Every finding on record at Somerset Healthcare & Rehabilitation Center

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations from wound consultations for one of 7 residents reviewed (Resident 1). Findings include: The facility's wound treatment management policy, dated April 24, 2026, indicated that to promote wound healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 2, 2026, revealed that the resident was cognitively intact, dependent for transfers, dressing, hygiene, toileting, putting on/taking off shoes, was not ambulatory, had an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) on admission, and had diagnoses including morbid obesity, malnutrition, diabetes and an unstageable pressure ulcer to right buttocks. A wound note for Resident 1, dated April 24, 2026, revealed the resident had an unstageable pressure ulcer to his right buttock with treatments recommendations to cleanse the wound with wound cleanser/normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply medical grade honey (used in clinical settings to treat wounds, burns, and skin infections), then calcium alginate (a dressing used to wounds with a high amount of drainage) to base of the wound, and secure with bordered dressing daily and as needed. Continue with autolytic debridement (products that harness the body's natural enzymes to safely liquefy and dissolve dead necrotic tissue). A nursing note for Resident 1, dated April 24, 2026, at 11:00 a.m. revealed that the resident was seen during wound rounds by the wound consultant Certified Registered Nurse Practitioner (CRNP), and the treatment was changed to the pressure ulcer on his right buttock. The new order was for one fourth strength external solution 0.125 percent Dakins solution (a solution used to treat and prevent tissue infections), cover with Dakins moistened gauze, then bordered gauze dressing every day shift and as needed for soiling/dislodgment. The wound treatment order to the right buttocks to cleanse with normal saline, apply Medi honey then calcium alginate to the wound bed, and cover with bordered gauze dressing daily and as needed was discontinued. A physician's order, dated April 24, 2026, included an order to cleanse right buttocks with one fourth strength external solution 0.125 percent Dakins solution, cover with Dakins moistened gauze, then bordered gauze dressing every day shift and as needed for soiling/dislodgment. The Treatment Administration Record (TAR) for Resident 1 for April 2026, revealed that Dakins was applied to the resident's right buttock on April 30, 2026. A wound note for Resident 1, dated April 30, 2026, revealed the resident had an unstageable pressure ulcer to his right buttock and the current treatment was medi honey, calcium alginate and bordered dressing. Treatment recommendations were to continue to cleanse the wound with wound cleanser/normal saline, apply medical grade honey, then calcium alginate to base of the wound, and secure with bordered dressing daily and as needed. Continue with autolytic debridement. A review of Resident 1's Treatment Administration Records (TAR's) for April 2026 revealed that staff applied the Dakins treatment as ordered to the resident's right buttocks on April 25, 27, 28, 29, and 30. There was no documented evidence in Resident 1's clinical record that the wound consultant CRNP changed the treatment to his right buttocks to Dakins solution on April 24, 2026. Interview with Assistant Director of Nursing (ADON) and the Registered Nurse Assessment Coordinator on May 27, 2026, at 3:14 p.m. confirmed that there was no documented evidence that the wound consultant CRNP changed the treatment to Resident 1's right buttocks on April 24, 2026. The ADON confirmed that the wound consultant documented in two places that the wound care was to remain the same with no changes. She had no idea why the nurse changed the order. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of seven residents reviewed (Residents 6, 7). Findings include:The facility's policy regarding showers, revised April 24, 2026, revealed that all residents would be provided with showers as per preference, schedules and safety. After completion of the resident's shower, the nurse aide was to document utilizing the resident's electronic medical record and paper record, if refused, given or bed bath given.A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated April 30, 2026, indicated that the resident was cognitively intact, able to understand and required supervision for showering. The resident's care plan, dated February 12, 2026, indicated that the resident required assistance with showers related to weakness associated with a new cancer diagnosis. Review of the nurse aide documentation and resident's shower records for May 2026, revealed that Resident 6 was to be showered twice a week on Tuesday and Saturday during the evening shift. However, there was no documented evidence as to why the resident refused showers on Saturday May 9 and Tuesday May 26, 2026, and why the shower on Saturday May 23, 2026, was documented as not applicable. A quarterly MDS assessment for Resident 7, dated May 11, 2026, indicated that the resident was cognitively intact, had diagnoses that included atrial fibrillation (an abnormal heart rhythm) and was dependent on staff for showering.Review of nurse aide documentation and the resident's shower records for April and May 2026, revealed that Resident 7 was to be showered twice a week during the day shift on Sundays and Wednesdays. However, there was no documented evidence that the resident received a shower on Sundays, May 10 and 17, and Wednesday May 13, 2026.Interview with the Assistant Director of Nursing on May 27, 2026, at 3:11 p.m. confirmed that there was no documented evidence that Residents 6 and 7 received showers as scheduled. In addition, she indicated that when a resident refuses a shower or bath then additional paperwork is to be filled out as to why, and this was not done. Also, not applicable regarding a shower or bath is never to be chosen in the documentation, and it was. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information and supplies in preparation for discharge for one of 7 residents reviewed (Resident 1) who was discharged to home. Findings include: The facility's discharge planning policy, dated April 24, 2026, indicated that the discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plan for care after discharge. It must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary will be provided to the receiving care provider at the time the resident leaves the facility. Reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the counter medications. A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services. For residents discharged to their home, the medical record should contain documentation that written discharge instructions were given to the resident, and if applicable, the resident representative. These instructions must be discussed with the resident, and resident representative and conveyed in a language and manner they will understand. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 2, 2026, revealed that the resident was cognitively intact, dependent for transfers, dressing, hygiene, toileting, putting on/taking off shoes, was not ambulatory, had an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) on admission, and had diagnoses including morbid obesity, malnutrition, diabetes and an unstageable pressure ulcer to right buttocks. A wound note for Resident 1, dated April 30, 2026, revealed the resident had an unstageable pressure ulcer to his right buttock measuring 5 centimeters (cm) x 2 cm x 0.1 cm. A physician's order, dated April 24, 2026, included an order to cleanse right buttocks with one fourth strength external solution 0.125 percent Dakins solution (a solution used to treat and prevent tissue infections), cover with Dakins moistened gauze, then bordered gauze dressing every day shift and as needed for soiling/dislodgment. The Treatment Administration Record (TAR) for Resident 1 for April 2026, revealed that Dakins was applied to the resident's right buttock on April 30, 2026. A wound note for Resident 1, dated April 30, 2026, revealed the resident had a new stage 2 pressure ulcer (pressure wound with superficial skin loss) to his left buttocks measuring 0.5 cm x 1 cm x 0.1 cm and recommended applying zinc (helps soothe, heal, and prevent skin irritations) and dry dressing. A nursing note for Resident 1, dated April 30, 2026, at 10:00 a.m. revealed that the resident was discharged to his home accompanied by his brother. His medications were given to him with education given on narcotic schedule and foley care and discharge instructions were sent. Review of Resident 1's discharge instructions, dated [DATE], revealed that he had a wound on his right buttock requiring treatment and there was no mention of the new stage 2 pressure ulcer to his left buttock requiring treatment. The was no documented evidence that wound care instructions were given to the resident or his brother to address the wounds to his right and left buttocks on discharge and no documented evidence that the wound care supplies and medications were given to the resident on discharge. Interview with the Assistant Director of Nursing and the Registered Nurse Assessment Coordinator on May 27, 2026, at 3:14 p.m. confirmed that there was no documented evidence that Resident 1 or his brother was made aware of the new stage 2 pressure ulcer to his left buttock requiring treatment, no documented evidence that wound care instructions were given to the resident or his brother on discharge and no documented evidence that the wound care supplies and medications were given to the resident on discharge. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety.Findings include: The facility's policy for storage of refrigerated foods, dated February 4, 2026, revealed that refrigerated foods would be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.Observations in the main kitchen on April 13, 2026, at 9:05 a.m. revealed a bowl of pasta salad that was opened and undated, a package of American cheese slices that was opened, wrapped in cellophane and undated in the walk in refrigerator; approximately one half of a jar of applesauce that was opened and undated, and one container of Lactaid milk that was opened and undated in the pantry refrigerator; a box of biscuits in the breakfast freezer that was open to the air; and a box of thickener in dry storage that was open to the air.Interview with the Dietary Director on April 13, 2026, at 9:05 a.m. confirmed that the food mentioned above should have been dated and not left open to air. 28 Pa. Code 211.6(f) Dietary Services.

