Every finding on record at Springfield Rehabilitation and Healthcare Center

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to complete a thorough fall investigation, including obtaining witness statements from the resident and the resident's roommate for one of two residents reviewed for falls. Findings include: Review of Resident R117's clinical record revealed Resident R117 was admitted to the facility on [DATE] with diagnoses of paraplegia (condition where a person loses movement and feeling in the lower half of their body, usually affecting both legs) chronic obstructive pulmonary disease (COPD- prevents airflow to the lungs, causing breathing problems), and chronic pain syndrome. Review of Resident R117's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated October 23, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Review of facility incident report submitted to department of health, dated November 26, 2025, revealed Resident R117 sustained a fall from bed. Further review revealed CNA was in the room with the resident providing care to the resident and wanted the wound nurse to look at the resident's bottom. Resident was positioned safely in the middle of the bed when the CNA left the room. As staff member went to get wound nurse residents roommate called out that the resident had fallen out of bed. Further review of facility incident report revealed the resident was noted to be bleeding from her head. Resident was kept on the floor until paramedics arrived for safety with RN present. Resident remained alert and oriented, answered questions appropriately. Resident stated she began to slide off the bed and she could not prevent it due to paraplegia. Review of facility investigation, dated November 25, 2026, revealed a witness statement from Employee E7, Nurse Aide, that revealed I was changing resident and I noticed she had an open area on her butt, I left resident on her side with pillows on her side to get (wound nurse) to look at her butt. I felt like she was safe in the bed when I went to get (wound nurse). I heard (wound nurse) walking down the hall, I made sure resident was safe position in the bed before leaving to get (wound nurse). I heard resident call out. Upon returning to room I found the resident on her right side on the floor between the beds. Further review of facility investigation revealed no statements were obtained from Resident R117 or Resident R117's roommate related to the fall incident. Interview on April 1, 2025, at approx. 10:00 a.m. with Employee E1, Director of Nursing, confirmed that there were no written statements obtained from Resident R117 or Resident R117's roommate related to the incident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29 (a) Resident rights

Based on observations, interview with staff and resident, and review of clinical record and facility's policy, it was determined that facility did not ensure to develop and implement a care plan related to assistive device and fall prevention measures for one of 18 residents reviewed (Resident R69)Findings include: Review of facility policy 'Comprehensive Person-Centered Care Plans,' revised March 2022, indicates that the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being , including: the resident's stated goals upon admission and desired outcome, and reflects currently recognized standards of practice for problem areas and conditions. Review of Resident R69's clinical record revealed admission date of January 22, 2026, with medical history of chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform), anxiety disorder, chronic respiratory failure with hypoxia (low levels of oxygen), muscle wasting and atrophy, gait and mobility abnormality. Interview with Resident R69 on Monday, March 30, 2026, at 10:00 am, revealed that she was sound asleep when she rolled out of bed during night shift on March 27, 2026, and had a fall resulting in injury to right eye. Further interview with Resident R69 revealed she previously requested grab bars to be placed on both sides of bed. Review of Resident R69's Interim Bed Rail Evaluation, initiated on January 23, 2026 and completed on February 4, 2026, indicated Resident R69 was ambulatory, has no impaired cognitive status or fluctuations in consciousness, has used bed rail to assist with bed mobility in the past for turning side to side, holding self to one side, pulling self from laying to sitting position, providing sense of security. Further review of Interim Bed Rail Evaluation revealed Resident R69 does not have any uncontrolled or involuntary body movements and does not have poor spatial awareness. Continued review of Interim Bed Rail Evaluation revealed that Resident R69 requested bed rail/safety assistive device to have left grab bar and right grab bar. Review of Resident R69's care plan revealed no evidence of goals and interventions related to grab bars or alternatives to bed rails. 