies

Based on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out of two sampled (Residents 72 and 74) to promote normal bowel activity to the extent practicable. Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Management / Laxative Protocol, last reviewed by the facility March, 2023, indicated that if there is no bowel activity noted for 3 days, the laxative protocol will be implemented by the charge nurse and nutritional interventions to improve natural bowel function may be introduced. A laxative, suppository or fleets enema will be given as ordered by the attending physician. This protocol will be initiated on the following residents includes; a resident who has not had a bowel movement in 3 days. The protocol is as follows: Milk of Magnesia (MOM) 30 cc by mouth (po), as needed (prn), with AM medication pass, if no results within 12 hours, use Dulcolax suppository, if no results from suppository, administer fleets, if no results after the use of fleets, notify physician for further orders. A review of the clinical record revealed that Resident 72 had physician orders dated August 1, 2023, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 cc by mouth every 24 hours as needed for constipation in the morning if no BM (bowel movement) in 3 days; -Dulcolax Suppository 10 MG (Bisacodyl), inset 1 suppository rectally every 24 hours as needed for constipation if MOM is ineffective in 12 hours; -Fleet Enema 7-19 gm/118 ml (Sodium Phosphates), insert 1 application rectally every 24 hours as needed for constipation if Dulcolax ineffective in 12 hours. Review of Resident 72's Documentation Survey Report v2 revealed staff documented NA or 2, and also multiple bland entries. Interview with Employee 2, ADON, on November 29, 2023, at approximately 10:20 AM, confirmed that the blanks indicated the task had not been completed or that staff failed to document; 2 indicates no bowel movement occurred, and the NA indicates the task is not applicable. Resident 72's bowel activity noted on the Documentation Survey Report v2 for September 2023, revealed that he did not have a bowel movement on September 24, 25, 26, and 27, 2023. Review of Resident 72's Medication Administration Record (MAR) for September, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. The resident's Documentation Survey Report v2 for October 2023, revealed that he did not have a bowel movement on October 1, 2, 3, and 4, 2023; did not have a bowel movement on October 13, 14, 15, and 16, 2023; and did not have a bowel movement on October 18, 19, 20, and 21, 2023. Review of Resident 72's Medication Administration Record (MAR) for October, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time periods without a bowel movement to promote bowel activity. A review of the clinical record revealed that Resident 74 had physician orders dated July 3, 2023, and October 8, 2023, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for constipation in the morning if no BM (bowel movement) in 3 days; -Dulcolax Suppository 10 MG (Bisacodyl), inset 1 suppository rectally every 24 hours as needed for constipation if MOM is ineffective in 12 hours; The resident's Documentation Survey Report v2 for September 2023, revealed that he did not have a bowel movement on September 11, 12, 13, and 14, 2023. Review of Resident 74's Medication Administration Record (MAR) for September, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. The resident's Documentation Survey Report v2 for November 2023, revealed that he did not have a bowel movement on November 13, 14, 15, and 16, 2023, and he did not have a bowel movement on November 20, 21, 22, and 23, 2023. Review of Resident 74's Medication Administration Record (MAR) for November, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time periods without a bowel movement to promote bowel activity. During an interview with the Nursing Home Administrator (NHA) on November 29, 2023, at approximately 1:50 PM, the NHA was unable to provide evidence that physician ordered bowel protocol was consistently carried out for Residents 72 and 74 during the above time frames without bowel activity. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records

Based on a review of the facility's infection control tracking logs and policy and staff interviews, it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly. Findings include: A review of the current facility policy titled Infection Control Program, dated July 27, 2023, revealed that the program's primary objective is to provide an effective facility-wide program for the surveillance, prevention, and control of infection. The program monitors the rates of healthcare-associated infections, uses systems to collect and analyze data, and organizes activities to prevent and control infections in residents and personnel. A review of the facility's infection control data revealed that the facility's infection control tracking did not reflect evidence of the consistent utilization of a comprehensive tracking system to monitor and investigate the causes of all types of infections. There was no evidence the facility was using an infection control tracking system to analyze infection clusters, identify changes in prevalent organisms, or recognize increases in the rate of infection in a timely manner. A review of the facility's infection control data revealed infection tracking logs dated August 2023, September 2023, and October 2023, failed to include resident room numbers, resident units, and the type of pathogen/infectious organism associated with the infection. A review of facility infection control data failed to reveal that the facility evaluated the data for potential patterns of infectious organisms within the facility. The facility analysis report included resident infection by general type but did not include resident location or pathogen. A review of facility analysis reports revealed the following: August 2023: Respiratory infections 1, skin infections 3, dental/oral infections 1, urinary tract infections (with foley) 1, urinary tract infections without foley 2, Scabies 1 September 2023: Respiratory infections 2, skin infections 0, dental/oral infections 0, urinary tract infections (with foley catheter) 2, urinary tract infections without foley catheter 3, conjunctivitis 1 October 2023: Respiratory infections 4, skin infections 4, dental/oral infections 0, urinary tract infections (with foley) 5, urinary tract infections without foley 13, conjunctivitis 1 During an interview on November 30, 2023, at 9:30 AM, the infection preventionist confirmed that the facility's data for the August 2023 through October 2023, did not include sufficient data to identify patterns and implement corresponding interventions to reduce the spread of infection based on the infection tracking. 28 Pa Code 211.12 (c) Nursing services 28 Pa. Code 211.10 (d) Resident care policies

Based on observation, a review of clinical records and select facility policy, and staff interviews it was determined that the facility failed to consistently provide necessary care and services to prevent the development of a pressure sore for one resident (Resident 9) out of 19 sampled residents. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of current facility policy entitled Pressure Ulcer Protocol Assessment/Prevention last reviewed by the facility May 2023, revealed that upon discovery of all wounds, an investigation will be initiated. Physician will be notified and family if applicable. A plan of care will be established to address prevention and treatment. The charge nurse will notify the wound care nurse of all skin break downs. The wound care nurse will assess the area on the next business day. All residents' skin will be inspected weekly by the charge nurse and documented on the treatment record. Any resident found at risk will have preventative measures instituted. Any resident found with a Stage 1-4 pressure area will have his/her physician notified, protocols reviewed and implemented treatment per physician orders. A review of Resident 9's plan of care for risk for impaired skin integrity due to impaired mobility, incontinence last revised July 21, 2022, revealed planned interventions that included to apply Desitin to buttock/sacral area in the morning and in the evening, apply skin prep and allevyn to both heels as ordered and evaluate, encourage resident to frequently shift weight, turn and reposition every 2 hours and as needed, monitor bony prominence for redness, monitor nutritional status, monitor resident's nutritional status, utilize pressure relieving devices on appropriate surfaces, pressure reduction surface to both bed and chair. A review of a Quarterly Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was severely cognitively impaired, does not walk, and was dependent on staff for toileting and transfers. Review of the clinical record revealed that Resident 9 was diagnosed with COVID-19 on October 26, 2023, and her meal consumption declined in the days leading up to, and after the diagnosis. Review of the clinical record revealed that on November 2, 2023, nursing staff identified a bruise measuring 2 cm x 1 cm on the resident's left shin. Review of