Every finding on record at Southwestern Veterans Center

Based on review of facility policy, facility and clinical record documentation, and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R2) was free of neglect during care which resulted in actual harm of a laceration (tear in the skin and underlying tissue) to the left forehead requiring five sutures (specialized threads or strands used to stitch together tissues following an injury or surgical procedure). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 1/16/26, indicated the purpose of protocol is to give guidance to provide protections for the health, safety, welfare, and rights of each resident residing in the facility by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat a resident's medical condition. The facility shall thoroughly investigate all allegations and include training for staff. The facility shall identify, correct and intervene in situations in which abuse, neglect, exploitation or misappropriation of resident property is more likely to occur. Identify, provide ongoing assessment, monitor and care plan appropriate interventions for residents with needs and behaviors which might lead to conflict or neglect. Review of facility policy Incident and Accident - Resident (Fall) dated 1/16/26, indicated this protocol is to provide guidance to assist with maintaining the resident's safety and prevention of serious injury to the extent possible and to ensure a consistent and effective approach to the management and review of the fall itself. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R2's admission record indicated that Resident R2 was admitted to the facility 6/9/26. Review of Resident R2's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of heart failure, heart disease, and lymphedema (condition characterized by swelling caused by an accumulation of fluid in the body's tissues). Further review of MDS indicated that Resident R2 is partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports truck and limbs, but provides less than half the effort. Further review of MDS indicated BIMS score of 15 cognitively intact. Review of physician orders indicated that on date 6/9/26, Resident R2 was ordered one assist for transfer with FWW (front-wheeled walker - mobility aid designed to provide support and stability for individuals who need assistance while walking), discontinued 8/2/26. Review of Resident R2's plan of care with an Approach start date of 6/9/26, indicated that he/she is a 1-assist for transfers with FWW, edited 8/3/26, to transfer - STS (sit-to-stand lift - device designed to help individuals with reduced mobility who can still perform specific tasks by themselves or with limited staff assistance), sling size - large. Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 7/3/26, Resident R2 is a 1-assit for transfers with FWW. Review of Resident R2's clinical progress note dated 7/8/26, at 7:26 a.m., by Registered Nurse Supervisor (RNS) Employee E11, revealed that around 7:00 a.m., unit Registered Nurse (RN) reported that resident (R2) was on the floor in his room. Resident (R2) was lying face down to the right of his nightstand on the window side of his bed, feet towards the bed. There is a moderate amount of blood under his head area, and he has a towel. He is alert and verbally responding to questions. CRNP (Certified Registered Nurse Practioner) arrived and assessed resident (R2). There was no increased pain with movement. There was no deformity lengthening, or outward rotation of any extremities. He has a laceration above his left eye that now is no longer bleeding. 911 arrived and we transferred him to the stretcher. Resident (R2) off unit at around 7:23 a.m. Further review of Resident R2's clinical progress note dated 7/8/26, at 8:38 a.m., by Certified Registered Nurse Practioner (CRNP) Employee E12, revealed resident (R2) evaluated today s/p (status post) accidental fall. On arrival to resident's (R2) room, he was lying on the floor face down. Alert and able to answer questions. Reports pain to left hip. No increased pain with palpitation. No deformity or instability on exam. Resident (R2) denied head, neck, or back pain. Was able to be rolled onto back with no increased pain. Laceration to forehead open but bleeding controlled. Assessment/Plan: 1. Fall with injury, 2. Longterm use of anticoagulation. Send to hospital for evaluation. Further review of Resident R2's clinical progress note dated 7/8/26, at 7:45 p.m., revealed resident (R2) returned from the emergency department with discharge instructions indicating a laceration to the left outer forehead repaired with five non-absorbable sutures. No active bleeding was noted upon return. Monitor for healing progress and prepare for suture removal as recommended on day seven, unless otherwise directed by the provider. Review of facility provided event report documentation dated 7/8/26, revealed Summary of Findings: Resident (R2) had a witnessed fall with a laceration to his head. Resident (R2) was being transferred with the assistance of one Nurse Aide (NA) but did not have his wheeled walker with him. He became unsteady and fell. Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 7/8/26, regarding care NA Employee E1 provided Resident R2 on 7/8/26, at time of fall. Witness statement revealed that NA Employee E1 admitted to using the Resident Roster, but when questioned about being aware that Resident R2 has a transfer order that includes a front-wheeled walker (FWW), NA Employee E1 responded No. ADON Employee E2 further questioned NA Employee E1 as follows:- If you were using the roster, please explain why you didn't use the front-wheeled walker with transfer? NA Employee answered, I don't know.- Did you use a FWW when transferring this resident (R2) from bed to chair scale and when attempting to move him from the chair scale to the PWC (power wheelchair)? Na Employee E1 answered, No, I did not. Review of documentation submitted by the facility dated 7/13/26, revealed that the facility initiated an investigation, regarding resident neglect on 7/8/26. Further review of submitted documents revealed that NA Employee E1, by her own admission, failed to utilize the proper transfer modality of the front-wheeled walker during the transfer which likely was a direct contributor to the fall, which resulted in the resident (R2) being sent to the emergency room for sutures. Allegation of neglect is substantiated. NA Employee E1 was an agency NA and her contract was terminated immediately. During an interview on 8/19/26, at 3:30 p.m., with the Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA) Employee E10, Quality Assurance (QA) Employee E3, and ADON Employee E4, information was disseminated that NA Employee E1 failed to implement the use of a FWW when transferring Resident R2 from chair scale to PWC on 7/8/26, resulting a fall and a laceration to Resident R2 forehead requiring sutures. The facility failed to ensure that Resident R2 was free of neglect during care which resulted in actual harm of a laceration to the left forehead requiring five sutures. This deficiency is cited as past non-compliance. On 7/8/26, the facility initiated an investigation into a witnessed fall of Resident R2, resulting in a forehead laceration. Facility identified that Resident R2's Resident Roster and care plan contained the correct transfer status of assist times 1 with FWW. When Resident R2 returns from the hospital, his care plan will be reviewed and updated with any new interventions. NA Employee E1 was identified as the perpetrator and their agency contract was terminated upon completion of investigation. Residents who utilize one person assist with FWW for transfers had their Resident Rosters and care plans reviewed for accuracy. Residents were interviewed to determine if they have any concerns with their ordered transfer status. All nursing staff to include Registered Nurses (RN's), Licensed Practical Nurse (LPN's) and NA's were re-educated on how to implement correct resident transfer orders and on what constitutes abuse/neglect when failing to follow the residents designated care plan. Random audits were initiated of residents requiring FWW for transfers to ensure the correct transfer method is being utilized. Audits are to be completed by the Registered Nurse Supervisor (RNS) or designee daily times seven days, week times 4 weeks, and monthly times 2 months. Audits will be forwarded to the QAPI committee for review and recommendations. Ad hoc QAPI committee meeting held on 7/9/26, and quarterly QAPI meeting held 7/16/26. Interviews conducted with NA Employees E5, E6, E7, E8, and E9, confirmed that the facility initiated education on 7/9/26, which included how to implement correct resident transfer orders, locations of resident transfer status, and on what constitutes abuse/neglect when failing to follow the residents designated care plan. During an interview with the NHA, ANHA Employee E10, QA Employee E3, and ADON Employee E4 on 8/19/26, at 3:30 p.m., and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect during care and had achieved substantial compliance as of 7/17/26. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, facility and clinical record documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a laceration (tear in the skin and underlying tissue) to the left forehead requiring five sutures (specialized threads or strands used to stitch together tissues following an injury or surgical procedure), for one of two residents reviewed (Resident R2). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Incident and Accident - Resident (Fall) dated 1/16/26, indicated this protocol is to provide guidance to assist with maintaining the resident's safety and prevention of serious injury to the extent possible and to ensure a consistent and effective approach to the management and review of the fall itself. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R2's admission record indicated that Resident R2 was admitted to the facility 6/9/26. Review of Resident R2's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of heart failure, heart disease, and lymphedema (condition characterized by swelling caused by an accumulation of fluid in the body's tissues). Further review of MDS indicated that Resident R2 is partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports truck and limbs, but provides less than half the effort. Further review of MDS indicated BIMS score of 15 cognitively intact. Review of physician orders indicated that on date 6/9/26, Resident R2 was ordered one assist for transfer with FWW (front-wheeled walker - mobility aid designed to provide support and stability for individuals who need assistance while walking), discontinued 8/2/26. Review of Resident R2's plan of care with an Approach start date of 6/9/26, indicated that he/she is a 1-assist for transfers with FWW, edited 8/3/26, to transfer - STS (sit-to-stand lift - device designed to help individuals with reduced mobility who can still perform specific tasks by themselves or with limited staff assistance), sling size - large. Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 7/3/26, Resident R2 is a 1-assit for transfers with FWW. Review of Resident R2's clinical progress note dated 7/8/26, at 7:26 a.m., by Registered Nurse Supervisor (RNS) Employee E11, revealed that around 7:00 a.m., unit Registered Nurse (RN) reported that resident (R2) was on the floor in his room. Resident (R2) was lying face down to the right of his nightstand on the window side of his bed, feet towards the bed. There is a moderate amount of blood under his head area, and he has a towel. He is alert and verbally responding to questions. CRNP (Certified Registered Nurse Practioner) arrived and assessed resident (R2). There was no increased pain with movement. There was no deformity lengthening, or outward rotation of any extremities. He has a laceration above his left eye that now is no longer bleeding. 911 arrived and we transferred him to the stretcher. Resident (R2) off unit at around 7:23 a.m. Further review of Resident R2's clinical progress note dated 7/8/26, at 8:38 a.m., by Certified Registered Nurse Practioner (CRNP) Employee E12, revealed resident (R2) evaluated today s/p (status post) accidental fall. On arrival to resident's (R2) room, he was lying on the floor face down. Alert and able to answer questions. Reports pain to left hip. No increased pain with palpitation. No deformity or instability on exam. Resident (R2) denied head, neck, or back pain. Was able to be rolled onto back with no increased pain. Laceration to forehead open but bleeding controlled. Assessment/Plan: 1. Fall with injury, 2. Longterm use of anticoagulation. Send to hospital for evaluation. Further review of Resident R2's clinical progress note dated 7/8/26, at 7:45 p.m., revealed resident (R2) returned from the emergency department with discharge instructions indicating a laceration to the left outer forehead repaired with five non-absorbable sutures. No active bleeding was noted upon return. Monitor for healing progress and prepare for suture removal as recommended on day seven, unless otherwise directed by the provider. Review of facility provided event report documentation dated 7/8/26, revealed Summary of Findings: Resident (R2) had a witnessed fall with a laceration to his head. Resident (R2) was being transferred with the assistance of one Nurse Aide (NA) but did not have his wheeled walker with him. He became unsteady and fell. Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 7/8/26, regarding care NA Employee E1 provided Resident R2 on 7/8/26, at time of fall. Witness statement revealed that NA Employee E1 admitted to using the Resident Roster, but when questioned about being aware that Resident R2 has a transfer order that includes a front-wheeled walker (FWW), NA Employee E1 responded No. ADON Employee E2 further questioned NA Employee E1 as follows:- If you were using the roster, please explain why you didn't use the front-wheeled walker with transfer? NA Employee answered, I don't know.- Did you use a FWW when transferring this resident (R2) from bed to chair scale and when attempting to move him from the chair scale to the PWC (power wheelchair)? Na Employee E1 answered, No, I did not. Review of documentation submitted by the facility dated 7/13/26, revealed that the facility initiated an investigation, regarding resident neglect on 7/8/26. Further review of submitted documents revealed that NA Employee E1, by her own admission, failed to utilize the proper transfer modality of the front-wheeled walker during the transfer which likely was a direct contributor to the fall, which resulted in the resident (R2) being sent to the emergency room for sutures. Allegation of neglect is substantiated. NA Employee E1 was an agency NA and her contract was terminated immediately. During an interview on 8/19/26, at 3:30 p.m., with the Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA) Employee E10, Quality Assurance (QA) Employee E3, and ADON Employee E4, information was disseminated that NA Employee E1 failed to implement the use of a FWW when transferring Resident R2 from chair scale to PWC on 7/8/26, resulting a fall and a laceration to Resident R2 forehead requiring sutures. The facility failed to ensure that Resident R2 received adequate supervision and implement effective transfer interventions as per physician order, resulting in actual harm when the resident fell and received a laceration to the left forehead requiring five sutures from an improper transfer which required a FWW. This deficiency is cited as past non-compliance. On 7/8/26, the facility initiated an investigation into a witnessed fall of Resident R2, resulting in a forehead laceration. Facility identified that Resident R2's Resident Roster and care plan contained the correct transfer status of assist times 1 with FWW. When Resident R2 returns from the hospital, his care plan will be reviewed and updated with any new interventions. NA Employee E1 was identified as the perpetrator and their agency contract was terminated upon completion of investigation. Residents who utilize one person assist with FWW for transfers had their Resident Rosters and care plans reviewed for accuracy. Residents were interviewed to determine if they have any concerns with their ordered transfer status. All nursing staff to include Registered Nurses (RN's), Licensed Practical Nurse (LPN's) and NA's were re-educated on how to implement correct resident transfer orders and on what constitutes abuse/neglect when failing to follow the residents designated care plan. Random audits were initiated of residents requiring FWW for transfers to ensure the correct transfer method is being utilized. Audits are to be completed by the Registered Nurse Supervisor (RNS) or designee daily times seven days, week times 4 weeks, and monthly times 2 months. Audits will be forwarded to the QAPI committee for review and recommendations. Ad hoc QAPI committee meeting held on 7/9/26, and quarterly QAPI meeting held 7/16/26. Interviews conducted with NA Employees E5, E6, E7, E8, and E9, confirmed that the facility initiated education on 7/9/26, which included how to implement correct resident transfer orders, locations of resident transfer status, and on what constitutes abuse/neglect when failing to follow the residents designated care plan. During an interview with the NHA, ANHA Employee E10, QA Employee E3, and ADON Employee E4 on 8/19/26, at 3:30 p.m., and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from accidents/incidents regarding transfer status of residents and had achieved substantial compliance as of 7/17/26. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain a resident's confidential personal and medical records for one of eight residents (Resident R4). Findings include: A review of the facility policy titled, Health Insurance Portability and Accountability Act dated 1/16/26, indicated that all staff must maintain the confidentiality and security of private health information in daily practice. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and dysphagia (difficulty swallowing). During an observation on 5/11/26, at 1:56 p.m. Resident R4 was observed in his room resting in a wheelchair, with a sign posted above is bed that stated I only eat pureed food. Review of Resident R4's clinical record failed to include any documentation that the above resident or their representatives approved the posting of private health information. During an interview on 5/14/26, at 10:05 a.m. Registered Nurse Employee E3 confirmed that the facility failed to maintain resident's confidential personal, and medical records for one of eight residents (Resident R4). 28 Pa. Code: 201.18(e)(1) Management

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of eight residents sampled with facility-initiated transfers (Residents R11 and R164).Findings include: Review of the facility policy Transfers and discharge date d 1/16/26, indicated that for a transfer to another provider the following information must be provided to the receiving provider: Contact information of the practitioner who was responsible for the care of the resident Resident representative information, including contact information Advance directive information All other information necessary to meet the resident's needs, which includes, but may not be limited to: Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs Diagnoses and allergies Medications (including when last received) Most recent relevant labs, other diagnostic tests, and recent immunizations All special instructions and/or precautions for ongoing care, as appropriate such as: Treatments and devices Transmission- based precautions such as contact, droplet, or airborne Special risk such as for falls, elopement, bleeding, or pressure injury and/or aspiration precautions The resident's comprehensive care plan goals Additional information, if there is any, outlined in the transfer agreement with the acute care provider. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/2/26, indicated diagnoses of high blood pressure, obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow), and constipation (fewer than three bowel movements per week). Review of the clinical record indicated Resident R11 was transferred to the hospital on 3/29/26, and returned to the facility on 4/1/26. Review of Resident R11's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the resident's transfer and expected return: the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R164 was admitted to the facility on [DATE]. Review of Resident R164's MDS dated [DATE], indicated diagnoses of high blood pressure, dysphagia (difficulty swallowing, and hemiplegia (paralysis on one side of the body). Review of the clinical record indicated Resident R164 was transferred to the hospital on 3/28/26, and returned to the facility on 3/31/26. Review of Resident R164's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals. During an interview on 5/13/26, at 1:53 p.m. the Quality Assurance Coordinator Employee E1 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of eight residents sampled with facility-initiated transfers (Residents R11, and R164). 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for two of six residents (Resident R3, and R30).Findings include: Review of the facility policy Vital Signs, Height and Weight dated 1/16/26, indicated that weights are obtained on admission, and monthly. Weights may be taken on a more frequent schedule such as weekly or daily per physician order. Weights are recorded in the electronic health record. Review of the facility policy Transcription of Physician Orders, dated 1/16/26, indicated that physician orders will be added into the electronic medical record. All new physician orders for medications and treatments are to be reviewed and added to electronic medical administration record as written by the physician. To clarify an order the licensed staff must never add to or change the order in question. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/2/26, indicated diagnoses of pneumonia, hypoxemia (low levels of oxygen in the blood) and urine retention. Review of Resident R30's physician order history dated 9/23/25-2/25/26, indicated to tamsulosin capsule; 0.4 mg; amt: 2; oral, Once A Day, 08:00 PM. 2/25/26- 3/18/26 tamsulosin capsule; - Crushed; 0.4 mg; amt: 0.8mg; oral Special Instructions: open capsule and sprinkleTwice A Day 08:00 AM, 08:00 PM 3/18/26-4/22/26 tamsulosin capsule; - Crushed; 0.4 mg; amt: 0.8mg; oral Special Instructions: opencapsule and sprinkle Once A Day 08:00 AM During an interview completed on 5/13/26, at 11:00 a.m. QA Coordinator Employee E1 confirmed that the facility transcribed the physician order incorrectly and did not follow the physician order. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and low back pain. Review of Resident R3's physician orders dated 3/7/25, indicated to check weight at 11 a.m. daily, and notify physician if there is weight gain of five pounds or more in three days. Review of Resident R3's clinical record indicated that weights were not obtained on the following days: 4/20/26, 4/21/26, 4/22/26, 4/23/26, 4/24/26, and 4/28/26. During an interview completed on 5/14/26, at 10:10 a.m. Registered Nurse Employee E5 confirmed that the facility failed to weight Residet R3 daily as ordered. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to implement resident's specific nutritional interventions in a timely manner, and failed to develop an individualized care plan to address the resident's specific nutritional concerns for one of eight (Resident R189) records reviewed.Findings include: Review of facility policy Nutrition dated 1/16/26, indicated to indicate nutrition in the resident's total plan of care, to identify residents at risk of poor nutrition status, to facilitate communication with the health care team. Nutritional assessment and resident care plan documentation will be provided for all residents and provide initial and regular review of nutritional care. Initial nutritional assessment is completed by the Registered Dietitian within 7 days of admission to the facility. Nutrition care plans will be completed upon admission, and reviewed quarterly, and when a resident has a significant change in his/her nutritional status. Care plans will be updated on an ongoing basis when approaches change. Review of facility policy Resident Care: Nursing Services: Plan of Care and RAI, MDS dated [DATE], indicated the purpose is to provide guidance regarding the development and implementation of a baseline care plan, to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events that are more likely to occur right after admission. Review of admission documents indicated that Resident R189 was admitted to facility 5/5/26, with diagnoses of Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), dementia (group of symptoms affecting memory, thinking and social abilities), and high blood pressure. Review of physician order dated 5/5/26, indicated Resident R189 Dietary order House, Thin, Pureed Special Instructions: no straws. Review of Comprehensive Nutritional assessment dated [DATE], indicated that Resident R189's Nutrition Orders: House diet, pureed foods, thin liquids. Feeding ability: Staff feed. Further review indicated Skin condition location and description: Stage 2 (partial thickness skin loss), coccyx. Initiate plan of care. Review of Comprehensive Nutritional Assessment progress note dated 5/5/26, indicated Resident R189 ate very little for lunch today. Visited with resident, unable to obtain dietary history and food and beverage preference from her, POA (Power of Attorney) provided some food and beverage preferences. Adding fortified shakes with all meals and Gelatein Plus (oral nutritional supplement) with lunch to support wound healing. Additional review of Resident R189's physician orders on 5/13/26, failed to indicate a current order for Gelatein Plus as recommended. Review of Resident R189's current plan of care failed to identify focus, goals, and interventions related to nutrition care and services. During an interview on 5/13/26, at 10:33 a.m., Registered Dietitian (RD) Employee E6 stated that she forgot to add Gelatein Plus to Resident R189's physician orders as recommended, and forgot to develop a baseline care plan to address nutrition care and services within 48 hours of admission, confirming that the facility failed to implement resident's specific nutritional interventions in a timely manner, and failed to develop an individualized care plan to address the resident's specific nutritional concerns for Resident R189. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.12(d)(3)(5)Nursing services.