28 Pa Code 211.10(d) Resident care polices 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility did not ensure development and implementation of a care plan related to the need for oxygen for 1 of 18 residents reviewed (Resident R10) Findings include:Review of facility policy titled Oxygen Administration, revised October 2010, states one is to verify a physician's order for the procedure in preparation for safe oxygen administration. Review of Resident R10's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses if chronic obstructive pulmonary disease (a progressive lung disease which makes breathing difficult), panlobular emphysema (chronic lung disease with noted uniform destruction of the air sacs used for gas exchange), and mild cognitive impairment. Resident was admitted on hospice care. Observation of Resident R10 on March 30, 2026 at 9:55 AM revealed resident was non-interviewable, was mouth breathing (breathing through the mouth) and on 2 Liters (L) of Oxygen (O2) via O2 concentrator and nasal cannula. Subsequent observations of Resident R10 on April 1, 2026 at 12:47 PM and April 2 at 10:56 AM revealed same. Review of Resident R10's clinical records revealed resident's oxygen saturation had dropped to 78% in the early morning on March 30, 2026, and (she/he) was noted to be dyspneic (having difficulty breathing) and hypoxic (state resulting from having a lack of oxygen in bodily tissues or cells). The resident was placed on a non-rebreather mask, then switched to oxygen via nasal cannula being administered at 4L/minute (min), after oxygen saturation had rebounded to 98% on the non-rebreather. By 9:55 AM that same day when observed, the resident's oxygen had been decreased to 2L/min. Interview with the Director of Nursing, Employee E2, at 9:45 AM on April 1, 2026 confirmed Resident R10 was receiving 2L/min of oxygen via nasal cannula, and revealed her statement that nursing can put patients on oxygen at a rate of 2 Liters per minute without an order but any more than that would require an order. Review of resident's care plan revealed no care plan related to oxygen use/administration. 28 Pa Code 211.10(d) Resident care policies 28 PA. Code 211.12(d)(1)(5) Nursing services

Based on resident interview, review of facility's policy and clinical record, it was determined that facility did not ensure hygiene care was provided as per resident's preference for one of 18 residents reviewed (Resident R86)Findings include: Review of facility policy 'Activities of Daily Living,' revised April 2025, indicates its purpose is to provide residents with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Review of Resident R86's clinical record revealed medical history of falls, multiple sclerosis (autoimmune disorder that affects the central nervous system), fracture of left lower extremity, asthma, muscle wasting and atrophy. Review of R86's Minimum Data Set (MDS- resident assessment of care needs), completed on January 16, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitive intact. Review of shower schedule for North unit revealed Resident R86 is scheduled for shower during day shift on Wednesdays and Saturdays. Interview with Resident R86 on Monday, March 30, 2026, at 10:30 am, revealed that she was offered a shower three times since admission on [DATE]. Review of Resident R86's plan of care (POC) revealed documented that shower was offered and received on April 1, 2026, at 11:11 am, completed by nurse aide, Employee E6. No evidence of prior history of completed showers as per Resident R86's schedule. Further review of R86's clinical record revealed no evidence of Resident R86 refusing hygiene care, specifically refusal of showers, as per her preference. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code (d)(1) nursing services

Based on review of clinical records, facility documentation, and resident representative and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice for one of four residents reviewed (Residents R16). Findings include: Review of Resident R16's clinical record revealed Resident R16 was admitted to the facility on [DATE] with a diagnosis of rhabdomyolysis (condition where damaged muscle tissue breaks down quickly and releases harmful substances into the blood), congestive heart failure (CHF- condition where the heart does not pump blood as well as it should, causing fluid to build up in the lungs and other parts of the body like the legs), and chronic kidney disease (long-term condition where the kidneys gradually lose their ability to filter waste and extra fluid from the blood). Review of Resident R16's Nutritional Risk Assessment, dated March 16, 2026, revealed the resident was at risk for malnutrition related to comorbidities. Further review indicated an order for weekly weights x 4. Review of Resident R16's weight records revealed the following: March 14, 2026- 140.6 pounds (lbs.)March 15, 2026- 140.2 lbs.March 30, 2026- 155 lbs. There was no documented weight obtained on or around March 23, 2026, as ordered. Interview on April 2, 2026, at approx. 