Every finding on record at Sarah Reed Senior Living

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to obtain weights according to physician's orders for one of eight residents reviewed for weight loss. (Resident R1). Findings include: A facility policy last reviewed on 12/26/24, entitled Height and weight monitoring, directed that all residents were to be weighed by the 10th of each month. Review of Resident R1's clinical record revealed an admission date of 5/3/25, with diagnoses that included stroke, heart failure, and kidney failure. A physician's order dated 5/3/25, revealed that Resident R1 was to be weighed every day shift starting on the 1st and ending on the 10th every month. As of 6/12/25, review of Resident R1's clinical record revealed no documentation that the resident had been weighed as physician ordered since admission on [DATE]. During an interview on 6/12/25, at approximately 11:35 a.m., the Director of Nursing confirmed that Resident R1 had not been weighed since admission. 28 Pa. Code 211.12(d)(1)(2) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of eight residents reviewed (Residents R8, R15, and R60). Findings include: A facility policy entitled, Care Plans dated 2/15/24, stated [NAME] will provide the resident and/or responsible party a copy of the baseline care plan at the new admission care plan meeting, which is typically held within 48 hours of admission. The provision of this will be documented on the New Admission Care Plan summary sheet. In addition, the nursing staff will provide the resident/responsible person with: a. A summary of the resident's medications and dietary instructions b. Any services and treatments to be administered by [NAME] or its staff. Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), and anxiety. Resident R8's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R8 and/or his/her representative. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), osteoarthritis (a joint disease that causes tissues in the joint to break down over time which can cause stiffness in the joint), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Resident R15's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R15 and/or his/her representative. Resident R60's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), hypothyroidism, and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Resident R60's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R60 and/or his/her representative. During an interview on 12/11/24, at 12:30 p.m. the Nursing Home Administrator confirmed that the clinical records of Residents R8, R15, and R60 lacked evidence that a written summary of the baseline care plan and order summary were provided the resident and/or his/her representative upon admission to the facility. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of two residents reviewed regarding range of motion (Resident R15). Findings include: Review of facility policy dated 2/15/24, entitled Range of Motion/Contracture Management indicated To increase flexibility and strength, also to prevent and/or decrease contractures. Review of facility policy dated 2/15/24, entitled Splinting indicated Splinting is used to protect joints and surrounding soft tissue. There must be a physician's order for splinting. Resident R15's admission record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), osteoarthritis (a joint disease that causes tissues in the joint to break down over time which can cause stiffness in the joint), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Resident R15's clinical record revealed a physician's order dated 9/07/24, that identified Left palm protector on at all times except hygiene per patient tolerance. Observations on 12/09/24, at 2:28 p.m. and at 3:10 p.m. revealed Resident R15 lying in bed with no palm protector (a soft round device placed in the palm of the hand to help with contractures and prevent fingers from pushing into the palm causing sores) to left hand. Observations on 12/10/24, at 8:04 a.m. and 10:00 a.m. revealed Resident R15 lying in bed with no palm protector to left hand. Observations on 12/11/24, at 11:35 a.m., at 11:55 a.m., and at 1:10 p.m. revealed Resident R15 lying in bed with no palm protector to left hand. Review of Resident R15's clinical record nursing progress notes lacked evidence that Resident R15 was not tolerating the palm protector. Review of Resident R15's therapy documentation dated 9/06/24, revealed that education was provided to staff upon occupational therapy discharge to make sure resident was wearing the palm protector daily. During an interview on 12/12/24, at 9:30 a.m. the Director of Therapy Employee E3 revealed that Resident R15's palm protector is considered a form of a splint. He/she also confirmed that Resident R15 should be wearing his/her palm protector daily per physician's orders. During an interview on 12/11/24, at 1:10 p.m. Restorative Nurse Employee E1 confirmed that Resident R15 did not have a palm protector on his/her left hand. Employee E1 also confirmed that Resident R15 should wear his/her palm protector daily per physician's orders. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have the required 14-day stop date or provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for two of 21 residents reviewed (Residents R8 and R15). Findings include: A facility policy entitled Psychoactive Medication Policy dated 2/15/24, stated that Orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believe that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for appropriateness of the medication. Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), and anxiety. A physician's order dated 11/12/24, identified to administer Lorazepam (anti-anxiety medication) 0.25 milliliters (ml) by mouth every 2 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), osteoarthritis (a joint disease that causes tissues in the joint to break down over time which can cause stiffness in the joint), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). A physician's order dated 11/15/24, identified to administer Lorazepam 0.25 milligrams (mg) by mouth every 12 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. During an interview on 12/11/24, at 12:08 p.m. the Nursing Home Administrator confirmed that Resident R8 and Resident R15's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to ensure an expired medication was discarded in a timely manner and failed to ensure that a medication was properly dated when opened in one of three medication carts reviewed ([NAME] medication cart). Findings include: Review of a facility policy entitled Medication Storage in the Facility dated [DATE], indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Insulin vials are stored in the refrigerator until opened. Then dated and placed in the med cart once opened. Manufacturer's recommendations for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Manufacturer's recommendations for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Observations of drug storage on [DATE], at approximately 3:33 p.m. of the [NAME] medication cart revealed Humalog insulin with an opened date of [DATE], and an opened Lantus insulin without an open date. During an interview at that time, Registered Nurse Employee E2 confirmed that the Humalog insulins opened date was past 28 days, therefore the expired medication should have been discarded, and that the open Lantus insulin lacked an open date, therefore the staff were unable to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two walk-in coolers and one of one dry storage areas reviewed in the kitchen. Findings include: Review of facility policy entitled Proper Storage of Fresh, Frozen, Leftover and Opened Food Products dated 2/6/24, indicated If a product is found that is past the use-by date, it is to be disposed of in a proper manner. Another policy entitled Food From Outside Sources dated 2/6/24, indicated unconsumed food will be disposed of consistent with the manufacturing guidelines, food labels . Observation of the kitchen areas on 6/5/24, at 10:10 a.m. revealed an open partially used container of pasta salad in the cooler with a use-by date of 5/30/24, observations in the dry storage area revealed eight cans of pureed ham with an expiration date of March 2024, one open gallon jug of molasses with a use-by date of 10/13/23, and two tubs of baking soda with an expiration date of 5/31/24. During an interview with the Dietary Manager on 6/5/24, at the time of the observations, he/she confirmed that the open container of pasta salad, eight cans of pureed ham, one open gallon of molasses, and two tubs of baking soda were beyond their use-by date and/or expiration dates. He/she also confirmed that the items should have been discarded by their use-by dates and/or expiration dates. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and sanitation in the walk-in freezer located in the main kitchen. Findings include: Review of the facility policy entitled, Refrigerated And Frozen Storage dated 2/6/2024, indicated that, The Food Service Department shall receive all food products in a manner that assures safety and quality of food products. All food items shall be placed on shelves and not on floor of refrigerator or freezer. Observations made during the initial kitchen tour on 3/19/2024, at approximately 11:00 a.m. revealed that there were several food items on the floor in the walk-in freezer located in the main kitchen. Interview conducted with the Food Service Director at that time confirmed the food items should not be on the floor in the walk-in freezer. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, clinical record review and staff interview, it was determined that the facility failed to ensure that a discharge summary, which included a recapitulation of the resident's stay and the resident's discharge status, physician's final diagnosis and prognosis or cause of death was completed for three of three closed clinical records reviewed (Residents CR94, CR95, and CR96). Findings include: A facility policy last reviewed 2/15/24, entitled Discharge Policy and Procedure indicated that a recapitulation of the resident's stay, a final summary of the resident's status and the disposition of medications would be part of the interdisciplinary summary discharge summary. A facility policy entitled Closed Record Policy dated 2/06/24, indicated that an interdisciplinary discharge summary is to be completed on all discharges from the facility by each member of the interdisciplinary team (IDT) and include: a short summary of resident's stay; final summary of resident status; disposition of medications; IDT on current caseload to sign off with specific instructions; physician's discharge prognosis, discharge diagnosis, cause of death, physician's signature- as applicable; and the summary goes to medical records with the chart. Resident CR94's closed clinical record revealed an admitted [DATE], with diagnoses that included diabetes (condition related to inadequate insulin and high blood sugars), high blood pressure and heart disease. Resident CR94's clinical record revealed the resident was discharged from the facility on 1/2/24. Further review of Resident CR94's clinical record, lacked evidence of a discharge summary having been completed which included a recapitulation of the resident's stay and a final summary of the resident's status. During interview on 3/22/24, at 10:10 a.m. the Director of Nursing (DON) confirmed that Resident CR94's closed clinical records lacked evidence of a discharge summary being completed. Resident CR96's closed clinical record revealed an admitted [DATE], with diagnoses including a broken rib, altered mental status, cognitive communication deficit, and difficulty speaking. Departmental progress notes revealed that Resident CR96 ceased to breath on 2/13/24, at the facility. Resident CR96's closed clinical record revealed that the physician's discharge summary was incomplete and did not include a cause of death. Resident CR95's closed clinical record revealed an admitted [DATE], with diagnoses including dyspnea (shortness of breath), surgery on the circulatory system, and acquired absence of lung. Departmental progress notes revealed that Resident CR95 discharged from the facility on 2/14/24. Resident CR95's closed clinical record revealed that the physician's discharge summary was incomplete and did not include a recapitulation of stay or reason for discharge. During an interview on 3/22/24, at 11:05 a.m. the DON confirmed that Resident CR96's physician's discharge summary was incomplete and did not include the cause of death and that Resident CR95's discharge summary was incomplete and did not include a recapitulation of stay or reason for discharge from the facility. 28 Pa. Code 211.5(d)(f)(xi) Medical records

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the contracted pharmacist provided separate, written reports of irregularities identified during the medication regimen review (MRR) for one of five residents reviewed for unnecessary medications (Resident R49). Findings include: A facility policy entitled, Medication Regimen Review and Reporting dated 2/06/24, indicated that findings/recommendations of interim (routine interval) MRR are communicated to the Director of Nursing (DON) or designee and medical director, and that the findings are documented and filed with other consultant pharmacist recommendations in the resident's chart. Resident R49's clinical record revealed an admitted [DATE], with diagnoses including left-sided paralysis post stroke, Type 2 Diabetes (condition of improper insulin levels and blood sugar control), heart failure, irregular heartbeat, and dementia. Resident R49's progress notes revealed MRR's were completed monthly and lacked evidence that documented findings/recommendations/irregularities were communicated to the DON or designee and medical director, and filed with other consultant pharmacist recommendations in the resident's chart. During an interview on 3/21/24, at 12:38 p.m. the DON confirmed there was no evidence that the pharmacist provided irregularities on a separate, written report sent to the medical director and DON for Resident R49. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for two of five residents reviewed (Residents R34 and R50). Findings include: A facility policy entitled Psychotropic Medication Policy dated 2/6/24, indicated that, PRN orders for psychotropic drugs are limited to 14 days. The attending physician or prescriber may extend the order beyond 14 days if he/she believes the order is appropriate. The prescriber must document the rational and duration when extending the order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident. Review of Resident R34's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety disorder (a disorder that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R34's clinical record revealed a physician's order to administer Lorazepam (anti-anxiety medication), 0.5 milligrams (mg) by mouth every 24 hours PRN for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of a pharmacy recommendation form revealed an order for Lorazepam 0.5 mg every 24 hours PRN which lacked a rational and a duration for the medication. Review of Resident R50's clinical record revealed an admitted [DATE], with diagnoses that included, dementia, hypertension, and traumatic brain injury (a serious condition that affects the brain's function because of a sudden impact or penetration to the head). Review of Resident R50's clinical record revealed a physician's order dated 2/9/24, to administer Lorazepam 0.5 mg by mouth every four hours PRN for anxiety and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Further review of Resident R50's clinical record revealed a physician's order dated 2/9/24, to administer Haloperidol (anti-psychotic) 0.5 mg by mouth every four hours PRN for agitation and lacked evidence that the resident was evaluated by the attending physician or prescribing practitioner. There also lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. During an interview on 3/21/24, at 12:54 p.m. the Nursing Home Administrator and Employee E1 confirmed that Resident R34's Lorazepam order and Resident R50's Lorazepam and Haloperidol orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. They also confirmed that Resident R50 was not evaluated by the attending physician or prescribing practitioner for the continuation of an anti-psychotic medication. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), clinical records and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set (MDS-federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment accurately reflected the status for one of 19 residents reviewed (Resident R90) Findings include: Review of the RAI manual instructions for Section M0300D1 Stage 4 Pressure Ulcers identified to code the number of currently present and whose deepest anatomical stage is a Stage 4. Review of Resident R90's clinical record revealed an admitted [DATE], with diagnoses that included Gullain Barre Syndrome (disorder in which the body's immune system attacks the nerves), pressure ulcer of the left buttock Stage 3 (full-thickness skin loss), pressure ulcer of sacral region Stage 4 (full-thickness skin loss extending through the muscle, tendon, or bone) and high blood pressure. Review of Resident R90's Quarterly MDS with an Assessment Reference Date (ARD) of 2/14/23, revealed that it was coded as having one Stage 3 pressure ulcer. Clinical record documentation from a wound consultant company dated 11/30/22 and 12/14/22, both revealed the presence of a Stage 3 pressure ulcer to the ischial tuberosity. Additional notes also on the following dates 11/30/22, 12/14/22, 12/29/22, and that continued weekly until 3/22/23, all revealed a Stage 4 pressure ulcer to the sacrum. Clinical record documentation entitled Weekly Wound Nurse Observation dated 1/02/23 through 3/20/23, all indicated a Stage 3 pressure ulcer to the coccyx. Resident R90's MDS with an ARD of 2/14/23, revealed under section M0300D1 as 0 for Stage 4 pressure ulcers. During an interview on 5/25/23, at 1:00 p.m. Registered Nurse Assessment Coordinator Employee E3 confirmed that Resident R90's 2/14/23, MDS was coded that Resident R90 had a Stage 3 pressure ulcer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on review of facility policy and manufacturer's instructions, observation, and staff interviews it was determined that the facility failed to properly administer resident medications for one of 