Based on observations, and staff interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in one of one medication rooms reviewed. Findings include: Observations in the facility's medication room on A-Wing on April 15, 2026, at 10:55 a.m. revealed two locked compartments in the medication refrigerator that were secured to a shelf, and the shelf was not secured to the refrigerator and was able to be removed. This unsecured shelf with two locked compartments contained two opened bottles of liquid lorazepam (a controlled medication used to treat anxiety) and one unopened bottle of liquid lorazepam. Interview with Registered Nurse 9 at the time of the observation confirmed that the shelf with the fixed locked narcotic box was not secured to the refrigerator and was able to be removed from the refrigerator. Interview with the Nursing Home Administrator on April 15, 2026, at 10:57 a.m. confirmed that the shelf with the fixed locked narcotic box in the refrigerator in the A-wing medication room should be permanently affixed to the refrigerator and not able to be removed. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide appropriate care for one of 33 residents reviewed (Resident 85) who had an indwelling urinary catheter. Findings include: The facility's policy regarding catheter use, dated February 4, 2026, indicated that residents with indwelling catheters should receive appropriate care for the catheter in accordance with current professional standards of practice. An admission note for Resident 85, dated April 7, 2026, at 5:24 p.m. indicated that the resident had a chronic indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder) related to cancer. An admission note for the resident, dated April 7, 2026, at 11:10 p.m. indicated that the resident was admitted related to a fall and urinary tract infection and his indwelling catheter was draining dark, amber colored urine. Observations of Resident 85 on April 13, 2026, at 11:37 a.m. revealed that the resident was sitting in wheelchair in his room with his urinary catheter bag hanging under his wheelchair with the bag and tubing in direct contact with the floor with no dignity/privacy cover on the urinary bag. Interview with Registered Nurse 8 on April 13, 2026, at 11:42 a.m. confirmed that Resident 85's urinary catheter bag and tubing were lying in direct contact with the floor and should not have been, and he confirmed that there was no dignity/privacy cover on the catheter bag. Interview with the Nursing Home Administrator on April 13, 2026, at 3:30 p.m. confirmed that Resident 85's urinary catheter bag and tubing should not have been on the floor and there should have been a dignity/privacy cover on the urinary bag. A care plan for Resident 85, dated April 7, 2026, indicated that the resident had a urinary catheter and indicated that staff were to monitor and document urinary output per facility policy. A facility task for the resident indicated that urinary catheter output was to be documented every shift. Review of Resident 85's clinical record revealed that there was no documented evidence that his urinary catheter output was documented on April 10, 2026, on the day shift; April 12, 2026, on the evening shift; and April 9 through April 13, 2026, on the night shift. Interview with the Director of Nursing on April 14, 2026, at 3:05 p.m. confirmed that Resident 85's urinary catheter output was not documented on the above-mentioned dates/shifts and they should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:.The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 13, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 16, 2026, identified repeated deficiencies related to care plan revision/implementation, quality of care, labeling/storage/disposal of medications, and proper infection control practices. The facility's plan of corrections for deficiencies regarding developing/implementing comprehensive care plans, cited during the survey ending March 13, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding developing/implementing comprehensive care plans.The facility's plan of correction for a deficiency regarding quality of care cited during the survey ending March 13, 2025, revealed that quality of care would be monitored by QAPI. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with regulations regarding quality of care. The facility's plan of correction for a deficiency infection cited during the survey ending March 13, 2025, revealed that infection control would be monitored by QAPI. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in maintaining compliance with regulations regarding infection control. The facility's plan of corrections for deficiencies regarding the storage/labeling/disposal of medications, cited during the survey ending March 13, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding labeling/storage/disposal of medications.Refer to F656, F684, F761, F880. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.

Based on clinical record review, as well as staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for four of 33 residents reviewed (Residents 1,10, 47, 82). Findings Include: A nursing note for Resident 1 dated February 14, 2025, at 7:51 p.m. revealed that the resident had been coughing all afternoon after eating a cookie and a large number of fluids. The physician was notified and advised to send the resident to the emergency room for evaluation. Review of Resident 1's clinical record revealed no documented evidence that that resident representative or the ombudsman was notified in writing of the transfer to the hospital on the above dates and times. A nursing note for Resident 10 dated September 8, 2025, at 2:40 a.m. revealed that during a dressing change the resident began spraying a steady stream of blood from his wound and was sent to the Emergency Room. A nursing note dated November 26, 2026, at 10:37 a.m. revealed that the resident was sent to UPMC Somerset Emergency Room. Review of Resident 10's clinical record revealed no documented evidence that that resident representative or the ombudsman was notified in writing of the transfer to the hospital on the above dates and times. A nursing note for Resident 47 dated April 3, 2026, at 1:45 p.m. revealed that the resident had a fall from a mechanical lift during a transfer, sustained injuries and was transferred to the hospital. Review of Resident 47's clinical record revealed no documented evidence that that resident representative or the ombudsman was notified in writing of the transfer to the hospital on the above dates and times. A nursing note for Resident 82 dated January 25, 2026, at 10:37 revealed that the resident was unresponsive and was being sent to the emergency room. Review of Resident 82's clinical record revealed that there was no documented evidence that the resident representative or the ombudsman was notified in writing of the transfer to the hospital. Interview with the Social Worker on April 16, 2026 at 9:26 a.m. revealed that she did not notify the resident's representative or the ombudsman of the hospital transfer for the resident's above, and was not aware that she was supposed to. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management .

Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect for two of 33 residents reviewed (Resident 28, 47). Findings include: The facility's policy regarding resident abuse/neglect, dated February 4, 2026, revealed that the facility would conduct a thorough investigation to determine facts specific to the case for any and all types of alleged violations.An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated April 8, 2026, revealed that the resident was cognitively intact, and was dependent on staff for daily care needs. A nursing note for Resident 28, dated April 8, 2026, at 5:08 p.m. revealed that the Nurse Aide notified the Registered Nurse that the resident had complaints of pain in her shoulder, and that during care she had assisted turning the resident and her bed moved. The resident's arm was jammed into the nightstand causing her shoulder pain. However there was no documented evidence that the facility investigated the above mentioned incident to rule out abuse or neglect as the cause.Interview with the Assistant Director of Nursing and Nursing Home Administrator on April 16, 2026, at 2:03 p.m. confirmed that the facility should have conducted an investigation into the cause of shoulder pain for Resident 28.A Quarterly MDS assessment for Resident 47, dated March 24, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs and had a diagnosis of Diabetic Neuropathy (a type of nerve damage caused by chronic high blood sugar).Investigation documents for Resident 47 dated April 3, 2026, at 1:45 p.m. revealed the writer was called to the residents room. Resident 47 was being transferred from bed to wheelchair utilizing mechanical lift and two staff members. Resident 47 was fidgeting in the sling and then reached out to grab his wheelchair. He then slid out of the sling onto the floor head first. Resident 47 was assessed and sustained a 3 cm laceration to the back of his head. No other injuries noted at time of assessment. The writer indicated the proper and correct size of sling was being used at the time of the transfer.A witness statement completed by Nurse Aide 4, dated April 3, 2026, revealed that she was transferring Resident 47 from his bed via a hoyer lift, and the resident slid from the sling and made contact with the floor. A witness statement completed by Nurse Aide 5, dated April 3, 2026, revealed that he was working with Nurse Aide 4 and when Resident 47 was being lifted he was reaching for his wheelchair and he slipped out of the sling and hit his head.There was no documented evidence that the facility's investigation indicated what type of lift was being used for the transfer and what type and size of sling was being used at the time of the transfer.Interview with the Director of Nursing on April 15, 2026, at 11:35 a.m. confirmed that she had no documented evidence that the investigation determined if the correct lift and sling was used at the time of the transfer when the resident slid out of the sling and onto the floor causing injuries and she should have.