Every finding on record at Southmont of Presbyterian Seniorcare

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance during care to prevent accidents which resulted in actual harm of a nondisplaced nasal bone (nose) fracture for one of five residents (Resident R1). This was identified as harm for past non-compliance.Findings include: Review of the facility policy Fall Risk Assessment Policy dated 11/21/25, indicated it is the policy of Presbyterian Senior Care Network to provide a safe environment. Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/7/26, indicated a diagnoses of cerebral infarct (stroke), hemiplegia right dominant side (paralysis right side of body), osteoporosis (weak fragile bones), and depression. Section C0500 indicated a Brief Interview for Mental Status (BIMS- is a screening test that aids in detecting cognitive impairment) score of 6 - severely impaired cognition. Section GG - Functional Abilities - Mobility, Question GG0170R indicated the resident was coded at a 01 dependent. Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident R1's care plan initiated 5/10/23, indicated the resident has an ADL (activities of daily living) deficit related to limited mobility. Resident is at risk for falls related to right side hemiplegia. The care plan goal indicated the resident will be free of falls, free of minor injury, and will not sustain serious injury (related to falls). Further review of Resident R1's care plan indicated an assist of one for bed mobility.The facility utilizes a whiteboard in each resident room. This is updated every shift at a minimum. This mechanism is used for resident care to include bed mobility, transfer status, adaptive equipment use, etc. Review of Resident R1's clinical record nursing progress note dated 6/3/26, at 10:35 p.m., indicated; alerted to residents' room by floor nurse with resident on the ground. States that CNA was doing care and resident rolled out of bed. Abrasion noted on bridge of nose, starting to bruise and slowly seeping blood. abrasions and swelling noted to forehead and right eye appears to be red and bruising. resident states that he feels sore. Medical provider called, video appointment was completed and orders received to send to hospital for evaluation. Further review of Resident R1's clinical record nursing progress note dated 6/4/26, at 4:15 a.m., indicated the hospital emergency department contacted the facility nursing staff, informing the resident will be transferred to another hospital. Resident R1returned to the nursing home from the hospital on 6/4/26, with a diagnosis that included a hairline nondisplaced nasal bone fracture. Review of NA Employee E1's signed witness statement dated 6/4/26, indicated, after completing care on Resident R1, I left him on his side towards the middle of the bed facing the door. I stated to the resident I was grabbing his brief and removed my hand from his side. As I was turning back with the brief, Resident R1 rolled off the bed. I immediately called for help. Review of the facility provided occurrence report indicated, NA Employee E1 had Resident R1 on his side to change his brief when he rolled out of bed. Resident was an assist of one for bed mobility. Resident interventions in place at the time of the fall, wide bed with bolsters, call light in reach, and low bed. Fall risk reassessed. Interview on 6/25/26, at 2:35 p.m. with NA Employee E1 indicated Resident R1 was rolled away from her onto his right-side and she turned away from the resident to reach for the brief and cream to compete the resident's care. NA Employee E1 confirmed, at the time she removed her hand away from the resident, turned her back to the resident, and was picking up the brief and cream on the chair behind her, was the moment Resident R1 rolled out of bed onto the floor. Review of NA Employee E1's personnel file indicated a hire date of 7/28/25, and Employee E1 received nurse aide training and competencies in the ability to provide care and identify safety hazards methods per the care plan, assisting with transfers, and transferring residents safely, completed on 7/28/25 with the most recent review date of 3/26/26 by NA Employee E1. On 6/4/26, the facility-initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) indicating the facility must ensure that; The resident environment remains as free from accidents hazards as is possible.-Each resident receives adequate supervision and assistance devices to prevent accidents. -Abuse and neglect. -Resident Mobility and Transfers.-Proper Bed Mobility Techniques.-Transfer Safety. This plan includes the following: -Immediate suspension of NA Employee E1.-Facility completed a full house audit to identify other residents who could benefit from a wider bed and who may benefit from a therapy screen for bed mobility. -Ongoing audits will be completed for two months, for all falls out of bed to evaluate equipment and therapy bed mobility evaluation. -Education was completed on 6/18/26, to all nursing staff on accidents, abuse and neglect.-Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes. During interviews on 6/25/26 from 10:00 a.m. to 2:50 p.m., the following was revealed: NA Employee E1 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. NA Employee E2 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. NA Employee E3 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs and completed the facility provided education. RN Employee E4 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. NA Employee E5 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. LPN Employee E6 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. NA Employee E7 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. RN Employee E8 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. LPN Employee E9 confirmed the use of the whiteboard when caring for residents to provide instruction for additional safety measures or any other needs, and completed the facility provided education. The facility has demonstrated compliance with the regulations since 6/18/26. During an interview on 6/25/26, at 3:00 p.m. with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance for the prevention of resident injury. During an interview on 6/25/26, at approximately 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain each resident received adequate supervision and assistance during care to prevent accidents which resulted in actual harm and was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents are free of significant medication errors for five of eleven residents reviewed (Resident R40, R59, R67, R69, and R113).Findings include: Review of the United States Food and Drug package insert for levothyroxine sodium (Synthroid, a synthetic thyroid hormone used to treat hypothyroidism, a condition where the thyroid gland does not produce enough T4) dated 12/2017, indicated: Administer once daily, preferably on an empty stomach, one-half to one hour before breakfast.Administer at least 4 hours before or after drugs that are known to interfere with absorption.Listed within the medications that interfere with levothyroxine absorption were:Proton-pump inhibitors - Gastric acidity is an essential requirement for adequate absorption of levothyroxine. Sucralfate, antacids and proton pump inhibitors may cause hypochlorhydria, affect intragastric pH, and reduce levothyroxine absorption. Review of the United States Food and Drug package insert for metolazone (diuretic water pill to treat fluid retention) dated 5/2019, indicated: Listed within the medications that interfere with levothyroxine absorption were:Furosemide (Lasix) and probably other loop diuretics given concomitantly (given at the same time) with metolazone can cause unusually large or prolonged losses of fluid and electrolytes. Review of facility policy Resident Directed Medication Administration dated 11/21/25, indicated that prescribed medications are administered safely, accurately, and in accordance with good nursing practice. Additionally, the policy indicated: SYNTHROID - Upon wakening on an empty stomach a minimum of 30 minutes prior to meal.Exceptions: Medications that must be given on a set schedule / specific time. Review of the clinical record indicated Resident R113 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/13/26, included diagnoses of hypothyroidism and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a physician's order dated 9/20/24, indicated Resident R113 was to receive levothyroxine 50 mcg, by mouth in the morning for hypothyroidism **Give before breakfast** During a medication administration observation on 5/21/26, at 8:25 a.m. Licensed Practical Nurse (LPN) Employee E2 was observed to provide Resident R113 her levothyroxine dose. LPN Employee E2 brought the medications to Resident R113 in her room, while Resident R113 was actively eating her breakfast. During an interview on 5/21/26, at 8:30 a.m. LPN Employee E1 confirmed that Resident R113's levothyroxine was ordered to be given at 7:00 a.m. Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE]. Review of the MDS dated included diagnoses of lymphedema (the build-up of fluid in soft body tissues) and a thyroid disorder. Review of a physician's order dated 5/6/26, indicated Resident R113 was to receive levothyroxine 50 mcg, one time a day for hypothyroidism. This order was specifically timed to be given at 7:00 a.m. Review of the Medication Admin Audit Report (documents orders and actual times provided for medications) for 5/21/26, revealed that Resident R113's levothyroxine was documented as given at 8:24 a.m. Review of the clinical record indicated Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's MDS dated [DATE], indicated diagnoses of hypogammaglobulinemia (immune system disorder characterized by abnormally low levels of immunoglobulins (antibodies) and a seizure disorder. The MDS did not include information regarding hypothyroidism / low-functioning thyroid gland. Review of a physician's order dated 7/26/25, indicated Resident R69 was to receive levothyroxine 75 mcg at 7:00 a.m. Review of a physician's order dated 7/26/25, indicated Resident R69 was to receive omeprazole (a protein-pump inhibitor) 40 mg at 7:00 a.m. Review of the Medication Admin Audit Report for 5/21/26, revealed that Resident R69 was provided both levothyroxine and omeprazole were documented as administered at 10:03 a.m. Review of the clinical record indicated Resident R59 was admitted to the facility on [DATE]. Review of Resident R59's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of a physician's order dated 7/26/25, indicated Resident R59 was to receive metolazone 5 mg at 7:00 a.m. on Monday, Wednesday, and Friday. Review of a physician's order dated 7/26/25, indicated Resident R59 was to receive bumetanide (a loop diuretic) 2 mg at 7:00 a.m. Review of the Medication Admin Audit Report for 5/20/26, revealed that Resident R59 was provided both metolazone and bumetanide were documented as administered concomitantly at 8:12 a.m. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure) and heart failure. Review of a physician's order dated 7/26/25, indicated Resident R67 was to receive metolazone 2.5 mg at 7:00 a.m., Give 30 minutes BEFORE giving AM Lasix dose. Review of a physician's order dated 7/26/25, indicated Resident R67 was to receive furosemide ( Lasix, a loop diuretic) 10 mg at 7:00 a.m. Review of the Medication Admin Audit Report for 5/21/26, revealed that Resident R67 was provided both metolazone and furosemide were documented as administered concomitantly at 8:35 a.m. During an interview on 12/18/25, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents are free of significant medication errors for five of eleven residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k) Pharmacy Services.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for three of eight sampled residents (Residents R1, R74, and R111).Findings include: Review of the facility policy Changing Nasal Cannulas and Masks reviewed on 11/21/25, with a prior review date of 11/21/24. The policy indicates, All residents who are receiving oxygen therapy shall have masks and nasal cannula tubing changed weekly and/or PRN. Review of Resident R1's admission record indicated he was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/27/26, indicated the diagnoses of respiratory failure (lungs cannot provide enough oxygen or remove enough carbon dioxide), schizophrenia (serious mental health condition affects thinking, feelings, and behavior), and seizure disorder (sudden disruptions of the brain's normal electrical activity). Review of Resident R1's current physician orders dated 2/24/26, indicated oxygen equipment, tubing and humidifier change once a day every Sunday. Resident is on 2 liters per minute of oxygen. Review of Resident R74's admission record indicated he was originally admitted on [DATE]. Review of Resident R74's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/7/26, indicated the diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), heart failure (the heart is unable to pump enough blood to meet the body's need for blood and oxygen), and hypertension (high blood pressure). Review of Resident R74's current physician orders dated 3/25/26, indicated oxygen equipment, tubing and humidifier change once a day every Sunday. Resident is on 2 liters per minute of oxygen. Review of Resident R117's admission record indicated he was originally admitted on [DATE]. Review of Resident R117's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/16/26, indicated the diagnoses of chronic obstructive pulmonary disease (COPD progressive lung disease limiting airflow to the lungs), heart failure (the heart is unable to pump enough blood to meet the body's need for blood and oxygen), and hypertension (high blood pressure). Review of Resident R74's current physician orders dated 4/27/26, indicated oxygen equipment, tubing and humidifier change once a day every Saturday. Resident is on 2 liters per minute of oxygen. Interview and observations on 5/19/26, at approximately 9:00 a.m. to 9:30 a.m., with Registered Nurse (RN) Employee E1, confirmed Resident's R1, R74, and R117 were observed, with oxygen tubing connected to their oxygen concentrator, the tubing had not been labeled and dated. During an interview on 5/19/26, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident rights for one of three residents (Resident R149).Findings include: Review of the Resident Rights policy last reviewed 11/21/25, indicated residents have the right to exercise their rights as a resident of the community and as citizen. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of Resident R149's clinical record indicated admission to the facility on [DATE]. Review of Resident R149's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated diagnoses of heart failure (heart muscle is unable to pump enoughblood to meet the body's need for blood and oxygen), hypertension (high blood pressure), and depression (feelings of sadness and loss of interest in activities) a BIMS of 14. Review of Section GG: Functional Abilities GG0170 mobility is dependent on staff for transfers and moving from one location to another. During an interview with Resident R149 on 5/19/25 at approximately 9:30 a.m., the resident expressed concerns over staff not making arrangements for her to go outside to smoke when she requests. Residet I understand I have to wait until staff is available, there is no set time schedule for smoking, a lot of days they just don't take me out even though I ask. It's frustrating I don't make a fuss, though I really would like to go out and smoke. Review of Resident R149's care plan dated 4/10/26 indicated Instruct resident about the facility policy on smoking: locations, times, safety concerns. During an observation and an interview on 5/20/26 at 10:45 a.m., with Resident R149 and the NHA. The resident stated again that she asks the staff if she can be taken out to smoke, the staff response is wait until we can get someone to take you, it's raining, or it's dark there is always some reason the staff can't do it. I have to wait until my daughter visits; she takes me out to smoke. The resident was asked when the last time the staff had taken her out to smoke, she was unable to recall a date when the staff last took her out to smoke. The resident stated that in the prior week, she recalls asking staff to take her out to smoke and the staff had not taken her out to smoke. During an interview on 5/20/26, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that care was provided in a manner which maintained resident rights. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility policies and documents, clinical record reviews, and staff interview, it was determined the facility failed to provide adequate supervision during transfer to prevent injury which resulted in the actual harm to Resident R1 of a leg fracture for one of five residents. This was identified as harm for past non-compliance. Findings include: Review of facility policy titled, Skilled Nursing-Lifting and Transferring Residents dated 11/20/24, revealed the facility will minimize the risk of injury to residents and transfer residents as safely as possible. Physical therapy will evaluate and recommend transfer status and the physician will obtain an order specifying resident transfer status. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Minimum Data Set assessment (MDS, periodic assessment of resident care needs) dated 8/8/25, included diagnoses of Arthritis and high blood pressure. Review of Section G: revealed Resident R1 was dependent (requiring assist of two helpers) for transfer from sit to stand. Resident R1 is alert and oriented and able to make needs known. Review of Resident R1's physician order dated 5/12/25, revealed Resident R1 required an assist of two staff members for toileting/transfers. Review of Resident R1's plan of care for ADL (activities of daily living) Self Care performance deficit-related to arthritis dated 10/11/24, requires resident to have an assist of two (staff members) for toileting. Review of Resident R1's progress note dated 10/22/25, revealed Resident R1 complained of pain in left lower leg/ankle. The resident stated the staff transferred [Resident] the last two nights and [he/she] bumped [his/her] leg on something. New orders obtained for x-ray scan for LEE (left lower extremity). Review of Resident R1's x-ray report dated 10/22/25, revealed Resident R1 sustained a fracture to the left distal fibula. Review of facility incident report dated 10/23/25, revealed Resident R1 complained of left lower leg pain with weight bearing subsequently x-ray was ordered. Review of NA (Nurse Aide) Employee E1's written statement dated10/22/25 revealed, I took the resident to the bathroom and put [him/her] on the bedside commode. The resident stated to be careful of my leg, and [Resident] was in pain. I hurt [Resident] when I took [him/her] to the bathroom. Review of NA Employee E1's personnel file indicated a hire date of 7/14/25, and Employee E1 received nurse aide training and competencies in the ability to confirm appropriate transfer methods per the care plan, assisting with transfers, and transferring residents safely, completed on 8/28/25. Review of facility documentation dated 10/21/25, for Investigation of Alleged Abuse, Neglect, Misappropriation of Property submitted 10/23/25 revealed Employee E1 attempted to transfer Resident R1 without an assist of two persons deemed safety required and was subsequently terminated. During an interview on 11/12/25, at approximately 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide sufficient supervision to prevent injury which resulted in the actual harm of a leg fracture for Resident R1. On 10/23/25, the facility-initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure that ordered transfer guidelines were understood and followed appropriately. This plan includes the following: -Immediate termination of NA Employee E1.-Facility completed a full house audit to ensure correct transfer statuses were documented for each resident.-Education was provided on 10/23/25, to all nursing staff on abuse and neglect.-Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes. During interviews on 11/12/25 from 10:40 a.m. to 2:30 p.m., the following was revealed: NA Employee E2 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E3 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E4 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E5 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E6 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/32/25. NA Employee E7 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E8 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E9 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E10 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E11 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E13 confirmed the use of the white when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E12 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E13 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E14 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E15 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. NA Employee E16 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E17 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E18 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E19 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E20 confirmed the use of orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E21 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E22 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E23 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E24 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E25 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. During interviews on 11/12/25, (NA Employees E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, and E16), confirmed they received point of care training on 10/23/25, for safe transfers. The facility has demonstrated compliance with the regulations since 10/23/25. During an interview on 11/12/25, at 3:00 p.m. with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident injury. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a left distal fibula (lower leg above the ankle) fracture for one of five residents reviewed (Resident R1). This was identified as harm for past non-compliance.Findings include: Review of facility document entitled, Corporate Compliance-Abuse Neglect dated 11/20/24, revealed neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated 8/8/25, included diagnoses of Arthritis, High Blood Pressure, Depression, and Osteoporosis (decrease in the amount of bone tissue). Resident R1 is alert and oriented and able to make needs known. Review of the MDS assessment dated [DATE], Section GG: Functional Abilities, Section GG0170 revealed Resident R1 was dependent on staff for bed to chair transfer. Review of Resident R1's plan of care for ADL (activities of daily living) Self Care performance deficit-related to arthritis dated 10/11/24, requires resident to have an assist of two staff for toileting. Review of Resident R1's [NAME] Board (listing of ADLs, continence levels, and behaviors, which generates directly from the resident care plan) utilized by nurse aide staff dated 10/20/25, revealed Resident R1 requires two or more staff helpers for transfers. Review of Resident R1's progress note dated 10/22/25, revealed Resident R1 complained of pain in left lower leg/ankle. The resident indicated the staff transferred [him/her] the last two nights and [resident] bumped [his/her] leg on something. New orders for x-ray to LEE (left lower extremity). Review of facility incident report dated 10/23/25, revealed the resident complained of left lower leg pain with weight bearing and an x-ray was ordered. Review of Resident R1's x-ray report dated 10/22/25, revealed Resident R1 sustained a fracture to the left distal fibula. Review of CNA (Certified Nurse Aide) Employee E1's statement dated 10/22/25 indicated I took the resident to the bathroom and put [Resident] on the bedside commode. The resident stated to be careful of my leg and was in pain. I hurt [Resident] when I took [Resident] to the bathroom. Review of CNA Employee E1's personnel file revealed a hire date of 7/14/25, and Employee E1 received CNA training and competencies in the ability to confirm appropriate transfer methods per the plan of care, assisting with transfers, and transferring residents safely, completed on 8/28/25. Review of the facility report submitted on 10/23/25, for Investigation of Alleged Abuse, Neglect, Misappropriation of Property revealed Employee E1 attempted to transfer Resident R1 without an assist of two persons as required and was terminated. During an interview on 11/12/25, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to protect a resident from neglect that resulted in actual harm for one of six residents which resulted in actual harm of a fractured left fibula to Resident R1. On 10/23/25, the facility-initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure ordered transfer guidelines were understood and followed appropriately. This plan included the following: -Immediate termination of NA Employee E1.-Facility completed a full house audit to ensure correct transfer status was documented for each resident.-Education was provided on 10/23/25, to all nursing staff on abuse and neglect.-Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes. During interviews on 11/12/25 from 10:40 a.m. to 2:30 p.m., the following was revealed: CNA Employee E2 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E3 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E4 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E5 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E6 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/32/25. CNA Employee E7 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E8 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E9 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E10 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E11 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E13 confirmed the use of the white when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E12 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E13 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E14 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E15 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. CNA Employee E16 confirmed the use of the white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E17 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E18 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E19 confirmed the use of the orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E20 confirmed the use of orders and white board when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Licensed Practical Nurse (LPN) Employee E21 confirmed the use of the orders and white bvoard when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E22 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E23 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E24 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. Registered Nurse (RN) Employee E25 confirmed the use of the orders when caring for residents to provide instruction for additional safety measures or any other needs, and facility education provided on 10/23/25. During interviews conducted on 11/12/25, (CNA Employees E2, E3, E4, E5, E6, E7, E8, E9, E10, E11, E12, E13, E14, E15, and E16), confirmed they received point of care training on 10/23/25, for bed mobility and safe transfers. The facility has demonstrated compliance with the regulations since 10/23/25. During an interview on 11/12/25, at 3:00 p.m. with the Nursing Home Administrator and Director of Nursing, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified the facility had implemented a plan of correction and achieved compliance ensuring the prevention of resident neglect. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make grievance boxes accessible to residents on four of four locations, nursing units (three, four and five) and main lobby. Findings include: A review of the facility policy Skilled Nursing-Grievance Policy Form and Log reviewed 11/20/24. Grievances may be submitted orally or in writing. These may be anonymous. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertain to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During rounds on 4/21/25, at approximately 10:30 a.m., Employee E1 social worker and surveyor observed and measured the height of the grievance boxes. Employee E1 social worker confirmed on the third, fourth, fifth floor nursing units, and main lobby, the grievance boxes were not accessible. Three of three nursing units (third, fourth and fifth) grievance boxes were blocked by equipment. The grievance box on the third-floor nursing unit had been mounted at approximately 59 inches and the lobby box at approximately 52 inches above the floor, out of the reach of residents in wheelchairs. During an interview, on 4/21/25, at 12:20 p.m., the Nursing Home Administrator confirmed the facility failed to make grievance boxes accessible to residents on four of four locations, nursing units (three, four and five) and main lobby. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of three residents reviewed (Resident R6). Findings include: Review of the facility policy Skilled Nursing - Dialysis Communication reviewed 12/16/24, indicated a dialysis communication binder will be initiated and utilized for all residents receiving dialysis. Section A to be completed by the nurse on duty prior to the transfer to the dialysis center. Section B to be completed by the dialysis center. Section C to be completed by the nurse on duty at the time of residents return to the facility. Review of the clinical record indicated Resident R6 was readmitted to the facility on [DATE], with diagnoses that included end-stage renal disease (ESRD - the kidneys permanently fail to work),dependence on renal dialysis, and diabetes. Review of the Minimum Data Set (MDS - periodic assessment of care needs) date 3/5/25, indicated the diagnoses remain current. Review of a physician ' s order dated 2/14/25, indicated Resident R6 was to receive dialysis three days a week on Monday, Wednesday, and Friday. Review of a care plan dated 6/7/23 and 7/31/23, indicated the following interventions: - Monitor vital signs before and after dialysis, notify doctor of any abnormalities. - Encourage the resident to go for the scheduled dialysis appointments. - Nursing will assess for pain over access area. - Nursing will assess for presence of adequate blood flow daily. Review of the dialysis communication forms from January 2025 through April 2025, revealed 17 communication forms out of 47 not fully completed either by the dialysis center, or after the residents return to the facility. During an interview on 4/24/25, at 011:30 a.m. the Assistant Director of Nursing (ADON) Employee E confirmed the facility failed to ensure the dialysis communication form was completed pre and post treatment between the facility and dialysis center. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on observations and staff interview, it was determined the facility failed to post contact information for Adult Protective Services (APS) as required, in the building. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 4/21/25, at approximately 10:30 a.m., on the third, fourth, fifth floor nursing units, and main lobby, revealed the facility did not have any elements of the APS contact information (agency name, address, email, and phone number) information posted or accessible to residents or resident representatives. During rounds on 4/21/25, at 10:30 a.m., Employee E1 social worker, confirmed that the APS contact information, was not posted in areas accessible to residents or resident representatives. During an interview, on 4/21/25, at 12:20 p.m., the Nursing Home Administrator, confirmed the facility failed to post contact information for Adult Protective Services (APS) as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Skilled Nursing - Elopement dated 12/16/24, indicated that those who have been diagnosed with dementia are at increased risk. Review of the clinical record revealed Resident R1 was originally admitted to the facility on [DATE]. Review of the referral received from the hospital, dated 12/9/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of an Elopement Observation assessment completed on 12/11/24, at 9:52 p.m. indicated Resident R1 was not at risk for elopement. Review of facility submitted information dated 12/13/24, indicated, On 12/13/24 therapist brought Resident R1 back from therapy to the South Hall nurses' station on the 3rd floor. Shortly after staff heard her chair alarm sounding and began looking for Resident R1. The staff continued searching for about 10 minutes until our supportive housing apartments located on campus, called and said that she had walked over to their building. Resident R1 had her purse, coat and shoes with her. She said she was trying to catch the bus. Resident R1was brought back to [the facility]. Vitals were taken and an assessment was completed all indicating that Resident R1 was ok. A wander guard (electronic monitoring bracelet) was added to Resident R1, and she is being moved to the 5th floor so the doors to the lobby will not be as accessible. Resident R1 had an elopement score on admission of 0 (indicating not an elopement risk). Another elopement risk assessment will be completed. On 12/13/24, the facility initiated a plan of correction that included: -A second elopement risk assessment was completed. -A Wanderguard was placed on Resident R1. -Resident R1 ' s care plan was updated. -Elevator and front door Wanderguard alarms were rechecked for functionality. -Reeducation of staff on the elopement policy and upkeep of the elopement binders. -Monthly audits to be completed for three months to ensure at risk residents have proper Wanderguards, orders, care plans, and information placed in the elopement binder. -Results will be brought to QAPI (Quality Assurance and Performance Improvement committee) for review. Review of Resident R1's clinical record on 1/2/25, revealed the elopement assessment and care plan were updated to include information on her attempted elopement, risk for further elopement, and interventions. During four interviews on 1/2/25, staff confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview on 1/2/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision to prevent elopement for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to implement effective safety measures by not providing hot liquids in a manner that promotes safety for one of four residents reviewed (Resident R78), which resulted in actual harm of a second degree burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for past non-compliance for one resident (Resident R78). Findings include: Review of the facility policy Investigating Adverse Events last reviewed, November 2023, indicated the facility will implement measures for residents at risk for accidents to prevent serious injury when possible. A review of the clinical record revealed that Resident R78 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, dementia, and chronic kidney disease. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 4/3/24, indicated that Resident R78 had moderately impaired cognitive ability and required extensive assist of one person for eating. A review of a nurse progress note dated 5/11/24, indicated resident R78's right upper thigh was noted to have blistering. The family and physician was notified. A review of an incident report dated 5/13/24, indicated Resident R78 had redness and blistering noted to right upper thigh, noted to be a possible burn. A review of a facility witnesses statements dated 5/12/24 and 5/13/24, indicated the following: Nursing Assistant (NA) Employee E1 indicated resident grabbed the bowl of soup off the dinner table and it ended up on the floor and in [resident] lap. NA Employee E2 indicated heard silverware and plate hit the floor, [resident] had knocked [resident's] food over, didn't see it on her clothes, was on her blanket and floor. A review of a physician order dated 5/12/24, indicated cleanse right thigh blister with saline solution, apply adaptic (non adhering wound dressing) to blister and cover with gauze and wrap with kling (dry dressing) wrap. A review of a wound progress note dated 5/14/24, indicated Resident R78 had a fluid-filled blister on top of right thigh measuring 5.5 centimeters (cm) in length and 5 cm in width. A review of a kitchen temperature log report dated 5/10/24, indicated the soup was served at 184 degrees Fahrenheit. A review of resident's care plan date initiated 6/29/23, indicated Resident R1 is to be offered mugs with lids to prevent burns due to history of Parkinson's disease. During a telephone interview on 5/30/24 at 2:08 p.m., NA Employee E1, revealed the soup was placed in middle of table and was uncovered. During an interview on 5/28/24 at 9:30 a.m., The Nursing Home Administrator (NHA) revealed Resident R1 is dependent on staff for eating. On 5/10/24, Resident R78 was set up at table and hot soup was placed in the middle of table when resident grabbed for soup and pulled soup onto lap and floor. The NHA confirmed that the facility failed to implement effective safety measures by not providing hot beverages in a manner that promotes safety for Resident R78, which resulted in actual harm of a second-degree burn. This deficiency is cited as past non-compliance. The facility provided documentation of in-service training that was provided to the dietary staff, including Registered Nurses, Licensed Practical Nurses, and Nurse Aides, at the facility on 5/20/24, which addressed following the facility policy and procedures for abuse neglect and serving hot beverages. The facility reviewed like residents for non-compliance with hot beverages and meal service on 5/20/24, and audited all residents' meals for accuracy daily times five days, and to continue weekly times three weeks, and monthly time two months thereafter. The facility has adjusted employee workflow's to allow for increased supervision of the dining area while meals are being served. Protective aprons have been ordered for residents in the dementia unit in case of spills of hot liquids. A review of the QA (Quality Assurance) documentation indicated substantial compliance for serving hot beverages has been achieved 5/20/24 and is ongoing. During interviews with staff on 5/30/24, from 2:00 p.m. through 1:35 p.m. revealed NHA, DON, NA Employee E1, and NA Employee E2 confirmed proper procedure for serving hot beverages. During interviews with Nurse Aide staff on duty on 5/30/24 from 2:00 p.m. through 2:35 p.m. confirmed proper procedures for serving hot beverages. During an interview on 5/28/24, at 9:30 a.m. with the NHA, and review of the facility's immediate actions, education, and review of the QA monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance on 5/20/24, which ensured residents are provided hot liquids in a manner that promotes safety. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 28 Pa Code: 211.10 (c)(d) Resident care policies. 28 Pa Code: 211.11 Resident care plan.

Based on a review of policy, observations and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to properly label and date food products in the walk in coolers creating the potential for unsafe conditions and the potential for cross contamination in the main kitchen and in two of three kitchenettes(4th and 5th floor kitchenettes). Findings include: A review of the facility Dietary- Sanitation, dated 11/20/23, indicated that the food service area will be maintained in a clean and sanitary manner. During an observation on 5/29/24, at 9:29 a.m. the following was observed in the Main Kitchen: In cooler #1 2 staff lunch bags a piece of an aloe plant undated opened mayo, 2 water bottles, a chocolate syrup a beverage dispenser with a red liquid undated. Cooler #2 Fans had white splotches, supposed mold on both fans Cooler #3 bag of chicken tenders and potatoes undated During an interview on 5/29/24 at 9:45 a.m., Director of Dietary Employee E5 confirmed the facility failed to properly label and date food products and maintain kitchen equipment as required. During an observation of the 5th floor kitchenette on 5/29/24, at 11:00 a.m., the following was observed: Gnats flying all cabinets handles sticky lower freezer has ice build up, possible seal not functioning. cabinets have food debris dried bread and buns moldy cabinet with one bottle of ketchup, two mustards, one relish and chocolate syrup undated when opened. During an observation of the 4th floor kitchenette on 5/29/24, at 11:15 a.m., the following was observed: Gnats flying cabinets sticky cabinets soiled with food debris, bowls not stored properly lower freezer has ice build up During an interview on 5/29/24, at 11:39 a.m., the Nursing Home Administrator confirmed that the facility failed to maintain the kitchenettes of the 4th and 5th floors in a sanitary manner allowing for the potential for cross contamination. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c)Dietary services. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of three residents (Residents R27 and R35). Findings include: Review of the facility policy Abuse Investigation/reporting Procedure, last reviewed 11/20/23, indicated that if the facility suspects alleged violations of abuse, neglect, exploitation or mistreatment(including injuries of unknown origin), the facility immediately conducts an investigation including interviews, observations and notification of necessary persons. The facility protects he resident(s) involved. Review of the clinical record indicated that Resident R27 was admitted to the facility on [DATE], with diagnoses which included heart failure, kidney failure, a stroke with right sided hemiplegia. A MDS ( Minimum Data Set- a periodic review of resident care needs) dated 5/3/24, indicated the diagnoses remained current. Review of an incident report dated 5/12/24, indicated that while staff were transporting the resident from the bathroom, staff bumped Resident R27's elbow on the doorframe causing a 1 cm x 1 cm skin tear. The treatment indicated a tegaderm(a clear, adhesive plastic dressing) was applied. Review of a progress note dated 5/29/24, indicated that the wound worsened to 2.7 c.m. x 1.7 c.m. requiring a Xeroform dressing( A non adherent dressing). Review of the clinical record indicated that Resident R35 was admitted to the facility with diagnoses which included dementia, difficulty walking, restless leg syndrome, anxiety and diabetes. A MDS dated [DATE], indicated the diagnoses remained current. Review of the physicians order summary indicated Resident R35 is a transfer with two assist. Review of an incident report indicated that while Resident R35 was being transferred with assistance of one staff, she obtained a skin tear of her left forearm when it hit into a walker. The incident report indicated a skin flap needed to be placed before a treatment was applied. An additional page attached to the incident report identified as skin tear/bruise check list indicated the area as a bruise measuring 7.5 cm x 2.5 cm. During an interview on 5/29/24, at 1:22 p.m. the Director of Nursing confirmed that the facility failed to identify, investigate and report potential neglect for two of three residents. 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 clinical records and staff interviews, it was determined the facility failed to provide person-centered care consistent with professional standards of practice by failing to follow physician orders for proper transfer of one of three residents(Resident R35) causing an injury. Findings included: Review of the clinical record indicated that Resident R35 was admitted to the facility with diagnoses which included dementia, difficulty walking, restless leg syndrome, anxiety and diabetes. A MDS(Minimum Data Set- a periodic review of resident care needs) dated 5/14/24, indicated the diagnoses remained current. Review of the physicians order summary indicated Resident R35 is a transfer with two assist. Review of an incident report indicated that while Resident R35 was being transferred with assistance of one staff, she obtained a skin tear of her left forearm when it hit into a walker. The incident report indicated a skin flap needed to be placed before a treatment was applied. An additional page attached to the incident report identified as skin tear/bruise check list indicated the area as a bruise measuring 7.5 cm x 2.5 cm. During an interview on During an interview on 5/29/24, at 11:45 a.m., Nurse Aide Employee E3 stated that she followed the Southmont 5th Floor Need to Know Care Sheet while transferring Resident R35 as that is how the staff provide care. The nurse aide staff do not have computer access. During an interview on 5/29/24, at 2:50 p.m., the Nursing Home Administrator(NHA) stated that the facility Nurse Aides(NA) do not have access to kardex at this time. Stated that when a physician order is changed on the Care Sheet is to be updated by the unit secretary. Resident R35's care sheet transfer status had not been changed as the night nurse who took the order off did not update the sheet. During an interview on 5/29/24, at 1:22 p.m. the Director of Nursing confirmed that the facility failed to fully investigate and review the incident and the information was not accurate on some of the report and the facility did not provide the Nurse Aide with the correct transfer order and the facility failed to provide person-centered care consistent with professional standards of practice by failing to follow physician orders for proper transfer of one of three residents causing an injury. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility to make certain that medical supplies were properly stored and/or disposed of on one of two nursing units (Third Floor Nursing Unit). Findings include: During an observation on [DATE], at 10:50 a.m., the third floor emergency cart identified the following expired items: 5- [NAME] suction tubing kits, dated [DATE] 3- intravenous catheter start kits, dated ,d+[DATE] 2- intravenous luer lock kits dated ,d+[DATE] 1- nasal cannula oxygen tubing kit dated ,d+[DATE] 2- 100 cc saline bottles for oxygen use dated [DATE] During an interview on [DATE], at 11:30 a.m., Registered Nurse Supervisor Employee E4 confirmed the facility failed to properly dispose of expired emergency cart biologicals. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 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, observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for four out of eleven sampled residents (Residents R16, R17, R39, and R48). Findings include: Review of the facility's policy Self-Administration of Medication last reviewed November 2022, indicated residents in the facility who wish to self-administer medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. The practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set assessment (MDS- a periodic assessment of care needs) dated 3/23/23, indicated a Brief Interview for Mental Status (BIMS- a screening test that aides in detecting cognitive impairment) of 11 indicating moderate impairment, and the diagnoses of high blood pressure, falls, and hyperlipidemia (too much fat in the blood). Review of Resident R39's physician orders failed to include an order for self-administration of medications. Review of Resident R39's care plan on 5/22/23 failed to include self-administration of medication management. Review of Resident R39's clinical record indicated the absence of a Self-Administration of Medication assessment. Observation of Resident R39's overbed table on 5/22/23, at 10:02 a.m. revealed a container of ocean nasal spray (treats dryness in the nose) and Visine eye drops (moisturizes the eye). Review of the admission record indicated Resident R17 admitted to the facility on [DATE]. Review of Resident R17's MDS dated [DATE], indicated Section C1000 Cognitive skills for daily decision making as severely impaired (never/rarely made decisions) and the diagnoses of high blood pressure, hyperlipidemia and heart failure (heart doesn ' t pump blood as well as it should). Review of Resident R17's physician orders failed to include an order for self-administration of medications. Review of Resident R17's care plan on 5/22/23 failed to include self-administration of medications management. Review of Resident R17's clinical record indicated the absence of a Self-Administration of Medication assessment. Observation of Resident R17's overbed table on 5/22/23, at 11:56 a.m. revealed a container of Systane eye drops (moisturizes the eye). Review of the admission record indicated Resident R16 admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated a BIMS of ten indicating moderate impairment and the diagnoses of high blood pressure, hyperlipidemia, and anemia (the blood doesn ' t have enough health red blood cells). Review of Resident R16's physician orders failed to include an order for self-administration of medications. Observation of Resident R16's overbed table on 5/22/23, at 11:59 a.m. revealed a container of ocean nasal spray. Review of the admission record indicated Resident R48 admitted to the facility on [DATE]. Review of Resident R48's MDS dated [DATE], indicated a BIMS of 13, indicating cognition is intact and the diagnoses of high blood pressure, heart failure, and diabetes (too much sugar in the blood). Review of Resident R48's physician orders failed to include an order for self-administration of medications. Review of Resident R48's care plan on 5/22/23 failed to include self-administration of medication management. Review of Resident R48's clinical record indicated the absence of a Self-Administration of Medication assessment that included use, storage and management of lancets (sharp needle used for finger sticks of diabetic residents). Observation of Resident R48's bed area on 5/22/23, at 12:05 p.m. revealed a container of lancets. During a tour with Assistant Director of Nursing (ADON) Employee E1 on 5/22/23, at 12:17 p.m. confirmed the above medications at bedside and that the facility failed to determine the ability to self-administer medications for four of eleven residents reviewed (Residents R16, R17, R39, and R48). 28 Pa. Code 211.10 c (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of 13 Residents (Residents R5, R67, R111, and R123). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility Hypoglycemia policy last reviewed 11/20/22, indicated the facility will recognize, and treated properly, hypoglycemia is defined as blood glucose less than 70 even in the absence of obvious signs and symptoms, the blood glucose will be rechecked in 15-30 minutes, and to document CBGs and treatments. A review of the facility Change in Resident's Condition or Status policy last reviewed 11/20/22, indicated the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident ' s medical/mental condition and/or status, if there is a need to alter the resident's medical treatment, and the Nurse Supervisor/Charge Nurse will record in the resident ' s medical record information relative to changes in the resident's medical/mental condition or status. Review of the medical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure (progressive heart disease that affects pumping action of the heart muscles causing fatigue, and shortness of breath), and depression. Review of Resident R5's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 3/30/23, indicated the diagnoses remain current. Review of a physician order dated 12/15/21, indicated to inject 70 units of Toujeo (a long-acting insulin) every 12 hours for diabetes. A physician order dated 3/2/22, indicated to check CBG as needed per hypoglycemic protocol. A physician order dated 12/12/22, indicated to inject Novolog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) per sliding scale. A physician order dated 12/28/22, indicated for glucometer checks at bedtime every night for monitoring, Review of Resident R5's clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 10/14/22, documented at 9:00 p.m., CBG was noted to be 406. On 10/16/22, documented at 9:00 p.m., CBG was noted to be 476. On 10/21/22, documented at 7:00 a.m., CBG was noted to be 480. On 10/23/22, documented at 9:00 p.m., CBG was noted to be 463. On 10/24/22, documented at 9:00 p.m., CBG was noted to be 519. On 10/25/22, documented at 9:00 p.m., CBG was noted to be 452. On 10/27/22, documented at 9:00 p.m., CBG was noted to be 488. On 10/31/22, documented at 9:00 p.m., CBG was noted to be 423. On 11/8/22, documented at 9:00 p.m., CBG was noted to be 498. On 11/11/22, documented at 7:00 a.m., CBG was noted to be 419. On 11/11/22, documented at 9:00 p.m., CBG was noted to be 470. On 11/13/22, documented at 9:00 p.m., CBG was noted to be 528. On 11/16/23, documented at 9:00 p.m., CBG was noted to be 443. On 11/18/22, documented at 9:00 p.m., CBG was noted to be 400. On 11/19/22, documented at 7:00 a.m., CBG was noted to be 450. On 11/21/22, documented at 9:00 p.m., CBG was noted to be 464. On 11/23/22, documented at 9:00 p.m., CBG was noted to be 473. On 11/24/22, documented at 9:00 p.m., CBG was noted to be 479. On 11/28/22, documented at 9:00 p.m., CBG was noted to be 494. On 11/29/22, documented at 7:00 a.m,. CBG was noted to be 485. On 12/4/22, documented at 9:00 p.m., CBG was noted to be 432. On 12/11/22, documented at 9:00 p.m., CBG was noted to be 446. On 12/21/22, documented at 7:00 a.m., CBG was noted to be 467. On 12/24/22, documented at 7:00 a.m., CBG was noted to be 443. On 1/5/23, documented at 9:00 p.m., CBG was noted to be 437. On 1/7/23, documented at 9:00 p.m., CBG was noted to be 428. On 1/26/23, documented at 9:00 p.m., CBG was noted to be 447. On 1/29/23, documented at 9:00 p.m., CBG was noted to be 463. On 1/31/23, documented at 9:00 p.m., CBG was noted to be 468. On 2/8/23, documented at 9:00 p.m., CBG was noted to be 513. On 2/9/23, documented at 9:00 