19 residents (Resident R38) and discard multi-dose vial of tuberculin (antigen used to detect tuberculosis) within the use by timeframe for one of four medication storage rooms observed ([NAME]) Findings include: Review of facility policy dated 2/16/23, entitled Medication Administration Injectable Vials and Amples indicated multi-dose medications must be dated when opened for determination of discard date based on manufacturer's instructions. Review of facility policy dated 2/16/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of manufacturer's instructions for the Tuberculin multi-dose vial directed that once open, they were to be used within 30-days, then discarded. Observation of Resident R38's room on 5/23/23, at 12:15 p.m. revealed a medication cup filled with multiple unknown medications sitting on the resident's bedside tray table. Review of Resident R38's admission record revealed an admitted [DATE], with diagnoses that included heart disease, chronic kidney disease and diabetes. A Self Administration of Medication assessment dated [DATE], indicated that Resident R38 was not capable of self administering medications. During an interview on 5/23/23, at 12:20 p.m. Registered Nurse Supervisor Employee E2 confirmed that Resident R38's medications should not have been left alone in the room for the resident. Observation of the [NAME] unit medication room on 5/24/23, at 1:35 p.m. revealed a Tuberculin multi-dose bottle was open, dated for 2/13/2023, with a discard date of 3/13/23, or 72-days past the open date. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that the multi-dose tuberculin vial was past the expiration date. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm of a lumbar and sacral fracture for one of five residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled Resident Abuse Policy and Procedure and Mandatory Reporting of Alleged Abuse dated 3/01/22, revealed, abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident R1's clinical record revealed an admitted [DATE], and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R1's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 5/31/22, revealed that Resident R1 required extensive two-person assist with transfers. A review of Resident R1's Self Care Deficit ADL (Activities of Daily Living) care plan, originally dated 5/25/22, revealed under the category, Transfer Status: Stand Up Lift For Transfers assist of two people. A review of Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E2, dated 7/23/22, at 12:30 p.m. c/o low back pain this shift, states he/she fell back into chair yesterday while using stand up lift, supervisor notified and Certified Nurse Aide (CNA) Employee E1 confirmed Resident R1 report. A nursing note written by Registered Nurse (RN) Employee E3, dated 7/23/22, at 5:33 p.m. revealed that Resident R1 stated he/ she fell out of the lift yesterday and now his/her back hurts but also told daughter that he/she fell out of lift this morning. The note also indicated that there have been no reports of Resident R1 falling out of the lift and she doesn't appear to have any injuries / bruising at this time. Physician was notified and orders for thoracic/lumbar/sacral x-ray along with a [MEDICATION(S)] (medicine patch for pain). In-house x-ray's were ordered on 7/23/22, and impression indicated, Mild vertebral compression anteriorly T6-9 no acute injury. A nursing note dated 7/30/22, at 1:30 p.m., revealed that Resident R1's family was requesting resident to go to hospital as resident was in pain due to her recent fall on 7/23/22, physician was notified and Resident R1 transferred to hospital. A review of the hospital physician notes, dated 7/30/22, revealed that Resident R1 went to the emergency room complaining of low back pain. Resident R1 stated that they fell from the lift while reaching for their hearing aides. CT scan ordered which revealed an Acute L1 compression fracture and acute sacral fracture. Review of information submitted by the facility, dated 7/30/22, revealed that Resident R1 was transferred with a stand-up lift on 7/23/22, around 6:30 a.m. from bed to chair, when Resident R1 let go of the stand-up lift NA Employee E1 notified nursing staff that Resident R1, sat down heavy in the wheelchair. Nursing staff notified of incident and checked for any injuries. Resident R1 did not complain of any pain until 7/23/22, at 12:30 p.m., which at that time RN supervisor was notified who then notified physician, x-rays ordered and impression indicated, Mild vertebral compression anteriorly T6-9 no acute injury. [MEDICATION(S)] ordered and Tylenol given, Resident R1 assessed at the time this was reported and deemed to not have any marks on his/her body to indicate a non-controlled fall. On 7/30/22, Resident R1's family reported that resident was having back pain and requested that resident be sent to hospital. Resident sent to hospital at this time and received a CT scan which revealed an Acute L1 compression fracture and acute sacral fracture. A review of documentation submitted by the facility, dated 7/30/22, revealed that the facility initiated an investigation and the NA was removed from the schedule and would not be returning. Review of the Director of Nursing's (DON) note of the interview conducted with NA Employee E1, dated 8/01/22, reflected that NA, Employee E1, stated that they had been trained on the use of the lift multiple times and was aware that Resident R1 was a two-person lift, however transferred the resident independently without assistance. During an interview on 8/09/22, at 11:00 a.m. the DON confirmed that the NA Employee E1 should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility neglected to utilize the appropriate transfer for a resident as care planned which placed the resident at risk for injury from an improper transfer method. As a result, there was actual harm of a lumbar and sacral fracture to Resident R1 requiring medical treatment at the hospital. This deficiency is cited as past non-compliance. On 8/01/22, the facility submitted a plan to include: The NA Employee E1 was removed from the schedule and would not be returning. The facility initiated re-educating all nursing staff, prior to their next shift after the 7/30/22, investigation of the 7/23/22, incident on abuse/neglect, location of transfer status and proper lift transfer procedures. The Assistant Director of Nursing (ADON) also is in process of monitoring all staff completing transfers. In addition to the reported plan of action, the facility also re-educated all staff how to correctly find a residents' transfer status on the e-care (electronic record) and behind residents' bathroom doors on the Kardex, starting in August 2022. All nursing staff re-education was in the process of being completed by August 2022. Interviews with Licensed Practical Nurse (LPN) Employee E4, RN Employee E3, and NA Employees E5, E6 and E7 confirmed that they were re-educated on where to find information regarding a resident's transfer status in the e-care and behind residents' bathroom doors and that any time a lift is used, there must be two staff to properly and safely complete the transfer with a lift. The employees stated that the information had been reviewed in June and are in the process of re-education again currently. The facility continued education for safe proper mechanics of transfer using a lift in June 2022 and again in August 2022, after the 7/23/22, incident of all staff related to knowing where to find resident transfer information, proper mechanics of a transfer, and were observed transferring a resident. The facility Nursing Home Administrator (NHA) stated that the facility was continuing the audits through September. The audit sheets for June through August were reviewed. The facility has demonstrated compliance with the mechanical lifts procedure since 8/09/22. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, facility documentation and review of clinical records and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care and in accordance with facility policy which resulted in actual harm of a lumbar and sacral fracture for one of five residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Lifting/Transferring Resident/Object, dated 3/01/22, revealed, Two staff persons are required for all transfers using the mechanical stand-up or the full lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling). A review of Resident R1's clinical record revealed an admitted [DATE], and included diagnoses of heart problems, kidney problems, lung problems, muscle weakness, and a pelvic fracture. A review of Resident R1's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 5/31/22, revealed that Resident R1 required extensive two-person assist with transfers. A review of Resident R1's Self Care Deficit ADL (Activities of Daily Living) care plan, originally dated 5/25/22, revealed under the category, Transfer Status: Stand Up Lift For Transfers assist of two people. A review of Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E2, dated 7/23/22, at 12:30 p.m. c/o low back pain this shift, states he/she fell back into chair yesterday while using stand up lift, supervisor notified and Certified Nurse Aide (CNA) Employee E1 confirmed Resident R1 report. A nursing