Every finding on record at Shippenville Nursing and Rehab

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (B wing medication cart) and one of two medication rooms reviewed (200/300 medication room) and failed to prevent the opportunity for potential unauthorized access of medications on one of three medication carts observed (C wing medication cart). Findings include: Review of facility policy entitled Labeling of Medications and Biologicals dated 1/22/26, indicated Labels for multi-use vials must include: The date the vial was initially opened or accessed.All opened or accessed vials should be discarded within 28 days. Review of facility policy entitled Medication Storage date 1/22/26, indicated During a medication pass, medications must be under the direct observation of the person administering medications, or locked in the medication storage area/cart. Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open vial of Tubersol (an injectable solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening. Observation of drug storage on 6/9/26, at 12:51 p.m. of the B-wing medication cart revealed an open pen of Lantus insulin lacking an open date. Observations in the 200/300 wing medication room revealed in the refrigerator an open vial of Tubersol with an open date of 4/1/26. During an interview on 6/9/26, at the time of observations LPN Employee E2 confirmed that the open Lantus insulin pen lacked an open date, and staff were unable to determine the discard date and the vial of Tubersol had an open date of 4/1/26. He/she also confirmed that the Lantus insulin pen and vial of Tubersol should have been discarded. Observations on 6/9/26, between 1:00 p.m. and 1:05 p.m. revealed LPN Employee E3 unlocked C wing medication cart parked in the hall against the wall with the drawers facing into the hallway. He/she then proceeded to walk down the hall and around the corner without securely locking C wing medication cart and was unable to view the medication cart. During an interview on 6/9/26, at 1:06 p.m. LPN Employee E3 confirmed that he/she left the C wing medication cart unlocked which was out of their view. He/she also confirmed that the medication cart should be locked when out of 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, clinical records, and staff interviews, it was determined that the facility failed to implement an intervention in a comprehensive person-centered care plan for a resident requiring suctioning (a procedure to remove unwanted fluid from a person) for one of 19 residents reviewed. (Residents R12). Findings include: Review of facility policy entitled, Comprehensive Care Plan dated 1/22/26, indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. and Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Review of Resident R12's clinical record revealed an admission date of 1/8/18, with diagnoses that included multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and dysphagia (difficulty swallowing). Review of Resident R12's physician's orders revealed an order for suction every four hours if cannot clear secretions. Review of Resident R12's plan of care revealed a plan of care for respiratory impairment dated 2/6/23, with an intervention of, may suction as directed for increased secretions. Change canister post suction. Observations on 6/9/26, at 1:45 p.m. and again at 2:13 p.m. revealed a suction machine (a medical device designed to remove unwanted fluids from a patient's body) sitting on Resident R12's bedside stand. The collection container (a container where the unwanted fluids are collected) was three quarters of the way full of cloudy liquid which appeared to be secretions. During an interview on 6/11/26, at 1:36 p.m. the Director of Nursing (DON) confirmed that Resident R12's respiratory impairment plan of care intervention to change canister post suction was not implemented. The DON also confirmed that care plan interventions should be implemented. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination during completion of a wound dressing change for one of 19 residents reviewed (Resident R29).Findings include: Review of facility policy entitled Wound Care dated 1/22/26, indicated Steps in the procedure. Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Observations on 6/11/26, at 11:01 a.m. revealed Registered Nurse (RN) Employee E1 completing a wound dressing change in Resident R29's room. During the dressing change RN Employee E1 removed a soiled dressing from Resident R29's coccyx. He/she then proceeded to clean the wound without washing his/her hands and changing his/her gloves after removing the soiled dressing. During an interview on 6/11/26, at 11:15 RN Employee E1 confirmed that he/she did not wash their hands or change gloves after removing the soiled dressing. RN Employee E1 also confirmed that he/she should have washed their hands and applied clean gloves before cleaning the wound. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R27). Findings include: Review of the facility policy Hemodialysis, dated 1/22/26, indicated that the licensed nurse will communicate to the dialysis facility and attending physician medication administration or withholding of certain medications prior to the dialysis treatment and document such orders. Review of Resident R27's clinical record revealed an admission date of 4/09/26, with diagnoses that included heart disease, heart failure, acquired absence of right & left leg below the knee, type II diabetes ( the body does not make enough insulin to control blood sugar), and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, and Friday each week for dialysis treatments. Review of physician's orders dated 4/09/26, indicated that Resident R27 was to have Calcium Carbonate Antacid (a medication used to treat indigestion and heartburn), 500 milligrams (mg) three times daily with meals and Novolog insulin per sliding scale blood sugar monitoring (a medication used to treat high blood sugar levels with blood sugar checks), before meals and at bedtime. Review of May and June 2026, Medication Administration Records (MARs) revealed that Resident R27 did not receive the following medications as ordered with reason given as: Not in Facility or Absent from Home Calcium Carbonate noon and Novolog insulin 11:30 a.m. doses on 5/4/26, 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/18/26, 5/20/26, 5/25/26, 5/27/26, 6/1/26, 6/3/26, 6/5/26, 6/8/26, and 6/10/26. There was no documentation until 6/11/26, that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R27 on dialysis days. During an interview on 6/11/26, at 1:30 p.m. the Assistant Director of Nursing confirmed that the above medications for Resident R27 were not administered on dialysis days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of 19 residents reviewed (Resident R12).Findings include: Review of facility policy entitled Suctioning the Upper Airway dated 1/22/26, indicated Empty and rinse collection container if necessary or as indicated by facility protocol. Review of Resident R12's clinical record revealed an admission date of 1/8/18, with diagnoses that include multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and dysphagia (difficulty swallowing). Review of Resident R12's physician's orders revealed an order for suction every four hours if cannot clear secretions. Review of Resident R12's plan of care revealed a plan of care for respiratory impairment dated 2/6/23, with an intervention of, may suction as directed for increased secretions. Change canister post suction. Review of Resident R12's treatment record revealed the last time that Resident R12's suction machine (a medical device designed to remove unwanted fluids from a patient's body) was documented as used was 4/1/26. Review of Resident R12's progress notes revealed the last note indicating that Resident R12's suction machine was used was dated 4/2/26. Observations on 6/9/26, at 1:45 p.m. and again at 2:13 p.m. revealed a suction machine sitting on Resident R12's bedside stand. The collection container (a container where the unwanted fluids are collected) was three quarters of the way full of cloudy liquid which appeared to be secretions. During an interview on 6/9/26, at 2:56 p.m. the Director of Nursing (DON) confirmed that Resident R12's suction machine collection container needed emptied. The DON also confirmed that the collection container should be emptied after every use. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of three residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 12/17/25, with diagnoses that included weakness, uncontrolled seizures and an inability to eat food by mouth. Resident R1's clinical record revealed a physician's order dated 12/17/25, that directed the administration/infusion of liquid nutrition/food by a gastric tube (a tube inserted into the stomach through which medications and liquid food can be administered), to run continuously at 50 cc's per hour. Resident R1's clinical record revealed a nurse's note at 9:12 p.m. on 12/30/25, that documented an observation that Resident R1's continuous tube feed infusion was not infusing as physician ordered. During interview on 4/18/26, at approximately 10:05 a.m., the Director of Nursing confirmed that the above nurse's note was correct, Resident R1's tube feed solution had not been infusing for approximately four hours on 12/30/25, as physician ordered. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety in the main kitchen, and resident pantries (D Wing, A Wing, Skilled Wing pantries and Kitchen). Findings include: Review of a facility policy entitled Floor stock and Supplement Distribution dated 2/18/25, revealed discarding expired and unlabeled products ., Supplements such as . Med Pass . will be dated upon opening and will have a three day use by date ., and Cleaning and sanitizing the unit pantry and refrigerator/freezers. Review of a facility policy entitled Food: Safe Handling for Food from Visitors dated 2/18/25, revealed Label food with the resident name and the current date and daily monitoring for refrigerator storage duration and discard of any food items that have been stored for seven or greater days. Review of a facility policy entitled Staff Attire dated 2/18/25, revealed The Dining Service Director ensures that all staff members have their hair off the shoulders, confined in a hair net or cap . Observations during a kitchen tour on 6/10/25, at 11:15 a.m. revealed seven bulk packages of instant potatoes with an expiration date of 5/12/25 were in the dry storage area. Observations during tray line on 6/10/25, at 4:05 p.m. revealed a dietary aide placing food on resident trays not wearing a hair net/restraint. During an interview on 6/10/25, at 11:15a.m. and again at 4:05 p.m. the Dietary Manager confirmed that the seven bulk packages of instant potatoes were expired and that the dietary aide was not wearing a hair net/restraint during tray line while handling resident food. He/she also confirmed that the instant potatoes should have been discarded and that the dietary aide should be wearing a hair net/restraint while in the dietary department. Observations on 6/10/25, at 4:20 p.m. of the D Wing pantry refrigerator used for residents revealed a brown substance on the shelves, a dry thick red substance under the bottom two drawers, and a yellow substance on the door shelves. During an interview on 6/10/25, at the time of observation Nursing Assistant (NA) Employee E4 confirmed that the refrigerator was not clean. Observation on 6/10/25, at 4:27 p.m. of the A Wing pantry refrigerator used for residents revealed a clear plastic container of watermelon dated 5/29/25, with no resident name on the container, a carton of Med Pass with an open date of 6/4/25, a clear yellow sticky substance covering the shelf in the refrigerator, and the freezer had a large amount of ice built up. During an interview on 6/10/25, at the time of observation Licensed Practical Nurse (LPN) Employee E5 confirmed that the watermelon lacked a resident name and was beyond the use by date, the Med Pass was beyond the use by date, the refrigerator was not clean and there was a buildup of ice in the freezer. He/she also confirmed that the food items should be labeled and discarded by their use by date, and the refrigerator and freezer should be clean and free from ice buildup. Observations on 6/10/25, at 4:33 p.m. of the Skilled Wing pantry refrigerator used for residents revealed a carton of Med Pass with an open date of 6/4/25, a Styrofoam cup of pudding with no label or date, the refrigerator shelf had a clear yellow sticky substance, and the freezer had a large amount of ice buildup. During an interview on 6/10/25, at the time of observation NA Employee E6 confirmed that the Med pass was beyond the use by date, the Styrofoam cup of pudding was lacking a label and date, the refrigerator was not clean and there was a buildup of ice in the freezer. He/she also confirmed that the food items should be labeled and discarded by their use by date, and the refrigerator and freezer should be clean and free from ice buildup. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records, facility policies and facility documents, observations, resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for 10 of 26 residents interviewed (Residents R3, R7, R21, R27, R42, R60, R76, R77, R93, and R199). Findings include: Review of facility policy entitled, Answering the Call Light dated 2/18/25, revealed If the resident's request is something you can fulfill, complete the task within five minutes if possible. Review of facility policy entitled Resident Showers dated 2/18/25, revealed Residents will be provided showers as per request or as facility schedule protocols . Review of facility policy entitled Activities of Daily Living (ADLs), Supporting dated 2/18/25, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs . Hygiene (bathing .). Review of facility job descriptions for a Nursing Assistant (NA) revealed Attends to the individual needs of the residents, which may include assistance with grooming, bathing, oral hygiene, feeding, incontinent care, toileting, colostomy care, prosthetic appliances, transferring, ambulation, range of motion, communicating or other needs in keeping with the individuals' care requirements .Answers residents' call bells promptly and courteously . Interviews during the Resident Council meeting on 6/11/25, between 10:30 a.m. and 11:00 a.m., revealed five out of five alert and oriented residents in attendance stated they are not receiving fresh ice water, and it is worse when agency staff are working. R77 and R3 had concerns related to staff not responding to their call bells timely and it took 45 minutes to an hour for call bell response, indicating it is worse on the weekends and/or when agency staff are working. Review of resident council minutes over six months from January, February, March, April, May, and June of 2025, revealed the following: January 2025 resident council minutes revealed 10 out of 10 residents in attendance stated that ice water is not passed enough. February 2025 resident council minutes revealed nine out of 10 residents in attendance stated that ice water is not passed at each shift and staff is slow answering call bells. One resident stated he/she rang the call bell, and an agency staff answered, left and never returned. He/she rang again, and a facility NA helped him/her. March 2025 resident council minutes revealed three out of 16 residents in attendance stated that ice water is not passed at each shift and four out of 16 residents stated staff is slow answering call bells. April 2025 resident council minutes revealed eight out of eight residents in attendance stated that ice water is not passed at each shift, seven out of eight residents stated staff is slow answering call bells, and two out of eight residents stated they were not receiving their showers. May 2025 resident council