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that appropriate signage was posted for a resident with special infection control isolation needs for two of 33 residents reviewed (Residents 5 and 79). Findings include: The facility's policy regarding Enhanced Barrier Precautions (EBP-infection control intervention designed to reduce transmission of multi-drug resistant organisms (a germ that is resistant to many antibiotic making treatment difficult) that employs targeted gown and glove use during high contact resident care activities), dated February 4, 2026, indicated that an order for enhanced barrier precautions will be obtained for residents with indwelling medical devices, such as urinary catheters (a thin, flexible tube inserted into the bladder to drain urine from the bladder),and feeding tubes (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth). A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated March 1, 2026, revealed that the resident was cognitively intact, required assistance with care needs, had a feeding tube and had a diagnosis of cancer. A care plan for the resident, dated February 23, 2026, indicated that the resident had a feeding tube and was on EBP. Physician's orders for Resident 5, dated February 24, 2026, included orders for Enhanced Barrier Precautions related to having a feeding tube. Observations of Resident 5's room on April 13, 2026, at 11:33 a.m. and again on April 15, 2026, at 9:38 a.m. revealed that there were no EBP signs posted at the entrance to the resident's room or inside the resident's room. An admission note for Resident 79, dated April 2, 2026, at 11:53 p.m. indicated that the resident was admitted with a urinary tract infection and had an indwelling catheter in place. A care plan for the resident, dated April 3, 2026, indicated that the resident had an indwelling catheter and was on EBP. Physician's orders for Resident 79, dated April 2, 2026, included orders for Enhanced Barrier Precautions related to having an indwelling catheter. Observations of Resident 79's room on April 13, 2026, at 11:50 a.m. and again at 2:44 p.m. revealed that there were no EBP signs posted at the entrance to the resident's room or inside the resident's room. Interview with the Assistant Diirector of Nursing/Infection Preventionist on April 15, 2026, at 12:27 p.m. confirmed that there was no signage posted at the entrance to Resident 5's and Resident 79's rooms or inside the resident's rooms to indicated they were on EBP. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to ensure resident beds were in safe operating condition for 3 of 33 residents reviewed (Residents 28, 37 and 53).Findings include: An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated April 8, 2026, revealed that the resident was cognitively intact, and was dependent on staff for daily care needs.Observations in Resident 28's room on April 13, 2026, at 9:29 a.m. revealed that her bed was locked, however, it moved freely while locked. Interview with Resident 28 at the time of the observation revealed that the bed not locking had been an issue.Interview with Nurse Aide 2 on April 13, 2026, at 9:29 a.m. revealed that she was aware that the bed has not been locking and that she informed the Licensed Practical Nurse when she first noticed it.Interview with Licensed Practical Nurse 10 on April 13, 2026, at 11:37 a.m. confirmed that she was told that Resident 28's bed moved, and she told the Nurse Aides to lock the bed but did not check the bed to see if there was an issue with the bed wheels not locking and securing.A significant change MDS assessment for Resident 37, dated March 16, 2026, indicated that the resident was cognitively intact, required moderate assistance with bed mobility and was dependent on staff for transfers from bed to chair and chair to bed. Observations in Resident 37's room on April 13, 2026, at 12:03 p.m. revealed that her bed was locked, however, it moved freely while locked. Interview with Resident 37 at the time of the observation revealed that the bed not locking had been an issue. Interview with Nurse Aide 11 on April 13, 2026, at 2:26 p.m. revealed that she was aware that the bed did not lock fully and moved, but did not make anyone aware. She indicated that she never had an issue with it when doing care on the resident and stated if you know what you are doing, it's not an issue. Observations in Resident 63's room on April 13, 2026, at 12:45 p.m. revealed that her bed was locked, however, it moved freely while locked. Interview with the director of maintenance on April 13, 2026, at 12:45 p.m. confirmed that he was not made aware verbally or in writing through a work order that the wheels on the beds mentioned above did not lock securely. 28 Pa. Code 201.18(b)(3) Administrator's Responsibility.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for one of 33 residents reviewed (Resident 37). Findings Include: A facility policy for psychotropic medication management dated February 4, 2026, indicated that as needed psychotropic medications shall be limited to no more than14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 16, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, received antianxiety medications (psychotropic medications) and had a diagnosis of anxiety. Physician's orders for Resident 37, dated March 25, 2026, revealed that the resident was to receive 0.5 milligram (mg) of Lorazepam (psychotropic antianxiety medication) every 12 hours as needed for anxiety. Review of Resident 37's Medication Administration Record (MAR) for March and April 2026, revealed that the resident received 0.5 mg of Lorazepam on March 25 at 9:02 p.m.; March 27 at 7:51 p.m.; March 28 at 9:01 p.m.; March 29 at 8:35 p.m.; March 30 at 7:55 p.m.; March 31 at 7:15 p.m.; April 1 at 8:58 p.m.; April 2 at 7:26 p.m.; April 3 at 7:16 p.m.; April 4 at 9:07 p.m.; April 5 at 8:10 p.m.; April 6 at 9:41 p.m.; April 7 at 8:45 p.m.; April 8 at 8:52 p.m.; April 9 at 7:27 p.m.; April 10 at 9:14 p.m.; April 11 at 9:08 p.m.; April 13 at 8:59 p.m.; and April 14 at 8:59 p.m. There was no documented evidence that a physician provided the rationale as required to extend the as needed psychotropic medication past 14 days. Interview with the Director of Nursing on April 16, 2026, at 2:36 p.m. confirmed that the facility failed to ensure that Resident 37's as needed Lorazepam was limited to 14 days or had a clinical rationale for continuing beyond 14 days. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 33 residents reviewed (Resident 49).Findings include: The facility's policy regarding a homelike environment, dated February 4, 2026, indicated that the facility was to provide a clean comfortable and homelike environment. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 18, 2026, revealed that the resident was cognitively intact and had diagnoses that included multiple sclerosis (a chronic medical condition where the immune system attacks the protective covering of the nerves in the brain and the spinal cord).Observations of Resident 49 on April 13, 2026, at 11:02 a.m., and April 14, 2026, at 10:50 a.m. respectively, revealed that she was lying in bed with a hole in the footboard of her bed measuring approximately six inches in diameter.Interview with the Director of Maintenance on April 14, 2026, at 11:34 a.m. revealed that he was unaware that Resident 49's bed had a hole in the footboard, and confirmed that it should have been replaced.28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance for 1 resident out of 33 residents reviewed. (Resident 28). Findings include:A Comprehensive Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 28 dated April 8, 2026, revealed that the resident was cognitively intact, was dependent on staff for toileting needs, and was always incontinent of bowel and urine.A review of Resident 28's comprehensive care plan, last revised on February 6, 2026, revealed a focus on bowel and bladder incontinence (inability to control urine or stool) with a history of chronic urinary tract infections and IBS, with interventions to include staff checking the resident for incontinence and changing the resident every two hours and as needed. Further review of the care plan revealed the resident required extensive assistance from two staff members for bed mobility.Observations of Resident 28 on April 17, 2026, at 12:15 p.m. revealed that the resident was waiting in the small dining area in the 200 hall and made a request to Nurse Aide 1 to go back to her room and Nurse Aide 1 replied that she would need to wait a minute. Observations of Nurse Aide 1 on April 17, 2026, at 12:26 p.m. walking into the dining area removing a tray from another resident and telling the resident she would be right back to take her to her room while ignoring and not acknowledging Resident 28. Observations of Nurse Aide 2 at 12:39 p.m. walking past the dining area and Resident 28 calling her over and requesting to go back to her room. Nurse Aide 2 went and got Nurse Aide 1 to assist resident to her bed. Observations of Resident 28 at 12:44 p.m. upon returning to her room revealed that she had been incontinent.Interview with Nurse Aide 1 on April 17, 2026, at 12:44 p.m. revealed that Resident 28 stated it was ok for her to wait until she was done removing lunch trays before taking her back to her room and Resident 28 spoke up and said, the hell I did, I told her it was ok to pass out trays first then take me to my room when she was done with that, not this long. Interview with Nurse Aide 1 also revealed that she had told Nurse Aide 3 to go to lunch prior to returning Resident 28 to her room and that she did not have the assistance she needed because Nurse Aide 3 went to lunch.Interview with Resident 28 on April 17, 2026, at 12:57 p.m. revealed that she requested to go back to her room due to being incontinent. Resident 28 did not want to state that in the dining area with other residents around. She simply requested to return to her room and once she was in the privacy of her room stated that she had been incontinent.Interview with the Assistant Director of Nursing on April 17, 2026, at 2:15 p.m. confirmed that the resident should have been returned to her room when requested. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 33 residents reviewed (Residents 37 and 49).Findings include:The facility's policy for medication administration, dated February 4, 2026, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered, and if the medication is a controlled substance, staff are to sign the narcotic book.