facility investigation dated November 3, 2023, at 1 PM revealed that the facility's wound care nurse was called to Resident 9's room to evaluate the skin integrity of the resident's left hip. The wound care nurse identified SDTI (suspected deep tissue injury: a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) which measured 7 cm x 6 cm. There was no mention of a concern with the resident's left shin. Further review of the investigation revealed that a low air loss mattress was to be applied to the bed. The facility's investigation did not identy the potential contributing factors to the development of left hip suspected deep tissue injury. Review of Resident 9's weight revealed that on August 17, 2023, the resident weighed 128.8 pounds. On November 6, 2023, the resident weighed 118.0 pounds, an 8.4% weight loss in less than 90 days/ 3 months. There was no evidence that the facility's dietitian was notified of changes in the resident's skin condition and increased nutritional needs to promote healing or the resident's significant weight loss increasing the resident's risk for skin breakdown and potential deterrent to healing. Observation of Resident 9 on November 27, 2023, at approximately 10 AM revealed the resident awake and sitting in resident lounge/dining area in her wheelchair. The resident was observed leaning to the left while in the chair. Interview with Employee 1, Registered Nurse, on November 28, 2023, at approximately 10 AM, revealed that she had identified what appeared to be a bruise on Resident 9's hip days before the SDTI was identified. According to Employee 1, the bruise was the size of the tip of her pinky finger. Employee 1 further stated that nurse aide staff had reported that Resident 9 favors her left side and confirmed that she did not report the bruised area when first observed. Observation of Resident 9 on November 29, 2023, at approximately 8:15 AM, revealed that she was in the resident lounge/ dining area in her wheelchair. The resident was again observed leaning to the left while in chair, the same side as her identified pressure injury. Observation of the resident's left hip on November 29, 2023, at approximately 1:30 PM, in the presence of Employee 1, RN, and the wound care nurse revealed that the area measured approximately 3 cm x 1.5 cm, the wound bed was covered with eschar (dark, crusty dead tissue). There was no drainage, the surrounding skin was flesh tone, and wound edges were intact. The facility was unable to demonstrate that the development of the resident's left hip pressure ulcer was unavoidable based on the lack of documented evidence that the facility had implemented resident specific interventions to address potential contributing factors, to include the resident's positioning in the chair, to prevent skin breakdown. Interview with the Assistant Director of Nursing (ADON) on November 29, 2023, at approximately 1:30 PM confirmed to identify potential cause/contributing factors for the development of Resident 9's deep tissue injury. The ADON further confirmed that the nursing staff failed to timely notify the dietitian of significant changes in the resident's weight and decline in meal consumption increasing the resident's risk for skin breakdown. There was no evidence that the facility explored potential seating arrangements due to the resident favoring her left side while seated in her wheelchair. Interview with the Nursing Home Administrator on November 30, 2023, at approximately 2:30 PM confirmed that the facility failed to demonstrate the implementation of individualized measures to prevent development and promote healing of a pressure ulcer for a resident with identified risk for skin breakdown. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (a)(d) Resident care policies

Based on review of information submitted by the facility, select facility policy and reports and clinical records and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 12 sampled residents. Findings include: Review of facility policy entitled Elopement, last reviewed by the facility April 2023, indicated it is the policy of the facility to promote resident safety through prevention of elopements, while allowing residents as much physical freedom as possible and to initiate a facility-wide search (including the grounds) immediately upon discovery of a missing resident. When residents who are identified as at risk to leave the facility unattended cannot be located on the unit, or any resident is identified as missing from the facility, the following procedure will be implemented: - The charge nurse will notify the nursing supervisor on duty. - The nursing supervisor will assign specific areas to be searched to specific staff. 1) will be assigned to search all areas within the unit including closets, bathroom, utility rooms, etc. 2) will be assigned to search all other areas in close approximation of where the resident was last seen. 3) will be assigned to search outside perimeters of the facility. 4) will search the ancillary areas. - The nursing supervisor will notify the Administrator and the Director of Nursing as soon as the search has commenced. Observation of a posting located at the first-floor nurse's station on January 30, 2024, at approximately 11 AM revealed that the posting indicated that when a [door] alarm sounds, check panel to see which door is sounding. Silence alarm by pressing 1 2 3 4, call the extension, or check the area of the alarm. If it is clear, reset the alarm. Always remember to reset! The doors are not alarmed if system is not reset. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included dementia unspecified severity with agitation, depression, and anxiety. According to the resident's MDS assessments, the resident was severely cognitively impaired. An Elopement Risk assessment dated [DATE], revealed that the results did not identify Resident 1 to be at risk for elopement. The resident's annual MDS assessment dated [DATE], indicated that Resident 1 had not experienced behaviors or wandering but was severely cognitively impaired with a BIMS score of 5. Review of Resident 1's clinical record revealed that the resident was receiving physical therapy from October 26, 2023, to November 22, 2023, due to a recognized changes in resident's ambulatory status, wheelchair mobility, and transfer status. According to the therapy documentation, Resident 1 made progress exhibiting improved core and bilateral lower extremity (BLE) strength and control, improved transfers and improved transfer ability. The resident had also accepted a wheelchair for mobility on nursing unit to decrease fall risk and propels wheelchair with BLE with supervision with good endurance. The resident was discharged from physical therapy to nursing care and restorative nursing program on November 22, 2023. Review of information submitted by the facility revealed that on December 4, 2023, at 6:30 PM, nursing staff recognized that Resident 1 was not in her room on the unit. At 6:35 PM a community member passing the facility found Resident 1 on the main road leads to the driveway entrance of the facility, picked up the resident in their car, and then contacted the police. The police contacted then facility, The facility reviewed video surveillance as part of their investigation, which was also reviewed by the surveyor on January 30, 2024, in the presence of the Nursing Home Administrator. When reviewed at the time of the survey ending January 30, 2024, the video showed Resident 1 had self-propelled herself in her wheelchair off the nursing unit and entered the second-floor elevator at 6:17 PM. The resident took the elevator to the basement level where she propelled herself through the hallway and opened the beauty shop exit door, which tripped the facility's alarm. Resident 1 then self-propelled through the opened therapy department door, and is no longer seen on the video. Further observation of the video surveillance revealed that s facility staff member responded to the location of the alarm, opening the beauty shop exit door and looking outside, and searched the immediate area, which included the unoccupied therapy room, but didn't find anyone in the vicinity. The staff member then returned to the nursing unit without looking outside. Resident 1 was then seen again on video surveillance footage walking outside the facility and down the facility driveway leading away from the building to the main access road where she was then out of video surveillance range. Observation conducted on January 30, 2024, of the the location where it was believed Resident 1 had exited the facility, revealed a flight of concrete stairs that the resident had to climb to get to the back parking lot of the building. According to interview the Nursing Home Administrator on January 30, 2024, the resident had left her wheelchair in the therapy department and independently walked up the flight of stairs. Upon return to the facility, Resident 1 was assessed with no injuries identified. The physician ordered the resident to be sent to the emergency room for further evaluation, with no concerns identified. Facility investigation determined that Resident 1 may have been looking for