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Residents R149).Findings include: Review of the facility policy Enteral Feedings Gastrostomy last reviewed 1/16/26, indicated to elevate head of bed a minimum of 45 degrees (or as per physician order) and instruct resident to remain in that position during and for 45 minutes after the feeding for bolus feedings. For continuous feedings, head of bed must remain at a minimum of 45 degrees (or as per physician order) at all times, unless pump is stopped to provide care. Review of the admission record indicated Resident R149 admitted to the facility on [DATE]. Review of Resident R149's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/26, indicated the diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R149's physician order dated 4/22/26, indicated Jevity 1.5 at 120 milliliters (ml)/hour from 8:00 a.m. through 8:00 p.m. Further review of Resident R149's physician order dated 4/20/26, indicated keep head of bed at 30 degrees at all times. Review of Resident R149's care plan dated 4/21/26, indicated to keep head of bed at 30 degrees at all times. Observation on 5/11/26, at 10:51 a.m. Resident R149 was observed lying flat in bed with the tube feeding connected and the pump indicated the feeding was infusing at 120 ml/hr. Observation and interview on 5/11/26, at 10:53 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R149 was lying flat in bed with the tube feeding connected and the pump indicated the feeding was infusing at 120 ml/hr. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide evidence medication regimen reviews (MRR) were reviewed by the resident's attending physician monthly for two of seven residents (Resident R3, and R4).Finding include: Review of the facility policy Drug Regimen Review, Monthly dated 1/16/26, indicated that the pharmacist will review the drug regimen of every resident's care levels every month and report results to the physician, and the physician will respond in the comment section. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and low back pain. Review of Resident R3's Medication Review Regimen dated 4/3/26, failed to include a response from the resident's attending physician. A Certified Registered Nurse Practitioner (CRNP) signed the note to the attending physician on 4/23/26, and the decision was made to review lab work and implement a vitamin D supplement. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and dysphagia (difficulty swallowing). Review of Resident R4's Medication Review Regimen dated 4/16/26, failed to include a response from the resident's attending physician.A CRNP signed the note to the attending physician on 5/12/26, and the decision was made to discontinue the following medication:-Voltaren gel (a medicated gel that relieve joint pain)) During an interview on 5/14/26, at 11:353 a.m. Quality Assurance Coordinator Employee E1 confirmed facility failed to ensure resident's medication regimen reviews (MRR) were reviewed by the resident's attending physician monthly for two of seven residents (Resident R3, and R4). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of left femur (thigh bone). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 1/16/25, indicated the purpose of protocol is to give guidance to provide protections for the health, safety, welfare, and rights of each resident residing in the facility by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat a resident's medical condition. The facility shall thoroughly investigate all allegations and include training for staff. The facility shall identify, correct and intervene in situations in which abuse, neglect, exploitation or misappropriation of resident property is more likely to occur. Identify, provide ongoing assessment, monitor and care plan appropriate interventions for residents with needs and behaviors which might lead to conflict or neglect. Review of facility policy Transfer Devices dated 1/16/25, indicated this protocol is to provide guidance for the facility regarding enhancing the residents'' quality of life, with the increased development of culture change, to the best abilities possible with resident agreement and tolerance by encouraging safe resident transfer independence while decreasing potential for injury to residents and staff. For the safety of the resident and staff, the facility incorporates the use of mechanical lifts, sliding boards, and other safety devices as ordered and when necessary, to assist with transfers to assist the resident with maintaining and achieving their highest practical level of care. Definition: Full Body Lift (Mechanical lift; Electric lift): Devices used to move residents who are unable to stand on their own or complete a transfer with staff assistance safely. Lift completes resident transfer from one surface to another. The facility maintains a no manual lift directive to minimize risk of injury to the resident and staff. When a resident has total dependance or requires extensive assistance of staff for transfers, a full body mechanical lift is the safest device for the resident and staff to utilize. Full body mechanical lifts with corresponding lift slings will be operated according to referenced manufacturer's guidelines. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 6/26/24. Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of diabetes mellitus (chronic condition characterized by high blood sugar levels due to the body's inability to produce or effectively use insulin), end stage renal disease (final stage of chronic kidney disease, where kidneys can no longer function adequate, requiring dialysis or a kidney transplant for survival), and hepatitis C (viral infection that causes liver inflammation which could lead to liver damage). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of 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. Further review of MDS indicated BIMS score of 13 cognitively intact. Review of physician orders indicated that on date 6/28/24, Resident R1 was ordered Transfers: Full mechanical lift. Review of Resident R1's care plan with an Approach start date of 11/4/21, indicated the he/she is a two person transfer with mechanical lift. Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 8/11/25, Resident R1 is to be transferred using a HOYER (a device that helps caregivers transfer patients with limited mobility from one place to another) 2 assist with large sling. Review of Resident R1's clinical progress note dated 8/9/25, at 5:07 p.m., revealed resident (R1) complained 10/10 pain to his left stump that is unrelieved by PRN (as needed) Tylenol. Residents left stump warm to touch and swelling noted. MD (doctor) called to inform of resident's condition, and gave verbal telephone order to send resident to the emergency room for evaluation. Further review of clinical nursing progress note dated 8/11/25, at 6:30 p.m., revealed Resident R1 returned from hospital via stretcher at 6:07 p.m. Further review of clinical physician services progress note dated 8/12/25, at 8:02 a.m., revealed that Resident R1 was found to have an acute comminuted (type of bone fracture where the bone is broken in three or more pieces) impacted and angulated (type of bone fracture that when a bone breaks and the ends of the bone fragments are not aligned) fracture of the distal left femur. Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 8/11/25, regarding care NA Employee E1 provided Resident R1 on 8/9/25. Witness statement revealed that NA Employee E1 admitted to physically picking Resident R1 up from his bed and placed him into his wheelchair. When asked by ADON Employee E2 if a Hoyer lift was used with a second person, NA Employee E1 stated No. Review of documentation submitted by the facility dated 8/14/25, revealed that the facility initiated an investigation, regarding resident neglect on 8/11/25. Further review of submitted documents revealed NA Employee E1 admitted that she failed to transfer Resident R1 utilizing the ordered transfer method (mechanical lift) and instead transferred him manually (by picking him up). Further review revealed that the facility cancelled NA Employee E1's contract because she did not follow facility policy when transferring a resident from his bed to his wheelchair. During an interview on 9/24/25, at 10:35 a.m., Quality Assurance (QA) Employee E3 confirmed that NA Employee E1 failed to transfer a resident properly who required a full body mechanical lift with a Hoyer device. During an interview on 9/24/25, at 3:15 p.m. with the Nursing Home Administrator (NHA) and DON it was confirmed that the facility failed to ensure that Resident R1 was free of neglect during care which resulted in actual harm of a fracture of left femur (thigh bone). During an interview with the Nursing Home Administrator (NHA) and DON on 9/24/25, at 3:15 p.m. and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from of neglect regarding transfer status of residents and had achieved substantial compliance as of 8/14/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, facility documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a fracture of the left femur, for one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Transfer Devices dated 1/16/25, indicated this protocol is to provide guidance for the facility regarding enhancing the residents' quality of life, with the increased development of culture change, to the best abilities possible with resident agreement and tolerance by encouraging safe resident transfer independence while decreasing potential for injury to residents and staff. For the safety of the resident and staff, the facility incorporates the use of mechanical lifts, sliding boards, and other safety devices as ordered and when necessary, to assist with transfers to assist the resident with maintaining and achieving their highest practical level of care. Definition: Full Body Lift (Mechanical lift; Electric lift): Devices used to move residents who are unable to stand on their own or complete a transfer with staff assistance safely. Lift completes resident transfer from one surface to another. The facility maintains a no manual lift directive to minimize risk of injury to the resident and staff. When a resident has total dependance or requires extensive assistance of staff for transfers, a full body mechanical lift is the safest device for the resident and staff to utilize. Full body mechanical lifts with corresponding lift slings will be operated according to referenced manufacturer's guidelines. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 6/26/24. Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of diabetes mellitus (chronic condition characterized by high blood sugar levels due to the body's inability to produce or effectively use insulin), end stage renal disease (final stage of chronic kidney disease, where kidneys can no longer function adequate, requiring dialysis or a kidney transplant for survival), and hepatitis C (viral infection that causes liver inflammation which could lead to liver damage). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of 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. Further review of MDS indicated BIMS score of 13 cognitively intact. Review of physician orders indicated that on date 6/28/24, Resident R1 was ordered Transfers: Full mechanical lift. Review of Resident R1's care plan with an Approach start date of 11/4/21, indicated he/she is a two person transfer with mechanical lift. Review of Resident Roster (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 8/11/25, Resident R1 is to be transferred using a HOYER (device that helps caregivers transfer patients with limited mobility from one place to another) 2 assist with large sling. Review of Resident R1's clinical progress note dated 8/9/25, at 5:07 p.m., revealed resident (R1) complained 10/10 pain to his left stump that is unrelieved by PRN (as needed) Tylenol. Residents left stump warm to touch and swelling noted. MD (doctor) called to inform of resident's condition and gave verbal telephone order to send resident to the emergency room for evaluation. Further review of clinical nursing progress note dated 8/11/25, at 6:30 p.m., revealed Resident R1 returned from hospital via stretcher at 6:07 p.m. Further review of clinical physician services progress note dated 8/12/25, at 8:02 a.m., revealed that Resident R1 was found to have an acute comminuted (type of bone fracture where the bone is broken in three or more pieces) impacted and angulated (type of bone fracture that when a bone breaks and the ends of the bone fragments are not aligned) fracture of the distal left femur. Review of facility provided investigation witness statement revealed Nurse Aide (NA) Employee E1 was interviewed by Assistant Director of Nursing (ADON) Employee E2 on 8/11/25, regarding care NA Employee E1 provided Resident R1 on 8/9/25. Witness statement revealed that NA Employee E1 admitted to physically picking Resident R1 up from his bed and placed him into his wheelchair. When asked by ADON Employee E2 if a Hoyer lift was used with a second person, NA Employee E1 stated No. Review of documentation submitted by the facility dated 8/14/25, revealed that the facility initiated an investigation, regarding resident neglect on 8/11/25. Further review of submitted documents revealed NA Employee E1 admitted that she failed to transfer Resident R1 utilizing the ordered transfer method (mechanical lift) and instead transferred him manually (by picking him up). Further review revealed that the facility cancelled NA Employee E1's contract because she did not follow facility policy when transferring a resident from his bed to his wheelchair. During an interview on 9/24/25, at 10:35 a.m., Quality Assurance (QA) Employee E3 confirmed that NA Employee E1 failed to transfer a resident properly who required a full body mechanical lift with a Hoyer device and two staff members. The facility failed to ensure that Resident R1 received adequate supervision and implemented proper transfer interventions resulting in actual harm of a fracture of the distal left femur from the improper transfer which required the use of a full body mechanical lift. This deficiency is cited as past non-compliance. On 8/11/25, facility was notified that Resident R1 was diagnosed with left femur fracture. Investigation was initiated. Facility identified that Resident R1's Resident Roster and care plan reflected correct transfer status utilizing a mechanical lift. Resident R1 to be re-evaluated on readmission to facility. NA Employee E1 was identified as potential perpetrator and facility suspended her/him pending investigation outcome. Residents who utilize mechanical lifts for transfers had their Resident Rosters and care plans reviewed for accuracy. Physician orders, Resident Rosters, and care plans were updated accordingly based on review. All nursing staff to include Registered Nurses (RN'S), Licensed Practical Nurse (LPN's) and NA's were re-education on how to implement correct patient transfer status, and what constitutes neglect when failing to follow the patients designated plan of care. Education provided required posttest completion for accuracy of understanding. Random audits were initiated to ensure the correct transfer method is being utilized for residents requiring mechanical lift for transfer. Audits are to be completed by the Registered Nurse Supervisor (RNS) or designee daily times seven days, week times 4 weeks, and monthly times 2 months. Audits will be forwarded to the QAPI committee for review and recommendations. Interviews with RN Employee E4 and E5, LPN Employee E6, and NA Employees E7, E8, and E9 on 9/24/25, confirmed that the facility-initiated education on 8/11/24, which included reporting abuse, neglect, and exploitation timely, following proper transfer protocols, and how to check a residents current transfer status. During an interview with the Nursing Home Administrator (NHA) and DON on 9/24/25, at 3:15 p.m. and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from accidents/incidents regarding transfer status of residents and had achieved substantial compliance as of 8/14/25. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.12(c) Nursing services28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of five residents (Residents R16, R38, R104, R128, and R166). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of the clinical record indicated Resident R16 was transferred to the hospital on 4/14/25. Review of Resident R16's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 4/14/25. Review of Resident R38's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R38's MDS dated [DATE], indicated diagnoses of cancer (an uncontrolled growth and division of abnormal cells), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the clinical record indicated Resident R38 was transferred to the hospital on 2/15/25. Review of Resident R38's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 2/15/25. Review of the clinical record indicated Resident R104 was admitted to the facility on [DATE]. Review of Resident R104's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood). Review of the clinical record indicated Resident R104 was transferred to the hospital on 3/26/24. Review of Resident R104's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/26/25. Review of Resident R128's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R128's MDS dated [DATE], indicated diagnoses of dry eye syndrome, hearing loss, and repeated falls. Review of the clinical record indicated Resident R128 was transferred to the hospital on 3/3/25. Review of Resident R128's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/3/25. Review of Resident R166's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R166's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of the clinical record indicated Resident R166 was transferred to the hospital on 2/23/25. Review of Resident R166's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 2/23/25. During an interview on 4/22/25, at 12:27 p.m. Social Work Director Employee E4 stated that the facility only notifies the local ombudsman of resident transfers. During an interview on 4/22/25, at 12:27 p.m. Social Work Director Employee E4 confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of five residents as required. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R16, R19, and R38). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of the clinical record indicated Resident R16 was transferred to the hospital on 4/14/25. Review of Resident R16's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's MDS dated [DATE], indicated diagnoses of atrial fibrillation (irregular heart rhythm), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the clinical record indicated Resident R19 was transferred to the hospital on 1/28/25. Review of Resident R19's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R38's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R38's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/17/25, indicated diagnoses of cancer (an uncontrolled growth and division of abnormal cells), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and, diabetes. Review of the clinical record indicated Resident R38 was transferred to the hospital on 2/15/25. Review of Resident R38's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 4/24/25, at 2:46 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents as required. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of six resident hospital transfers (Residents R16, R19, R38, R128, and R166). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of the clinical record indicated Resident R16 was transferred to the hospital on 4/14/25, and remained out to the hospital during review on 4/24/25. Review of Resident R16's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 4/14/25. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's MDS dated [DATE], indicated diagnoses of atrial fibrillation (irregular heart rhythm), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the clinical record indicated Resident R19 was transferred to the hospital on 1/28/25. Review of Resident R19's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 1/28/25. Review of Resident R38's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R38's MDS dated [DATE], indicated diagnoses of cancer (an uncontrolled growth and division of abnormal cells), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and, diabetes. Review of the clinical record indicated Resident R38 was transferred to the hospital on 2/15/25. Review of Resident R38's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 2/15/25. Review of Resident R128's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R128's MDS dated [DATE], indicated diagnoses of dry eye syndrome, hearing loss, and repeated falls. Review of the clinical record indicated Resident R128 was transferred to the hospital on 3/3/25. Review of Resident R128's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 3/3/25. Review of Resident R166's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R166's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of the clinical record indicated Resident R166 was transferred to the hospital on 2/23/25. Review of Resident R166's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 2/23/25. During an interview on 4/24/25, at 2:46 p.m. the Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for five of six resident hospital transfers as required. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Residents R13, R31, and R51). Findings include: Review of facility policy Supplemental Oxygen Therapy dated 1/16/25, indicated used cannulas, masks, and tubing shall be stored in a plastic bag, off the floor, labeled with the Resident's name, when not in use. Review of facility policy Noninvasive Ventilation: BiPAP, CPAP dated 1/16/25, indicated when not in use, assembled headgear, masks, and tubing shall be stored in a plastic bag, labeled with the resident's name and date. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), hypertension (the force of the blood against the artery walls is too high), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R13's physician order dated 3/4/25, indicated BiPAP equipment care to be completed every week on Sundays, on daylight shift, that includes replacing the storage bag for mask, tubing, and headgear and label with resident' s name and current date. During an observation on 4/21/25, at 9:27 a.m. Resident R13's BiPAP machine was observed on the nightstand beside the bed with the BiPAP mask sitting beside it, not in the storage bag as required. During an interview on 4/21/25, at 10:00 a.m. Registered Nurse (RN) Employee E15 confirmed Resident 13's BiPAP was not properly stored in a plastic bag while not in use and the facility failed to provide appropriate respiratory care for Resident R13. Review of Resident R31's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R31's MDS dated [DATE], indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), depression, and sleep apnea (a condition when you stop breathing while your sleeping). Review of a physician order dated 3/4/25, indicated a BiPAP with six liters of oxygen to be administered every night at bedtime. Review of a physician order dated 3/4/25, indicated BiPAP equipment care to be completed every week on Sundays, on daylight shift, that includes replacing the storage bag for mask, tubing, and headgear and label with resident ' s name and current date. During an observation on 4/21/25, at 10:25 a.m. Resident R31's BiPAP machine was observed on the nightstand beside the bed with the BiPAP mask sitting beside it. No storage bag was observed. During an interview on 4/21/25, at 10:29 a.m. Licensed Practical Nurse Employee E9 confirmed Resident R31's BiPAP was not properly stored in a plastic bag while not in use and the facility failed to provide appropriate respiratory care for Resident R31. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions). Review of a physician order dated 7/12/24, indicated to administer oxygen up to 6 liters via nasal cannula as needed to maintain oxygen saturation levels between 88% to 92%. Review of a physician order dated 7/12/24, indicated to clean oxygen concentrator filter and change and label the following with date weekly on Sunday evening shift. 1. Nasal cannula tubing/mask/neb tubing. 2. Distilled water container. 3. Plastic storage bag(s), label with resident name in addition. Review of a physician order dated 2/27/25, indicated to assist resident with doffing (removing) CPAP upon awakening. Empty humidifier chamber of any remaining water. Place mask/tubing/headgear into plastic labeled storage bag. During an observation on 4/21/25, at 10:10 a.m. Resident R51's nasal cannula was observed lying on the floor to the left of the resident's bed. During this observation, Resident R51's CPAP machine was observed on a bedside table to the right of the bed. The CPAP mask was observed sitting on top of the machine. During an observation on 4/21/25, at 10:38 a.m. Resident R51's nasal cannula tubing was observed wrapped around the oxygen flow meter, now off of the floor. During this observation, Infection Preventionist Employee E1 was informed that the nasal cannula was previously observed on the floor. During an interview on 4/21/25, at 10:38 a.m. Infection Preventionist Employee E1 confirmed Resident R51's nasal cannula and CPAP were not properly stored in a plastic bag while not in use and that the facility failed to provide appropriate respiratory care for Resident R51. Review of Resident R51's care plan on 4/22/25, failed to include the development of a plan of care and interventions for the resident's oxygen therapy and CPAP therapy. During an interview on 4/23/25, at 12:09 p.m. Registered Nurse Assessment Coordinator Employee E6 confirmed that the facility failed to develop a plan of care and interventions related to Resident R51's oxygen and CPAP therapy. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for five of eight residents (Residents R13, R16, R21, R91, and R104). Findings include: Review of the facility policy Permitted Charges for Medical Records dated 1/16/25, indicated the medical record is an accounting of events and interactions between an individual and a healthcare provider. Medical records assist in analyzing trends in healthcare use, an individual's characteristics and quality of care. Review of the facility job description Registered Nurse (RN) indicated the RN is to record daily care performed for the residents on the appropriate forms and the approved electronic medical record and establish and maintain effective communication with resident, family, and staff. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), hypertension (the force of the blood against the artery walls is too high), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R13's current physician orders on 4/23/25, indicated check and record vitals (temperature, pulse, blood pressure, oxygen saturation, respirations, and weight) on the fifth of each month per facility policy. Special instructions - weights can be started at the beginning of each month; weight and vitals are due to be completed and recorded by the fifth of each month. Review of Resident R13's weight record in the Electronic Medical Record (EMR) on 4/23/25, at 1:15 p.m., failed to include a documented weight for the month of April 2025. Interview on 4/24/25, at 3:05 p.m. Registered Dietitian Employee E7 confirmed that the weights should be entered into the EMR, and the facility failed to maintain complete and accurate documentation for Resident R13. Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of a physician order dated 2/13/23, indicated to check and record vitals (temperature, pulse, blood pressure, oxygen saturation, respirations, and weight) on the 5th of each month, per facility policy. Weights can be started at the beginning of each month; weights and vitals are due to be completed and recorded by the 5th of each month. Review of Resident R16's weight record in the EMR on 4/23/25, failed to include a documented weight for the month of December 2024. Review of Resident R16's December 2024 Medication Administration Record (MAR) indicated the resident's weight was not performed on 12/5/24, as ordered. The documented reason was, already complete. During an interview on 4/23/25, at 2:57 p.m. Registered Dietitian Employee E7 confirmed Resident R16's weight was not documented in the EMR and that the facility failed to maintain complete and accurate documentation for Resident R16. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated diagnoses of constipation, hypocalcemia (low levels of calcium in the blood), and Vitamin D deficiency. Review of a progress note dated 4/6/25, completed by RN Employee E16 stated, Resident continues to have menial tasks for staff that she requests one at a time. She first had RN go to her room on her way back in her wheelchair. Then, 2 minutes after RN left her room, she rang the call light. Resident seems to be anxious and incessantly wants staff in her room. In addition to the call bell, resident calls the nurses station from her phone. She flags down staff as they are walking down the hall near her. Her request are for the staff to take whatever food as a snack, she wants to talk/tell stories, she wants pulled up (even though she is a good foot and a half from the bottom of the bed and would hit her head if she were laying down and not sitting up), then she complains about her brief after she is pulled up (staff will continuously fix her location in the bed and then her brief (when one is fixed, the other bothers her and it is a continuous cycle). Resident just continuously has small requests, one at a time, continuously calling staff, or hunting them down. Resident continuously asked to make all needs known at one time. Review of a progress note dated 4/19/25, completed by RN Employee E17 stated, Resident continues to seek staff assistance/attention each time she sees someone. If resident sees someone near the door, walk by, or hears a voice, she will yell for them repeatedly. When staff acknowledge that they will be over when they are finished assisting the resident they are currently with, she acts like she does not hear it and continues to yell. However, she can hear fine other times. Then if another staff member is seen or heard, she continues to yell for them. All needs are met each time. She is fed, has a variety of drinks, is comfortable, clean and dry. She asks for multiple tasks to be completed at the same time. She will wait right beside the medication cart, resident, phone, or nurse's station while nursing is assisting another resident or on the phone and obsessively find a reason for attention. Most of the time, it is a request that could have waited until it was her turn again. She continues to monopolize each staff members time to the extent of her ability to do so. During an interview on 4/25/25, at 9:35 a.m. the Director of Nursing (DON) confirmed that the facility failed to chart accurately and appropriately for Resident R21 as required. Review of Resident R91's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R91's MDS dated [DATE], indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Parkinson's Disease (disorder of the nervous system that results in tremors), and depression. Review of Resident R91's current physician orders on 4/23/25, indicated check and record vitals (temperature, pulse, blood pressure, oxygen saturation, respirations, and weight) on the fifth of each month per facility policy. Special instructions - weights can be started at the beginning of each month; weight and vitals are due to be completed and recorded by the fifth of each month. Review of Resident R91's weight record in the Electronic Medical Record (EMR) on 4/23/25, at 2:00 p.m., failed to include a documented weight for the month of April 2025. Interview on 4/24/25, at 3:05 p.m. Registered Dietitian Employee E7 confirmed that the weights should be entered into the EMR, and the facility failed to maintain complete and accurate documentation for Resident R91. Review of the clinical record indicated Resident R104 was admitted to the facility on [DATE]. Review of Resident R104's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood). Review of a physician order dated 11/28/23, indicated to obtain monthly weight. Special instructions: monthly weights are to be completed by the 5th day of every month and reweighed if +5 or -5 pound difference. Review of Resident R104's weight record in the EMR on 4/23/25, failed to include a documented weight for the month of November 2024. Review of Resident R104's November 2024 MAR indicated the resident's weight was not performed on 11/5/24, as ordered. The documented reason was, already done. During an interview on 4/23/25, at 2:57 p.m. Registered Dietitian Employee E7 confirmed Resident R104's weight was not documented in the EMR and that the facility failed to maintain complete and accurate documentation for Resident R104. Review of a progress note dated 4/21/25, completed by RN Employee E17 stated, Resident has excessively rang the call bell this morning. Each time staff enter, he whines with something he wants done. Multiple staff have assisted resident and asked if there is anything else they can do prior to leaving the room. Resident states no and then would ring the call bell very soon again. Resident is Clean and dry, he has been fed and provided with beverages, he has been repositioned, he had PRN (as needed) analgesics this AM. During an interview on 4/25/25, at 9:35 a.m. the DON confirmed that the facility failed to chart accurately and appropriately for Resident R104 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, group interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to ensure anonymous grievance boxes are readily accessible for resident use on three of three floors (Second, Third, and Fourth Nursing Floor). Findings include: The facility Resident Rights policy dated 1/16/25, indicated that the resident has the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment or reprisal. The nursing home must address the issue promptly. During an observation on 4/21/25, at 2:30 p.m. no grievance boxes were located on the Second Nursing Floor where residents, resident representatives, or visitors could utilize, if needed. During an observation on 4/21/25, at 2:36 p.m. no grievance boxes were located on the Third Nursing Floor where residents, resident representatives, or visitors could utilize, if needed. During an observation on 4/21/25, 2:41 p.m. no grievance boxed were located on the Fourth Nursing Floor were residents, resident representatives, or visitors could utilize, if needed. During an observation on 4/21/25, at 2:45 p.m. an anonymous grievance box was observed in the lobby hall sitting on a ledge with six wheelchairs being stored in front of it. The anonymous grievance box was not readily accessible to anyone at this time. During an interview on 4/21/25, at 2:49 p.m. the Assistant Nursing Home Administrator Employee E10 confirmed that the anonymous grievance box was in the lobby hallway and that there are no other grievance boxes throughout the facility that are readily accessible to residents, resident representatives, or visitors. During an interview on 4/21/25, at 2:51 the Assistant Nursing Home Administrator Employee E10 confirmed that the anonymous grievance box in the lobby hallway was blocked by six wheelchairs and was not readily accessible. During an interview on 4/22/25, at 9:31 a.m. Social Worker, Grievance Officer, Employee E4 stated, I'm not familiar with any grievance boxes on the nursing floors. There is something down on the first floor but I'm not sure where its at. Residents usually come to me to file a grievance. During a group interview on 4/22/25, at 11: 00 a.m. three out of seven residents during a group meeting did not know where to find a grievance box in the facility, stated no grievance boxes were on the units, all you do is give your grievance to the social worker, and were unsure of how to file a grievance anonymously. During an interview on 4/22/25, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure anonymous grievance boxes are readily accessible for resident, resident representative, and visitor use on three of three floors (Second, Third, and Fourth Nursing Floor). 28 Pa. Code 201.18e(4)Management. 28 Pa. Code 201.29(a)Resident rights.

Based on facility policy, clinical record review and interviews with staff, it was determined that the facility failed to revise the comprehensive care plan to reflect resident's current needs for three of six residents (Residents R29, R85, and R88). Findings include: Review of facility policy Comprehensive Care Plans (Nursing Care) dated 1/16/25, indicated the care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the admission record indicated Resident R29 admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/25, indicated diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (the force of the blood against the artery walls is too high), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R29's physician order dated 6/26/24, indicated sulfamethoxazole-trimethoprim (antibiotic) tablet; 400-80 milligrams twice daily for bacteremia (infection of the blood). Review of Resident R29's current care plan on 4/24/25, failed to include interventions, goals or management of the long-term antibiotic or bacteremia. Review of the admission record indicated Resident R85 admitted to the facility on [DATE]. Review of Resident R85's MDS dated [DATE], indicated diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and pain. Review of Resident R85's physician order dated 7/25/24, indicated check resident wander guard (a bracelet that alerts staff if a resident attempts to go beyond a supervised area) every shift for placement and functionality every night shift. Review of Resident R85's current care plan on 4/24/25, indicated the wander guard ordered 7/25/24, was not care planned timely. The care plan intervention was not initiated until 11/7/24. Interview on 4/23/25, at 12:01 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed Resident R29 and Resident R85's care plans were not revised to reflect the resident's current status as required. Review of the clinical record indicated Resident R88 was admitted to the facility on [DATE]. Review of Resident R88's MDS dated [DATE], indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and constipation. Review of a physician order dated 4/11/25, indicated to administer Glucerna 1.5 (a type of tube feeding formula) at 40 mL (milliliters)/hour via gastric tube (a tube surgically inserted via the abdomen into the stomach to provide nutrition). Review of Resident R88's care plan dated 6/4/24, revealed an intervention to administer Glucerna 1.5 at 35mL/hour via gastric tube continuously. During an interview on 4/23/25, at 2:59 p.m. Registered Dietitian Employee E7 confirmed that the facility failed to revise Resident R88's care plan to reflect the resident's current status as required. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of six residents (Residents R51 and R113). Findings include: Review of facility policy MDS 3.0 Completion, Maintenance, and Submission dated 1/16/25, indicated all disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section O: Special Treatments, Procedures, and Programs - Question O0110C1, Oxygen therapy: Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes their own oxygen mask, cannula. O0110C3, Intermittent: check if oxygen therapy was intermittent (i.e., not delivered continuously for at least 14 hours per day). - Section O: Special Treatments, Procedures, and Programs - Question O0110G1, Non-invasive Mechanical Ventilator: Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device. O0110G3, CPAP: check if the non-invasive mechanical ventilator support was CPAP. -Section O Special Treatments, Procedures, and Programs - Question O0110K1, Hospice Care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the management of terminal illness and related conditions. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions). Review of a physician order dated 7/12/24, indicated to administer oxygen up to 6 liters via nasal cannula as needed to maintain oxygen saturation levels between 88% to 92%. Review of a physician order dated 2/27/25, indicated Auto CPAP 15/6 pressure. Assist resident with donning (applying) every night. Fill humidifier chamber with distilled water. Check mask seal for air leaks, adjust headgear straps as needed. Apply chin strap. Resident to be assisted to lateral sleeping position with wedge pillow. Review of Resident R51's March 2025 Vitals - O2 (Oxygen) Saturation documentation revealed the resident received intermittent oxygen therapy for ten days of the 14-day look-back period. Review of Resident R51's March 2025 Treatment Administration Record revealed documentation to indicate the resident used his CPAP machine twice within the 14-day look-back period. Review of Resident R51's quarterly MDS dated [DATE], Section O - Special Treatments, Procedures, and Programs: Question O0110C1 was not checked to indicate the resident received oxygen therapy during the 14-day look-back period. Question O0110G1 was not checked to indicate the resident received non-invasive mechanical ventilator therapy during the 14 day look-back period. During an interview on 4/23/25, at 12:15 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed Resident R51's quarterly MDS dated [DATE], was coded incorrectly and should have been coded to capture the resident's oxygen and non-invasive mechanical ventilator therapy. Review of clinical record indicated that Resident R113 was admitted to the facility on [DATE]. Review of Resident R113's MDS dated [DATE], indicated diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and bipolar disorder (a mental condition marked by alternating periods of elation and depression). Section O - Special Treatments, Procedures, and Programs: Question O0110K1 was checked to indicate that resident received hospice care while a resident. Review of Resident R113's clinical record failed to reveal that resident was ordered hospice services. During an interview on 4/23/25, at 11:47 a.m. RNAC Employee E6 confirmed that resident R113 has never received hospice services and that the MDS dated [DATE], was marked incorrectly. 