note written by Registered Nurse (RN) Employee E3, dated 7/23/22, at 5:33 p.m. revealed that Resident R1 stated he/ she fell out of the lift yesterday and now his/her back hurts but also told daughter that he/she fell out of lift this morning. The note also indicated that there have been no reports of Resident R1 falling out of the lift and doesn't appear to have any injuries / bruising at this time. Physician was notified and orders for thoracic/lumbar/sacral x-ray along with a [MEDICATION(S)] (medicine patch for pain). In-house x-ray's were ordered 7/23/22, and impression indicated,Mild vertebral compression anteriorly T6-9 no acute injury. A nursing note dated 7/30/22, at 1:30 p.m., revealed that Resident R1's family was requesting resident to go to hospital as resident was in pain due to her recent fall on 7/23/22, physician notified and Resident R1 transferred to hospital. A review of the hospital physician notes, dated 7/30/22, revealed that Resident R1 went to the emergency room complaining of low back pain. Resident R1 stated that they fell from the lift while reaching for their hearing aides. CT scan ordered which revealed an Acute L1 compression fracture and acute sacral fracture. Review of information submitted by the facility, dated 7/30/22, revealed that Resident R1 was transferred with a stand-up lift on 7/23/22, around 6:30 a.m. from bed to chair, when Resident R1 let go of the stand-up lift NA Employee E1 notified nursing staff that Resident R1, sat down heavy in the wheelchair. Nursing staff notified of incident and checked for any injuries. Resident R1 did not complain of any pain until 7/23/22, at 12:30 p.m., which at that time RN supervisor was notified who then notified physician, x-rays ordered and impression indicated, Mild vertebral compression anteriorly T6-9 no acute injury. [MEDICATION(S)] (pain medicine) patch ordered and Tylenol given, Resident R1 assessed at the time this was reported and deemed to not have any marks on his/her body to indicate a non-controlled fall. On 7/30/22, Resident R1's family reported that resident was having back pain and requested that resident be sent to hospital. Resident sent to hospital at this time and received a CT scan which revealed an Acute L1 compression fracture and acute sacral fracture. A review of documentation submitted by the facility, dated 7/30/22, revealed that the facility initiated an investigation and the NA was removed from the schedule and would not be returning. Review of the Director of Nursing's (DON) note of the interview conducted with NA, Employee E1, dated 8/01/22, reflected that NA, Employee E1, stated that they had been trained on the use of the lift multiple times and was aware that Resident R1 was a two-person lift, however transferred the resident independently without assistance. During an interview on 8/09/22, at 11:00 a.m. the DON confirmed that the NA Employee E1 should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility failed to ensure that Resident R1 was provided adequate assistance in accordance with their care plan to utilize a mechanical lift, causing a lumbar and sacral fracture from an improper transfer. This deficiency is cited as past non-compliance. On 8/01/22, the facility submitted a plan to include: The NA Employee E1 was removed from the schedule and would not be returning. The facility initiated re-educating all nursing staff, prior to their next shift after the 7/30/22, investigation of the 7/23/22, incident on abuse/neglect, location of transfer status and proper lift transfer procedures. The Assistant Director of Nursing (ADON) also is in process of monitoring all staff completing transfers. In addition to the reported plan of action, the facility also re-educated all staff how to correctly find a residents' transfer status on the e-care (electronic record) and behind the residents' bathroom doors on the Kardex, starting in August 2022. All nursing staff re-education was in the process of being completed by August 2022. Interviews with Licensed Practical Nurse (LPN) Employee E4, RN Employee E3, and NA Employees E5, E6 and E7, confirmed that they were re-educated on where to find information regarding a resident's transfer status in the e-care and behind the residents' bathroom doors and that any time a lift is used, there must be two staff to properly and safely complete the transfer with a lift. The employees stated that the information had been reviewd in June and are in the process of re-education again currently. The facility continued education for safe proper mechanics of transfer using a lift in June 2022 and again in August 2022, after the 7/23/22, incident of all staff related to knowing where to find resident transfer information, proper mechanics of a transfer, and were observed transferring a resident. The facility Nursing Home Administrator (NHA) stated that the facility was continuing the audits through September. The audit sheets for June through August were reviewed. The facility has demonstrated compliance with the mechanical lifts procedure since 8/09/22. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect by administering medication not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the policy Blood Glucose Testing dated 3/1/22, revealed that blood glucose monitoring should be obtained including frequency of the testing and guidelines for responding to results. The policy stated that blood glucose monitoring assists in the evaluation of episodes of [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (elevated blood sugar) to determine appropriate treatment. In addition blood glucose monitoring can be done as a nursing measure to assess a change in a residents condition. Review of Resident R59's clinical record revealed an admitted [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R59's nutrition related care plan originally dated 9/08/17, identified that the resident is a diabetic and may have incidents of either [CONDITION(S)] or [CONDITION(S)]. The care plan referenced BG (blood glucose [sugar]), 70 mg/dl and to observe for symptoms of [CONDITION(S)] may occur quickly and include symptoms such as shakiness, nervousness or anxiety, irritability or impatience, confusion inducing [CONDITION(S)], rapid/fast heartbeat, hunger, nausea, sleepiness, blurred vision, tingling lips or tongue, headache, weakness or fatigue, or anger, stubbornness, loss of coordination. Review of R59's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if blood sugar is below 150 milligrams/deciliter (mg/dl). Review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of information submitted by the facility dated 3/25/22, revealed that .Resident was found on floor upon entering the room. X-ray results read acute fracture of ring finger proximal phalanx .Resident stated she was attempting to transfer from her motorized wheelchair to her manual wheelchair when she stood up and could feel her blood glucose was low. Resident stated she does not remember anything after standing up Upon further investigation the 4pm blood glucose was 98. Resident ate supper, and the blood glucose came up to 136. At 5pm the resident received 4 units of insulin coverage. At 7:30 p.m. resident had fallen on the floor. A med error was discovered, as resident had orders to hold 4 units of insulin if blood glucose was less than 150 . Review of an x-ray report of the right hand exam dated 3/24/22, revealed that Resident R59, sustained a fracture of right ring finger. During an interview on 4/19/22, at 10:40 a.m. Resident R59 stated that she has had incidents in the past where her blood sugar went low and she was unable to tell that her blood sugar was dropping. During the interview, the resident was awake, alert and oriented to surroundings. Observation during the interview revealed that Resident R59 had a cast on her right hand and wrist. During an interview on 4/20/22, at 3:00 p.m. the Director of Nursing confirmed that the nurse neglected to follow the insulin orders that resulted in Resident R59 sustaining a fall and subsequent harm of a fracture of the right ring finger. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the policy Blood Glucose Testing dated 3/1/22, revealed that blood glucose monitoring should be obtained including frequency of the testing and guidelines for responding to results. The policy stated that blood glucose monitoring assists in the evaluation of episodes of [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (elevated blood sugar) to determine appropriate treatment. In addition blood glucose monitoring can be done as a nursing measure to assess a change in a residents condition. Review of Resident R59's clinical record revealed an admitted [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R59's nutrition related care plan originally dated 9/08/17, identified that the resident is a diabetic and may have incidents of either [CONDITION(S)] or [CONDITION(S)]. The care plan referenced BG (blood glucose [sugar]), 70 mg/dl and to observe for symptoms of [CONDITION(S)] may occur quickly and include symptoms such as shakiness, nervousness or anxiety, irritability or impatience, confusion inducing [CONDITION(S)], rapid/fast heartbeat, hunger, nausea, sleepiness, blurred vision, tingling lips or tongue, headache, weakness or fatigue, or anger, stubbornness, loss of coordination. Review of R59's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if blood sugar is below 150 milligrams/deciliter (mg/dl). Review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of information submitted by the facility dated 03/25/22, revealed that .Resident was found on floor upon entering the room. X-ray results read acute fracture of ring finger proximal phalanx .Resident stated she was attempting to transfer from her motorized wheelchair to her manual wheelchair when she stood up and could feel her blood glucose was low. Resident stated she does not remember anything after standing up Upon further investigation the 4pm blood glucose was 98 mg/dl. Resident ate supper, and the blood glucose came up to 136 mg/dl. At 5pm the resident received 4 units of insulin coverage. At 7:30 p.m. resident had fallen on the floor. A med error was discovered, as resident had orders to hold 4 units of insulin if blood glucose was less than 150 mg/dl . Review of an x-ray report of the right hand exam dated 3/24/22, revealed that Resident R59, sustained a fracture of right ring finger. During an interview on 4/19/22, at 10:40 a.m. Resident R59 stated that she has had incidents in the past where her blood sugar went low and she was unable to tell that her blood sugar was dropping. During the interview, the resident was awake, alert and oriented to surroundings. Observation during the interview revealed that Resident R59 had a cast on her right hand and wrist. During an interview on 4/20/22, at 3:00 p.m. the Director of Nursing confirmed that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to assure physician's orders and resident's Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of a facility policy entitled POLST reviewed on [DATE], indicated that upon admission, the Admissions Nurse will review the POLST with the resident or responsible person, and that a copy will be retained on the medical chart, with the Social Worker, and a copy provided to the responsible party. Review of Resident R10's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no physician's order regarding Resident R10's code status. Review of a POLST dated [DATE], indicated that Resident R10 desired CPR (Cardiopulmonary Resuscitation -emergency lifesaving procedure performed when the heart stops beating). Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R49's clinical record lacked a physician's order to identify a code status as either Full Code (perform CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death). A POLST dated [DATE], lacked any indication of Resident R49's wish for CPR or DNR. Review of Resident R95's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order dated [DATE], indicated that Resident R95 was a Full Code. A POLST dated [DATE], indicated that Resident R95's wish was to be a Do Not Resuscitate. During interviews on [DATE], at 1:00 p.m. with Licensed Practical Nurse (LPN) Employee E3 and on [DATE], at 8:50 a.m. with the Director of Nursing, it was confirmed that Resident R49's clinical record lacked a physician's order to indicate a code status as Full Code or DNR and the POLST also lacked any indication of Resident R49's wish for CPR or DNR. During an interview on [DATE], at 10:38 a.m. Registered Nurse Supervisor Employee E2 confirmed that Resident R95's physician's order and the POLST were not consistent with information and should be, and that Resident R10's clinical record was lacking a physician's order regarding code status. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the opportunity for unauthorized access of medications on one of four nursing units observed (The Pines). Findings include: Review of a facility policy entitled, Medication Storage in the Facility dated 3/01/22, indicated that medication carts and dedication supplies are locked or attended by persons with authorized access. Observation on 4/18/22, between 12:40 p.m. and 4:00 p.m. revealed that The Pines treatment cart was positioned in the hallway across from room [ROOM NUMBER] and was observed to be unlocked and not attended by staff, and residents and staff were observed walking by the cart in the hallway. Observation on 4/19/22, at 9:19 a.m. revealed that The Pines treatment cart was again positioned in the hallway across from room [ROOM NUMBER] and was unlocked and not attended by staff. A visitor was observed entering and exiting room [ROOM NUMBER], and residents and staff were observed walking by the cart in the hallway. Observation of the contents of the unlocked treatment cart revealed the following individually prescribed treatments: Drawer 1; four tubes of Santyl ointment (prescription medicine for wound healing), three tubes of Triad cream (Zinc-oxide based paste for light-to-moderate levels of wound drainage), one tube of [MEDICATION(S)] cream (cream to relieve redness, itching, swelling, or other discomforts caused by certain skin conditions), and one tube of double antibiotic ointment (combination ointment made of two antibiotics used to treat minor wounds). Drawer 2; three tubes of [MEDICATION(S)] ointment (used to treat pain and swelling), three tubes of [NAME] ointment (cream for itching, swelling, and redness caused by certain skin conditions), and one tube of Triamcinolone ointment (cream for itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions). Drawer 3; one tube of [MEDICATION(S)] ointment. Drawer 4; one bottle of Dakin's solution (strong topical antiseptic widely used to clean infected wounds, ulcers, and [CONDITION(S)]). Registered Nurse Supervisor Employee E2 confirmed that the cart should be locked when not in use and the unit nurse has the key, and that the cart is usually unlocked so that the wound nurses (not here today) and other nursing staff can access the resident's treatments. During an interview on 4/19/22, at 3:00 p.m. the Director of Nursing confirmed that the cart should be locked when not in view. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent potential cross contamination (transfer of microbes from one surface to another) during a dressing change for one of 21 residents reviewed (Resident R95). Findings include: Review of facility policies entitled Handwashing/Hand sanitizing and Clean/Sterile Dressing Change both dated 3/01/22, and both indicated that staff are to wash their hands after removing gloves. Review of Resident R95's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of wound care on 4/19/22, at 1:00 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 placed a clean towel on the tray table, set out wound dressings, washed his/her hands and applied clean gloves, opened dressings, normal saline solution and gauze, changed his/her gloves and did not wash his/her hands. LPN Employee E1 then removed the soiled dressing containing drainage, changed his/her gloves and did not wash his/her hands. LPN Employee E1 then cleansed the wound, changed gloves and did not wash his/her hands. LPN Employee E1 then applied the clean dressing, changed gloves and did not wash hands, then gathered and disposed of supplies, and washed his/her hands. LPN Employee E1 failed to perform hand hygiene when removing gloves for the duration of the wound treatment. During an interview at that time LPN Employee E1 confirmed that he/she should have cleansed his/her hands after removing gloves. During an interview on 4/20/22, at 8:48 a.m. the Director of Nursing confirmed that when staff are performing wound care, they are expected to perform hand hygiene when changing gloves. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm when the resident suffered a laceration that required medical treatment at a hospital for one of five residents reviewed (Resident R1). Findings include: Review of the Resident Abuse Policy and Procedure and Mandatory Reporting of Alleged Abuse policy, dated 7/28/21, revealed, abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of a facility form entitled, Two Person Stand Pivot Transfer Compentency indicated that staff are to assure that all limbs are safely positioned. Review of the Certified Nurse Assistant (CNA) job description revealed that the nurse aide knows and adheres to all departmental and facility policies . and assists residents with mobility, range of motion exercises, transferring, transporting. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's annual Minimum Data Set assessment (MDS-periodic assessment of resident care needs), dated 9/21/20, revealed that Resident R1's transfer status was an extensive assist, two-person physical assist. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Self Care Deficit / requires assist with ADL's (activities of daily living) Care Plan dated 9/18/20, revealed that Resident R1's transfer status was an assist of two. Review of a facility incident report dated 10/26/21, at 8:30 a.m. revealed that Resident R1 was transferred by a Nurse Aide (NA) in the bathroom and during the transfer, the resident's right lower leg was cut. The description from the nurse assessment indicated the right lower extremity (RLE) (lower leg) with a laceration six centimeters (cm's) by five cm's, deep skin flap, triangle shaped. Tissue exposed. [NA] reported that resident was in shower chair, had transferred from wheelchair to shower chair, NA reported that they saw blood and then found the injury. The report indicated that the family and physician were notified and Resident R1 was transported to the emergency room . Review of a nurse's note dated 10/26/21, at 9:37 a.m. revealed that the nurse was called to the shower room after Resident R1 received a laceration to RLE. Review of the emergency room report dated 10/26/21, at 1:28 p.m. revealed that Resident R1's reason for visit was a leg injury and final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurses's note dated 10/26/21, at 3:32 p.m. revealed that per the ER nurse, Resident R1 would be returning back to facility with seven sutures placed to RLE. Review of the information dated 10/26/21, submitted by the facility revealed that Resident R1 was transferred by a staff from the wheelchair to the shower chair and received a laceration to the right lower leg and is ordered to be a two-person transfer. The Registered Nurse Supervisor's note of the interview conducted with NA, Employee E1, dated 10/26/21, reflected that NA, Employee E1, stated that they transferred the resident alone and without assistance. During an interview on 11/03/21, at 1:00 p.m. the Nursing Home Administrator confirmed that the staff person should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility neglected to utilize the appropriate transfer for a resident as ordered which placed the resident at risk for injury from an improper transfer method. As a result, there was actual harm to Resident R1 requiring medical treatment at the hospital. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility competencies and facility documentation, and staff interview, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received a laceration (cut) that required medical treatment at a hospital for one of five residents reviewed (Resident R1). Findings include: Review of the facility form entitled, Two Person Stand Pivot Transfer Compentency, indicated to assure that all limbs are safely positioned. Review of the Certified Nurse Assistant (CNA) job description revealed that the nurse aide knows and adheres to all departmental and facility policies . and assists residents with mobility, range of motion exercises, transferring, transporting. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease (progressive mental deterioration that destroys memory and other important mental functions), dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), anxiety, muscle weakness and protein calorie malnutrition. Review of Resident R1's annual Minimum Data Set assessment (MDS-periodic assessment of resident care needs), dated 9/21/20, revealed that Resident R1's transfer status was an extensive assist, two-person physical assist. Review of a physician's order dated 10/12/21, revealed that Resident R1 was ordered an assist x (times) 2 with transfers. Review of the Self Care Deficit / requires assist with ADL's (activities of daily living) Care Plan dated 9/18/20, revealed that Resident R1's transfer status was an assist of two. Review of an incident report dated 10/26/21, at 8:30 a.m. revealed that Resident R1 was transferred by a nurse aide (NA) in the bathroom and during the transfer, the resident's right lower leg was cut. The description from the nurse assessment indicated the right lower extremity (RLE) (lower leg) with a laceration six centimeters (cm's) by five cm's, deep skin flap, triangle shaped. Tissue exposed. [NA] reported that resident was in shower chair, had transferred from wheelchair to shower chair, NA reported that they saw blood and then found the injury. The report indicated that the family and physician were notified and Resident R1 was transported to the emergency room . Review of a nurse's note dated 10/26/21, at 9:37 a.m. revealed that the nurse was called to shower room after Resident R1 suffered a laceration to RLE. Review of the emergency room report dated 10/26/21, at 1:28 p.m. revealed that Resident R1's reason for the visit was a leg injury and final diagnosis was right leg laceration with laceration repair. Review of a nurses's note dated 10/26/21, at 3:32 p.m. revealed that per the ER nurse, Resident R1 would be returning back to facility with seven sutures placed to RLE. Review of the information dated 10/26/21, submitted by the facility, revealed that Resident R1 was transferred by a staff from the wheelchair to the shower chair and received a laceration to the right lower leg and is ordered to be a two-person transfer. Review of the Registered Nurse Supervisor's note of the interview conducted with NA, Employee E1, dated 10/26/21, reflected that NA, Employee E1, stated that they transferred the resident alone and without assistance. During an interview on 11/03/21, at 1:00 p.m. the Nursing Home Administrator confirmed that the staff person should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility failed to provide a safe transfer that resulted in actual harm of a leg laceration to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of 23 residents reviewed (Resident R3) was free of neglect during care which resulted in actual harm of a distal left femur fracture. This deficiency is cited as past non-compliance. Findings include: A review of facility policy titled, Resident Abuse Policy And Procedure And Mandatory Reporting Of Alleged Abuse, dated 8/01/20, revealed that, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. A review of Resident R3's clinical record revealed an admitted [DATE], and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R3's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 7/07/20, revealed that Resident R3 required a two person assist with transfers. A review of the Self Care Deficit ADL (Activities of Daily Living) care plan originally dated 8/05/19, revealed, Transfer Status: Stand Up Lift For Transfers May Use Full Lift For Transfers If Needed. The Lifting/Transferring Resident/Object policy, dated 8/01/20, revealed, Two staff persons are required for all transfers using the mechanical stand-up or the full lift. A review of the hospital physician notes, dated 8/24/20, revealed that Resident R3 went to the emergency room complaining of a femur fracture. Resident R3 stated that an aide helping Resident R3 get up from her wheelchair was pulling the resident up with her hands and Resident R3 was twisted and then felt pain to the left femur region. A review of Resident R3's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E1, dated 8/24/20, at 9:24 a.m. during am care resident noted to have increased pain to her leg: would not allow author to assess ROM (range of motion), appeared to be internally rotated as well .x-ray ordered. At 11:45 a.m., x-ray results back noted distal femur fracture. Review of information submitted by the facility, dated 8/24/20, revealed during a.m. care Resident R3 reported increased pain to the left lower extremity to the Nurse Aide (NA) and the NA reported the increased pain to the Nursing Supervisor who assessed the resident and found the left lower extremity appeared internally rotated The Nurse Practitioner was notified and ordered X-rays. The femur X-rays revealed a spiral/oblique type distal diaphyseal (bone [NAME] that occurs along the shaft of a long bone) fracture without significant displacement and the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the investigation revealed that agency NA Employee E2 reported on 8/24/20 that on 8/22/20 and 8/23/20, NA Employee E2 was aware that Resident R3 was a two person lift, however transferred the resident independently into bed. Also included was agency NA Employee E2's orientation information which revealed on 9/03/19, the NA signed a form that stated, I understand using the wrong lift per directions on a resident's care plan will result in a willful neglect and mishandling of medical equipment violation. Any deviation from a resident's course of treatment, inattention to the needs of the resident or failure to comply with [NAME] [NAME] Senior Living policies of two staff members using the mechanical lifts (stand-up/full lift) will also constitute a willful neglect violation, signed after review of the lifting policy. A review of documentation submitted by the facility, dated 8/24/20, stated that the facility investigated the incident, that the agency NA Employee E2 was aware of Resident R3 transfer status and required two person assistance and had transferred the resident without the use of a stand up lift. During an interview on 6/11/21, at 8:40 a.m. the Nursing Home Administrator confirmed that after the investigation was completed, it was discovered that agency NA Employee E2 had transferred Resident R3 without the use of a lift as required. The facility failed to ensure that Resident R3 was free from neglect resulting in actual harm of a left lower femur fracture from an improper transfer without the use of the appropriate lift and done independently and not with the required two person assistance. This deficiency is cited as past non-compliance. On 8/24/20, the facility submitted a plan to include: The agency NA Employee E2 was removed from the schedule and would not be returning. The facility initiated re-educating all agency staff, prior to their next shift on the location of medical records and location of transfer