her old room. The resident's room was recently changed on November 8, 2023, to place her closer to the nurse's station due to frequent falls and attempts to self-rise from her wheelchair. Due to her cognitive impairment, the resident was unable to verbalize why she left the facility or where she was going. Review of witness statement completed by Employee 1, licensed practical nurse, dated December 4, 2023, revealed that she returned from break as the alarm was being disarmed (silenced) by Employee 2, nurse aide. According to Employee 1, Employee 2 stated that the alarm was tripped by the beauty shop door. Employee 1 then asked Employee 2 to go check the area and when she returned, Employee 2 reported that nobody was downstairs. Then approximately 20 minutes later, the wife of a resident called the unit to inform her that she passed a vehicle who had someone in their car, they assumed it was a resident here [at the facility] so decided to call {the facility}. Immediately I notified my supervisor and performed a head count on my unit. Review of witness statement completed by Employee 2, nurse aide, dated December 4, 2023, revealed that just before dinner trays were picked up on [unit] 28, the door alarm was going off. Employee 2 checked the alarm panel and it read beauty shop. Employee 2 then cancelled the alarm and reset the door. Employee 1 then returned from break and the aides reported the alarm. I went down to investigate why the beauty shop alarm was going off, it was coming from a chair in the physical therapy room. I turned off the alarm and started to call 'hello, anyone down here?' The chemical room door was open, Employee 2 looked inside, no one was there so she closed the door. Employee 2 then returned to the unit after not finding/seeing anyone in the basement. There was no indication that any facility employee went outside to look in the immediate vicinity of the exit door, when no one was immediately visible from the vantage point of looking from the doorway. Interview with the Nursing Home Administrator and the Director of Nursing on January 30, 2024, at approximately 3:00 PM, confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident, who left the facility and its grounds unsupervised. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of information submitted by the facility, select facility policy and reports and clinical records and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 12 sampled residents. Findings include: Review of facility policy entitled Elopement, last reviewed by the facility April 2023, indicated it is the policy of the facility to promote resident safety through prevention of elopements, while allowing residents as much physical freedom as possible and to initiate a facility-wide search (including the grounds) immediately upon discovery of a missing resident. When residents who are identified as at risk to leave the facility unattended cannot be located on the unit, or any resident is identified as missing from the facility, the following procedure will be implemented: - The charge nurse will notify the nursing supervisor on duty. - The nursing supervisor will assign specific areas to be searched to specific staff. 1) will be assigned to search all areas within the unit including closets, bathroom, utility rooms, etc. 2) will be assigned to search all other areas in close approximation of where the resident was last seen. 3) will be assigned to search outside perimeters of the facility. 4) will search the ancillary areas. - The nursing supervisor will notify the Administrator and the Director of Nursing as soon as the search has commenced. Observation of a posting located at the first-floor nurse's station on January 30, 2024, at approximately 11 AM revealed that the posting indicated that when a [door] alarm sounds, check panel to see which door is sounding. Silence alarm by pressing 1 2 3 4, call the extension, or check the area of the alarm. If it is clear, reset the alarm. Always remember to reset! The doors are not alarmed if system is not reset. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included dementia unspecified severity with agitation, depression, and anxiety. According to the resident's MDS assessments, the resident was severely cognitively impaired. An Elopement Risk assessment dated [DATE], revealed that the results did not identify Resident 1 to be at risk for elopement. The resident's annual MDS assessment dated [DATE], indicated that Resident 1 had not experienced behaviors or wandering but was severely cognitively impaired with a BIMS score of 5. Review of Resident 1's clinical record revealed that the resident was receiving physical therapy from October 26, 2023, to November 22, 2023, due to a recognized changes in resident's ambulatory status, wheelchair mobility, and transfer status. According to the therapy documentation, Resident 1 made progress exhibiting improved core and bilateral lower extremity (BLE) strength and control, improved transfers and improved transfer ability. The resident had also accepted a wheelchair for mobility on nursing unit to decrease fall risk and propels wheelchair with BLE with supervision with good endurance. The resident was discharged from physical therapy to nursing care and restorative nursing program on November 22, 2023. Review of information submitted by the facility revealed that on December 4, 2023, at 6:30 PM, nursing staff recognized that Resident 1 was not in her room on the unit. At 6:35 PM a community member passing the facility found Resident 1 on the main road leads to the driveway entrance of the facility, picked up the resident in their car, and then contacted the police. The police contacted then facility, The facility reviewed video surveillance as part of their investigation, which was also reviewed by the surveyor on January 30, 2024, in the presence of the Nursing Home Administrator. When reviewed at the time of the survey ending January 30, 2024, the video showed Resident 1 had self-propelled herself in her wheelchair off the nursing unit and entered the second-floor elevator at 6:17 PM. The resident took the elevator to the basement level where she propelled herself through the hallway and opened the beauty shop exit door, which tripped the facility's alarm. Resident 1 then self-propelled through the opened therapy department door, and is no longer seen on the video. Further observation of the video surveillance revealed that s facility staff member responded to the location of the alarm, opening the beauty shop exit door and looking outside, and searched the immediate area, which included the unoccupied therapy room, but didn't find anyone in the vicinity. The staff member then returned to the nursing unit without looking outside. Resident 1 was then seen again on video surveillance footage walking outside the facility and down the facility driveway leading away from the building to the main access road where she was then out of video surveillance range. Observation conducted on January 30, 2024, of the the location where it was believed Resident 1 had exited the facility, revealed a flight of concrete stairs that the resident had to climb to get to the back parking lot of the building. According to interview the Nursing Home Administrator on January 30, 2024, the resident had left her wheelchair in the therapy department and independently walked up the flight of stairs. Upon return to the facility, Resident 1 was assessed with no injuries identified. The physician ordered the resident to be sent to the emergency room for further evaluation, with no concerns identified. Facility investigation determined that Resident 1 may have been looking for her old room. The resident's room was recently changed on November 8, 2023, to place her closer to the nurse's station due to frequent falls and attempts to self-rise from her wheelchair. Due to her cognitive impairment, the resident was unable to verbalize why she left the facility or where she was going. Review of witness statement completed by Employee 1, licensed practical nurse, dated December 4, 2023, revealed that she returned from break as the alarm was being disarmed (silenced) by Employee 2, nurse aide. According to Employee 1, Employee 2 stated that the alarm was tripped by the beauty shop door. Employee 1 then asked Employee 2 to go check the area and when she returned, Employee 2 reported that nobody was downstairs. Then approximately 20 minutes later, the wife of a resident called the unit to inform her that she passed a vehicle who had someone in their car, they assumed it was a resident here [at the facility] so decided to call {the facility}. Immediately I notified my supervisor and performed a head count on my unit. Review of witness statement completed by Employee 2, nurse aide, dated December 4, 2023, revealed that just before dinner trays were picked up on [unit] 28, the door alarm was going off. Employee 2 checked the alarm panel and it read beauty shop. Employee 2 then cancelled the alarm and reset the door. Employee 1 then returned from break and the aides reported the alarm. I went down to investigate why the beauty shop alarm was going off, it was coming from a chair in the physical therapy room. I turned off the alarm and started to call 'hello, anyone down here?' The chemical room door was open, Employee 2 looked inside, no one was there so she closed the door. Employee 2 then returned to the unit after not finding/seeing anyone in the basement. There was no indication that any facility employee went outside to look in the immediate vicinity of the exit door, when no one was immediately visible from the vantage point of looking from the doorway. Interview with the Nursing Home Administrator and the Director of Nursing on January 30, 2024, at approximately 3:00 PM, confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident, who left the facility and its grounds unsupervised. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a clinical record review and staff and resident interviews, it was determined that the facility failed to provide the necessary behavioral health care and services to attain the highest practicable mental and psychosocial well-being of one resident out of the 19 sampled (Resident 8). Findings include: A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses to include anxiety disorder (a mental health disorder involving excessive fear or worry) and osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 12, 2023 revealed that Resident 8 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 13-15 indicates cognition is intact). A review of Resident 8's plan of care, initiated December 8, 2021, revealed that the facility identified that the resident had a mood problem related to anxiety with planned interventions of administering medications as ordered, assisting the resident, family, and caregivers to identify strengths and positive coping skills and reinforce these; monitoring and recording mood to determine if problems seem to be related to external causes; and monitoring, recording, and reporting to the physician patterns, signs, and symptoms of depression, anxiety, and sad mood. A review of Resident 8's Patient Health Questionnaire (PHQ-9 is a tool used to assess the severity and symptoms of depression) dated July 27, 2023, revealed that the resident was at mild risk for depression. Resident 8's care plan related to problem with mood was revised on July 28, 2023, with the planned intervention to have an external provider consult and follow up as indicated. At the time of the survey ending November 30, 2023, there was no evidence that an external provider consultation had occurred. A progress note dated August 20, 2023, at 6:00 PM, indicated that Resident 8 was experiencing feelings of doom and despair. A review of Resident 8' depression screen (PHQ-9) dated September 12, 2023, indicated that the resident was at moderate risk for depression, which was an increase from the resident's prior screen completed on July 27, 2023. Nursing noted on September 12, 2023, at 8:53 AM that Resident 8 had periods of increased anxiety, calls or yells out, and can be demanding with staff. The entry stated that Resident 8 feels tired and restless many days, her appetite is poor, she has trouble sleeping many days, and she has trouble concentrating on things. During an interview on November 27, 2023, at 10:25 AM, Resident 8 stated that she has a terrible case of the blues and sometimes feels like not continuing on with life. There was no evidence that the facility had addressed the resident's behavioral health care needs related to depression and anxiety, and developed and implemented person-centered care plans that include and support the behavioral health care needs for the resident's diagnosed conditions. The facility failed to revise the resident's behavioral health care plan in response to the resident's increased risk for depression noted on September 12, 2023, and signs of increased anxiety nursing noted on September 12, 2023, which was confirmed during interview on November 29, 2023, at approximately 1:00 PM, with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on review of 19 clinical records and resident payor source data, and staff interview, it was determined that the facility failed to offer routine annual dental services for one private payor source resident reviewed. (Resident 24). Findings include: Resident 24 was admitted to the facility on [DATE], with diagnosis to include depression and dementia, and her payor source was private pay. Review of Resident 24's annual MDS dated [DATE] quarterly MDS dated [DATE], April 21, 2023 and July 17, 2023 and annual MDS assessment dated [DATE], all indicated that the resident was severely cognitively impaired. Documentation provided by the facility indicated that the resident was last seen by a Dentist on December 29, 2021. A 2023 Dental Screening Consent Form was completed on December 20, 2022, and indicated that the resident's representitive wanted the resident to have a dental screening. There was no documentation that Resident 24 was offered dental services since December 29, 2021. Interview with the Administrator on November 29, 2023 at 10:30 a.m. confirmed that the facility had no documented evidence that Resident 24 received dental services since December 29, 2021. 28 Pa. Code 211.5 Dental Services

Based on a review of clinical records, select facility policy and fall reports and staff interview it was determined that the facility failed to implement their established policy to identify and timely address potential contributing factors to resident falls and provide sufficient staff supervision and an effective individualized safety plan to repeated prevent falls, resulting in multiple fractures, thigh, pelvis and ankle, for one resident out of 18 sampled (Resident 72). Findings included: Review of the facility's policy, entitled Fall Prevention and Risk Assessment Program last reviewed by the facility December 2021, indicated that it is the facility policy to identify those residents at risk for falls and to evaluate an incident to determine any areas or risk that is amenable to modifications, while maximizing each resident's freedom to be mobile with minimal risk of injury. The results of the evaluation and the safety devices to be used will be reported to the charge nurse on the unit. The fall risk program includes assessment, evaluation, and individualized plan of care with interventions, along with regular evaluation of appropriateness of the plan. All new admissions and re-admission will be assessed within twenty- four hours for fall risk. Additionally, the fall risk assessment will be triggered on a current resident under the following conditions: significant change as outlined by the MDS ([Minimum Data Set]- a federally mandated standardized assessment conducted at specific intervals to plan resident care) guidelines and any other condition that warrants an assessment. The evaluation results will be used to reflect the changes in the interventions utilized to reduce falls and injury. These will be entered into the resident's plan of care and will be reviewed to ascertain the current fall precautions are appropriate and/or if new ones need to be instituted. As part of the of the Fall Risk Program, residents will have medications reviewed for side effects/drug interactions that may increase the risk of falls. Review of Resident 72's clinical record revealed admission to the facility on [DATE], after the resident had sustained a fall with fractures prior to admission. Review of an admission fall risk evaluation dated March 15, 2021, revealed that the resident was at high risk for falls. A quarterly Minimum Date Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 1, 2021, indicated that the resident had severe cognitive impairment with a BIMS score of 7 (Brief Interview for Mental Status - a tool to assess cognitive function The BIMS is a brief screener that aids in detecting cognitive impairment. It does not address all possible aspects of cognitive impairment; a score of 0-7 indicates severe cognitive impairment) and required extensive of two-person assistance with bed mobility, transfers, walking, and toileting. A fall report dated April 26, 2021, at 7:15 PM revealed that the resident had an unwitnessed fall. Staff found the resident lying on the floor of the resident's room with the wheelchair leaning on the resident. The intervention was to discontinue the clip alarm (pull string alarm is clipped to the resident) and to apply a bed and chair pad alarm (Bed alarms and sensor pads are used to alert staff that the resident is trying to get out of bed or chair). A fall report dated May 8, 2021, at 6:25 PM revealed that the resident had an unwitnessed fall. Staff found the resident on the floor in doorway of the bathroom in the resident's room. The intervention put into place was to adjust a timed toileting program in place for the resident. Review of the facility's fall report dated May 21, 2021, at 7:28 PM revealed the resident had an unwitnessed fall. Staff again found the resident on the floor in the doorway of the bathroom in the resident's room. The intervention put into place was to have a PT (physical therapy) screen performed. The resident's care plan, initiated June 10, 2021, revealed that the resident had a mood/anxiety problem related