minutes revealed seven out of eight residents in attendance stated that ice water is only provided if families get it for them or request it from staff and two out of eight residents stated they were not receiving their showers. June 2025 resident council minutes revealed residents are not receiving ice water regularly and call bells are not being answered timely. Review of the Grievance Logs from January, February, March, and April of 2025 revealed grievances related to call bell response time, residents not receiving showers, and fresh ice water not being passed. During an interview on 6/10/25, at 1:00 p.m. with alert and oriented Resident R27, he/she indicated that he/she waits for an hour at a time often to have his/her call bell responded to and does not receive ice water, unless he/she asks for it. Resident R27 stated, What happens to the residents who cannot ask for it? During an interview on 6/10/25, at 1:45 p.m. with alert and oriented Resident R42 he/she expressed that he/she was not receiving their showers because the shower room on their hall had no hot water. He/she expressed that the facility has other shower rooms that the staff could use. He/she expressed that their hair has not been washed since their last shower. Observation of the resident at the time of interview revealed Resident R42's hair appeared that it had not been washed. Follow up interview with Resident R42 on 6/11/25, at 9:30 a.m. revealed that the resident expressed that they are scheduled to get a shower on Tuesdays and Fridays on the afternoon shift. The resident expressed that he/she tracks their showers on the calendar in their phone and the last date marked was 5/27/25. Review of Resident R42's shower documentation revealed that he/she only received a shower on 5/27/25, 6/3/25, and 6/10/25, which was not on all of his/her scheduled shower days. During an interview on 6/10/25, at 1:30 p.m. with alert and oriented Resident R60 he/she expressed that they were not receiving showers because the shower room on their hall had no hot water. The resident expressed that he/she wanted to go to the other hall's shower room, but staff would never to that. Follow up interview on 6/11/25, at 2:05 p.m. revealed that Resident R60 expressed that they never refuse their shower, and is scheduled to get showers on Wednesdays and Saturdays on the afternoon shift. Review of Resident R60's shower documentation revealed that he/she received a shower on 5/21/25, and did not receive another shower until 6/11/25. The documented shower dates did not reflect his/her shower schedule. During an interview on 6/11/25, at 10:50 a.m. with alert and oriented Resident R93, revealed that they wait for an hour while sitting on the bedside toilet to have the call bell responded to by staff, and when he/she desires to get out of bed in the morning. During an interview on 6/11/25, at 1:00 p.m. alert and oriented Resident R199, indicated that they have not received a bath/shower since being admitted on [DATE]. Resident R199 asked for their hairbrush during the interview to itch their hair. Resident R199 stated, My hair is driving me crazy, it is so itchy due to not washing it. Review of Resident R199's shower documentation revealed that their shower days were Tuesdays and Fridays. The Director of Nursing (DON) confirmed that Resident R199 did not receive his/her scheduled shower on Tuesday, 6/10/25. During an interview on 6/11/25, at 2:06 p.m. the DON confirmed that residents have the right to get their showers when they are scheduled or when they request. He/she also confirmed that showers should be done per the resident's shower schedule or when requested by the resident. During an interview on 6/12/25, at approximately 12:30 p.m. the DON confirmed that residents have the right for fresh ice water throughout each day and to have their call bells answered timely to meet each resident's needs. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy, facility documents, and resident and staff interviews, it was determined that the facility failed to correct Resident Council concerns for a period of six months (January 2025 through June 2025). Findings: Review of facility policy, Resident Council, dated 2/18/25, indicated A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.). Review of the Resident Council minutes and Grievances over the past six months, January 2025 through June 2025, revealed a pattern/trend with issues regarding residents not receiving ice water. During a Resident Council meeting on 6/11/25, at 10:30 a.m. interviews with alert and oriented Residents R3, R7, R21, R76, and R77, who all attend Resident Council meetings regularly, indicated that concerns of not receiving fresh ice water have not improved. Resident R77 indicated he/she only receives it if a family member is visiting and gets it for him/her. An interview with the Director of Nursing on 6/12/25, at approximately 12:30 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding residents not receiving ice water from the January 2025, February 2025, March 2025, April 2025, May 2025, and June 2025 Resident Council meetings. No evidence was provided to ensure the residents' concerns verbalized and further stated in the Resident Council minutes for the past six months reviewed was noted of timely corrective actions. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner for two of three medication carts reviewed (A Wing medication and Skilled Wing medication cart). Findings include: Review of a facility policy entitled Medication Storage dated 2/18/25, revealed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Manufacturer's recommendations for Latanoprost (a type of eye drop), indicated that once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for six weeks. Manufacturer's recommendations for Lantus (a long-acting insulin), indicated that an opened multiple-dose vial stored at room temperature should be discarded after 28 days. Observations of the A Wing's medication cart on 6/10/25, at approximately 2:30 p.m. revealed an opened bottle of Latanoprost eye drops without an open date, therefore the staff were unable to determine the discard date. Licensed Practical Nurse (LPN) Employee E1 confirmed at that time, that the opened bottle of Latanoprost lacked an open date, and staff were unable to determine the discard date. Observations of the Skilled Wing's medication cart on 6/10/25, at approximately 4:15 p.m. revealed an opened vial of Lantus without an open date, therefore the staff were unable to determine the discard date. LPN Employee E2 confirmed at that time, that the opened Lantus vial lacked an open date, and staff were unable to determine the discard date. During an interview with the Regional Clinical Director on 6/12/25, at 12:05 p.m. it was confirmed that insulins and eye drop medications should be properly labeled with an open date for staff to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R18). Findings include: Review of facility policy entitled Oxygen Administration dated 2/18/25, revealed Verify that there is a physician's order for this procedure. Review the physician's orders . Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at . and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of Resident R18's clinical record revealed an admission date of 11/7/20, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes (a health condition that caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R18's physician's orders revealed an order dated 6/18/22, for oxygen at 2 liters/minute (LPM)via NC (nasal cannula-a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) every shift for shortness of breath. Observations on 6/10/25, at 1:25 p.m. revealed Resident R18 was sitting in their room with supplemental oxygen in place and oxygen concentrator liter flow set at 2 LPM. Activities Assistant Employee E10 removed Resident R18's nasal cannula at the time of observation and assisted the resident to an activity without re-applying oxygen. Resident R18 returned to their room at 2:30 p.m. During an interview on 6/10/25, at 2:40 p.m. Activities Assistant Employee E10 confirmed that Resident E18 went to and activity and did not have oxygen on until he/she returned to their room. During an interview on 6/10/25, at 2:47 p.m. Licensed Practical Nurse Employee E3 confirmed that Resident R18 should have his/her oxygen on at all times. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, 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 three residents reviewed (Resident R5). Findings include: Review of facility policy entitled Resident Mobility and Range of Motion dated 2/18/25, indicated Residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent a further decrease in ROM. And Residents with limited mobility will receive appropriate services, equipment . to maintain or improve mobility . Review of Resident R5's clinical record revealed an admission date of 2/4/25, with diagnoses that included hemiplegia and hemiparesis (a condition where a person is paralyzed and unable to move one side of their body and muscle weakness), hypertension (high blood pressure), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R5's clinical record revealed a physician order for LAFO (a device to support the left lower leg and foot) to be donned (put on) in AM and doffed (taken off) with PM care, skin checked prior to and after donn/doff AFO dated 5/19/25. Review of Resident R5's plan of care for ADL (activities of daily living) self-care deficit related to impaired mobility revealed an intervention for LAFO to be donned on AM care and doffed with PM care with an initiated date of 5/19/25. Review of Resident R5's clinical record revealed documentation lacked evidence that LAFO was applied as ordered. Observations on 6/10/25, at 3:00 p.m. and again at 3:40 p.m. revealed Resident R5 sitting in his/her wheelchair with no LAFO to their left foot/leg. Observations on 6/11/25, at 9:15 a.m., 10:30 a.m., 12:30 p.m., and again at 1:30 p.m. revealed Resident R5 sitting in his/her wheelchair with no LAFO to their left foot/leg. Observations on 6/12/25, at 9:00 a.m., 11:10 a.m., and again at 12:50 p.m. revealed Resident R5 sitting in his/her wheelchair with no LAFO to their left foot/leg. During an interview on 6/12/25, at 12:50 p.m. the Regional Nurse Consultant confirmed that Resident R5 did not have a LAFO on his/her left foot/leg per physician's orders and also confirmed that Resident R5 should have his/her LAFO on their left foot/leg 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 provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 26 residents reviewed (Residents R15, R51 and R89). Findings include: A facility policy entitled Care Plans-Baseline dated 2/18/25, revealed The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident R15's clinical record revealed an admission date of 4/18/25, with diagnoses that included sacrococcygeal disorders (a range of conditions affecting the sacrum and coccyx [triangular bone and tailbone at the base of the spine], including pain, tumors, and structural abnormalities), end stage renal disease (a condition where the kidneys cannot remove waste and balance fluids), hemiplegia and hemiparesis following cerebral infarction (paralysis, muscle weakness affecting one side of the body after a stroke), and diabetes mellitus (a condition when your blood sugar is too high). 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 R51's clinical record revealed an admission date of 3/20/25, with diagnoses that included dementia (thinking and social symptoms that interfere with daily living), atrial fibrillation (irregular heartbeat), and weakness. R51's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R51 and/or his/her representative. Resident R89's clinical record revealed an admission date of 9/04/24, with diagnoses that included dementia, orthostatic hypotension (blood pressure drops upon sitting up or standing up from lying down), and fracture of the nasal bones. R89's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R89 and/or his/her representative. During an interview on 6/12/25, at approximately 11:35 p.m. the Regional Clinical Consultant confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Resident R15, Resident R51, or Resident R89 and/or their representative. 28 Pa. Code 211.10(c) Resident care plan 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 provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of four residents reviewed (Resident R46). Findings include: Review of facility policy entitled Transfer and Discharge (including AMA[against medical advice]) dated 2/18/25, revealed For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who is responsible for the care of the resident; b. Resident representative information, including contact information; c. Advance directive information; . and Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative . Review of Resident R46's clinical record revealed an admission date of 11/3/22, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically), and chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs). Review of Resident R46's clinical record revealed a progress note dated 4/8/25, at 4:55 p.m. identifying a transfer to the hospital. The clinical record lacked evidence that Resident R46's necessary clinical information was communicated to the receiving health care provider. Resident R46's clinical record also lacked evidence indicating that Resident R46 and/or their representative was provided with a copy of the facility bed-hold policy upon transfer. During an interview on 6/12/25, at 12:30 p.m. the Regional Nurse Consultant confirmed that there was no evidence that Resident R4 and/or their representative was provided with a copy of the facility bed-hold policy that included the cost per day; confirmed that there was no evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer; and also confirmed when the transfers occurred the resident and/or their representative should have been provided with bed hold policy and clinical information should be provided to the receiving healthcare provider upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to assure physician orders and resident's Pennsylvania Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for two of 22 residents reviewed (Residents R46 and R60). Findings include: Review of facility policy entitled Advance Directives dated [DATE], revealed Upon admission, the resident will be provided with written information concerning the right to refuse or accept . and to formulate an advance directive ., Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. And The Director of Nursing Services . of advance directives so that appropriate orders can be documented in the resident's medical record . Review of Resident R46's clinical record revealed an admission date of [DATE], with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically), and chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs). Review of Resident R46's paper clinical record revealed a POLST dated [DATE], signed by the physician for Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest)- Full Code. Review of physician's orders revealed an order dated [DATE], for Do Not Attempt Resuscitation (DNR- allow natural death). Further review of Resident R46's clinical record revealed a second POLST dated [DATE], with no evidence of the resident and/or resident representatives' signature for Do Not Attempt Resuscitation (DNR- allow natural death). Review of Resident R60's clinical record revealed an admission date of [DATE], with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R60's clinical record revealed an incomplete POLST dated [DATE], part A of the POLST was not filled out to indicate Resident R60's wishes of a Full Code or DNR. During an interview on [DATE], at 10:40 a.m. Licensed Practical Nurses Employees E8 and E9 revealed that during an emergent situation the staff refer to resident's paper chart to determine resident Life Sustaining wishes. During an interview on [DATE], at 10:50 a.m. the Director of Nursing (DON) confirmed that Resident R46's POLST in the paper chart was for Full Code and Resident R46's electronic clinical record POLST was for DNR and lacked the resident and/or resident representatives' signature. He/she confirmed that Resident R60's POLST was incomplete and did not identify Resident R60's wishes of a Full Code or DNR. He/she also confirmed that a resident's advance directive should match in both paper and electronic records and advance directive should be complete indicating the resident and/or resident representative wishes. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i)(vii) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross-contamination during completion of a wound dressing change for one of one residents reviewed (Resident R75). Findings include: Review of facility policy entitled Wound Care dated 2/18/25, indicated Wipe reuseable supplies with alcohol as indicated (i.e., scissor blades .) Review of facility policy entitled Cleaning and Disinfection of Resident Care-Items and Equipment dated 2/18/25, indicated Reusable items are cleaned and disinfected or sterilized between residents . Observations on 6/12/25, at 1:50 p.m. revealed Licensed Practical Nurse (LPN) Employee E7 completing a wound dressing change in Resident R75's room. During the dressing change LPN Employee E7 used scissors to cut the soiled dressing from Resident R75's right foot. LPN Employee E7 then placed the scissors on a towel covering Resident R75's bedside table. After completing the dressing change LPN Employee E7 picked up the scissors and placed them in their pocket without cleaning the scissors. During an interview on 6/12/25, at the time of observation, LPN Employee E7 confirmed that he/she cut the soiled dressing off of Resident R75's right foot with the scissors and placed the scissors in their pocket without cleaning them. He/she also confirmed that the scissors should have been cleaned before placing them in their pocket. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to enter physician's orders timely resulting in a delay in treatment for one of eight residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission date of 4/8/25, with diagnoses that included osteomyelitis (an infection in the bone), weakness, and type II diabetes (the body does not use insulin properly). Resident R1's clinical record revealed he/she arrived at the facility on 4/8/25, at approximately 10:00 a.m. His/her medication orders which included Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams (an antibiotic used to treat many different infections caused by bacteria) were not entered into the facility electronic health record system for the nurses to be alerted when the medication was due to be administered. This resulted in Resident R1 missing his/her noon dose of Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams and his/her 6:00 p.m. dose being administered late. During an interview on 4/30/25, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that facility failed to enter the physician's orders timely which resulted in a missed and a late dose Resident R1's antibiotic medication. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure the physician was contacted regarding an incomplete order prior to medication administration for one of eight residents reviewed (Resident R1). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of the facility's job description for RNs revealed The purpose of the RN is to deliver care to residents utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation under the direction of the residents' attending physician. The RN will effectively interact with residents, family and other health team members while maintaining all standards of professional nursing. Review of Resident R1's clinical record revealed an admission date of 4/8/25, with diagnoses that included osteomyelitis (an infection in the bone), weakness, and type II diabetes (condition where the body does not use insulin properly). Resident R1's order summary revealed a physician's order for Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams (an antibiotic used to treat many different infections caused by bacteria), use 1 dose intravenously every 6 hours for 5 days. The physician's order lacked the amount the medication was to be reconstituted with and/or the rate the medication was to be administered. Resident R1's clinical record progress notes dated 4/8/25, documented that Resident R1 received his/her Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams at 8:08 p.m. and 11:36 p.m. and that the medication was reconstituted per instructions and on 4/9/25, that the Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams was administered at the wrong rate and route. Review of facility documents dated 4/10/25 and 4/15/25, revealed that the RN failed to ensure the physician was contacted regarding an incomplete medication order prior to administering the medication for the first and second doses. During an interview on 4/30/25, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the RN failed to contact the physician regarding the incomplete medication order prior to the medication administrations that did not adhere to professional nursing standards. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure medications are obtained from pharmacy in a timely manner for one of 12 residents reviewed (Resident R1). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.145. Functions of the Licensed Practical Nurse (LPN), (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place and 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of facility job descriptions for LPNs and RNs revealed both are expected to utilize nursing knowledge and skills in the safe implementation of basic preventative therapeutic and rehabilitative nursing care of assigned resident as evidenced by documentation and observation of positive resident care outcomes, perform delegated nursing functions using established procedures, policies, guidelines and standards as observed by the registered nurse, and administer treatments, medications, and diets accurately. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a group of thinking and social issues that interfere with daily living), parkinsonism (a central nervous system disorder that affects movements), and anxiety. Resident R1's clinical record progress notes documented that on 11/04/2024, Resident R1 was tired and had a fever. He/she was tested for COVID, with positive results. At that time, the physician was contacted, and an order was received to give Paxlovid (300/100) (an antiviral medication used to treat mild to moderate COVID) oral tablet therapy give two tablets by mouth two times a day for COVID starting on 11/05/2024, for five days. Review of facility documents from pharmacy dated 11/1/2024, through 11/7/2024, revealed that the Paxlovid was never received from the pharmacy for Resident R1. Review of additional facility documents revealed six LPNs, and one RN failed to ensure the pharmacy was faxed the original order for the Paxlovid and failed to follow-up with the pharmacy once realizing the Paxlovid was ordered in the medication administration record for Resident R1 but was not available for several days. During an interview on 2/19/2025, at approximately 1:00 p.m. the Director of Nursing and the Regional Director of Clinical Operations confirmed that the Paxlovid ordered for Resident R1 was never received from the pharmacy, due to nursing staff's failure to fax the original order to the pharmacy and nursing staffs' failure to follow-up with the pharmacy regarding the status of the medication delivery. 