status. The Registered Nurse Quality Coordinator (RNQC)/Supervisor also monitored all agency staff completing transfers. In addition to the reported plan of action the facility also re-educated all staff how to correctly find a residents' transfer status on the e-care (electronic records), starting in September 2020. All nursing staff re-education was completed by November 10, 2020. Interviews with Licensed Practical Nurse (LPN) Employee E3, RN Employee E5, and NA Employees E4 and E6 confirmed that they were re-educated on where to find information regarding a resident's transfer status in the e-care and that any time a lift is used, there must be two staff to properly and safely complete the lift. The three employees stated that the information is received at their yearly hire date and there was a special training this year. LPN Employee E3 had only been employed for two and one half months and stated that he/she had received the information in orientation. Review of the training and competencies performed with regular staff occurred beginning in January 2021 including transfers observed completed by staff and ability to find the transfer status of residents. Audits of agency staff re-education regarding transfers reviewed, completed on first assignment scheduled to work after the 8/24/20, incident. The RNQC/Supervisor also monitored all agency staff completing transfers. Audits of all facility staff conducted throughout the month of September 2020, were reviewed. The form addressed the staff's knowledge of where to find the transfer status of a resident. Inservicing/competancies were conducted for all staff between January 2021 and March 2021, regarding transfer/lift information with observations of transfers, proper use of lifts and finding transfer information for residents and the facility is in the process of completing the second quarter of audits by the end of June 2021. The facility has demonstrated compliance with the mechanical lift procedure since 8/24/20. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, facility documentation and review of clinical records and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care and in accordance with facility policy which resulted in actual harm of a left femur fracture for one of 23 residents reviewed(Resident R3), and failed to investigate the occurrence of a fall for one of 23 residents (Resident R28). This deficiency is cited as past non-compliance. Findings include: The, Lifting/Transferring Resident/Object policy, dated 8/01/20, revealed, Two staff persons are required for all transfers using the mechanical stand-up or the full lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling). A review of Resident R3's clinical record revealed an admitted [DATE], and included diagnoses of heart problems, kidney problems, lung problems, difficulty in walking, and repeated falls. A review of Resident R3's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 7/07/20, revealed that Resident R3 required extensive two person assist with transfers. A review of Resident R3's Self Care Deficit ADL (Activities of Daily Living) care plan, originally dated 8/05/19, revealed under the category, Transfer Status: Stand Up Lift For Transfers: May Use Full Lift For Transfers If Needed. A review of Resident R3's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E1, dated 8/24/20, at 9:24 a.m. during am care resident noted to have increased pain to her leg: would not allow author to assess ROM (range of motion), appeared to be internally rotated as well .X-ray ordered. At 11:45 a.m., X-ray results back noted distal femur fracture. A review of the hospital physician notes, dated 8/24/20, revealed that Resident R3 went to the emergency room complaining of a femur fracture. Resident R3 stated that an aide helping Resident R3 get up from her wheelchair was pulling the resident up with her hands and Resident R3 was twisted and then felt pain to the left femur region. Review of information submitted by the facility, dated 8/24/20, revealed during a.m. care Resident R3 reported increased pain to the left lower extremity to the Nurse Aide (NA) and the NA reported the increased pain to the Nursing Supervisor who assessed the resident and found the left lower extremity appeared internally rotated. The Nurse Practitioner was notified and ordered X-rays. The femur X-rays revealed a spiral/oblique type distal diaphyseal fracture without significant displacement. Also reported was the resident had an order for a stand-up lift for transfers and had not had any reports of a fall. A review of the investigation revealed that agency NA Employee E2 reported on 8/24/20 that on 8/22/20 and 8/23/20, agency NA Employee E2 was aware that Resident R3 was a two person lift, however transferred the resident independently into bed. A review of documentation submitted by the facility, dated 8/24/20, revealed that the facility initiated an investigation and the agency NA was removed from the schedule and would not be returning. During an interview on 6/11/21, at 8:40 a.m. the Nursing Home Administrator (NHA) confirmed that the agency NA Employee E2 had transferred Resident R3 independently and did not use a lift as reported. The facility failed to ensure that Resident R3 was provided adequate assistance in accordance with their care plan to utilize a mechanical lift, causing a left femur fracture from an improper transfer. This deficiency is cited as past non-compliance. On 8/24/20, the facility submitted a plan to include: The agency NA Employee E2 was removed from the schedule and would not be returning. The facility initiated re-educating all agency staff, prior to their next shift after the 8/24/20 incident on the location of medical records and location of transfer status. The Registered Nurse Quality Coordinator (RNQC)/Supervisor also monitored all agency staff completing transfers. In addition to the reported plan of action, the facility also re-educated all staff how to correctly find a residents' transfer status on the e-care (electronic record), starting in September 2020. All nursing staff re-education was completed by November 10, 2020. Interviews with Licensed Practical Nurse (LPN) Employee E3, RN Employee E5, and NA Employees E4 and E6 confirmed that they were re-educated on where to find information regarding a resident's transfer status in the e-care and that any time a lift is used, there must be two staff to properly and safely complete the transfer with a lift. The three employees stated that the information is received at their yearly hire date and there was a special training this year. LPN Employee E3 had only been employed for two and one half months and stated that he/she had received the information during orientation. The facility continued education between January 2021 and March 2021, of all staff related to knowing where to find resident transfer information, proper mechanics of a transfer, and were observed transferring a resident. The facility NHA stated that the facility was continuing the audits through June. The audit sheets for January through March were reviewed. The facility has demonstrated compliance with the mechanical lift procedure since 8/24/20. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation and facility policies and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm when the resident suffered a laceration that required medical treatment at a hospital for one of 22 residents reviewed (Resident CR22). Findings include: The Resident Abuse Policy and Procedure and Mandatory Reporting of Alleged Abuse policy, dated 8/01/2017, stated, abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility policy, Lifting/Transferring Resident/Object, dated 8/01/2017, revealed that a two person transfer was, essentially the same as a one person, however one person on each side of resident with one arm under the resident and one arm behind. The Certified Nurse Assistant (CNA) job description revealed that the nurse aide knows and adheres to all departmental and facility policies . and, assists residents with mobility, range of motion exercises,transferring, transporting. Resident CR22's Face Sheet revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident CR22's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs) dated 02/08/17, revealed that Resident CR22's transfer status was an extensive assist, two person physical assist. The physician's orders [REDACTED]. The Physical Therapy Plan of Care dated 05/10/17, revealed that Resident CR22's prior residence and living arrangement was an assist of two people transfer status (may use turn stand with transfers). An incident report dated 05/06/17, at 9:15 p.m. revealed that Resident CR22 was transferred by a nurse aide in the bathroom and during the transfer, the resident's right lower leg was cut. The description from the nurse assessment indicated a right lateral calf (lower leg) with a deep laceration that had the skin flapped open. The report indicated that the family and physician were notified and Resident CR22 was transported to the emergency room . The nurse's note dated 05/06/17, at 9:52 p.m. revealed the, CNA (nurse aide) reported that resident was transferring from wheel chair to toilet and bumped her RLE (right lower extremity) on a sharp edge