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 16, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and was receiving routinely scheduled and as needed pain medication.Physician's orders for Resident 37, dated January 21, 2026, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every six hours as needed for pain.Physician's orders for Resident 37, dated March 18, 2026, included orders for the resident to receive 5 mg of oxycodone every six hours as needed for pain.A review of Resident 37's MAR, dated January and April 2026, revealed that 5 mg of oxycodone was administered to the resident on January 29 at 8:35 a.m.; April 4 at 7:16 a.m.; and April 5 at 7:16 a.m. However, a review of the resident's controlled medication record (a form that accounts for each tablet/pill/dose of a controlled drug) for January and April 2026, revealed no documented evidence that 5 mg of oxycodone was signed out for administration on the above-mentioned dates and times. Interview with the Director of Nursing on April 16, 2026, at 3:40 p.m. confirmed that there was no documented evidence on Resident 37's controlled medication record to indicate that 5 mg of oxycodone was signed out for administration on the above-mentioned dates and times. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 18, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and was receiving as needed pain medication.Physician's orders for Resident 49, dated January 21, 2026, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every six hours as needed for pain.Physician's orders for Resident 49, dated October 10, 2024, included orders for the resident to receive 0.5mg clonazepam (a medication used to treat anxiety) every 12 hours.A review of Resident 49's MAR, dated 2026, revealed that 5 mg of oxycodone was administered to the resident on March 10, 2026 at 8:17 p.m., and 0.5mg clonazepam was administered on April 1, 2026, at 9:00 a.m. However, a review of the resident's controlled medication record (a form that accounts for each tablet/pill/dose of a controlled drug) for March and April 2026, revealed no documented evidence that 5 mg of oxycodone was signed out for administration on the above-mentioned date and time, and that 0.5mg clonazepam was signed out in error on the above date and time.Interview with the Director of Nursing on April 16, 2026, at 3:40 p.m. confirmed that there was no documented evidence on Resident 49's controlled medication record to confirm that 5mg of oxycodone and 0.5mg of clonazepam were administered on the above dates and times.28 Pa Code 211.5(f) Clinical Records.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 33 residents reviewed (Resident 49), and failed to obtain urine culture results for effective antibiotic treatment of a urinary tract infection for one of 33 residents reviewed (Resident 85).Findings include: Physician's orders for Resident 49, dated September 20, 2024, included an order for the resident to receive Refresh Relieva Opthalmic Solution 0.5-0.9% *Carboxymethylcellulose-Glycerin (eye drops used to rehydrate and protect hydration for eyes), instill 1 drop in both eyes three times a day for dry eyes unsupervised self-administration and may keep at bedside. Observations of Resident 49's room on April 16, 2026, at 10:10 a.m. revealed no evidence of Refresh Relieva Opthalmic Solution in her room. Interview with Licensed Practical Nurse 7 on April 16, 2026, at 10:10 a.m. revealed that she was not aware that Resident 49 did not have the physician ordered eye drops, and that the resident will inform staff when she needs more. Interview with Resident 49 on April 16, 2026, at 11:37 a.m. revealed that she has not had that eye drop for over a year. Interview with the Director of Nursing on April 16, 2026, at 1:51 p.m. confirmed that Resident 49 should have had her eye drops per physician's order. An admission note for Resident 85, dated April 7, 2026, at 5:24 p.m. indicated that the resident had a chronic indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder) related to cancer. An admission note for the resident, dated April 7, 2026, at 11:10 p.m. indicated the resident was admitted related to a fall and a urinary tract infection and that his indwelling catheter was draining dark, amber colored urine. A care plan for the resident, dated April 8, 2026, indicated that the resident had a urinary tract infection and he was receiving an antibiotic. Hospital discharge instructions for Resident 85, dated April 7, 2026, indicated that the resident had a pending urine culture (detects the specific bacteria in the urine to determine the best antibiotic for treatment) in process. Physician's orders for Resident 85, dated April 7, 2026, indicated that the resident was to receive 800-160 milligrams (mg) of Sulfamethoxazole-Trimethoprim (an antibiotic) every morning and at bedtime for a urinary tract infection for 20 administrations. Physician's notes for Resident 85, dated April 9, 2026, April 10, 2026, and April 13, 2026, respectively, revealed that the resident had a urinalysis showing many bacteria and were waiting on culture results. As of April 14, 2026, at 12:57 p.m. there was no documented evidence that the facility had obtained Resident 85's urine culture results from the hospital. Results of Resident 85's urine culture were obtained on April 14, 2026, at 2:24 p.m. The final results, dated April 9, 2026, showed that the resident had a positive urinalysis showing greater than 100, 000 colonies of Enterococcus faecalis (bacteria) with sensitivities (determines the best antibiotic for treatment) to Ampicillin, Daptomycin, Linezolid and Vancomycin (antibiotics). However, the resident had been receiving Sulfamethoxazole-Trimethoprim (an antibiotic without sensitivities to the bacteria) since admission to the facility on April 7, 2026. Interview with the Assistant Director of Nursing on April 15, 2026, at 12:19 p.m. indicated that the hospital would not give the results of Resident 85's urine culture to the facility because they were not the ordering physician; however, they were able to receive the results on April 14, 2026, when requested. 28 Pa. Code 211.12 (d) (1)(5) Nursing Services

Based on review of facility policies, as well observations and staff interviews , it was determined that the facility failed to maintain an environment free from potential safety hazards related to resident beds for three of 33 residents reviewed (Residents 10, 28, and 56) and by not having a formal system for choosing the correct mechanical lift sling for one of 33 residents reviewed (Resident 47).Findings include: A facility policy for safe and homelike environment dated, February 4, 2026, revealed the facility will provide a safe, clean, comfortable and homelike environment, and includes ensuring that the resident can receive care and services safely and that the physical layout of the facility both inside and outside, maximizes resident independence and does not pose a safety risk. Observations during care to Resident 28 on April 13, 2026, at 10:53 a.m. revealed that when the resident was being rolled in bed, the bed moved several feet the opposite direction from the resident and the resident was close to rolling out of bed. The wheels of Resident 28's bed could not be safely secured and locked so that the bed did not move during care, repositioning, or transfer of the resident. Observations of Resident 10's bed on April 13, 2026, at 11:13 a.m. revealed that the wheels did not safely lock and secure with the resident in the bed. Observations of Resident 58's bed on April 13, 2026, at 11:26 a.m. revealed that the wheels did not safely lock and secure with the resident in the bed. Interview with the Maintenance Director on April 13, 2026, at 11:30 a.m. revealed that he was not notified of any concerns by residents, staff, or visitors that the beds were not able to be locked and secured. He confirmed that he should have been notified and the beds should have been able to be locked and secured so that they did not move during care, repositioning, or transfers of the residents. A facility policy for using a mechanical lift (a battery-powered or hydraulic patient transfer device designed to safely move non-ambulatory, bedridden, or bariatric individuals) dated February 4, 2026, revealed that the facility will establish the general principles of safe lifting using a mechanical lift device and that it is not a substitute for the manufacturer's training or instructions. Steps in the facility's procedure included measuring the resident for proper sling size and purpose according to the manufacturer's instructions. Manufacturer's instructions for the Invacare Reliant Mechanical Lift dated 2022, recommend the use of an Invacare approved sling recommended by the individual's doctor, nurse or medical assistant for the comfort and safety of the individual being lifted. Invacare slings are made specifically for the use with Invacare patient lifts for the safety of the patient. Do not use slings and patient lifts from different manufacturers. A Quarterly MDS assessment for Resident 47, dated March 24, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, required transfer with a mechanical lift and staff assistance of two, and had diagnoses that included diabetic neuropathy (a type of nerve damage caused by chronic high blood sugar). Facility investigation documents for Resident 47 dated April 3, 2026, at 1:45 p.m. revealed the writer was called to the resident's room. Resident 47 was being transferred from bed to wheelchair utilizing a mechanical lift and two staff members. Resident 47 was fidgeting in the sling and then reached out to grab his wheelchair. He slid out of the sling onto the floor headfirst. Resident 47 was assessed and had sustained a 3-centimeter (cm) laceration to the back of his head. He complained of arm pain, back pain and hip pain and was able to move all extremities. Resident 47 was sent to the emergency room for evaluation. The writer indicated that the proper and correct size of sling was being used at the time of the transfer. Observations in the shower room on April 14, 2026, at 11:15 a.m. revealed an Invacare reliant mechanical lift, several slings of different colors with faded labels, with no indication of weight limits or size information. Interview with Nurse Aide 3 on April 14, 2026, at 10:51 a.m. revealed that if she needs a sling, she just looks at the sling to see if it would fit the resident by holding it up to see if it is big enough. She also stated that she asks the resident which sling is usually used or checks with the Licensed Practical Nurse. Observations in the shower room with the Assistant Director of Nursing on April 16, 2026, at 2:38 p.m. revealed several slings of different colors and fabrics with faded labels with no indication of weight limits or size information or that they were compatible with the facility's lift equipment. Interview with Assistant Director of Nursing on April 16, 2026, at 2:45 p.m. confirmed that the facility does not have a formal system for choosing the correct patient lift sling to ensure safety and compatibility with lifting equipment. Interview with the Nursing Home Administrator on April 16, 2026, at 3:17 p.m. confirmed that the facility does not have a formal system for choosing the correct patient lift sling to ensure safety and compatibility with lifting equipment. 