to depression/anxiety with a goal that the resident will be/remain free of [CONDITION(S)] drug related complications, including movement disorder, discomfort, [CONDITION(S)], gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions in place are to administer medications as ordered if non-pharmacological interventions (likes ice cream sandwiches which is sometimes effective) are ineffective. Monitor for side effects and effectiveness. Additionally, the care plan, initiated June 10, 2021 indicated that the resident was at high risk for falls related to confusion, incontinence, psychoactive drug use, unaware of safety needs, may have blood pressure changes due to hypertension, [CONDITION(S)], dementia, and Alzheimer's disease and that the resident had multiple falls. Planned interventions to reduce falls were to anticipate the needs of the resident, call light in reach and encourage the resident to use it, encourage resident to participate in activities to promote exercise, ensure resident is wearing appropriate footwear, PT/OT to evaluate as indicated, review information on past falls and attempt to determine care of falls. Record possible root cause, the resident needs activities that minimize the potential for falls while providing diversion and distraction and alarm/device for bed and chair. A fall report dated October 13, 2021, at 8:30 AM revealed that the resident's alarm was sounding. When staff responded and they found the resident's bed empty. The staff witnessed the resident fall to the floor from outside of her bathroom. The resident was transferred to the acute care hospital and was diagnosed with a fractured right femur (thigh bone) and pelvis. The resident was known to attempt self-toileting. Alarms proved ineffective in preventing multiple falls prior to October 13, 2021. There was no documented evidence that the facility had developed and implemented an individualized plan to maintain the resident's safety and prevent repeated falls, including necessary staff supervision and prompted or timed toileting assistance at frequent intervals to prevent the resident's falls. A fall risk evaluation was not performed upon the resident's return from the hospital (October 18, 2021) as indicated in the facility policy. There were no new interventions developed and implemented after Resident 72 returned to the facility on [DATE], after the fall during which she sustained a fractured right femur and pelvis, demonstrating that the prior safety interventions were ineffective. A fall report dated December 22, 2021, at 7:15 PM, indicated that Resident 72 had an unwitnessed fall. Staff heard the wheelchair alarm sounding and responded to the resident's room. Resident 72 was observed sitting on the floor in front of the bathroom door in her room. The report noted that the resident presented right ankle deformity. The resident was transferred to an acute care hospital. Subsequent progress notes revealed that the resident had sustained a right ankle fracture as a result of the fall and remained in the acute care hospital until December 29, 2021. Review of Resident 72's timed toileting program revealed that the resident had been toileted on December 22, 2021 at 6:00 PM and was identified as continent. However further review of the timed toileting program revealed that staff had completed the form for the entire week from December 22, 2021, through December 29, 2021, although Resident 72 was hospitalized at that time and not in the facility that week. Review of Resident 72's December 2021 medication administration record revealed that during the late afternoon of the day of the resident's fall on December 22, 2021, the resident received Lorazepam 0.5 mg, 1 tablet at 4:48 PM. (an antianxiety medication with possible side effects of drowsiness, dizziness, tiredness and weakness). Progress notes indicated that the medication was administered on December 22, 2021, to treat the resident for increased restlessness and suspicious thoughts of persons taking her clothes. There was no documentation that the medication had been evaluated for effectiveness after administration or the resident's mood and behavior after medication administration. The resident had a history of falls and unsafe behaviors known to the facility. The resident had been displaying restless behavior approximately two hours prior to the fall and was administered a psychoactive drug in response, with potential sedating side effects. There was no documented evidence that the facility had increased supervision of the resident and timely monitored the resident's behavior to prevent another fall with serious injury. The facility failed to consistently and effectively implement the care planned interventions to reduce falls including to anticipate the needs of the resident and reviewing information on past falls and attempt to determine cause of the falls. There was no indication that the facility had recorded possible root causes of each fall or the specific activities the resident needed to minimize the potential for falls while providing diversion and distraction as noted on the plan of care. An interview with the NHA (nursing home administrator) on January 21, 2022, at approximately 2:00 PM failed to provide evidence that the facility had consistently and accurately performed fall evaluations as noted in facility policy in an attempt to identify contributing and risk factors and implement an individualized plan, including sufficient staff supervision to prevent falls with serious injuries for this resident. Refer to F758 28 Pa. Code 211.10 (a)(d) Resident care policies Previously cited 3/12/21 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services Previously cited 10/20/21, 3/12/21, 11/15/19 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 3/12/21, 11/15/19

Based on a review of the facility's abuse prohibition and transfer policies, employee personnel records, information submitted by the facility, select resident incident/accident and investigative reports, and clinical records and staff interviews it was determined that the facility neglected to provide the necessary care and services to avoid pain and serious bodily injury, a fractured leg, and necessary services post fall to prevent further harm to one resident out of five reviewed (Resident 1). Findings include: A review of the facility policy entitled Prevention of Abuse, Neglect and the Misappropriation of Resident Property provided by the facility at the time of the survey ending October 20, 2021, revealed it is the policy of the facility to maintain an environment free of abuse, neglect, and misappropriation of resident property. Neglect was identified in the policy as, neglect refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safe, adequate and appropriate services, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 27, 2021, indicated that the resident was cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive function) of 4 and required extensive staff assistance with activities of daily living including transfers. Review of Resident 1's current plan of care, initiated on June 9, 2021, revealed that the resident had an ADL self-care performance deficit related to confusion, dementia, and limited mobility. The resident's goal was that the resident will allow completion of care by staff. A care planned intervention in place at the time of a fall with injury that occurred on October 4, 2021, was that the resident was to be transferred with the assistance of two staff and a rolling walker. Review of information submitted by the facility on October 4, 2021, revealed that while Resident 1 was being transferred from the shower chair to her wheelchair, Resident 1 leaned back causing both Employee 1 (an agency nurse aide) and Resident 1 to fall to the floor. The information submitted by the facility indicated that Resident 1 required extensive assistance of two persons for transfers. Employee 1, Nurse Aide (agency) then picked the resident up off the floor and placed Resident 1 in her wheelchair. Employee 1 then requested Employee 2, Nurse Aide, the oncoming Nurse Aide to notify Employee 3, licensed practical nurse (LPN) of the incident. Review of a written statement regarding the resident's fall completed by Employee 1 revealed that Employee 1 indicated that while transferring Resident 1 from the shower chair to the resident's wheelchair, the resident leaned backwards. As Employee 1 attempted to push Resident 1 forward, both the resident and the employee, fell to the floor. Employee 1's statement noted that the resident landed on top of her on the floor. Employee 1 also noted that prior to licensed nursing staff conducting an assessment of Resident 1 for any injuries sustained during the fall, Employee 1 picked the resident up from the floor and placed the resident into the wheelchair without assistance from another staff member. After placing the resident in the wheelchair, Employee 1 then asked Employee 2, nurse aide, to see if Employee 3, LPN, could come and assess the resident. Review of facility policy entitled: Transfer of Resident Policy, indicated that it is the facility policy to protect its residents by preventing against injury