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 maintain a clean and sanitary resident common area for one of four resident units (Alzheimer's Care Unit). Findings include: Review of facility policy entitled Quality of Life - Homelike Environment dated 2/18/25, indicated The facility staff and management shall maximize .the characteristics of the facility that reflect . homelike setting. Clean, sanitary and orderly environment. Observations on 2/29/25, at 10:00 a.m. of the Alzheimer's Care Unit (ACU) revealed three sitting chairs and a couch in the common area. The chairs and couch cushions had several areas of a brown substance which appeared to be stains caused from moisture. The arms of the furniture had rips in the fabric and the stuffing was coming out. On the wall in the common area was a box with television cable attached to it, the box was pulling off of the wall. Observations of a resident room revealed a curtain covering a window with the fabric on the back of the curtain ripped and hanging down. Observations of a wall in a resident room revealed below the window there were gouges in the wall. During an interview with the Nursing Home Administrator on 2/19/25, at 10:55 a.m. he/she confirmed that the furniture in the common area in the ACU had stains on the cushions and tears in the fabric, the cable box was not attached to the wall, the curtain in the resident room was ripped and the wall was in need of repair. He/she also confirmed that the furniture should be clean/without tears, the cable box should be connected to the wall, and the curtains and wall should be in good repair. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of clinical records, facility documentation, and facility policies, and staff and resident interviews, it was determined that the facility failed to provide immediate care and services to include emergency services regarding a fall impacting both knees that was later identified as bilateral patella (kneecaps) fractures with actual harm of continued pain for over 24-hours for one of 23 residents reviewed (Resident R51). Findings include: Review of the facility policy entitled, Assessing Falls and Their Causes dated 7/13/22, revealed that if evidence of an injury is found, apply first aid and/or obtain medical treatment immediately. The policy also revealed that assessments of delayed complications from a fall should occur for 48 hours after the fall. Review of Resident R51's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R51's Resident Assessment and Care Screening, Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 5/8/22, revealed that his Brief Interview for Mental Status (BIMS) was a 15 which identified that the resident had intact cognition. Review of Resident R51's Controlled Drug Record for [MEDICATION(S)] Acetaminophen revealed that on 7/14/22, at 11:57 a.m. that he received one tablet of [MEDICATION(S)] Acetaminophen 5-325 milligram (mg) for moderate/severe pain before physical therapy and his later fall. During an interview on 9/23/22, at 9:50 a.m. with Resident R51 regarding his fall on 7/14/22, at 1:45 p.m. in the physical therapy area, he revealed that he was walking with a walker and his right toe caught on the floor resulting in a loss of balance. Resident R51 then fell on his kneecaps with feet and toes in an ankle plantar flexion position (extension of the ankle so that the foot points down and away from the leg). Resident R51 stated that the pain was so bad that he was screaming that it hurt and that he hit his head during the fall and also heard a crack. Resident R51 stated that his knees swelled up right away and hurt when his feet were being put onto the foot rests of the wheelchair. Once Resident R51 was assisted back into bed, the pain was better as long as his legs remained still. During the interview, Resident R51 was also questioned if he received ice or had neurological checks (monitoring regarding any head trauma) done and Resident R51's answer was no. During an interview on 9/23/22, at 10:20 a.m. Physical Therapy Assistant (PTA) Employee E2 revealed that Resident R51 was walking with a walker and his right toe caught on the floor which resulted in a fall straight down onto his knees with feet and toes in an ankle plantar flexion position. PTA Employee E2 stated that Resident R51 was screaming in pain that his knees hurt and did not hit his head. Review of a witness statement dated 7/14/22, from PTA Employee E2, with no time identified, revealed that all of a sudden patient's knees buckled and bent past 90 degrees and patient fell on to his butt and on to the right side of his body. He/she stated that Resident R51 didn't hit his head but yelling out in pain that his knees and back were hurting. PTA Employee E2 also stated, Patient stated he hit his head during the fall .I bent patient's knees past 90 degrees to get his feet on leg rests, patient was laughing and joking .and had no complaints of pain or .grimacing. During an interview on 9/23/22, at 11:08 a.m. Registered Nurse Supervisor (RNS) Employee E3 revealed that he/she assessed Resident R51 by moving his legs, bending his knees, palpating areas on his body, and found him to have no injury or pain. In addition, he/she said that Resident R51 initially denied any pain and was laughing and talking with staff. RNS Employee E3 stated he/she followed protocol and called the doctor and reported no injury. Review of a nursing progress note written from RNS Employee E3 on 7/14/22, at 1:45 p.m. revealed that Resident R51 was unsure if he hit his head but there were no bumps noted on palpation .moving arms and feet without difficulty but did have pain with movement of knees. During an interview with Nurse Aide (NA) Employee E4 on 9/23/22 at 11:14 a.m., he/she stated that there were around five people in the physical therapy area, so they tried to pick up Resident R51 off the floor but they were not able to do so. NA Employee E4 got the Hoyer lift (mechanical lift) and noticed that Resident R51's coloring was white like he/she was in shock and pain. In addition, NA Employee E4 stated, he was not talking much .I think he was in shock. During an interview on 9/23/22, at 10:51 a.m. Resident R33 who was in the physical therapy area at the time of the fall, revealed that Resident R51's knees gave out, he lost his balance, went backwards, fell on his bent knees and screamed in pain. In addition, Resident R33 stated that there were about five physical therapists in the PT room and then nurses came and Resident R51 said that his knees hurt. Review of a nursing progress note written by RNS Employee E3 on 7/14/22, at 6:05 p.m. revealed that Resident R51 felt dizzy so a Hoyer lift was used to place him back into bed due to his knee pain. Review of Resident R51's clinical record revealed a progress note written from the Nurse Practioner (NP) on 7/14/22, at 7:43 p.m. after he/she assessed Resident R51. The NP wrote that Resident R51 had bilateral knee effusions with ecchymosis (condition that occurs when excess fluid accumulates in or around the knee joint, common causes include arthritis and injury to the ligaments or meniscus, which is cartilage in the knee). The NP also stated that Resident R51 was a new patient to him/her. The NP ordered an x-ray of the bilateral knees and an increase for [MEDICATION(S)] Acetaminophen 5-325 mg for moderate/severe pain to every 8 hours instead of every 12 hours. Review of a nursing progress note written by RNS Employee E3 on 7/14/22, at 8:05 p.m. revealed that Resident R51 noticed that he had swelling and bruising of bilateral great toes with decreased range of motion. RNS Employee E3 notified the doctor and x-rays of the feet were ordered. Review of a nursing progress note written by Licensed Practical Nurse (LPN) Employee E5 on 7/14/22, at 8:35 p.m. revealed that Resident R51 received a [MEDICATION(S)] Acetaminophen Tablet 5-325 mg for moderate/severe pain. Review of a nursing progress note written by LPN Employee E6 on 7/15/22, at 7:45 a.m. revealed that Resident R51 had pain in the bilateral knees and feet, knees are swollen, and toes are bruised. Also, at 7:47 a.m. LPN Employee E6 gave