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 and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 33 residents reviewed (Residents 37 and 49). Findings include: The facility's policy for medication administration, dated February 4, 2026, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered; and if the medication is a controlled substance, staff are to sign the narcotic book. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated March 16, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and was receiving routinely scheduled and as needed pain medication. Physician's orders for Resident 37, dated January 21, 2026, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every six hours as needed for pain. Physician's orders for Resident 37, dated March 18, 2026, included orders for the resident to receive 5 mg of oxycodone every six hours as needed for pain. Review of the controlled drug records (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 37 for February 2026, March 2026 and April 2026, revealed that a 5 mg tablet of oxycodone was signed out on February 22, 2026, at 7:00 a.m.; February 26, 2026, at 7:00 a.m.; February 28, 2026, at 8:41 p.m.; March 22, 2026, at 8:30 p.m.; April 3, 2026, at 8:46 a.m.; and April 12, 2026, at 7:57 p.m. However, there was no documented evidence in Resident 37's clinical record that the signed-out doses of oxycodone were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 16, 2026, at 3:40 p.m. confirmed that there was no documented evidence in Resident 37's clinical record to indicate that the signed-out doses of oxycodone were administered to the resident on the above-mentioned dates and times. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 18, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and was receiving as needed pain medication. Physician's orders for Resident 49, dated June 25, 2025, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every six hours as needed for pain. Review of the controlled drug records (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 49 for February 2026, revealed that a 5 mg tablet of oxycodone was signed out on February 6, 2026 at 6:00 a.m. However, there was no documented evidence in Resident 49's clinical record that the signed-out doses of oxycodone were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 16, 2026, at 3:38 p.m. confirmed that there was no documented evidence in Resident 49's clinical record to indicate that the signed-out doses of oxycodone were administered to the resident on the above-mentioned date and time. 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who were receiving enteral feedings received appropriate treatment and services to prevent complications for one of 33 residents reviewed (Resident 5). Findings include: A facility policy regarding care and treatment of feeding tubes, dated February 4, 2026, indicated that in accordance to facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location. Tube placement will be verified before beginning a feeding and before administering medications. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated March 1, 2026, revealed that the resident was cognitively intact, required assistance with care needs, had a feeding tube and had a diagnosis of cancer. A care plan for the resident, dated February 24, 2026, indicated that the resident had a feeding tube and staff were to check for tube placement and gastric contents/residual per facility protocol. Physician's orders for Resident 5, dated February 26, 2026, included orders for the resident to receive Glucerna 1.2 Cal enteral feedings three times a day at 8:00 a.m., 12:00 p.m. and 7:00 p.m. continuous at a rate of 120 milliliters (ml) per hour via his peg tube and to take down approximately three hours or when total volume of 360 cubic centimeters (cc) have been infused. Physician's orders for Resident 5, dated March 4, 2026 and March 16, 2026, included orders for the resident to receive bolus Glucerna 1.2 Cal enteral feedings four times a day at 6:00 a.m., 10:00 a.m., 4:00 p.m. and 8:00 p.m. in the amount of 237 mL via his peg tube. Physician's orders for Resident 5, dated April 13, 2026, included orders for the resident to receive bolus Glucerna 1.2 Cal enteral feedings four times a day at 6:00 a.m., 10:00 a.m., 4:00 p.m. and 8:00 p.m. in the amount of 237 mL via his [NAME]. Review of Resident 5's clinical record revealed that there was no documented evidence that feeding tube placement was verified prior to beginning feedings as per the facility policy. A facility policy related to medication administration via enteral tube, dated February 4, 2026, indicated that enteral tube placement must be verified prior to administering any fluids or medications. Physician's orders for Resident 5, dated February 24, 2026, included orders for staff to flush his peg tube with 30 cc of water before and after medications and feedings. Review of Resident 5's clinical record revealed that there was no documented evidence that feeding tube placement was verified prior to administering any fluids or medications as per the facility policy. Interview with the Director of Nursing on April 16, 2026, at 12:44 p.m. confirmed there was no documented evidence in Resident 5's clinical record that feeding tube placement was verified prior to administering feedings and before and prior to administering any fluids or medications as per the facility policy. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and or implement a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 33 residents reviewed (Residents 5 and 12).Findings include: A facility policy for Care Plans, dated February 4, 2026, indicated that nursing staff and/or the interdisciplinary team were to develop and implement resident specific person-centered care plans. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated March 1, 2026, revealed that the resident was cognitively intact, required assistance with care needs and had a diagnosis of cancer. A care plan for the resident, dated February 12, 2026, indicated that the resident was receiving chemotherapy. Interview with Resident 5 on April 16, 2026, at 9:50 a.m. revealed that he was going for a PET (Positron Emission Tomography) scan (test used to detect cancer) today. He stated that he receives chemotherapy every three weeks and has had about four rounds so far. He indicated that he had a mediport (a surgically implanted device placed under the skin, usually in the upper chest, to provide easy, long-term access to a vein for chemotherapy, blood draws, and medications) and they use it for chemotherapy. He stated that they flush the port when he gets chemotherapy. A mediport was observed to his right chest. There was no documented evidence in the resident's clinical record that a care plan was developed for the mediport. Interview with the Director of Nursing on April 16, 2026, at 2:31 p.m. confirmed that there was no documented evidence in Resident 5's clinical record that a care plan was developed to reflect that the resident had a mediport. A quarterly MDS assessment for Resident 12, dated January 27, 2026, revealed that the resident was severely cognitively impaired, required extensive assistance from staff for her care, and had diagnoses that included vascular dementia and anxiety. Resident 12's current care plan, revised May 20, 2025, indicated that the resident was to have a Velcro STOP sign (a nylon banner that visually deters residents from entering) across her doorway. Observations of Resident 12's room/doorway on April 13, 14 and 15, 2026 respectively, revealed that she had no Velcro STOP safety banner in place across her doorway as care planned. Interview with the Social Service Director and Licensed Practical Nurse 6 on April 15, 2026, at 2:06 p.m. and 3:00 p.m. respectively, confirmed that the resident did not have a Velcro STOP safety banner across her doorway as care planned. They also revealed that Resident 65 roams throughout the facility and four other residents have STOP banners across their doorways to discourage her from entering those rooms. Interview with the Assistant Director of Nursing on April 15, 2026, at 3:25 p.m. confirmed that the resident did not have a Velcro STOP safety banner across her doorway as care planned, and she should have. 28 Pa. Code 211.11(d) Resident care plans.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of fire safety plans, clinical records, and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans and emergency evacuation plans for one of seven residents reviewed (Resident 1) who required the use of a mechanical lift for transfers, resulting in a left hip fracture. Findings include: The facility's current Fire Response Plan revealed for emergency removal of a resident from bed when working alone revealed that staff were to slip both arms under the resident's body and pull the resident towards the edge of the bed then drop to their knee nearest the head. Staff were to pull the lower half of the resident's body from the bed so that the extended knee supported the resident's hips. Staff were to use both arms to lower the resident's upper body to the floor, let the resident's legs slide gently to the blanket, and pull the resident from the room head first. The facility's current Emergency Evacuation Plan revealed that residents in immediate danger were to be evacuated to a safe location. Staff were to use good judgement with the transfer of residents. Next staff were to continue to evacuate residents to their designated outside area. Nurse aides would assist in the evacuation of residents to designated outside evacuation areas for each wing, as directed. Staff were to use good judgement with the transfer of residents to the safest mode of transportation to evacuate the facility or area. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 3, 2024, revealed that the resident sometimes could make himself understood, sometimes could understand others, was cognitively impaired, and had diagnoses that included dementia and a stroke. The resident's care plan, revised April 21, 2021, revealed that he required a mechanical lift with the assistance of two staff for transfers. A functional ability and goals form, completed by the Director of Rehabilitation, dated August 25, 2024, revealed that Resident 1 was dependent on staff for transfers from the chair/bed to chair and tub/shower. A facility investigation, dated November 11, 2024, at 6:20 p.m., indicated that staff was attempting to transfer Resident 1 to his wheelchair during an active fire evacuation. They were unable to safely transfer him to his chair without more assistance, so he was lowered to the floor with two staff members present. A draw sheet was then placed under the resident and four persons transferred the resident from the floor to the chair. Resident 1 complained of pain on his left side at the time of the transfer. There were no injuries observed at the time of the incident. A nursing note, dated November 12, 2024, at 12:42 a.m., revealed that Resident 1 complained of pain all over, especially to the lower back, left hip, and left leg. He yelled when the nurse touched his leg. New orders were received for x-rays of the lumbar spine, left hip, and left femur. An x-ray report, dated November 12, 2024, revealed that the resident's left hip had an acute (recent) displaced (out of line) intertrochanteric (the upper part of the thigh bone) fracture. A written statement by Licensed Practical Nurse 3, dated November 12, 2024, revealed that Nurse Aide 4 went in to transfer Resident 1 into his wheelchair. The resident had his legs out over the side of the bed and was lying back on the bed. Nurse Aide 4 asked her to help him transfer Resident 1 and she told him that she had to get gloves. In the meantime Nurse Aide 4 bear hugged Resident 1 to lift him up, he was dead weight, and his legs buckled under him. She told Nurse Aide 4 to lower the resident to the floor so he did not fall. A written statement by Nurse Aide 4 on November 14, 2024, revealed that C wing began to fill up with smoke and they started to get residents out during the evacuation. He and a nurse picked up Resident 1 after they sat him up. When they tried to turn him to put the wheelchair under him, his legs gave out underneath him, so they laid him down on his back. The facility's employee orientation checklist, dated September 5 2024, revealed that Nurse Aide 4 completed training regarding fire safety and evacuation procedures. Interview with the Director of Rehabilitation on November 19, 2024, at 12:20 p.m. revealed that Resident 1 always required a mechanical lift for transfers and that transferring the resident out of bed with a one assist, stand and pivot, during the fire drill was not appropriate. Interview with Licensed Practical Nurse 3 on November 19, 2024, at 12:36 p.m. revealed that Nurse Aide 4 came to the door and asked for help to transfer Resident 1. The resident's legs were off the bed and he was lying flat on the bed, and she told him give her a minute. Nurse Aide 4 then bear hugged Resident 1, and she could see the resident was going down. She could not help lift Resident 1, since he was dead weight, and she told Nurse Aide 4 to lower Resident 1 to the floor and she would get help. She confirmed that Nurse Aide 4 lifted Resident 1 and when he turned to put the resident in his chair, she could see the resident going down. She confirmed that Resident 1 was a mechanical lift and always was a lift, and Nurse Aide 4 bear hugged Resident 1 and tried to transfer him by himself. Interview with Nurse Aide 4 on November 19, 2024, at 4:33 p.m. confirmed that he did bear hug Resident 1 to get him up and into his wheelchair. He reported that Licensed Practical Nurse 3 did not physically help to stand him, but tried to get the wheelchair under the resident, but when he could not get the resident into the chair, she then told him to lay the resident down. He stated that he was aware that Resident 1 was a mechanical lift. Interview with the Director of Nursing on November 19, 2024, at 2:46 p.m. confirmed that Nurse Aide 4 did not transfer Resident 1 out of bed with a mechanical lift due to a fire evacuation. She was not sure if the resident was a mechanical lift or could assist with transfers. Interview with the Nursing Home Administrator on November 19, 2024, at 4:05 p.m. revealed that she was not aware that Nurse Aide 4 bear hugged Resident 1 and attempted to transfer him out of bed by himself. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for one of three residents (Resident 2) reviewed who ingested hand sanitizer, resulting in a blood alcohol level of 0.29. Findings include: Review of the clinical record for Resident 2 revealed that she was a new admission to the facility on [DATE], from the hospital. A progress note for Resident 2, dated June 28, 2024, revealed that report was received from a hospital nurse. The resident was admitted to the hospital on June 19, 2024, for alcohol intoxication, hypotension (low blood pressure), and a fall in which she hit her head. A progress note for the resident, dated June 28, 2024, at 6:45 p.m. revealed that the resident arrived from the hospital via Med Van in stable condition. A hospital discharge summary for Resident 2, dated June 28, 2024, revealed that she had frequent ingestions of hand sanitizer or Listerine to become intoxicated and had frequent emergency department visits/admissions for the issue. The resident was brought to the hospital on this occasion after staff found a bottle of hand sanitizer in her room. On June 22, 2024, another empty container of hand sanitizer was found by the registered nurse, indicating that the resident was able to access more of it. Discharge diagnoses included ambulatory dysfunction and hand sanitizer poisoning. A baseline care plan for Resident 2, dated June 28, 2024, revealed that she had an Altered Mood State or Behavior due to a history of alcoholism and drinking sanitizer. Staff were to keep hand sanitizer out of the resident's room. An investigation report for Resident 2, dated July 1, 2024, 8:34 a.m. revealed that a nurse aide reported that when she walked the resident back to her bed from the bathroom and straightened up her bed pads, she found an empty bag of hand sanitizer that is normally in the hand sanitizer case on the wall. The resident denied drinking the hand sanitizer. She stated that a gentleman who was changing the hand sanitizer bag let her have it because she was not able to use the wall unit. A statement completed by Nurse Aide 1, dated July 1, 2024, revealed that during breakfast she walked Resident 2 back to her bed from the bathroom. When she straightened up the bed pads so Resident 2 could get back into bed, she found an empty bag of hand sanitizer in her bed. The licensed practical nurse and Director of Nursing were notified. A nursing note for Resident 2, dated July 2, 2024, at 2:44 a.m., revealed that the nurse aide entered the resident's room and smelled hand sanitizer. The nurse aide found a water cup (the size they give water in for meds) full of sanitizer on the night stand. The licensed practical nurse reported seeing the cup earlier in her shift but thought it had water in it. Unsure if the resident ingested any of it, and it looked like it was still full and not touched. Will place in provider book to be seen for this behavior. A social service note for Resident 2, dated July 2, 2024, at 8:48 a.m., revealed that the writer met with the resident and with the Nursing Home Administrator. They discussed the issue with the hand sanitizer. Firm boundaries were set by the Nursing Home Administrator that she is not permitted hand sanitizer due to her history of drinking it. An Interdisciplinary Team note, dated July 2, 2024, at 9:43 a.m., revealed that Resident 2 was found with a cup of hand sanitizer in her room, and the cup was immediately removed by staff. Additional interventions were placed to remove extra cups from the resident's room and check the contents of the cups every shift, along with other interventions. A new care plan for Resident 2, dated July 2, 2024, revealed that she has a behavior problem of excessive drinking related to substance use disorder. The resident has accused staff of supplying hand sanitizer when they have not. The resident will not have hand sanitizer in her room. Staff were to monitor her room for cups and remove any that are unnecessary. Staff were to assist the resident to develop more appropriate methods of coping with thoughts of using substances, encourage the resident to express feelings appropriately, and educate the resident/family/caregivers on successful coping and interaction strategies such as participating in activities that encourage sobriety. The resident needs encouragement and active support by family/caregivers when the resident uses these strategies, and staff were to praise any indication of the resident's progress/improvement in behavior. The resident's triggers for substance use are stress and boredom. The resident's behavior is de-escalated by talking about feelings. A nursing note for Resident 2, dated July 2, 2024, at 2:48 p.m., revealed that three empty bags of hand sanitizer and a cup containing hand sanitizer was found in her room. The resident continued to deny drinking the hand sanitizer. She opened her eyes to questions and answers questions, stated that she does not feel good, that her head hurts, and that she was sick in her stomach. Staff is currently sitting with her one-on-one. The Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area) was updated, and orders were received for STAT (immediate) blood work that included an Ethanol (ETOH - a simple alcohol) level for ETOH abuse/drank hand sanitizer, complete blood count (CBC - a blood test that measures many different parts and features of your blood), comprehensive metabolic panel (CMP - a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working), check vitals every one-hour times four for monitoring for drinking hand sanitizer. Then check vitals every two hours times four, then every four hours times four for ETOH abuse/drank hand sanitizer. Neuro checks (a neurological exam that evaluates the brain and nervous system functioning) every four hours times 12 hours for ETOH abuse/drank hand sanitizer and one-on-one supervision every shift for ETOH abuse. A progress note for Resident 2, dated July 2, 2024, at 9:30 p.m., revealed that the CRNP was notified of the