p.m., CBG was noted to be 402. On 2/10/23, documented at 7:00 a.m., CBG was noted to be 403. On 2/10/23, documented at 5:00 p.m., CBG was noted to be 435. On 2/10/23, documented at 9:00 p.m., CBG was noted to be 411. On 2/11/23, documented at 7:00 a.m., CBG was noted to be 483. On 2/11/23, documented at 12:00 p.m., CBG was noted to be 535. On 2/11/23, documented at 5:00 p.m., CBG was noted to be 415. On 2/11/23, documented at 9:00 p.m., CBG was noted to be 460. On 2/17/23, documented at 9:00 p.m., CBG was noted to be 476. On 2/19/23, documented at 9:00 p.m., CBG was noted to be 482. On 2/26/23, documented at 9:00 p.m. CBG was noted to be 470. On 3/5/23, documented at 9:00 p.m., CBG was noted to be 445. On 3/14/23, documented at 9:00 p.m., CBG was noted to be 416. On 5/6/23, documented at 7:00 a.m., CBG was noted to be 412. On 5/6/23, documented at 11:00 a.m., CBG was noted to be 435. Review of Resident R5's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, and the physician was not notified of abnormal results on the above listed dates. Further review of the eMAR for November 2022, revealed on 11/18/22, at 9:57 p.m. the glucometer read ' HI ' indicating that sugar is too high to read. Review of the care plan dated 1/7/23, indicated nursing will assess/record/report to the physician any signs and symptoms of hypo/hyperglycemia, nursing will monitor/record/report results of lab/diagnostic work to the physician, nursing will check blood glucose as ordered and as needed, and to document in the resident ' s record. The facility was unable to access the care plan prior to 1/7/23. Review of a clinical record indicated Resident R67 was admitted to the facility on [DATE], with diagnoses that included diabetes, and depression. Review of Resident R67 ' s MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 10/14/21, indicated to check blood glucose before breakfast, without coverage. Review of Resident R67's eMAR revealed that the resident's CBG's were as follows: On 1/16/23, documented at 7:00 a.m., CBG was noted to be 517. On 4/2/23, documented at 7:00 a.m., CBG was noted to be 422. On 4/3/23, documented at 7:00 a.m., CBG was noted to be 412. On 5/16/23, documented at 7:00 a.m., CBG was noted to be 404 A review of Resident R67's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, interventions were not documented, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R67's care plan dated 4/6/20, indicated nursing will assess/record/report to the physician any signs and symptoms of hypo/hyperglycemia, nursing will monitor/record/report results of lab/diagnostic work to the physician, nursing will check blood glucose as ordered and as needed, and to document in the resident ' s record. Review of a clinical record indicated Resident R111 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of Resident R111's MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 8/9/22, indicated to inject Novolog insulin per sliding scale, if over 400 notify MD before meals and at bedtime. Review of Resident R111's eMAR revealed that the resident's CBG's were as follows: On 11/3/22, documented at 12:00 p.m., CBG was noted to be 416. On 11/8/22, documented at 12:00 p.m., CBG was noted to be 533. On 11/9/22, documented at 12:00 p.m., CBG was noted to be 550. On 12/5/22, documented at 12:00 p.m., CBG was noted to be 439. A review of Resident R111's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, interventions were not documented, and the physician was not notified of abnormal results on the above listed date. Review of a clinical record indicated Resident R123 was admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure, and depression. Review of Resident R123's physician order dated 4/18/23, indicated to inject Humalog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale and if over 400 call MD. Review of Resident R123's eMAR revealed that the resident's CBG's were as follows: On 5/17/23, documented at 8:00 a.m., CBG was noted to be 69. A review of Resident R123's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, interventions were not documented, blood sugar was not rechecked, and the physician was not notified of abnormal results on the above listed date. A review of Resident R123's care plan indicated to give diabetes medication as ordered by doctor, and monitor/document for side effects and effectiveness. During an interview on 5/25/23, at 9:50 a.m. Licensed Practical Nurse (LPN) Employee E5 stated for residents with no blood glucose parameters and a CBG under 70 she would implement the hypoglycemic protocol, and over 380, she would call the doctor, document, and recheck the CBG in 15-30 minutes. During an interview on 5/25/23, at 10:00 a.m. LPN Employee E8 stated for residents with no blood glucose parameters she would call the doctor is CBG was under 70 or over 400, she would notify the doctor, recheck the CBG in one hour, assess the resident, and document interventions and symptoms. During an interview on 5/25/23, at 10:06 a.m. Registered Nurse (RN) Employee E11 stated for residents with hyper-/hypoglycemia check the chart for parameters and if no parameters were listed, she would notify the doctor if blood glucose was under 70 or over 400. She would recheck in 15 - 30 minutes, assess the resident and document in the medical record. During an interview on 5/25/23, at 10:25 a.m. LPN Employee E14 stated she would check the doctor ' s orders, if no parameters ordered she would notify the doctor for blood glucose under 60 or over 400. She would assess the resident, give the ordered insulin, and document in the medical record. During an interview on 5/25/23, at 10:30 a.m. LPN Employee E15 stated for residents with no parameters for blood glucose she would notify the doctor if under 70 or over 300, re-check the blood glucose every 15 minutes, and document in the chart. During an interview on 5/10/23, at 9:22 a.m., RN Employee E18 stated for blood glucose under 70 or over 400 and no parameters she would call the doctor and document. During an interview on 5/10/23, at 1:35 p.m. the Assistant Director of Nursing Employee E1 confirmed the facility failed to document hypo/hyperglycemic episodes, failed to follow hypoglycemic protocols, and failed to notify the MD of changes in condition for Residents R5, R67, R111, and R123. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policies, documents, clinical records, and staff interview it was determined that the facility failed to make certain a resident was free from neglect for one of 11 residents (Resident R33). Findings include: The facility's Corporate Compliance-Abuse Neglect policy dated 5/5/17, last reviewed November 2022 indicated that every person in the network will be treated with consideration, respect, and full recognition of his/her dignity and individuality. All personnel are individually and jointly responsible to ensure persons are free from any form of abuse. The admission record indicated that Resident R33 was admitted to the facility on [DATE], with diagnoses that included depression, adjustment disorder with anxiety disorder, and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning.) Review of Resident R33's Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 12/16/22, indicated that these diagnoses are current. Review of the witness statement completed by Nursing Assistant (NA) Employee E29 dated 12/23/23 indicated when she arrived on the unit on the morning of 12/23/22, Employee E21 was sitting on the couch as Resident R33 was in the middle of the living room in her wheelchair with a wet pajama top on and a wet brief on. It was then indicated Employee E21 just laughed and said they've been up all night. It was stated that four residents were up and all worked up. It was indicated all residents were soiled this morning and a complete bed change was necessary. Review of the witness statement completed by NA Employee E23 dated 12/23/23 indicated when she arrived on the unit on the morning of 12/23/22, Employee E21 was sitting on the couch on his phone while Resident R33 was sitting in the middle of the living room with no pants or socks, only a wet brief and wet shirt. It was indicated the resident was sobbing for help and Employee E21 continued to sit on the couch on his phone while he laughed. It stated several patients were up and soiled and very upset, yelling and crying. Review of the witness statement completed by Registered Nurse (RN) Employee E2 dated 12/25/22, indicated NA Employee E20 and NA Employee E21 were in and out of Resident R33's room giggling and laughing. It was indicated Resident R33 stated she was locked in her room for an hour. Review of the witness statement completed by Licensed Practical Nurse (LPN) Employee E22 dated 12/25/22 for Resident R33, indicated Resident R33 stated two aides locked her in her room and no one would come. Review of the witness statement completed by the Director of Nursing dated 12/27/22 for Resident R33 indicated Resident R33 reported the same details almost word for word per the incident that she previously reported to LPN Employee E22. It was indicated even though Resident R33 has a diagnosis of dementia, she was very accurate on all the details she presented and her recollection of the incident never changed. During an interview on 5/23/22, at 1:50 p.m., the Assistant Director of Nursing confirmed the facility failed to protect one of three residents from neglect who was left soiled in brief (Resident R33). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.28(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record, facility investigative reports and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of mental abuse and/or neglect for one of four residents (Resident R48). Finding include: Review of the facility policy Corporate Compliance - Abuse/Neglect, Section III Response to allegation of abuse indicated that any witnesses will be instructed to describe the incident in full, use exact words and include a graphic description of the scene, positioning of alleged victim, personnel, and time etc. Review of the admission record indicated Resident R48 admitted to the facility on [DATE]. Review of Resident R48's MDS dated [DATE], indicated a BIMS of thirteen (cognitively intact) and the diagnoses of high blood pressure, heart failure, and diabetes (too much sugar in the blood). Review of facility investigation dated 9/23/22, at 10:30 a.m. indicated Resident R48 was not happy that the staff were showering her and said it was against doctors' orders. In Resident R48's bed staff found her personal belongings, old dried stool wrapped in wipes in her bed and old lancets. The mattress was removed due to sanitary reasons. Resident R48 feels she was being abused. Further review of facility investigation indicated that a thorough interview involving all staff members potentially involved was not completed. The facility investigation had a witness statement from one aide, Nursing Assistant (NA) Employee E28, regarding the events on 9/23/23 surrounding the shower. During an interview on 5/26/23, at 1:30 p.m. the Assistant Director of Nursing confirmed the investigation lacked a thorough list of all staff who should have been interviewed during the investigation and that the facility failed to thoroughly investigate Resident R48's allegation of mental abuse and/or neglect for one of four residents (Resident R48). 28 Pa. Code:201.14(a) Responsibility of licensee 28 Pa. Code 201.18 e (1) Management. 28 Pa. Code 211.10 c (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained and obtain a physician order for dialysis treatment for one of two dialysis residents. (Resident R29). Findings include: A review of the facility policy Dialysis and dialysis service agreement dated 1/25/23, indicated the dialysis communication binder will be initiated and utilized for all residents receiving dialysis. It is indicated a new communication form for each day of dialysis treatment is to be utilized and Section C is to be completed by the nurse on duty at the time of the resident's return to the facility. It is indicated that completed communication forms will be filed in the medical record in the consult section. A review of the clinical record revealed that Resident R29 was admitted to the facility on [DATE], with diagnoses that included end stage kidney failure and dialysis. Review of Resident R29's Minimum Data Set (MDS - periodic assessment of care needs) dated 3/20/23, indicated that these diagnoses were current upon review. A review of Resident R29's physician orders dated 12/27/22, indicated that Resident R29 received hemodialysis (a process to mechanically clean the blood) on Monday Wednesday and Fridays. A review of Resident R29's Dialysis Communication Form from 5/1/23 through 5/24/23 indicated the facility failed to fully complete Section C: To be completed by nurse on duty at time of return vital signs and assessment for eight out of ten days During an interview on 5/24/23, at 10:06 a.m. the Registered Nurse Unit Manager Employee E11 confirmed that the facility failed to make certain consistent dialysis communication was maintained for Resident R29. 28 Pa. Code: 211.5(f)(g)(h) Clinical records 28 Pa. Code: 201.14(a)(e)(1) Management 28 Pa. Code: 201.14(b)(3) Management 28 Pa. Code: 211.10(c) Resident care policies 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of the facility policies, clinical record review, and staff interviews, it was determined that the facility failed to provide necessary supervision and an environment free of accidental hazards, to ensure that hot liquids were not accessible, resulting in actual harm for one of four Residents (Resident R47). Findings include: Review of facility policy Skilled Nursing-Adverse Events, dated 1/2020, indicates definitions: Adverse event: unexpected occurrence that resulting in serious injury or loss of customer satisfaction. Review of policy Skilled Nursing- Feeding guidelines, dated 1/2020 and re-reviewed 12/3/21, indicated that the Purpose of the policy was to assure safe oral food intake, and the policy indicates that: Residents that require assistance to consume their meal must have a seated assistant, unless otherwise instructed by nursing team leader. Review of [NAME] Health Care Burn Stages - Second degree (partial thickness) [CONDITION(S)] - defines a second degree burn as: Second-degree [CONDITION(S)] involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Review of Resident R47's profile face sheet indicated that they were admitted [DATE], with diagnosis [CONDITION(S)] (progressive disease marked by tremor, muscular ridged and not precise movement), unspecified dementia without behavioral disturbance (person loses the ability to think, remember, learn, make decisions, and solve problems) muscle weakness (lack of muscle strength), and history of TIA (clot blocks the blood to part of the brain). Review of Resident R47's quarterly MDS assessment (minimum data assessment - periodic assessment of resident care needs) indicated the diagnoses remained current. During a review of the quarterly MDS Section G Functional Status Activities of Daily Living (ADL)- Eating dated 2/15/22, indicated Resident is in need of extensive assistance, and a one person assist with eating. Review of information submitted by the facility on 3/29/22, indicated that Resident R47's leg was burned when reaching for hot soup. Review of facility documentation Southmont Temperature Log dated 3/28/22, Dinner Meal Food Items Serving Temperature: indicates that Chicken Florentine Soup: Kitchen =207, Begin = 190, End = 156. Review of facility documentation Quality Peer Review Committee Bruise and Skin Tear Investigation dated 3/28/22, indicated that Resident pulled soup bowl across the table and spilled in his lap. Burn to top and lateral side of right leg. The facility documentation indicated that the only two staff who provided services to Resident R47 up until the time of the incident were: Nurse Aide Employee E4 and a casual Licensed Practical Nurse (LPN) Employee E8. Review of facility documentation Witness Statement dated 3/28/22, revealed Resident was yelling out hot. Staff was serving dinner when resident was heard staff found resident with soup overturned on his lap poured towards his R thigh. Resident said, It just happened when I yelled. Staff immediately removed soup bowl off resident placed towel on resident took him to be changed Nurse charge notified promptly. Second witness statement dated 3/28/22, indicated was serving dinner heard Resident yelling hot. No other witness statements were included in the facility documentation. Review of facility documentation quarterly dietary assessment dated [DATE], indicates Resident R47 is confused and combative at times, and is fed by staff. During an interview on 6/29/22, at 12:43 p.m. Registered Nurse Unit Manager Employee E3, confirmed that facility documentation indicated Resident R47 wound had yellow slough - with blister. Review of Resident R47's care plans for ADL's in place on 3/28/22, indicated that: Problem statement: I am unable to feed myself with supportive statement of: provide verbal cues and encouragement for resident to self-feed. Monitor for fatigue. Staff to feed resident remainder of meal. Staff assistance of one for eating. During an interview on 6/29/22, at 12:49 p.m. Nurse Aide Employee E4 indicated that staff put down soup in front of Resident R47. Resident R47 grabs at food items and staff sit with him to assist with eating. Staff was not sitting with Resident R47 when staff was passing meals. The staff person who put the soup down was LPN Employee E8 who does not work full time, and the next thing NA Employee E4 heard was Resident R47 yelling hot. During an interview on 6/30/22, at 12:00 pm. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to maintain an environment free from accidental hazards which resulted in actual harm to Resident R47 received a second degree burn from soup during a meal. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 e (1) Management. 28 Pa. Code 211.10 c (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services