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for two of eight residents (Residents R40 and R89). Findings include: Review of facility policy Comprehensive Care Plans last reviewed on 1/16/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE]. Review of Resident R40's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated diagnoses of anemia (low levels of iron in the blood), high blood pressure, and Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking). Review of a physician order dated 9/23/24, indicated to administer mirtazapine (an antidepressant) 7.5 mg (milligrams) by mouth at bedtime. Review of a physician order dated 9/23/24, indicated to administer ramelteon (a sedative/hypnotic) 8 mg by mouth at bedtime. Review of a physician order dated 2/5/25, indicated to administer Trintellix (an antidepressant) 20 mg by mouth every morning. Review of Resident R40's current care plan failed to include the development of goals and interventions related to the resident's antidepressant and sedative/hypnotic medication therapy. During an interview on 4/24/25, at 10:51 a.m. the Director of Nursing confirmed Resident R40's care plan did not reflect the use of antidepressant and sedative/hypnotic medications, and that the facility failed to develop and implement a comprehensive care plan to meet care needs for Resident R40 as required. Review of Resident R89's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R89's MDS dated [DATE], indicated diagnoses of difficulty swallowing, vitamin deficiency, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Resident R89's physician order dated 4/30/20, indicated to apply bilateral lower knee TED hose (compression stockings designed to prevent blood clots, and swelling in the legs) daily at 2:30 p.m. for PVD (peripheral vascular disease, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident R89's current care plan failed to include use of TED hose. During an interview on 4/23/25, at 11:42 a.m. Registered Nurse Assessment Coordinator Employee E6 confirmed Resident R89's care plan did not reflect the use of TED hose, and that the facility failed to develop and implement a comprehensive care plan to meet care needs for Resident R89 as required. 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)(3)(5) Nursing Services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R88). Findings include: Review of the clinical record indicated Resident R88 was admitted to the facility on [DATE]. Review of Resident R88's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/13/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and constipation. During an observation on 4/21/25, at 12:18 p.m. Resident R88's call bell was observed on the floor under the resident's bed. During an interview on 4/21/25, at 12:19 p.m. Licensed Practical Nurse Employee E2 confirmed Resident R88's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R88's call bell needs. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, facility documentation, facility investigation and staff interviews, it was determined that the facility failed to provide adequate supervision for one of three residents (Resident R1), which resulted in actual harm when an unsupervised fall occurred, and Resident R1 sustained multiple rib fractures, punctured lung and hospitalization which resulted in death. This failure created an Immediate Jeopardy situation for one of three residents (Resident R1). Findings include: Review of facility policy Fall Prevention Program dated 4/21/23, indicated the purpose of this protocol is to provide guidance to the department of Military and Veterans Affairs (DMVA), Bureau of Veterans Homes (BVH), State Veterans Homes (SVHs) to assist in fall management and prevention reducing the risk of serious injury from falls. Review of Resident R1's admission record indicated he/she was admitted on [DATE]. Review of Resident R1's MDS (minimum data set - a brief periodical assessment of resident needs) dated 11/16/23, indicated diagnosis of psychotic disorder with delusions (presence of one or more delusions- psychosis lost touch with reality), repeated falls, and unspecified dementia with behavioral disturbances (dementia affects your thinking, memory, reasoning, personality, mood and behavior with behavioral disturbances). Review of the MDS Section J 1700 dated 9/14/23, indicated: the resident has had a history of falls with injury. Review of progress notes dated 11/5/23, indicated writer at nurses station, charting heard a loud thump. Looked down the hallway and observed resident lying on the floor between wall and housekeepers cart with head of resident facing the nurses station. Resident C/O pain in head, left arm, left shoulder and generalized pain. Resident states he hurts everywhere and yelled out in pain anytime he was touched to assess. Resident R1 was sent out to the hospital and returned with arm in sling with fracture of shoulder. Review of Resident R1's care plan initiated 11/6/23, revealed Resident R1 is at risk for falls with the goal to remain injury free. Approach initiated 11/5/23 staff supervision 1:1 when a staffing allows (person sits with a resident to maintain their safety) due to high fall risk and frequent falls. Approach initiated 11/6/23, when unable to provide 1:1 supervision, resident is to be q15 minute safety checks due to high fall risk and frequent falls. Approach initiated 11/7/23, indicated 1 person assist, to utilize w/c for mobility when out of bed. Approach initiated 11/1/23, indicated to increase intensity of visual observation when resident is in room. No documentation could be provided for 15 minute safety checks due to high fall risk and frequent falls. Review of the clinical record failed to include further documentation of 1:1 supervision. Review of additional facility documentation daily staffing sheet failed to identify a 1:1 for Resident R1. Review of the clinical record showed inconsistent documentation of any type of supervision for Resident R1 to prevent fall or injury. Review of the MDS Section J 1700 dated 11/16/23, indicated: the resident has had falls that are more recent with injury and major injury. Review of progress notes dated 11/18/23, 6:00 p.m. (for incident at 5:15 per clinical note) indicated: As we got too Resident R1 room we heard the bed alarm then a loud thump, Both the writer of this note and the Nurse Aide rushed into the room. Resident found face down with head facing the window and feet facing the bed. Resident moaning in pain and repeatedly saying my back hurts, please don't leave me. Resident R1 initial assessment in the facility was completed on 11/18/23, at 5:15 p.m. ambulance was called for an emergency transfer (5:22 p.m.) and left facility at 5:50 p.m. MD was notified of fall at 5:15 p.m. Review of facility documentation signature page event report incident report indicated: Resident R1 fall 11/18/23, 5:30 p.m. Fall risk assessment: Description: unwitnessed fall with injury, Observation details: actual fall Mental status/level of consciousness - disoriented x3 diminished safety awareness Balance and Gait: Balance problem while standing, while walking change in gait pattern when walking through doorway, decreased muscular coordination, jerking or unstable when making turns, requires use of assistive devices, Ambulation/Elimination status: impaired mobility/incontinent Does resident have a history of falls in last 3 months: three or more falls Evaluation Fall risk score - Score of 10 or higher represents a high risk for falls - total fall risk score = 21.0000 Level: At Risk Possible contributing factors: indicated resident has poor safety recall, and that the resident tis impulsive and that Resident R1 is unsafe on their own. Review of hospital record history of present illness dated 11/18/23, 11:13 p.m. indicated: Resident R1 presented to level 2 trauma following a unwitnessed ground level fall. Of note, Resident R1 is on warfarin (blood thinner). Resident R1 previously fell last week and fractured his left clavicle (break in the collarbone). Impression and Plan: CT (x-ray) trauma pan scans obtained which demonstrate multiple rib fractures, and a small hemothorax (blood collects between chest wall and lungs). Plan for trauma surgery service admission. Diagnosis: Fall, multiple rib fractures, small pneumothorax (collapsed lung). Review of hospital record dated 11/24/23, indicated: Imaging (x-rays) revealed multiple right posterior medial rib fractures. Resident R1 was admitted to the hospital in the ICU (Intensive Care Unit) for pain control and pulmonary care (care for diseases affecting lungs). Repeat CT (x-ray) chest revealed moderate to large right hemothorax (with complete collapse of the right lower lobe), and near complete collapse of the right middle lobe (collapse of the right lung). Chest tube (tube inserted through chest into lung to reinflate or drain fluid) was placed on 11/20/23. Review of Certificate of Death, dated 12/4/23, Time of Death approximate 18:17 p.m. (6:17 pm.) p.m. revealed Resident R1 had ceased to breath on 12/3/23, with the immediate cause listed as Complications of Blunt Force Trauma of the Trunk and subsequent conditions as Fall. Review of facility video of nursing care unit hallway revealed a facility nurse walked by the room and looked in roughly 4 1/2 minutes prior to the fall. She walked by the rooms and looked in the doors. She did not stop to check to see if Resident R1 needed anything, was positioned correctly, had call bell accessible, etc. During interviews on 12/20/23, between 3:14 p.m. and 5:00 p.m., the following was indicated by employees: Employee E1: Resident R1 was declining and had been on 1:1 after a previous fall where he/she broke their collar bone. Administration determines who has 1:1 - staff was told that we would not be doing a 1:1 that day of Resident R1 fall. Resident R1 needed a 1:1 he/she was a fall risk. Employee E2: Resident R1 care plan does say 1:1 when staffing allows, and administration decides who gets the 1:1. Not aware of any criteria for 1:1. Employee E3: Resident R1 was on a 1:1 had behaviors. Staff was told he/she would not be a 1:1 and another resident was provided a 1:1. Staff working thought Resident R1 was still a fall risk. Employee E4: Administration makes decisions on 1:1, decided in the morning and gets told to staff working on nursing units who will need a 1:1. Employee E5: has never done a 1:1 at the facility but has worked on the nursing unit prior (the nursing unit in question had three 1:1). Employee was unaware of 1:1 for any residents on the unit. Employee E6: Resident R1 use to have a sitter but didn't have one that day, was a fall risk. Doesn't know why 1:1 not provided. On 1/4/23, at 12:34 p.m. the Nursing Home Administrator (NHA) was made aware that an Immediate Jeopardy situation existed, and the Immediate Jeopardy template was provided to the NHA. On 1/4/23, at 4:45 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -All residents will be assessed utilizing the fall risk acuity observation by 1/5/24, resident fall care plans will be updated accordingly. -The process Evaluating Increased Observations for Residents with Behaviors or High Risk for Falls was developed, and education was initiated to nursing staff 1/2/24, which included providing care and services to meet resident needs and interventions related to falls including 1:1. -All clinical staff will be educated on the Bureau of Veterans Homes policy for Freedom of Abuse, Neglect, Exploitation, and Misappropriation of Resident property, Fall prevention program policy the process, of evaluating increased observations, for residents with behaviors for high risk falls, the fall risk assessment, fall risk care plans and fall interventions used for fall precautions. -Facility will conduct audits on residents who are requiring any fall interventions weekly for 4 weeks and then monthly for 2 months to ensure that interventions are in place to meet resident needs and interventions related to falls, including 1:1 observation. Bureau of Veterans Homes policy for Fall Prevention Program was reviewed on 1/4/24. Results of these audit will be reviewed at monthly Quality Assurance meetings to maintain ongoing compliance. The facility did the following for the plan of correction: -All residents were assessed for fall risk acuity assessments by 1/5/24. -1:1 residents were identified as needing updated fall prevention care plans and received fall prevention care plans by 1/5/24. -Facility implemented process Evaluating Increased Observations for Residents with Behaviors or High Risk for Falls was developed and education was initiated to nursing staff 1/2/24, which included providing care and services to meet resident needs and interventions related to falls including 1:1. -Substantial number of staff were trained on new process by 1/6/24. -Tools were implemented for QA process of identifying residents with fall risk and staff have been trained on using new forms. -Staff received training on fall prevention program, policy, process of evaluating increased observations, for residents with behaviors for high-risk falls, the fall risk assessment, fall risk care plan and fall interventions used for fall precautions. -Staff received training on Abuse, Neglect, Exploitation, and Misappropriation of Resident property. -Staff have been trained via email or in-person training. During interviews of staff working on-site on 1/6/24, between 10:00 a.m. and 11:00 a.m. all clinical staff (31 of 31) confirmed they were trained on fall risk acuity assessment/fall prevention and Neglect. The Immediate Jeopardy was lifted on 1/6/24, at 2:00 p.m. During interviews on 12/21/23, at 11:30 a.m. Director of Nursing (DON) confirmed that Resident R1 was a fall risk, had a care plan for 1:1 as staffing permitted. There was a 1:1 on the nursing unit the day of the fall but, it was not for Resident R1. That the cause of death for Resident R1 is listed as Complications of Blunt Force Trauma of the Trunk and subsequent conditions as Fall. During an interview on 1/6/24, at 2:05 p.m. the NHA and DON confirmed that the facility failed to provide adequate supervision and interventions for Resident R1 to prevent an unwitnessed fall, which resulted in actual harm when an fall occurred, and Resident R1 sustained multiple rib fractures, punctured lung and hospitalization which resulted in death. This failure created an Immediate Jeopardy situation for one of three residents (Resident R1). 28 Pa. Code201.18e(1) Management. 28 Pa. Code201.20(a)(b) Staff development. 28 Pa. Code201.29(a)c(d) Resident rights.