stat lab results, CBC, CMP, and an ETOH level of 0.29 milligrams per deciliter (mg/dL) (normal is 0-0.05 mg/dL). She was also made aware that they found a 4th bag of empty hand sanitizer in her room that the resident had hidden behind her pillow. The resident has had a one-on-one sitter since the previous bags were removed, so they know she has not taken any since previous discovery. A statement completed by Activity Aide 2, dated July 2, 2024, revealed that upon doing Resident 2's psychosocial evaluation, she noticed a bag of medical supplies in the corner. Another employee had mentioned her behavior, and I told her about the medical supplies. The Assistant Director of Nursing asked Activity Aide 2 to go in one-on-one with the resident. While in the room Activity Aide 2 noticed a gel-like substance in the resident's cup and when the Nursing Home Administrator came in, Activity Aide 2 gave her the cup that she removed from the resident's tabletop by the bed. Activity Aide 2 continued one-on-one until 4:32 p.m. when it was the end of the shift. The resident appears lethargic (a symptom that involves an unusual decrease in consciousness). A statement completed by Central Supply 3, dated July 2, 2024, revealed that she was informed that Resident 2 had wound care products in her room. Central Supply 3 checked with the Assistant Director of Nursing to see if she allowed them in her room because some of the products had alcohol in them. The Assistant Director of Nursing checked the electronic medical record and confirmed that she should not have wound care products because she does not have any wounds. Central Supply 3 went and found Resident 2's nurse aide (Nurse Aide 1) and asked if she could go along to find them. They went into the resident's room and asked if she had products. The resident was not making sense and just kept stating, The man, the man, the man. They found the wound products on her nightstand. On top of the wound products there was a bag of the resident's belongings. As Central Supply 3 went to grab the bag to move it, she saw one brand of hand sanitizer empty in the bag and asked the resident where it came from. Resident 2 stated the man twice. Then she just kept saying, I do not know. They went and got the Assistant Director of Nursing and The Director of Nursing. A statement completed by the Assistant Director of Nursing, dated July 2, 2024, revealed that Central Supply 3 came to the office and asked if Resident 2 should have wound supplies in her room. The Assistant Director of Nursing double checked the medical record and confirmed that the resident did not have any wounds. Central Supply 3 said that she was going to remove the supplies from the room. She immediately returned to the office and explained that she found an empty bag of hand sanitizer on top of the wound supplies. The Assistant Director of Nursing went to the resident's room and asked to go through her belongings. The Assistant Director of Nursing began looking and opened the drawer to the nightstand and found another empty bag of hand sanitizer. The Assistant Director of Nursing sent Central Supply 3 to notify the Director of Nursing and the Nursing Home Administrator of the findings. The Assistant Director of Nursing stayed with the resident to ensure her safety. While interviewing the resident, she appeared intoxicated. The Assistant Director of Nursing stayed with the resident while nursing staff contacted the physician for orders/instructions. The resident was placed on one-on-one observation. Activity Aide 2 came to the room and provided direct supervision. A statement completed by Account Manager/Housekeeping 4, dated July 2, 2024, revealed that she went into Resident 2's room to assist in cleaning the resident's room. While cleaning around her bed she picked up a backpack off the floor and found an almost empty bag of hand sanitizer, removed it from the room, and gave the hand sanitizer bag to the nurse. There was no documented evidence that after the first bag of hand sanitizer was found on July 1, 2024, or when the cup of hand sanitizer was found on July 2, 2024, that a thorough search of the resident's room and belongings was completed until the three additional bags of hand sanitizer were found. Interview with the Nursing Home Administrator and the Director of Nursing on July 9, 2024, at 2:25 p.m. revealed that they were aware of Resident 2's history of drinking hand sanitizer prior to her admission, so they removed the hand sanitizer from the room that she was going to be in. They indicated that she was also in isolation so they removed the hand sanitizer from the isolation cart that was going to be outside of the resident's room. They confirmed that Resident 2's ETOH level was 0.29 mg/dL and that staff only performed a visual search of the resident's room after finding the first bag of hand sanitizer on July 1, 2024, and the cup of hand sanitizer on July 2, 2024. When the additional bags of hand sanitizer were found on July 2, 2024, they obtained the resident's permission to search her belongings and room, which resulted in finding one more bag of hand sanitizer. They indicated that the resident went on one-on-one supervision at that time until she was discharged to a rehab facility. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policy and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained for all residents on the C wing when the temperature outside was dangerously low, creating a situation in which 38 of 38 residents reviewed (Residents 1-38) were placed in Immediate Jeopardy related to low temperatures. Findings Include: Review of the facility policy HVAC Failure, last reviewed January 2021, indicated that in the event of a heating failure residents would be provided with extra blankets and if required, relocated to warmer spaces within the facility. Interview with Resident 1 on January 27, 2022, at 9:51 a.m. revealed that she was cold and could not get warm. She was ambulating and stopped to state that she was very cold and would like the room much warmer. Her room temperature was 62.6 degrees Fahrenheit. Interview with Resident 2 on January 27, 2022, at 9:51 a.m. revealed that the resident was very cold all night and that she was still cold. She was sitting in her recliner with at least two shirts on and a blanket over her lap. Her room temperature was 59.8 degrees Fahrenheit. Interview with Resident 3 on January 27, 2022, at 9:48 a.m. revealed that she was chilly and had several blankets on up to her neck while in bed. Her room temperature was 58.4 degrees Fahrenheit. Interview with Resident 4 on January 27, 2022, at 9:42 a.m. revealed that she was lying in her bed with her blankets over her head rocking back and forth. She said that she was cold and would not pull the blanket from over her head. Her room temperature was 61.9 degrees Fahrenheit. Interview with Resident 5 on January 27, 2022, at 9:51 a.m. revealed that she was cold and she did not like being cold. She wanted the heat turned on. Her room temperature was 62.6 degrees Fahrenheit. Interview with Resident 6 on January 27, 2022, at 9:35 a.m. revealed that he was sitting in his chair in his room and he stated he was cold. His room temperature was 61.3 degrees Fahrenheit. Interview with Resident 7 on January 27, 2022, at 9:35 a.m. revealed that she was sitting up in her bed with multiple blankets pulled up to her chin. She said that she was very cold all night and still not able to get warm. Her room temperature was 63.7 degrees Fahrenheit. Interview with Resident 8 on January 27, 2022, at 09:40 a.m. revealed that she was cold all night long and could not get warmed up. Her room temperature was 66.4 degrees Fahrenheit. Interview with Resident 9 on January 27, 2022, at 9:36 a.m. revealed that she was cold and she stated her hands were blue tinted because she was so cold. Her room temperature was 64.4 degrees Fahrenheit. Interview with Maintenance Employee E1 on January 27, 2022, at 10:05 a.m. revealed that he was called in to the building on Saturday, January 22, 2022, by nursing staff because the C wing was cold. During observations of the facility on January 27, 2022, from 9:35 a.m. to 10:05 a.m., with Maintenance Employees E1 and E2, the following temperatures on the C wing were observed: C wing hallway was 64.3. Resident 10's room temperature was 62.3 degrees Fahrenheit. Resident 6's room temperature was 61.3 and 60.4 degrees Fahrenheit. Resident 7's room temperature was 63.7 and 63.4 degrees Fahrenheit. Resident 13's room temperature was 61.0 and 61.4 degrees Fahrenheit. Residents 9 and 15's room temperature was 64.4 degrees Fahrenheit. Resident 16's room temperature was 64.7 and 66.5 degrees Fahrenheit. Residents 17 and 18's room temperature was 62.9 degrees Fahrenheit. Residents 8 and 19's room temperature was 66.4 and 69.6 degrees Fahrenheit. Residents 20 and 21's room temperature was 68.6 degrees Fahrenheit. Residents 3, 4, 22, and 23's room temperature was 58.4, 61.9, and 63.7 degrees Fahrenheit. Residents 2, 24, 25 and 26's room temperature was 59.8, 63.9, 66.9 and 68.1 degrees Fahrenheit. Resident 27's room temperature was 64.7 degrees Fahrenheit. Resident 28's room temperature was 63.3 degrees Fahrenheit. Residents 1 and 5's room temperature was 62.6 degrees Fahrenheit. Resident 29's room temperature was 63.7 degrees Fahrenheit. Residents 30 and 31's room temperature was 61.7 degrees Fahrenheit. Residents 32 and 33's room temperature was 63.0 and 63.3 degrees Fahrenheit. Interview with Licensed Practical Nurse 3 on January 27, 2022, at 11:05 a.m. revealed that the C wing was cold when she arrived to work around 6:45 a.m. and she made sure the residents had extra blankets. She stated that it was colder on the long hall of C unit than the short hall, but that both areas were very cold. Interview with Licensed Practical Nurse 4 on January 27, 2022, at 11:08 a.m. revealed that she arrived at 6:40 a.m. and that she was waiting for maintenance to arrive to correct the heat issue and that she made sure the residents were covered with lots of blankets and as comfortable as she could make them. Interview with Nurse Aide 5 on January 27, 2022, at 11:10 a.m. revealed that she arrived at 6:45 a.m. and that it was cold inside because of the temperature outside. She stated that she gave the residents extra blankets, put sweaters on some, and closed all of their blinds to prevent cold air coming in from their windows. Interview with Nurse Aide 6 on January 27, 2022, at 11:26 a.m. revealed that she arrived at 6:40 