Resident R51 a [MEDICATION(S)] Acetaminophen Tablet 5-325 mg for moderate/severe knee pain. Review of a nursing progress note written by LPN Employee E6 on 7/15/22, at 11:06 a.m. stated that x-rays are being done on Resident R51. Also, LPN Employee E6 at 2:27 p.m., revealed that the x-rays showed bilateral knee patella fractures but no fractures in the bilateral feet. Review of a nursing progress note written by LPN Employee E6 on 7/15/22, at 5:53 p.m. revealed that Resident R51 left for the emergency room (ER) at 3:45 p.m, over 24-hours after the fall. Review of a nursing progress note written by RN Employee E7 on 7/15/22, at 6:15 p.m. revealed that Resident R51 was being discharged back to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Post-Fall Evaluation Considerations Tool revealed a category of Mental Status/Sensory, that indicated neuro checks are to be completed when a resident has hit their head and additionally, dizziness and pain are part of the category. Another category on the tool included motor function regarding muscle weakness and range of motion. Resident R51 experienced muscle weakness when he couldn't participate in getting himself off the physical therapy floor with the assistance of several staff and later experienced dizziness. Another category of the tool included medications and that they can mask acute symptoms. Resident R51 experienced pain in his knees limiting his range of motion that involved the knees and he required pain medication at 11:57 a.m. on 7/14/22, just prior to physical therapy session. Resident R51 continued to require pain medication after the fall incident. The facility failed to provide immediate care and services to address a fall resulting in pain/injuries regarding emergency services evaluation and complete monitoring to include neurological checks for possible head trauma for Resident R51. The facility also failed to provide additional interventions such as ice packs, take into consideration that Resident R51 received a pain pill prior to physical therapy and continued to require pain medication for knee pain, and to follow the facility's Post-Fall Evaluation Considerations Tool. The facility's failure resulted in Resident R51 waiting for more than 24-hours with continued pain before being sent to the ER and diagnosed with bilateral patella fractures and obtaining bilateral knee immobilizers to help stabilize his knee fractures. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to prevent a fall with an injury for one of 12 residents reviewed (Resident R2). Findings include: During a tour of the facility on February 9, 2016 at 9:45 A.M., Resident R2 was observed seated in a wheelchair with a brace applied to the right wrist and a black and blue bruise, approximately 1/4 inches wide by 2 inches long, on the cheek under the left eye. The admission face sheet revealed that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment (MDS- a periodic review of resident care needs) dated December 23, 2015, revealed that Resident R2's mental status was indicated as severely impaired. Review of the information, dated January 23, 2016, submitted by the facility revealed that on January 22, 2016 at 6:00 P.M., Resident R2 was being transported in a wheelchair by the nursing staff from the dining room to Resident R2's room when the blanket covering her legs became caught in the wheel of the wheelchair and caused Resident R2 to fall forward out of the wheelchair, striking the floor. Upon further questioning by the state agency, it was revealed that no leg rests were present on the wheelchair at the time of this incident and that the blanket did not become tangled in the wheel of the wheelchair until after the resident's feet had planted on the floor. The nursing progress note dated January 20, 2016 at 10:18 A.M., revealed that Resident R2 was, dependent with wheelchair mobility for long distances. The nursing progress note, dated January 22, 2016 at 7:20 P.M., revealed that the resident's feet became tangled in her blanket, making her feet hit the floor and causing her to fall forward out of her wheelchair onto the floor with subsequent transport to a local hospital for evaluation. The same progress note also indicted that Resident R2 was having repeated episodes of confusion and was unable to follow simple directions in regards to her own safety. A nursing progress note dated January 22, 2016 at 10:41 P.M., revealed that Resident R2 was returned to the facility at 9:00 P.M. A nursing progress note dated January 22, 2016 at 10:43 P.M., revealed that the local hospital had called the facility and stated that Resident R2 would have to return to the hospital. The nursing progress note revealed that the X-ray results showed non-displaced fractures of the C1 and C2 vertebrae (bones in the upper spine). A nursing progress note dated January 23, 2016 at 9:15 A.M., revealed that the family notified the facility that Resident R2 had been transferred to a hospital that provided more specialized care. The X-ray reports dated January 23, 2016, revealed that Resident R2 had suffered an acute Type II dens (a toothlike bone that acts as a pivot in the upper spine) fracture of the cervical vertebra C2 (a bone in the upper spine), an inferior orbital wall fracture (bony wall under the eye) and a mildly impacted (the bone breaks into multiple fragments which are driven into each other) fracture of the distal radius (bone in the forearm). The facility failed to identify a safe method for transport for a resident with severely impaired mental status. 483.25 (h) Free of Accident Hazards/Supervision/Devices. Previously cited 07/23/15. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 07/23/15. 28 Pa. Code: 201.18(b)(1)(3) Management. Previously cited 07/23/15. 28 Pa. Code: 201.18(e)(1) Management. Previously cited 07/23/15. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 10/26/15, 07/23/15, 06/06/14. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 07/23/15, 06/06/14.

Based on review of facility policies, an incident report, clinical records and staff interviews, it was determined that the facility neglected to provide the care and services required to prevent injury to one of 28 residents reviewed resulting in actual harm (Resident R10). The findings include: The Reporting Alleged Abuse Violation policy, dated 5/13/2015, revealed that, it is the responsibility of all employees to immediately report any violation of abuse, neglect and violations are also reported to state agencies. The policy also stated, neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The Verification of Investigation of Alleged Mistreatment, Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Resident/Patient Property Guideline, dated 5/13/2015, revealed that in the event of an allegation of neglect, the center investigates the alleged violation thoroughly and reports the results of all investigations to the Executive Director as well as to state agencies as required by the state and federal law. Review of information dated 6/04/2015 submitted by the facility, revealed that Resident R10 was transferred from the bed to the wheelchair and Resident R10 fell from the lift to the floor causing a laceration (a type of injury where the skin is torn, cut or punctured) to the back of the resident's head. The report indicated, resident ordered and care planned to transfer with a Maxi lift (a mobile passive lift, used to move residents who cannot transfer from one surface to another on their own), sling size on lift assessment indicated a small sling use based solely on weight, however a medium sling use is in place for resident due to physical characteristics and contractures (permanent avoidable limb deformity due to lack of movement). A small sling was not big enough for resident. Resident R10 was transferred to the hospital where he/she received two staples to a laceration and returned to the facility on [DATE]. Follow up action, documented in the event