Based on facility policy, facility documents, clinical records, staff interview, it was determined that the facility failed to ensure that two out of twelve residents were free from physical abuse and neglect, which caused actual harm to residents (Residents R1 and R3). Findings: Review of facility policy Prevention of Resident Abuse, dated 12/17/20, revealed that resident abuse is defined as the willful deprivation of goods or services which are necessary to maintain physical, mental, and psychosocial well-being or mental health. Neglect is defined as any act or omission which causes or may cause a resident emotional or physical pain, harm or injury, violates the resident's rights or fails below reasonable standards or care or conduct are considered neglect. Review of Resident R1's clinical record, indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's care plan dated 4/29/21, for wandering related to dementia, revealed an ongoing goal that the resident will wander safely within environment. Approaches include: Redirecting resident away from unsafe areas or other resident rooms, attempt to determine cause of wandering and relieve if possible, and to mark room door with name or photo to aid in remembering location. The care plan for physically abusive behavioral symptoms with a date of 6/11/21, revealed an ongoing goal that the resident will not physically abuse other resident ' s, visitors, and/or staff. Approaches include: [MEDICATION(S)] 25mg po at 8 a.m. and 2 p.m. and daily prn (as needed). Monitor and record effectiveness, avoid over-stimulation, and divert resident ' s behavior by encouraging activity/calling daughter. Review of Resident R1's progress notes dated 6/11/21, indicated that resident was witnessed by nursing staff grabbing another resident ' s left wrist then striking employee in the upper left arm when attempting to separate. Review of Resident R1's progress note dated 6/12/21, indicated that Resident R1 given prn [MEDICATION(S)] for severe agitation. Resident unable to be redirected or distracted. Resident is arguing and yelling with staff. Making attempts to be near resident he believes is his wife, gets upset when redirected . Review of Resident R1's progress note dated 6/18/21, indicated that resident had fallen per Nursing Assistant (NA) Employee E1. Resident R1 was observed face down on the sheets, facial laceration approximately 3 cm located left lateral eye, skin tear on right knee approximately 2cm round and left knee 1cm. Resident R1 was sent to local hospital. Review of facility fall investigation dated 6/18/21, Commonwealth Witness Statement, NA Employee E1 stated, I helped the resident to his room about 22:00. I came out of the room and heard him call out. Went back in and saw the resident climbing on to the bed. I ran and got the nurse. Review of Resident R1's progress note dated 6/19/21, indicated that Resident R1 returned from local hospital 3 sutures (sterile surgical threads that are used to repair cuts) intact at left eyebrow laceration site. Review of Resident R1's progress note dated 6/20/21, at 4:00 p.m. revealed that resident is still lethargic and c/o back pain, and also not wanting to ambulate or move BUE much which is out of character for this resident. Call placed to on-call MD and situation discussed. Resident R1 was sent back to the hospital ED (emergency department) for re-evaluation. Call received from, neurologist, (specialists who treat diseases of the brain and spinal cord, peripheral nerves and muscles) revealed resident had a mild [CONDITION(S)] (cerebral vascular accident- loss of blood flow to part of the brain) on the left side of the brain. Resident admitted pending further workup. Review of facility incident and accident report dated 7/12/21, at 8:30 a.m. revealed that the facility had a video of NA Employee E1, on 6/18/21, forcefully pushing Resident R1 into his room, exiting the room, going to another resident's room to answer a call bell and then getting the Registered Nurse (RN) and going back to Resident R1 room. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/16/21, at 11:30 a.m. the Director of Nursing (DON) confirmed the Facility's fall investigation began on 6/22/21, when she reviewed the surveillance video footage for unit 4S nursing unit it was observed that NA Employee E1 forcefully push Resident E1 into his room. DON stated upon discovery of the incident, NA Employee E1 was brought in for a statement and suspended. Review of Resident R3's clinical record, indicated the resident was originally admitted to the facility on [DATE], and a readmitted [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R3's care plan dated 7/12/21, for falls revealed an ongoing goal that the resident will remain free from injury related to falls. Inventions include: place resident at nursing station when out of bed to wheelchair, reapply soft helmet if removed by resident when out of bed, offer back to bed prior to 9:00 p.m., PT/OT assessment S/P fall to evaluate for non-slip mat to wheelchair to prevent sliding out of wheelchair. Review of Resident R3's progress note dated 7/11/21, indicated that resident was observed on her left side face down on the floor, a laceration noted on her left forehead with active bleeding present. Resident sent via ambulance to local hospital. During an interview on 7/27/21, at 11:45 a.m., Assistant Director of Nursing (ADON) Employee E5 & Quality Assurance (QA) Employee E6 stated that NA's look on the roster to see adaptive equipment needs of residents. ADON Employee E5 confirmed that Resident R3's soft helmet was not included on the resident roster and the facility neglected to apply the helmet as included in the resident's plan of care and confirmed that the NA Employee E4 still works at the facility and they did not retrain on helmet usage but was retrained on wheelchairs. During an interview on 7/27/21, at 2:45 p.m., NA Employee E4 stated she looks for adaptive equipment on the roster, care tracker or on the chart. NA Employee E4 stated, that Resident R3 did not have her helmet on at the time of the incident. During an interview on 8/4/21, at 2:50 p.m. the Director of Nursing confirmed the facility failed to protect two residents from abuse and neglect. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201. 18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a review of clinical records, facility staff education documents, facility specific documents, and staff interviews, it was determined that the facility failed to make certain that residents were protected from an unsafe chemical that resulted in actual harm for a resident (Resident R1) when the resident ingested drain cleaner resulting in [CONDITION(S)] injury, hospitalization and intubation. This failure created a past non-compliance Immediate Jeopardy situation for 25 of 36 residents who were able to reach the top of the maintenance cart and resided on the dementia unit. Findings include: Review of the facility policy, Safety Policy Statement, dated 3/9/20, indicated that staff will know and follow safety precautions published by the manufacturer on a Safety Data Sheet (SDS, a document that lists information relating to occupational safety and health for the use of various substances and products) while using chemicals. Review of the Environmental Protection Agency (EPA - a federal agency, that sets and enforces rules and standards that protect the environment) publication, Label Review Manual: Chapter Seven, dated 07/2014, indicated the following: - Toxicity Category 1: Fatal if swallowed. - Toxicity Category 2: May be fatal if swallowed. - Toxicity Category 3: Harmful if swallowed. Review of the SDS for Drain Rocket (a chlorinated drain cleaner) dated 10/4/16, indicated in Section 2: Hazards Identification that Drain Rocket is designated to have acute oral Toxicity Category of 1, 2. The facility's current Maintenance Repairman Job Description indicated that the repairman performs work in accordance with the facility's general safety rules and the safety rules for this position. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 12/17/20, indicated the resident's diagnoses included, non-Alzheimer's dementia (a group of brain disorders that result in behavioral, cognitive, or language changes) and depression. The resident's Activities of Daily Living (ADL) for locomotion was documented as independent, with no help or staff oversight at any time and only needs assistance with set up in the wheelchair. The resident's Functional Limitations in Range of Motion was documented that he had no impairment with his upper extremities (shoulder, elbow, wrist, hand). The care plan updated 2/20/21, indicated that Resident R1 is at risk of injuring himself related to confusion, was able to self-propel on and off the unit unassisted, and had wandering behaviors. Review of Resident R1's progress notes from 8/26/20, through 2/26/20, revealed the following: On 9/10/20, at 3:38 p.m.: Resident is observed removing food from other residents, placing various meal items into his undergarments, seeking out and attempts to remove, 'leftovers.' Resident needs monitored to ensure these behaviors do not occur and that he does not eat after another resident. On 9/13/20, at 8:57 p.m.: Resident had several episodes of aggression towards staff. Also taking other residents' food from their trays and stuffing it in his pants and socks. On 9/16/20, at 9:35 p.m.: Resident R1 did attempt to steal garbage and gloves off of this RN's med cart during evening med pass. On 10/3/20, at 9:20 p.m.: Resident was observed on multiple occasions, stuffing random food items and miscellaneous hygiene products up into his shirt, into his chair and also down into his pants. Resident is not able to be redirected or deterred from this behavior. Resident becomes incredibly aggressive and agitated if staff members attempt to assist him to rid his clothing and chair of these collected items. On 12/15/20, at 2:45 p.m. psychosocial assessment noted that Resident R1 has wandering disease. On 1/23/21, at 9:20 a.m.: Resident was noted by staff to have a shiny metal object protruding from the calf area his right sock that was metallic in color. Staff wanted to remove it for concern of safety. He had seated himself on bed. Staff asked this writer to help with removal of the object as resident was upset. Three staff members assisted to calm resident as this writer attempted to remove right sock and the resident kicked this writers' right forearm. No residents were in harms way. Sock was then carefully removed by this writer. A broken in half plastic spoon was removed from sock. Review of the facility provided timeline, extracted from the facility video surveillance, indicated the following occurred on 2/26/21: -2:43 p.m. Maintenance Repairman (MR) Employee E1 was in a resident room, with his cart unattended with two bottles of Drain Rocket drain opener on top of the cart. -2:43 p.m. Resident R1 took the first bottle of Drain Rocket and attempted to open it. Resident R1 then took the second bottle of Drain Rocket and attempted to open it. -2:44 p.m. Employee E1 returned to his cart, and was observed looking over the top of his cart. Employee E1 did not inquire from staff the possible whereabouts of the missing Drain Rocket. -2:44 p.m. Resident R1 drank from the bottle of Drain Rocket, spit on the floor, and yelled for water. -2:48 p.m. Resident R1 was noted to be vomiting. Emergency Services and the Poison Control Center were called. -3:06 p.m. Local police responded to the unit. -3:16 p.m. Resident R1 exited the facility with Emergency Services and local police. A nurses' note dated 2/26/21, at 3:01 p.m. indicated that Resident R1 had taken a bottle of Drain Rocket from a maintenance cart in the hallway and drank it. Staff reports the resident immediately spit on the floor, then went into the room and began flushing mouth with running water and spitting into the sink. The nurses' note further indicates that the resident began vomiting and appeared very distressed. A nurse practitioner's note dated 2/26/21, at 3:02 p.m. indicated that Resident R1was seen for evaluation after ingestion of a toxic substance. The resident was noted to be continuously clearing his throat and reporting burning sensation in his mouth and throat. The note further indicated that Resident R1 was transported via emergency services to the hospital. A review of the documentation submitted by the facility dated 3/2/2021, indicated that Resident R1 was admitted to the hospital with a diagnosis of laryngeal [CONDITION(S)] (swelling of a portion of the throat), was placed into a chemically induced coma and was intubated (placed on a ventilator to assist with breathing). During an interview on 3/3/21, at 11:55 a.m. Employee E1 confirmed that he left the Drain Rocket unsecured on the top of his maintenance cart when he entered the resident room. During a review of new employee orientation education documents, Employee E1 signed that he had received education on hazardous substances on 3/9/20. During an observation of the maintenance carts and interview with Facility Maintenance Manager Employee E2 on 3/3/21, at 12:11 p.m. all maintenance carts had locking compartments available. During an observation of the maintenance carts and interview on 3/4/21, at 12:30 p.m. the Facility Maintenance Manager Employee E2 confirmed all maintenance carts were in fully operable condition, and further stated that all seven maintenance carts' locking mechanisms were functional on 2/26/21, and that seven housekeeping carts were taken out of service for non-operable locking mechanisms. The Commandant (Nursing Home Administrator) and the Deputy Commandant were made aware that an Immediate Jeopardy situation existed for residents residing on the dementia unit on 3/3/21, at 5:00 p.m. and a corrective action plan was requested. On 3/3/21, at 5:02 p.m. the Immediate Jeopardy template was provided to facility administration. On 3/3/21, at 8:31 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. The resident was transferred out to the hospital and currently remains there. 