a.m. and that she made sure residents had extra sweaters and blankets. Interview with Nurse Aide 7 on January 27, 2022, at 11:30 a.m. revealed that she felt cold when she walked onto the C unit, that she provided extra blankets, and that no residents wanted to shower so she agreed to clean them up later. A review of the temperatures that were obtained by the staff at the building on Saturday, January 22, 2022, when the temperature was noted to be 'cool' on the C wing and in the resident's rooms on the C wing was: Resident 10's room temperature was 69 degrees Fahrenheit. Resident 6's room temperature was 65 degrees Fahrenheit. Residents 11 and 12's room temperature was 69 degrees Fahrenheit. Resident 14's room temperature was 68 degrees Fahrenheit. Resident 9's room temperature was not recorded. Resident 16's room temperature was 68, 70, 69.1, 68, 68.1 degrees Fahrenheit. Residents 17 and 18's room temperature was 69.1, 68.2, 65.4, 65.2 degrees Fahrenheit. Residents 8 and 19's room temperature was 70, 68.8, 69.8, 71.6, 69.4 degrees Fahrenheit. Residents 20 and 21's room temperature was 68, 69, 68.3, 67.5 degrees Fahrenheit. Residents 3, 4, 22, and 23's room temperature was 66, 65.1, 66.5, 66.8, 67.9, 67.3 degrees Fahrenheit. Residents 2, 24, 25, and 26's room temperature was 67, 65.2, 66.6, 67.5, 67.3, 67.5 degrees Fahrenheit. Resident 27's room had no temperatures recorded. Resident 28's room had no temperatures recorded. Residents 1 and 5's room had no temperatures recorded. Resident 29's room temperature was 70.1, 70.0, 69.4, 69 degrees Fahrenheit. Resident 30 and 31's room temperature was 69.8, 70, 70.7, 69.7 degrees Fahrenheit. Resident 32 and 33's room temperature was 70.2, 70.1, 69.4, 70.4 degrees Fahrenheit. Resident 34's room temperature was 69.9, 70, 70.1, 69.8 degrees Fahrenheit. Residents 35 and 36's room temperature was 70.2, 70, 70.1, 69.9 degrees Fahrenheit. Resident 37's room temperature was 72.5, 70.3, 70.1, 72, 72 degrees Fahrenheit. Resident 38's room temperature was 71, 71.3, 71, 70 degrees Fahrenheit. On January 23, 2022, at 6:00 a.m. the following temperatures were recorded by the facility staff: Resident 10's room temperature was 71.8 degrees Fahrenheit. Resident 6's room temperature was 69.9 degrees Fahrenheit. Residents 11 and 12's room temperature was 71.7 degrees Fahrenheit. Resident 7's room temperature not recorded. Resident 13's room temperature was 70.8 degrees Fahrenheit. Resident 14's room temperature was 70.3 degrees Fahrenheit. Resident 9 and 15's room temperature was not recorded. Resident 16's room temperature was 69.8 degrees Fahrenheit. Residents 17 and 18's room temperature was not recorded. Residents 8 and 19's room temperature was 72 degrees Fahrenheit. Residents 20 and 21's room temperature was 71.3 degrees Fahrenheit. Residents 3, 4, 22, and 23's room temperature was 69.3 degrees Fahrenheit. Residents 2, 24, 25, and 26's room temperature was 68.8 degrees Fahrenheit. Resident 27's room temperature was 72 degrees Fahrenheit. Resident 28's room temperature was 72.9 degrees Fahrenheit. Residents 1 and 5's room temperature was 70.8 degrees Fahrenheit. Resident 29's room temperature was 71.1 degrees Fahrenheit. Residents 30 and 31's room temperature was 70.6 degrees Fahrenheit. Residents 32 and 33's room temperature was 72.4 degrees Fahrenheit. Resident 34's room temperature was not recorded. Residents 35 and 36's room temperature was not recorded. Resident 37's room temperature was 72.1 degrees Fahrenheit. Resident 38's room temperature was 73.1 degrees Fahrenheit. On January 24, 2022, at 7:00 a.m., 8:00 a.m., 4:00 p.m., and 5:00 p.m., respectively, the following temperature were obtained by the facility staff: Residents 6, 7, 10, 11, and 12's room temperature was not recorded. Resident 13's room temperature was 68.7, 68.9, 72, 72.1 degrees Fahrenheit. Resident 14's room temperature was 68.3, 68.4, 71.8, 71.9 degrees Fahrenheit. Residents 9 and 15's room temperature was 68, 68.1, 71.4, 71.3 degrees Fahrenheit. Resident 16's room temperature was 68.4, 68.8, 71.4, 71.8 degrees Fahrenheit. Residents 17 and 18's room temperature was 66.4, 66.6, 67.4, 67.8 degrees Fahrenheit. Residents 8 and 19's room temperature was 70.1, 70.7, 68.8, 68 degrees Fahrenheit. Residents 20 and 21's room temperature was 68.8, 68.9, 72.1, 71.2 degrees Fahrenheit. Residents 3, 4, 22, and 23's room temperature was 68.3, 68.4, 71.3, 71.4 degrees Fahrenheit. Residents 2, 24, 25, and 26's room temperature was 68.1, 68.2, 706, 70.2 degrees Fahrenheit. Resident 28's room temperature was 70, 70.2, 72.4, 72.3 degrees Fahrenheit. Residents 1 and 5's room temperature was 68.3, 68.1, 70.3, 70.1 degrees Fahrenheit. Resident 29's room temperature was 71, 71, 71.7, 71.4 degrees Fahrenheit. Residents 30 and 31's room temperature was 69.3, 69.2, 69.8, 70 degrees Fahrenheit. Residents 32 and 33's room temperature was 70.1, 70.4, 72.3, 72.1 degrees Fahrenheit. Resident 34's room temperature was 67.5, 67.9, 67.9, 67.5 degrees Fahrenheit. Residents 35 and 36's room temperature was 69.7, 69.4, 71.3, 71.3 degrees Fahrenheit. Resident 37's room temperature was 70.3, 70.4, 74, 74.3 degrees Fahrenheit. Resident 38's room temperature was 70.3, 70.7, 71.4, 71.2 degrees Fahrenheit. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 27, 2022, at 9:01 a.m. revealed that there were two windows found open near the C wing on Saturday, January 22, 2022, which left the cold weather into the building and the furnace was not able to catch up. They called in an HVAC company who came to the building and determined that there was a leak in the main circulation pump. They turned the alternate circulation pump on at that time; however, it could not generate the necessary amount of heat needed to warm the C wing and resident rooms. They provided extra blankets for the resident's on the C wing. They stated that they offered for residents to move out of the C wing to different rooms for warmth; however, none moved. At 9:01 a.m. on January 27, 2022, it was -10 degrees Fahrenheit outside at the facility. The NHA stated that the furnace just could not keep up with the cold weather. They stated that they offered residents the opportunity to move, but none of them wanted to move. When asked why the residents were not moved off the C unit with low temperatures, they stated that there were not enough empty beds on the A wing because of the red zone where COVID-19 positive residents are housed. They could not mix COVID-19 positive and COVID-19 negative residents in the same rooms and therefore there would not be enough rooms for all the residents to be moved off the C wing. On January 27, 2022, at 1:07 p.m. the NHA was informed that the health and safety of the residents was placed in Immediate Jeopardy due to the lack of heat on the C unit and within the residents' rooms. The facility submitted and implemented an immediate action plan to ensure each resident's room temperature would be at or greater than 71 degrees Fahrenheit and that the residents would be comfortable. The plan included that the residents would be provided with extra blankets and offered to move to other rooms that may be warmer. The facility developed an education plan for all nursing staff to provide residents with diet appropriate warm liquids, warm showers, and that the doctor would be notified if any residents developed signs of hypothermia. The plan included that temperature checks would continue and that if a resident's room temperature would drop below 65 degrees Fahrenheit, the resident would be moved to a warmer room. The facility would obtain additional heating resources from a third party company and would engage the services of an HVAC company to determine how to fix the heating problem permanently. Interview with the NHA on January 27, 2022, at 6:15 p.m. included that temperature checks would continue and that if a resident's room temperature would drop below 65 degrees Fahrenheit, the resident would be moved to a warmer room somewhere in the building. The Immediate Jeopardy was lifted on January 28, 2022, at 2:05 p.m. after it was confirmed that the facility had provided the necessary education to staff to identify when residents would need to be moved to warmer rooms, to determine when emergency services needed to be initiated for heat in the building, and that the main heating source would be updated in order to function properly. The facility obtained four small and two large portable heaters that were placed on the C wing and temperatures in the residents' rooms reached 70 degrees Fahrenheit or above. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on clinical record reviews and staff interviews, it was determined that the facility failed to intervene in an attempt to prevent falls for one of 22 residents reviewed (Resident R5), resulting in a fall with a fractured hip. Findings include: A quarterly Minimum Data Set (MDS) assessment (a required assessment of a resident's abilities and care needs), dated May 30, 2015, indicated that Resident R5 required extensive assistance with transfers and ambulation (walking). The resident's care plan, dated March 29, 2015, indicated that the resident was at risk for falls, was to wear appropriate footwear, was non-compliant with the use of the call bell, and refused to ask for assistance. The care plan did not include interventions to address the resident's noncompliant call bell use and her refusal to ask for assistance. An incident report, dated May 14, 2015, revealed that Resident R5 got up unassisted, ambulated to the bathroom, and fell . The report indicated that the resident was not wearing non-skid socks (or other appropriate footwear) at the time of the fall and did not use her call bell to ring for assistance to go to the bathroom. The investigation revealed that the resident would get up on her own with the use of a cane and never rang for assisstance. There was no documented evidence that prior to the resident's fall on May 14, 2015, interventions were put into place in an attempt to prevent falls for the resident when she did not use the call bell and ambulated without assistance. A hospital record, dated May 14, 2015, revealed that Resident R5 had a fractured femur (hip). Interview with the Director of Nursing on September 10, 2015, at 2:45 p.m. confirmed that there were no interventions in place to address fall prevention when the resident would not use her call bell and ambulated unassisted. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 8/4/15, 2/19/15, 1/6/15, 11/5/14, 10/9/14.