covered in electrical tape located by the footrest. The emergency room report dated 05/06/17, at 10:18 p.m. revealed that Resident CR22 was brought to the emergency room with a laceration that occurred after a transfer in the resident's bathroom. The report indicated that Resident CR22's right leg had a nine centimeter laceration over the right shin with a large C-shaped laceration/avulsion (all layers of skin torn away) to the lateral (outside) right leg and was treated and received 16 surgical staples. Review of the information dated 05/09/17, submitted by the facility, revealed that Resident CR22 was transferred by a staff from the toilet to the wheelchair and received a laceration to the right lower leg and is ordered to be a two person transfer. The Director of Nursing's note dated 05/07/17, reflected that NA, Employee E4, indicated that they transferred the resident without assistance stating, I thought I could do it. During an interview on 09/29/17, at 8:39 a.m. the Nursing Home Administrator confirmed that the staff person should not have transferred Resident CR22 alone and there should have been two staff. The facility neglected to utilize the appropriate transfer for a resident as ordered which placed the resident at risk for injury from an improper transfer method. As a result, there was actual harm to the resident requiring medical treatment at the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/28/16, 09/17/15 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2)(3)(e)(1) Management Previously cited 09/17/15 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 07/13/17, 10/28/16

Based on a review of facility policy, clinical record and hospital records and staff interviews, it was determined that the facility failed to provide timely, appropriate, and effective interventions for a resident involved in an accident causing a significant change in condition, resulting in actual harm of a fractured left lower leg for one of 22 residents reviewed (Resident R1). Findings include: The facility policy, Physician/Family Notification of Resident Change of Condition or Residents Incidents, dated 8/01/17, indicated that the physician would be notified immediately if the following situations occur: 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2. A significant change in the resident's physical, mental, or psychosocial status. Specifically, a significant change refers to a deterioration in health, mental or psychosocial status that is life threatening or clinically complicated. Resident R1's admission record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A Resident Incident Report for Resident R1 dated 05/07/17, at 2:30 a.m. revealed that Resident R1 was observed propelling her power wheelchair into the wall bumping her left lower leg. The registered nurse assessment, at the time of the incident, revealed the left ankle to have a scant amount of swelling noted and ice was applied. Resident R1's pain level on a scale of 1-10 (1 being the lowest amount of pain and 10 the greatest) was a 5 at the time of the incident. Resident R1 had been medicated with [MEDICATION NAME] HCL (a pain medication) 5 milligrams (mg) every six hours as needed, one hour prior to incident at 1:10 a.m. for aching. Resident R1's mental status was marked alert and oriented x 3 (indicating awareness of person, place, and time). The incident report indicated that the physician was not informed of the Resident R1's symptoms or condition until 1:10 p.m., a period of approximately ten hours later. Nursing notes dated 05/07/17, at 4:26 a.m. revealed that Resident R1 was then in the hallway in the electric wheelchair driving into the wall, 1:1 attention provided and behaviors stopped, resident layed back in bed, slight swelling noted to left ankle noted with pain and tenderness, ice applied and prn oxy adm. with positive effects, skin intact, no bruising noted Nursing notes dated 05/07/17, at 8:05 p.m. revealed Resident R1, yelling out in room all of AM The nursing notes also indicated that Resident R1 was tearful at times as well. Resident has swelling noted to left ankle area that is firm and slightly warm to touch. Left ankle greater than right ankle. Resident R1's May 2017 Medication Administration Record [REDACTED]. The May 2017 MAR indicated [REDACTED]. The clinical record lacked any evidence that any other interventions for pain were done at that time. There was no evidence that the physcian was informed of the incident, the resident's pain and condition, until the resident was transferred to the emergency room at 1:20 p.m. more than 10 hours after the incident. Review of the hospital record, including Resident R1's X-ray report of the left ankle revealed distal tibial and mid to proximal fibular diaphyseal fractures with diffuse soft tissue swelling (broken left lower leg). During an interview on 09/29/17, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the clinical record lacked any evidence that Resident R1's physician was notified until 1:10 p.m. on 05/07/17, a period of more than 10 hours after the incident. The facility failed to inform Resident R1's attending physician of the symptoms displayed by Resident R1 after the incident on 05/07/17, that occurred at 2:30 a.m., until 1:10 p.m., a period of more than 10 hours. The was no evidence that new interventions were provided to Resident R1 to treat the observed symptoms. There was no evidence that comfort measures were provided for Resident R1 after 8:15 a.m. until 1:20 p.m., when Resident R1 was transferred to the hospital (a total of 5 hours) on 05/07/17, resulting in actual harm to Resident R1. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited 07/13/17, 10/28/16 (at 42 CFR 483.25) 28 Pa. Code 201.18(a)(b)(1) Management 28 Pa. Code 211.5(f)(g) 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services Previously cited 10/28/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 07/13/17, 10/28/16

Based on review of clinical records, facility policies and facility documentation and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received a laceration (cut) that required medical treatment at a hospital for one of 22 residents reviewed (Resident CR22). Findings include: The facility policy dated 08/01/17, revealed that a two person transfer was essentially the same as a one person, however one person on each side of resident with one arm under the resident and one arm behind. The Certified Nurse Assistant (CNA) job desciption revealed that the nurse aide knows and adheres to all departmental and facility policies . and assists residents with mobility, range of motion exercises, transferring, transporting. Resident CR22's Face Sheet revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident CR22's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs),dated 02/08/17, revealed that Resident CR22's transfer status was an extensive assist, two person physical assist. The physician's orders [REDACTED]. The Physical Therapy Plan of Care dated 5/10/17, revealed that Resident CR22's prior residence and living arrangement was an assist of two people transfer status (may use turn stand with transfers). An incident report dated 05/06/17, at 9:15 p.m. revealed that Resident R22 was transferred by a nurse aid in the bathroom and during the transfer, the resident's right lower leg was cut. The description from the nurse assessment indicated the right lateral calf (lower leg) with a deep laceration that had the skin flapped open. The report indicated that the family and physician were notified and Resident CR22 was transported to the emergency room . A nurse's note dated 05/06/17, at 9:52 p.m. revealed that CNA (nurse aide) reported that resident was transferring from wheel chair to toilet and bumped her RLE (right lower extremity) on a sharp edge covered in electrical tape located by the footrest. The emergency room report dated 05/06/17, at 10:18 p.m. revealed that Resident CR22 was brought to the emergency room with a laceration that occurred after a transfer in the resident's bathroom. The report indicated that Resident CR22's right leg had a nine centimeter laceration over the right shin with a large C-shaped laceration/avulsion (all layers of skin torn away) to the lateral (outside) right leg and was treated and received, 16 surgical staples. Review of the information dated 05/09/17, submitted by the facility revealed that Resident CR22 was transferred by a staff from the toilet to the wheelchair and received a laceration to the right lower leg and is ordered to be a two person transfer. The Director of Nursing's note of the interview conducted with NA, Employee E4, dated 05/07/17, reflected that NA, Employee E4, indicated that they transferred the resident by without assistance stating, I thought I could do it. During an interview on 09/29/17, at 8:39 a.m. the Nursing Home Administrator confirmed that the staff person should not have transferred Resident CR22 alone and that there should have been two staff during the transfer. The facility failed to provide a safe transfer that resulted in actual harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/28/16, 09/17/15 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 09/17/15 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 07/13/17, 10/28/16