and or fall during transfer and transfer status will be reflected on the Kardex on each shift, which Nurse Aides will review on each shift. The Transfer of Resident policy also revealed that should a fall occur during a transfer, the resident should remain on the floor and made as comfortable as possible until evaluated by the charge nurse/supervisor. When transferring from floor, a mechanical lift is to be utilized. According to Employee 1's witness statement, Employee 1 removed Resident 1 from the floor prior to assessment for injury and did not use a mechanical lift as per facility policy. Review of a written statement regarding the fall completed by Employee 2 revealed that she was asked by Employee 1 to assist with the placement of a chair alarm under the resident. Employee 2 indicated that she assisted by sliding the chair alarm under the resident. It was at this time that Employee 1 told her that Resident 1 fell during a transfer in the shower room. Review of a written statement regarding the fall completed by Employee 3 revealed that Employee 2 requested that Employee 3 assess Resident 1 in the shower room. Employee 3 indicated that when Employee 3 arrived, Resident 1 was seated in a Broda chair (tilting wheelchair) and in extreme pain. Employee 3 indicated that it was then that Employee 1 reported that during the transfer, Resident 1 leaned backward causing both Employee 1 and Resident 1 to fall to the floor. Review of the incident/accident report dated October 4, 2021, revealed Employee 3 noted that Resident 1 was assisted to bed with assist of two persons and an assessment was performed. Employee 3 indicated Resident 1's right hip was edematous (swollen) and the right leg was internally rotated. The resident was transferred to the hospital on October 4, 2021, and diagnosed with a displaced right subtrochanteric femur (long bone in upper portion of the leg) fracture requiring ORIF (Open reduction internal fixation- is a type of surgery used to stabilize and heal a broken bone) of her right subtrochanteric (subtrochanteric region [proximal portion of the femur] is defined as within 5 centimeters distal the lesser trochanter femur fracture). Review of Resident 1's clinical record dated September 2021 and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of the injury on October 4, 2021, the resident's pain level was rated as a 10 (on a scale of 0-10 with 10 being the most severe) by Employee 3. Resident 1 returned to the facility on [DATE], from the acute care hospital post-surgical repair of her displaced subtrochanteric femur fracture. A physician order was noted on October 9, 2021, for [MEDICATION(S)] (a pain medicine similar to an opioid and is classified as a synthetic opioid) tablet 50 milligrams, give 1 tablet by mouth every 6 hours as needed for pain-moderate. An order was also noted on October 9, 2021, for [MEDICATION(S)]- Acetaminophen Tablet 5-325 milligrams give 1 tablet by mouth every 6 hours as needed for pain- severe. The resident's October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Employee 1's personnel record revealed a hire date of September 22, 2021 and abuse prohibition training was provided upon hire. Interview with Employee 4, Registered Nurse Staff Development Coordinator, on October 20, 2021, at 10:45 AM revealed that she reviewed the facility policies with Employee 1 as indicated on the Acknowledgement or Orientation and Training for dated September 22. 2021. with Employee 4 stated because Employee 1 was an agency aide, the staffing agency verifies the employee's competencies as a nurse aide. Continued interview with Employee 4 revealed that nursing staff determine the required level assistance of each resident by accessing PCC (Point click care- electronic health record), which is where the information is listed. Employee 4 stated that nurse aides access PCC through the kiosks on the walls on each unit. Observation of Resident 1 on October 2, 2021, at approximately 1:45 PM revealed that the resident was in her bed with her eyes closed and under the covers. The surveyor attempted to conduct an interview with resident, which was unsuccessful as the resident was non-verbal during attempted interview. Interview with Employee 5, Licensed Practical Nurse, on October 20, 2021, at approximately 1:48 PM revealed the resident frequently receives [MEDICATION(S)]- Acetaminophen (narcotic pain medication prescribed for severe pain) because the [MEDICATION(S)] (synthetic narcotic pain medication ordered for moderate pain) does not seem to hold her over well. Employee 2, a nurse aide, stated during interview on October 20, 2021, at 2 PM that when care is provided to the resident she continues to display signs of pain as she moans and grimaces. Review of the PCC electronic nurse aide documentation of tasks completed for residents, provided to the surveyor on October 22, 2021(information provided after survey exit due to corporate controls on information at the time of the survey ending October 20, 2021) revealed no indication that Employee 1 had provided any care to Resident 1 on October 4, 2021, the date of the resident's fall with fracture had occurred. There was no evidence that Employee 1 had accessed the nurse aide electronic documentation system on that date to view Resident 1's specific care needs and level of assistance required with ADLs to assure the resident received the necessary care and services to prevent serious bodily injury. Telephone Interview with the Director of Nursing on October 22, 2021 at approximately 3:15 PM revealed that the facility determined that Employee 1 did log into PCC on her date of hire on September 22, 2021, had created a username and password. However, the DON verified that there was no evidence in PCC that Employee 1 was accessing PCC using her username and password since her hire date and first login on September 22, 2021. The DON stated that the facility determined that Employee 1 was utilizing another agency nurse aides account and login information to document resident care. The facility concluded their abuse investigation on October 5, 2021, at 9:00 AM, indicating that the alleged neglect of Resident 1 by identified perpetrator Employee 1 (a nurse aide), but the conclusion status was noted as NA. Review of a written statement revealed the Director of Nursing indicated she interviewed Employee 1 regarding Resident 1's fall during transfer on October 4, 2021. According to the DON's statement Employee 1 provided no reason or explanation as to why she transferred Resident 1 by herself and without the assistance of another staff member as required. According to the DON's statement when Employee 1 was asked about accessing PCC to view resident's care needs and the facility's transfer policy after a fall, the DON indicated that Employee 1 either didn't know or didn't remember when questioned. Interview with the Director of Nursing and Nursing Home Administrator (NHA) on October 20, 2021, at approximately 2:15 PM, confirmed that Employee 1 neglected to provide Resident 1 with necessary services to prevent serious physical injury and severe pain. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (e)(1)(3) Management Previously cited 3/12/21 28 Pa. Code 201.29(a) Resident rights Previously cited 3/12/21, 11/15/19 28 Pa. Code 201.29(c) Resident rights Previously cited 3/12/21 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 3/12/21, 11/15/19

Based on observation, a review of clinical records, information submitted by the facility, select resident incident/accident and investigative reports, video surveillance footage and staff and resident interview it was revealed that the facility failed to ensure that one resident out of 18 sampled was free from physical abuse, which caused psychosocial harm and humiliation (Resident 6). Findings include: A review of the facility policy entitled Prevention of Abuse, Neglect and the Misappropriation of Resident Property reviewed by the facility July 17, 2020, revealed it is the policy of the facility to maintain an environment free of abuse, neglect, and misappropriation of resident property. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of funds or property. Resident will not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members of legal guardian, friends, or other individuals. Abuse in this policy will refer to the willful infliction of injury, unreasonable confinement or punishment, mental anguish or misappropriate of resident property. A review of Resident 6's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 29, 2020, indicated that the resident was severely cognitively impaired and required extensive staff assistance with activities of daily living including dressing. Review of information submitted by the facility on February 18, 2021, revealed that a camera had been placed in Resident 6's room on February 10, 2021, in response to a report of a missing personal item on that unit. This resident's room, with permission of the family, was chosen based on her incapability and room location, being a distance from the nurse's station. A review of a resident incident and accident report and a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property report form for investigation of alleged abuse, neglect and misappropriation dated February 18, 2021, at 12:00 PM revealed that when the facility reviewed footage of hidden camera on February 17, 2021, Employee 3, nurse aide, was observed striking (open handed) Resident 6 in the head, on two separate occasions, while providing her care. Employee 3 was immediately escorted out of the building. According to information submitted by the facility dated February 18, 2021, an assessment of Resident 6 completed on the evening of February 17, 2021, revealed that the resident had no visible injuries following the physical abuse. Observation of Resident 6 on March 10, 2021, at approximately 10:00 AM revealed that the resident was out of bed in her wheelchair, dressed and leaning on overbed table. The surveyor attempted to conduct an interview with resident, which was unsuccessful as the resident was non-verbal during attempted interview. Resident 6 made no attempt to verbally answer questions, just waved at surveyor. Employee 3 did not submit a written statement to the facility regarding the incident, but the Director of Nursing (DON) conducted a verbal interview with Employee 3 on February 17, 2021. The Director of Nursing initially informed Employee 3 that there had been a complaint from a family member regarding how he approached resident care. The Director of Nursing questioned Employee 3 if there was any reason for a family to think that he was being inappropriate during care, inquiring if he was rough with care or hurting anyone. According to the contents of the interview, which was provided by the facility, Employee 3 replied no to all questions posed to him by the DON. Employee 3 further stated that he would never hurt any of our residents; that he could not help it if they didn't like men. The facility provided evidence of an additional interview with Employee 3 that was conducted on February 18, 2021, via telephone by the Nursing Home Administrator (NHA), the Director of Nursing, and Human Resources. Employee 3 did not provide any explanation for the video footage captured of him striking Resident 6. According to the written report of the interview, Employee 3 was made aware based on the evidence, his employment with the facility was terminated and that the local police, the Department of Health (The State Survey Agency) and the local Area Agency on Aging had been notified of the event. Observation of video footage conducted by surveyors in the presence of the Nursing Home Administrator on March 11, 2021, revealed no date and time stamp on the footage. It was determined through interview that the facility failed to set the date and time setting prior to placing the camera in Resident 6's room. According to the video footage viewed, the initial observation date was January 1, 2021. Camera date January 2, 2021, at minute 2:52 through 2:55, revealed Employee 3 was observed getting the resident into bed. Employee 3 assisted Resident 6 from her wheelchair to her bed in hurried and abrupt manner. Once Resident 6 was in bed the Employee 3 pulled her pillow out from behind her head, again roughly and abruptly, the resident was observed to hold her head up until he replaced the pillow. Employee 3 put her body pillows in position and blanket on the resident. As Employee 3 walked to the left side of the resident's bed, he hit Resident 6 on the left side of her head/face with an open hand, which startled the resident and she began to swing her right arm. Employee 3 then walked over to the right side of the bed and hit Resident 6 in the face/head again open handed. Employee 3 then left the resident's room. Surveyor observation of the video footage revealed that the resident was not observed to be combative or displaying behavioral symptoms during the above encounter with Employee 3 and Employee 3's actions appeared to be without precipitating factors. Continued surveyor observation of the video footage with a date stamp of January 8, 2021, at minute 2:07 through 2:09, revealed Employee 3 was observed caring for resident while in bed. Initially the view of care provided was shielded by a blanket, only Employee 3 was visible. Once the blanket was placed on the resident, Employee 3 was seen grabbing and pinching Resident 6's right side/waist, which startled the resident and she swung her right arm in response. Based on the date of the camera placement as reported by the facility on February 10, 2021, and the camera video start date of January 1st, it was concluded that the initial physical abuse of Resident 6 by Employee 3 occurred one day after the camera (February 11, 2021) was placed and then again on the seventh day after the camera was placed (February 17, 2021). Review of Employee 3's personnel record revealed a hire date of November 29, 2019. Further review of Employee 3's personnel record revealed abuse training was provided upon hire. A review of the facility's annual abuse training revealed that Employee 3 received this training again in January 2020. The facility concluded their abuse investigation on February 18, 2021, indicating that the alleged abuse of Resident 6 by identified perpetrator Employee 3 (a nurse aide), had been substantiated and the employee was terminated on February 18, 2021. The facility's completed abuse investigative report (PB-22) dated February 19, 2021, submitted to the State Survey Agency also noted that a police investigation was performed by the local police and was ongoing. A review of Magisterial District Judge Criminal Docket issued February 26, 2021, revealed Employee 3 was arraigned on charges of neglect of Care-Dependent Person and Endangers welfare of Care-Dependent person for whom he is responsible. Employee 3 had a preliminary arraignment on February 27, 2021 and was released on unsecured bail on February 27, 2021. A preliminary hearing was scheduled for April 7, 2021. Interview with the Nursing Home Administrator (NHA) on March 9, 2021, at approximately 11:00 AM, confirmed that the facility placed the clock video camera in Resident 6's room on February 10, 2021, due to a report of missing items on the unit. The NHA verified that the facility had not developed or implemented a specific plan to timely and consistently view/screen the video footage after the camera was put into place. Additionally, the facility failed to set up the date and time setting on the camera for accurate timing of any potential incidents and the ability to identify a specific date and time that an incident occurred. According to the NHA, the ADON chose to view the footage on February 17, 2021, which revealed Employee 3 striking Resident 6 while providing care Interview with the Director of Nursing on March 12, 2021, at approximately 2:30 PM, and surveyor viewing of the video footage confirmed that Resident 6 had been physically abused by Employee 3, a nurse aide, during care and the resident was not free from physical abuse. Applying the reasonable person concept, in the case of Resident 6, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused and harassed by Employee 3, Resident 6 would have suffered psychosocial harm and humiliation. Refer F610 483.12 (a)(1) Free from abuse and neglect 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.18 (e)(3) Management Previously cited 11/30/18 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12 (a) Nursing services Previously cited 11/15/19 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services Previously cited 11/30/18, 11/15/19

Based on a review of clinical records and select resident incident reports, observation and staff interview, it was determined that the failed failed to provide sufficient staff assistance and utilize safe technique during care to prevent falls for two residents and injury to one resident out of 22 sampled (Residents 23 and Resident CR2). Findings include: A review of the clinical record revealed that Resident 23 has multiple [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to a quarterly Minimum Data Set assessment (MDS - a federally mandated periodic standardized assessment to identify specific resident care needs) dated October 20, 2015, revealed that the resident was cognitively impaired, required extensive assistance of two staff for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture), transfers, and toilet use. The resident was also identified with impairment of the upper extremity. Review of the resident's current comprehensive plan of care, which was initiated on May 21, 2015, indicated that the resident had a problem with a self-care deficit with planned interventions for extensive assistance with two persons for repositioning, 2 ½ side rails as enablers for turning/repositioning and body pillows to the left and right side of the bed for proper positioning. Review of a RESIDENT SAFETY ASSESSMENT dated May 19, 2015, revealed that the resident has paralysis/paresis on the left arm, hand, leg and foot, a short attention span and is disoriented at times. She was to utilize a personal alarm in bed . Review of a resident incident report dated June 29, 2015, at 1:15 PM, indicated that the resident had fell to the floor of the doorway to her room. A