2. Education was initiated for facility staff members by the Deputy Commandant, Director of Nursing, Registered Nurse Supervisor, or designee on chemical storage. Remaining staff who need educated will have it completed when they report for duty or by calling. Anticipated date of completion is 3/5/21. 3. Education will be initiated for facility staff members by the Deputy Commandant, Director of Nursing, Registered Nurse Supervisor, or designee on safety precautions for residents with Dementia/Altered Mental Status and staff will complete validation of understanding. Staff will be educated when they report for duty or by calling. Staff will complete the training prior to interacting with residents. Anticipated date of completion is 3/5/21. 4. A whole house sweep to validate chemicals were secured was completed on 2/26/21. Any unsecured chemicals were secured at that time. Seven housekeeping carts were pulled from service to have the locking mechanisms repaired. 5. Storage of Chemical Policy was created for the maintenance department and added to the maintenance manual on 2/26/21. 6. Audits were initiated on 2/27/21, every shift for Maintenance, Housekeeping, and Nursing to validate compliance with chemical storage. Audits are submitted to the QAPI Committee for review and evaluation for effectiveness. 7. Audits will be completed weekly from 3/5/21 through 4/2/21, to validate compliance with chemical storage. Audits are submitted to the QAPI Committee for review and evaluation for effectiveness. 8. Audits will be completed every two weeks from 4/5/21 through 4/162/21, to validate compliance with chemical storage. Audits are submitted to the QAPI Committee for review and evaluation for effectiveness. 9. Audits will be completed monthly times three months from 4/19/21 through 7/14/21, to validate compliance with chemical storage. Audits are submitted to the QAPI Committee for review and evaluation for effectiveness. During an interview on 3/4/21, at 12:30 p.m. Environmental Services Worker (EVS) Employee E3 confirmed that she received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During a group interview on 3/4/21, at 12:32 p.m. Therapy Employees Employee E4, E5, and E6 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During an interview on 3/4/21, at 12:34 p.m. Security Officer Employee E7 confirmed that he received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During an interview on 3/4/21, at 12:35 p.m. Security Officer Employee E8 confirmed that he received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During an interview on 3/4/21, at 12:38 p.m. Dietary Worker Employee E9 confirmed that she received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During a group interview on 3/4/21, at 12:40 p.m. Dietary Employees Employee E10 and E11 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During an interview on 3/4/21, at 12:45 p.m. Maintenance Employee E12 confirmed that he received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During an interview on 3/4/21, at 12:47 p.m. Maintenance Employee E13 confirmed that he received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During a group interview on 3/4/21, at 12:50 p.m. Maintenance Employees Employee E14, E15 and E16 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During a group interview on 3/4/21, at 12:55 p.m. Environmental Supervisor Employee E17 and Environmental Services Worker Employee E18 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During interviews completed on Three North Nursing Unit on 3/4/21, at 1:00 p.m. Licensed Practical Nurse (LPN) Employee E19, and Nurse Aides (NA) Employees E20 and E21 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During interviews completed on Three South Nursing Unit on 3/4/21, at 1:10 p.m. Registered Nurse (RN) Employee E22 and NA Employee E23 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During interviews completed on Four North Nursing Unit on 3/4/21, at 1:17 p.m. RN Employee E25 and NA Employees E24, E26 and E27 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During interviews completed on Four South Nursing Unit on 3/4/21, at 1:28 p.m. NA Employees E28, E29 and E30 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During interviews completed on Two North Nursing Unit on 3/4/21, at 1:36 p.m. RN Employee E31, LPN Employee E32 and NA Employees E33 and E34 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. During interviews completed on Two South Nursing Unit on 3/4/21, at 1:45 p.m. LPN Employees E35 and E36 and NA Employees E37 confirmed that they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview. A review of the documentation received from the facility on 3/4/21, at 3:14 p.m. revealed that all elements of the Corrective Action Plan were substantially completed per the facility's action plan. This revealed this this was determined to be past non-compliance on February 27, 2021. During an interview on 3/8/21, at 12:56 p.m. the Deputy Commandant confirmed that 25 of the 36 residents on the dementia unit possessed the physical capability to walk/self-propel in the hallway on their own, and possessed the physical dexterity to take a bottle from the top of a cart. During an interview on 3/4/21, at 4:15 p.m. the Commandant and the Deputy Commandant confirmed the facility failed to make certain that residents were protected from an unsafe chemical that resulted in actual harm for one resident when the resident ingested Drain Rocket (Resident R1). Previously cited: 28 Pa Code: 201.14(a) Responsibility of Licensee. Previously cited: 4/17/19, 11/22/19 28 Pa Code: 201.18(b)(1)(e)(1) Management. Previously cited: 11/22/19 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited: 11/22/19 28. Pa. Code. 211.12(d)(1) Nursing Services. Previously cited: 11/22/19, 1/2/20 28. Pa. Code. 211.12(d)(5) Nursing Services. Previously cited: 11/22/19

Based on review of facility policies, facility documentation, clinical record review and investigation reports as well as staff interviews, it was determined that the facility failed to make certain that a resident was free from neglect for one of 5 residents (Resident R1) reviewed that resulted in harm when the resident developed an unstageable pressure ulcer (slough or eschar obscures the extent of tissue loss) to the sacrum (triangular bone at the base of the spine), due to a bed pan being left underneath a resident and peri-care (washing the genitals and anal area to prevent skin breakdown) not being completed. Findings include: Review of the facility abuse policy dated 12/1/17, Bureau of Veterans' Homes Freedom from Abuse, Neglect, Exploitation and Misappropriation Resident Property states The SVH shall prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat a resident's medical condition. Resident R1's face sheet with an original date of 6/1/17, and a readmitted [DATE], includes [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set assessment (MDS - a periodic resident assessment) with a target date of 6/7/18, included a resident Brief Interview of Mental Status (BIMS a tool used to assess a resident's cognition) as a 14 meaning the resident is alert and oriented with few cognition problems. The MDS also indicated that the resident needed to be turned and repositioned and that he required assistance from staff for bed repositioning. Review of clinical record Care Plan dated 12/11/17, indicated that ADL (Activities of Daily Living) Functional/Rehabilitation Potential Resident unable to independently change position while in bed as evidenced by requiring staff assistance to reposition .Approach .Provide assistance as needed or requested for repositioning in bed. Review of information dated 7/3/18, submitted by the facility, on 6/10/18, at 10:55 a.m. revealed that Resident R1 (a paraplegic with no sensation from the abdomen to lower extremities) was placed on a fracture bed pan (a bed pan that is not as deep as a regular bed pan) on 6/8/18, which remained under the resident until the morning of 6/10/18. Staff noted a reddened indentation with an area of skin integrity loss. A review of the clinical documentation Observation Detail List Report dated 6/10/18, indicated Registered Nurse (RN) Employee E1, was called to the unit at 6:30 a.m. to assess Resident R1. The assessment indicated a dark red/purplish horseshoe shaped area noted, measuring approximately 24.5 cm (centimeter) in diameter and 1.5 cm thick rim area present .open area also noted to mid right lateral buttocks without drainage . Left mid lateral buttocks area with grayish/purple area noted measuring approximately 2 cm with skin intact. Additional clinical documentation from Wound Healing Solutions dated 6/11/18, revealed an unstageable pressure ulcer and injury of the sacrum extending thru bilateral buttock secondary to deep tissue injury (DTI - a pressure-related injury to subcutaneous tissues under intact skin). Analysis: Initial assessment wound present since 6/10/18, contributing factor: bed pan . A review of a witness statement from Licensed Practical Nurse (LPN) Employee E2, dated 6/12/18, revealed that LPN Employee E2, had placed Resident R1 on the bed pan and asked Nursing Assistant (NA) Employee E3, to remove Resident R1 from the bed pan. During an interview on 7/6/18, at 10:50 a.m. LPN Employee E2, stated she had placed Resident R1 on a bed pan on 6/8/18, did not remove him from the bed pan and thought that NA Employee E3, had removed the bed pan. Review of a witness statement for NA Employee E3, (who worked with Resident R1 on 6/8/18) dated 6/11/18, revealed that Resident R1 did not receive peri-care, a shower (Resident R1's shower day is Friday (6/8/18)) or Foley catheter care (cleaning the area around the drainage tube to prevent infection). During an interview on 7/6/18, at 10:00 a.m. NA Employee E3, stated she did not remove Resident R1 from his bed pan, did not provide peri-care, a shower or Foley catheter care. Review of a witness statement for NA Employee E4, (who worked with Resident R1 on 6/9/18) dated 6/10/18, revealed that NA Employee E4, did not round on residents with NA for next shift, did not provide Foley catheter care, did not turn or check (more than are you ok), or provide peri-care to Resident R1. Review of a witness statement for LPN Employee E5, (who worked with Resident R1 on 6/9/18) dated 6/10/18, reported failure to provide Foley care (flushed only), did not check brief, did not provide peri-care, did not offer alternative bathing solutions (whirlpool) to Resident R1. Review of a witness statement for NA Employee E6, (who worked with Resident R1 on 6/9/18) dated 6/10/18, reported failure to provide a bed bath, checked brief, but did not think it looked wet, and did not provide peri-care to Resident R1. During an interview on 6/29/18, at 10:55 a.m. with the Director of Nursing (DON) confirmed a bed pan was placed under Resident R1 on 6/8/18 and was not removed until 6/10/18. During an additional interview on 6/29/18, at 4:00 p.m. the DON confirmed that the bed pan that was left underneath Resident R1 resulted in a pressure injury (unstageable) and that the employees failed to provide peri-care from 6/8/18 to 6/10/18, resulting in neglect. The facility failed to make certain that a resident was free from neglect for one resident (Resident R1) that resulted in harm when the resident developed an unstageable pressure ulcer to the sacrum, due to a bed pan being left underneath a resident and peri-care not being completed. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/15/17, 12/9/16. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 9/15/17, 12/9/16. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 9/15/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/9/16. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 9/15/17.

Based on review of clinical records, facility policy, an incident report and staff interview, it was determined that the facility failed to provide safe transport of a resident in a wheelchair which resulted in actual harm for one of four residents reviewed (Resident R1). Findings include: The facility policy entitled, Wheelchair Safety, dated 12/20/15, indicated that any concerns regarding the safety of residents in the wheelchairs will be referred to the Occupational Therapy (OT) department for re-evaluation. Review of the clinical face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment (MDS- a periodic assessment of care needs) dated 5/2/16, indicated the Resident R1 had severe cognitive impairment, only sometimes had the ability to understand others, was totally dependent on staff for transfers and for locomotion off the unit and had a history of [REDACTED]. Review of the information dated 6/17/16, at 10:12 a.m. submitted by the facility, revealed that Resident R1 was being transported via wheelchair to another nursing unit by Nurse Aide (NA), Employee E3. While approaching a threshold in the floor, Employee E3 requested Resident R1 to raise his feet. Resident R1 did so and then lowered his feet where they caught the threshold, resulting in a fall forward onto the floor. Resident R1 sustained a laceration (cut) of the forehead, requiring transfer to the hospital on [DATE], at 10:37 a.m. Review of the, Resident Progress Note (the title of the computer documentation form for all disciplines) dated 6/17/16, at 4:38 p.m. indicated that Resident R1 returned from the hospital with 18 sutures (stitches) to close the laceration. During an interview on 7/14/16, at 1:10 p.m. the Occupational Therapist/ Rehabilitation Department Director, Employee E4, confirmed that Resident R1 had been issued leg rests for his wheelchair in May 2016, due to left knee bursitis (joint inflammation causing pain). During an interview on 7/14/16, at 2:15 p.m. Employee E3 confirmed that he/she did not apply the leg rests to Resident R1's wheelchair prior to the transport on 6/17/16, and that he/she had been instructed to use the leg rests for transport. During an interview on 7/14/16, at 3:30 p.m. the Director of Nursing confirmed that the staff failed to safely transport Resident R1 on 6/17/16, resulting in injury. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/12/14. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/12/14. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/15/16.