report, revealed that, it will be required that two staff members perform the lift transfer on this resident. The admission record revealed that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment (MDS- a periodic review of resident care needs), dated 5/13/15, revealed that Resident R10 had a transfer status of two plus persons with physical assist. The Lift Mobility Status Form, dated 4/30/2015, revealed that Resident R10 was to be transferred with a Maxi lift with two staff and the staff were to utilize the medium (yellow) sling. The form indicated that the sling sizes were the following: Small (red) Medium (yellow) Large (green) X Large (blue) XX Large (white) The facility investigation from the 6/04/15 incident provided a statement from Nurse Aide (NA), Employee E3, who was transferring Resident R10 from the bed to the wheelchair, .put (Resident R10) in the sitting position was taking (Resident R10) to (Resident R10's) chair and it came unhooked and (Resident R10) fell to the floor. Employee E3 had to call for assistance. Registered Nurse (RN), Employee E5's, interview summary revealed that Employee E3 was transferring Resident R10 from the bed to the wheelchair using the Maxi lift when one hook came loose and the resident fell out of the sling and landed on the floor, head first. The facility Summary Report, dated 06/05/2015, revealed that Resident R10 was transferred using a Maxi lift and the green (medium) sling. The report indicated the physician's orders [REDACTED]. The 4/30/2015 sling assessment was determined by looking solely at the weight of Resident R10 who required a Medium (yellow) sling, which was inconsistent with the Summary Report that noted the medium sling was green. Interview of staff on the summary report indicated that the resident tends to lean back and always has knees up, due to contractures, when transferred and due to physical characteristics and the contractures, the staff utilized a green (large) sling. During an interview on 7/22/2015, at 11:05 a.m., the Director of Nursing (DON) referred to the manufacturer's guidelines regarding the lift utilized in the transfer. The manufacturer's guidelines for the, Maxi Move Operating and Product Care Instructions for the Maxi lift, dated August 2006, indicated, lifts are designed for one caregiver and, there are circumstances, such as combativeness, obesity, contractures, etc., of the individual that may dictate the need for a two person transfer. The DON stated that Resident R10 did not require two persons for the lift. During an interview on 7/23/2015, RN, Employee E4, revealed that the lift assessment should have been followed requiring two people for the transfer. The facility failed to review all available documentation and report accurate information during the investigation of a fall from a lift that revealed neglect from lack of supervision resulting in actual harm to a resident. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 6/6/14, 7/19/13. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 6/6/14. 28 Pa. Code: 201.18 (b)(1)(3) Management. Previously cited 7/19/13. 28 Pa. Code: 201.29(d) Resident rights. 28 Pa. Code: 201.29(j) Resident rights. Previously cited 6/6/14.

Based on review of clinical records and facility documentation, manufacturer's guidelines, hospital 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 utilizing a lift for one of 28 residents reviewed (Resident R10) and failed to provide a safe environment for one of two residents reviewed with a bed placed against the wall (Resident R22). The findings include: The manufacturer's guidelines, Maxi Move Operating and Product Care Instructions for the Maxi lift (a mobile passive lift, used to move residents who cannot transfer from one surface to another on their own) , dated August 2006, indicated, lifts are designed for one caregiver and there are circumstances, such as combativeness, obesity, contractures, etc. of the individual that may dictate the need for a two person transfer. The Admission Record revealed that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment (MDS- a periodic review of resident care needs) dated 5/13/2015, revealed that Resident R10 had a transfer status of two plus persons with physical assist. The physician's orders [REDACTED]. The Lift Mobility Status Form, dated 4/30/2015, revealed that staff were to use a Maxi lift for transfer, using medium yellow sling, and utilizing two persons for the lift. The form indicated that the sling sizes were the following: Small (red) Medium (yellow) Large (green) X Large (blue) XX Large (white) Review of information dated 6/04/2015 submitted by the facility, revealed that Resident R10 was transferred from the bed to a wheelchair and Resident R10 fell from the lift to the floor causing a laceration (a type of injury where the skin is torn, cut or punctured) to the back of the resident's head. The report indicted, resident ordered and care planned to transfer with a Maxi lift . Resident sent to Clarion Hospital, emergency room for evaluation. Hospital nursing notes, dated 6/04/2015, revealed that EMS (Emergency Medical Service) stated to the hospital nurse that staff at the facility, dropped patient using a lift and patient fell straight back, hitting head on floor. Lac (laceration-cut) to back of head. C/O (complained) of lower back pain with radiation into hips. The hospital discharge record, dated 6/04/2015, revealed that Resident R10 was discharged to the facility with the [DIAGNOSES REDACTED]. The facility investigation, dated 6/05/2015, revealed that Resident R10 was being transferred using a green (medium) sling, not a yellow sling, as the physician ordered, during the transfer. Nurse Aide (NA), Employee E3, attempted to transfer Resident R10 from the bed to the wheelchair when the resident fell from the lift. Employee E3's statement (no date available) revealed that when the fall occurred, Employee E3 called for assistance. There was no evidence to indicate that there were two staff present with Resident R10 when the resident was transferred from the bed to the wheelchair. The investigative summary, dated 6/05/2015, indicated that the yellow sling did not fit appropriately and the green (medium) sling was utilized for transfers for Resident R10 by the staff, which was inconsistent with the Lift Mobility Status Form, dated 4/30/2015 that indicated the medium sling was yellow. The summary also indicated the staff changed the color of the sling to a bigger size due to physical characteristics and contractures (permanent, avoidable limb deformity due to lack of movement) and Resident R10 tends to lean back and always has knees up due to contractures, during the actual transfer. There was no indication that the physician was notified of the increase in sling size by the staff to accommodate the resident's needs. During an interview on 7/23/2015, at 9:10 a.m., Registered Nurse, Employee E4, confirmed that the lift assessment for Resident R10 should have been followed (two person assist during the use of the lift). The facility failed to provide adequate supervision for a resident from an improper transfer resulting in actual harm to the resident. During observation of resident rooms on 7/20/2015, from 11:15 a.m. through 12:55 p.m., it was observed that Resident R22's bed was placed against the wall. Further investigation revealed that Resident R22's bed linens could easily contact the electrical socket on the wall where the bed was placed and that two electrical cords were plugged into the two electrical sockets. During an interview on 7/21/2015, at 10:50 a.m., Maintenance Employee E7 confirmed that the bed should not be against the wall unless there was a barrier placed between the electrical outlet and the bed. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3) Management. Previously cited 7/19/13. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 6/6/14, 7/19/13. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 6/6/14.