subsequent RESIDENT SAFETY ASSESSMENT dated July 24, 2015, also indicated the same results as the assessment of May 19, 2015. According to nursing documentation dated November 3, 2015, at 3:57 AM, the resident was transferred to the emergency room for evaluation and treatment. Nursing documentation dated November 9, 2015, at 2:50 PM (late entry for November 3, 2015 at 2:30 AM), revealed that the resident had a fall from bed during incontinence care. She had epistaxis (bleeding nose) and complaints of right shoulder and right knee pain and was sent to the emergency room . Nursing documentation noted that the resident returned from the hospital on November 3, 2015, at 7:15 AM, with a nasal fracture. At 7:45 AM, on November 3, 2015, it was noted that her right knee was ecchymotic (bruised) and edematous (swollen). Review of a corresponding incident investigation revealed that on November 3, 2015, at 2:30 AM, Employee 1, (a nurse aide) was providing pericare to the resident. Upon rolling the resident onto her right side the resident fell from bed onto the floor. The resident presented a nasal deformity, bleeding and ecchymosis, a right knee abrasion with ecchymosis and edema and a laceration to the bridge of nose. The resident also had complaints of right shoulder, right knee pain, and a headache. The resident was sent to the emergency room and had a CT Scan (diagnostic imaging test) of the head for a suspected head injury and the results indicated that the resident had a nasal fracture and soft tissue swelling. A written statement provided by Employee 1 on November 3, 2015, revealed that while she was providing pericare to the resident and she rolled the resident onto her right side. The resident fell from bed onto the floor. The resident's half side rails were up while giving care and the resident was alert and cooperative. Employee 1 stated indicated that she was next to the bed providing care and the resident's right leg slid off the bed and she was unable to stop the resident from falling onto the floor. A fall assessment, completed after this fall, dated November 3, 2015, revealed that the resident had a previous fall four months prior whereby she lost her balance. As a result, this fall assessment indicated that the resident had a fall risk score of 14 out of 20, which considered the resident at medium risk for falls. The resident was observed sleeping in bed with the siderails elevated and the bed against the wall on December 17, 2015, at approximately 11:20 AM Interviews with Employees 2 and 3 (nurse aides) on December 17, 2015, at approximately 11:30 AM, revealed that the resident usually gets repositioned with two staff; one on each side of the bed. These employees also stated that the resident cannot use her left arm to grab due to a stroke (CVA). An interview conducted with Employee 1 on December 18, 2015, at approximately 10:45 AM, regarding the circumstances surrounding the resident's fall of November 3, 2015, revealed that Employee 1 stated that it was hard to get the resident in the center of the bed. She also relayed that at that time, she utilized the heel lifter (device to keep the resident's heels off of the mattress) for this resident and that it was placed under the bedsheet. When she rolled the resident toward her, while the resident was utilizing the heel lifter, the resident's right leg came off of the side of the bed and Employee 1 could not stop her from rolling onto the floor. Employee 1 stated that the resident is repositioned with the assist of one person, unless the resident is being uncooperative, then she will be an assist of two. Observations made of the resident on December 18, 2015, at approximately 11:10 AM, revealed that she was seated in wheelchair, after being transferred with the Hoyer Lift (mechanical lift) with the assistance of two nurse aides (Employees 2 and 4). The resident was observed with her left arm dangling from the side of the wheelchair. The surveyor asked the resident if she could raise her left arm. The resident raised it, but weakness was observed in the resident's left arm and hand. Employee 4 confirmed at that time that the resident has weakness in her left arm and hand. Employee 4 stated that the resident could elevate the left arm somewhat, but she cannot use it to grab onto her bed siderail. Employee 4 also stated that she places the heel lifter on top of the mattress, during the resident's care. Employee 4 further stated that she is aware that other nurse aides place the heel lifter under the sheet on the bed. Employee 4 further stated that when she repositions the resident in bed, she moves the heel lifter device up or down from the resident or takes it off of the bed, because it is hard to roll the resident with the heel lifter in place. The facility's follow-up to this fall of November 3, 2015, indicated that the resident's care plan was reviewed and adjusted from the assist of one person for bed mobility to now include the assistance of two staff for all bed mobility positioning. However, there was no documented evidence available for review at the time of the survey that the resident's care plan had indicated that the resident required the assistance of only one person for repositioning at the time of the fall. A review of bed mobility documentation from October 1, 2015, through December 18, 2015, indicated that the resident required the assistance of two for bed mobility on an almost daily basis. 30 entries were noted during the facility utilized the assistance of only one person for bed mobility, through December 15, 2015, and after the resident's fall with fracture on November 3, 2015. There was no documented evidence available for review of the criteria the staff used to ascertain if the resident would be provided one or two staff assistance for bed mobility. The resident's care plan, which was initiated on May 21, 2015, and revised on November 3, 2015, indicated that the resident required the assistance of two for positioning, but through December 18, 2015, staff had not been consistently provided two person assistance to the resident. This failure to provide the necessary amount of staff assistance with the resident's positioning was confirmed during interview with the Assistant Director of Nursing on December 18, 2015. A review of the clinical record revealed that Resident CR2 had multiple diagnoses, which included congestive heart failure (chronic condition in which the heart does not pump blood normally which may cause weakness and shortness of breath) and abnormal posture. According to a quarterly MDS assessment dated [DATE], the resident was severely cognitively impaired, required extensive assistance of two for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture), transfers, and toilet use. Review of the resident's current comprehensive plan of care, which was initiated on November 25, 2014, indicated that the resident had a self-care deficit with planned interventions for extensive assistive with activities of daily living (the need for one or two staff members for bed mobility to ensure the resident's safety was not indicated). The resident's most recent quarterly MDS Assessment for bed mobility, indicated that the resident required the assistance of two staff members for bed mobility as of March 3, 2015. Review of the resident's ADL (Activity of Daily Living) Detail Report noted that on April 5, at 11:12 a.m.; April 6, at 12:16 a.m.; and April 6, 2015, at 2:48 p.m., 2015, the resident required the extensive assistance of two staff members for bed mobility. A nurses note dated April 6, 2015, at 10:50 PM, revealed that while receiving pericare and a bed change from staff, the resident rolled over on the right side and extended both legs beyond the bed perimeter. The resident then fell out of bed landing on both knees. A laceration to the resident's left knee and a 4 centimeter crescent shaped skin tear were noted. The resident was transferred to the emergency room . A nurses note dated April 7, 2015, at 3:45 AM noted that the resident returned to the facility from the emergency room . The resident received 4 sutures to the left knee. The resident's right forearm had a 3 cm crescent shaped skin tear with 3 steri strips in place. Review of a resident Incident Summary report dated April 6, 2015, at 10:30 PM, revealed that the resident fell from her bed during routine care and linen change by Employee 6 (nurse aide). A review of the witness statement from Employee 6 revealed that the assistance of only one staff member was provided when the fall had occurred. The Incident Summary report noted that the suspected reason for the fall was that the resident rolled over too far, extending her legs, beyond the bed. The intervention to prevent further incidents was to change the resident's bed mobility status to the assist of two staff. Interview with the director of nursing on December 17, 2015, at 9:30 AM, failed to provide evidence that the facility had provided adequate staff assistance and utilized a safe technique to maintain the resident's safety and prevent injury during the provision of care to the resident with limited mobility. 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 11/21/14