12:15 p.m. with Resident R16's representative revealed on March 30, 2026, he/she had concern regarding increased swelling in the resident's legs. The representative requested the resident be reweighed and go to the hospital due to concern of CHF exacerbation (worsening of heart failure symptoms, where fluid builds up more than usual in the body, causing problems like shortness of breath, swelling, and rapid weight gain). Once the facility reweighed Resident R16, the resident was noted to have gained approximately 15 pounds since admission. Review of Resident R16's social worker progress note, dated March 30, 2026, revealed resident/family reported concern over leg swelling and wanting to go to hospital. SS (Social Services) notified nursing of request. Review of Resident R16's nurse practitioner progress note, dated March 31, 2026, revealed spoke with patient and (representative) at bedside at length. Concerned about CHF exacerbation. CXR (chest x-ray) done which shows L (left) pleural effusion. On exam, lungs diminished, no wheeze/rhonchi. Trace LE (left leg) edema w/o (without) pain. Pt (patient) and (representative) requested hospitalization. Review of nursing progress notes, dated March 31, 2026, revealed Resident R16 was transferred to the hospital for exacerbation of CHF. Review of nursing progress note, dated April 1, 2026, revealed Resident R16 was admitted to the hospital for acute CHF exacerbation (sudden worsening of heart failure symptoms requiring intervention). Interview on April 2, 2026 at approx. 1:00p.m. with Director of Nursing, Employee E1, confirmed Resident R16's weights were not obtained as ordered on March 23, 2026. 28 PA. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, interview with residents' and staff, review of policies and review of clinical records, it was determined that facility did not ensure residents' received adequate supervision and assistive device to prevent accidents for two of 18 residents reviewed. (Residents R69, R117) Findings include: Review of facility policy 'Bed Safety and Bed Rails,' revised August 2022, indicates that consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Further review of policy indicates that for the purpose of policy, bed rails include side rails, safety rails and grab/assist bars. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: roll guards, foam bumpers, lowering the bed and/or use of concave mattress to reduce rolling off the bed. Review of Resident R69's Minimum Data Set (MDS- assessment of resident's needs), completed on January 29, 2026, revealed Brief Interview for Mental Status (BIMS) score of 12, which indicated that the resident had moderate cognitive impairment. Further review of Resident R69's fall risk evaluation, completed on January 22, 2026, indicates fall risk score of 12, which indicated the resident was at moderate risk for falls. Review of Resident R69's Interim Bed Rail Evaluation, initiated on January 23, 2026 and completed on February 4, 2026, indicated Resident R69 was ambulatory, had no impaired cognitive status or fluctuations in consciousness, used bed rail to assist with bed mobility in the past for turning side to side, holding self to one side, pulling self from laying to sitting position, providing sense of security. Further review of Interim Bed Rail Evaluation revealed Resident R69 did not have any uncontrolled or involuntary body movements and did not have poor spatial awareness. Resident R69 requested bed rail/safety assistive device to have left grab bar and right grab bar. Observations of Resident R69, on Monday, March 30, 2026, at 10:00 am, revealed Resident R69 in room [ROOM NUMBER] bed A, with a bruise of the right eye. Interview with Resident R69 at the time of the observation revealed that (she/he) was sound asleep when she rolled out of bed during night shift on March 27, 2026, and had a fall resulting in injury to right eye. Further interview with Resident R69 revealed she previously requested grab bars for assistance. Review of facility completed investigation report, completed on March 30, 2026, at 1:42 pm, indicates that while in bed, (she/he) turned on her right side and fell off the bed on to the floor. Review of Resident R69's hospital discharge summary revealed a cat scan of the head completed on March 27, 2026, at 10:19 am, which revealed a small hemorrhagic contusions within the left greater than right anterior cranial fossa; soft tissue hematoma over the right lateral supraorbital soft tissues. Further observations of Resident R69 room environment on Monday, March 30, 2026, at 10:00 am, revealed no evidence of grab bars on bed A in room [ROOM NUMBER]. Interview with Physical Therapy Director, Employee E4, on April 2, 2026 at 10:25 am, revealed that occupational therapist and nursing staff were responsible for initiating order for grab bars and communicating with maintenance employees to implement grab bars for Resident R69. Interview with the Director of Nursing. Employee E1 on March 31, 2026 at approximately 10:30a.m. revealed that it was missed to communicate with maintenance to place bed rails on Resident R69's bed. Review of Resident R117's clinical record revealed Resident R117 was admitted to the facility on [DATE] with diagnoses paraplegia (condition where a person loses movement and feeling in the lower half of their body, usually affecting both legs) chronic obstructive pulmonary disease (COPD- prevents airflow to the lungs, causing breathing problems), and chronic pain syndrome.Review of Resident R117's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated October 23, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.Review of Resident R117's care plan, dated July 29, 2025, revealed the resident is at risk for falls related to decondition. Review of Resident R117's MDS, dated [DATE], revealed the resident's ability to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed) was coded as dependent. Review of facility incident report submitted to the department of health on November 26, 2025, revealed Resident R117 sustained a fall from bed. Further review revealed CAN (nurse aide) was in the room with the resident providing care to the resident and wanted the wound nurse to look at the resident's bottom. Resident was positioned safely in the middle of the bed when the CNA left the room. As staff member went to get wound nurse residents roommate called out that the resident had fallen out of bed. Further review revealed the resident was noted to be bleeding from her head. Resident was kept on the floor until paramedics arrived for safety with RN (registered nurse) present. Resident remained alert and oriented, answered questions appropriately. Resident stated she began to slide off the bed and she could not prevent it due to paraplegia. Review of facility investigation, dated November 25, 2026, revealed a witness statement from Employee E7, Nurse Aide, that revealed I was changing resident and I noticed she had an open area on her butt, I left resident on her side with pillows on her side to get (wound nurse) to look at her butt. I felt like she was safe in the bed when I went to get (wound nurse). I heard (wound nurse) walking down the hall, I made sure resident was safe position in the bed before leaving to get (wound nurse). I heard resident call out. Upon returning to room I found the resident on her right side on the floor between the beds.Review of nurse aide, Employee E7, CNA statement sheet for falls revealed the nurse aide last witnessed Resident R117 in bed lying on her side. Interview on April 1, 2025, at approx. 10:30 a.m. with Employee E1, Director of Nursing, confirmed the nurse aide, Employee E7, left Resident R117 lying on her side in bed when she walked out of the room to get another staff member. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 PA. Code 211.12(d)(1)(5) Nursing services

Based on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment.Findings include: Review of the facility's facility assessment, dated January 09, 2025, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with Employee E1, Administrator, on April 02, 2026, at approximately 10:00 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility did not ensure a dressing covering a central line was changed as ordered by the physician for one of one resident review with a central line. (Resident R106) Findings Include: Review of Resident R106's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses including cutaneous abscess of right lower limb (usually caused by bacterial infection, a collection of pus within or under the skin), extended spectrum beta lactamase (ESBL) resistance (resistance of a specific type of microorganism to a particular type of antibiotics, which cause infection), and methicillin susceptible staphylococcus aureus infection (type of staph infection that can be treated with penicillin-related antibiotics). Review of Resident R106's clinical records revealed Resident R106 was prescribed a course of IV (intravenous) antibiotic Cefazolin sodium starting on March 29, 2026, at 6:00 a.m. to be completed on May 1, 2026. Review of CDC guidelines indicates central lines (CVCs), including Peripherally inserted central venous catheters or PICC, such as the one the patient had, should only be placed when essential, one of the indications including long-term IV therapy which is generally defined as lasting more than a few weeks (can be months). PICC is inserted through a peripheral vein in the arm (basilic or cephalic) with the tip resting in a large central vein near the heart. Further review of CDC guidelines indicate transparent dressings covering the entry site, are to be changed at least every 7 days. Insertion of CVCs is done under sterile technique/procedure and strict infection control practices (eg hand hygiene) are to be followed for care of the line, although one can wear either clean or sterile gloves when the dressing on the line is changed. This is so as to prevent central line-associated bloodstream infections, where germs (bacteria or fungi) enter the bloodstream through a central line. Observation of Resident R106's PICC transparent dressing on April 2, 2026, at 9:04 AM revealed dressing with date 3/25 and initials the initials of person who had changed the dressing. Review of Resident R106's clinical records revealed a one time order for dressing to be changed on March 29, 2026, along with an additional order for dressing to be changed every 7 days, to start on March 30, 2026. Further review of clinical records revealed an updated one time order for the PICC dressing to be changed on April 2, 2026, along with an additional order for dressing change every 7 days, to begin on April 3, 2026. Interview with Infection Preventionist, Employee E8, at 9:08 AM confirmed Resident R106's PICC dressing was dated March 25, 2026. Further observation revealed Unit Manager (North Unit), Employee E5, entered Resident R106's room to change her PICC dressing immediately after Infection Preventionist confirmed the date on the dressing. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to monitor and provide appropriate and timely intervention to prevent further weight loss for 1 of 3 residents reviewed. (Resident R1)Findings include: Review facility policy on Weight Assessment and Intervention revealed that under section Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain under section policy interpretation and implementation. Under section Weight Assessment: #1. Residents are weighed on admission at intervals established by the interdisciplinary team #3 any weight change of 5% of more since the last weight assessments is retaken the next day for confirmation. #a. If the weight is verified nursing will immediately notify the dietitian. #4. Unless notified of significant weight change the dietitian will review the unit weight record monthly to follow individual weight trends over time. #5. The threshold for a significant and planned and undesired weight loss will be based on the following criteria. #c. 6 months-10% weight loss is significant; greater than 10% is severe. Under section Evaluation: #1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met the evaluation includes: #a. The residents target weight range. #b. The resident's calorie protein and other nutrient needs compared with a resident's current intake. #c. The relationship between current medical condition or clinical situation and recent fluctuations in weight and #d. Whether and to what extent weight stabilization or improvement can be anticipated. #2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of unspecified Severe Protein Calorie Malnutrition. Review of Resident R1's Initial malnutrition risk assessment dated [DATE], reveal the resident had severe fat loss severe muscle loss is at risk for malnutrition related to acute and chronic medical conditions. Review of Resident R1's nutritional risk assessment dated [DATE], revealed that recent weight was 126.6 pounds (December 27, 2025), Under section malnutrition risk: Has moderate decrease in food intake over the last three months due to loss of appetite digestive problems chewing or swallowing difficulties. Under section Assessment and Plan: Resident is at nutritional risk related to acute on chronic medical conditions with low BMI (body mass index) for age, impaired skin integrity and altered texture diet. Under section Recommendations and Plan: Continue Regular Diet, mechanical soft texture, soft bite sized pieces with assistance, thin liquids consistency with diet texture and liquid consistency per SLP (Speech-Language Pathologist) recommendations.Continued review of the nutritional assessment revealed that the resident's son requested that the resident continued to receive the nutritional supplements Ensure Plus 8 oz. three times a day (350 kcal, 16 gm protein/8 oz.) and Magic Cup 4 oz. twice a day (290 kcal, 9 gm protein/4 oz.) as (he/she) did in the hospital. He also provided resident's food preferences which include hot dogs, french fries, and eggs.It was also recommended MVI (multivitamins)/Mineral supplement to promote wound healing and weekly weight monitoring x 4 weeks. Review of Resident R1's care plans dated December 29, 2025, revealed that Resident R1 has a nutritional problem or potential nutritional problem related to acute on chronic medical conditionsincluding Parkinson's Disease, s/p falls, anemia, severe PCM, metabolic encephalopathy with low BMI (body mass index- a measure of body fat based on height and weight) for age, impaired skin integrity (stage 2 and 3 pressure injuries), altered texture diet, significant weight loss x less than one month. Goals: Will maintain adequate nutritional status as evidenced by maintaining weightwithin 5% of CBW, no s/sx (signs and symptoms) of malnutrition, and consuming at least 75% of at least 3 meals daily through review date. Interventions: Monitor and record intake at meals, obtain weights at ordered intervals, monitor/record/report PRN (as needed) s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Report abnormal findings to practitioner. Document findings and interventions. (*May be done by Dietitian). Review of Resident R'1s weight record reveal that on December 26, 2025, Resident R1's weight was 127 pounds; on January 7, 2026, Resident R1's weight was 110 pounds; on January 8, 2026, Resident R1's weight was 113.8 pounds. Further, a re-weigh dated January 8, 2026, revealed that Resident R1's weight was 107 pounds. Review of the dietician's progress notes dated January 8, 2026, revealed Nutrition Progress Note and significant weight loss x less than one month, oral intake; mostly 51-75% intake recorded, although resident's son states that resident has been mostly refusing mechanical soft foods. Summary/Recommendations: Resident triggering for unintentional and unfavorable significant 13.4% weight loss within less than one month which may be related to variable per mouth intake with refusal of some meals, increased nutrient demand for wound healing and chronic medical conditions. Resident's son reports that resident's usual weight was about 150 lbs. six months ago based on home health records and states that resident has been having a decline in his weight. Magic Cup from twice a day (BID) to 4 oz. three times a day (TID) with meals (290 kcal, 9 gm protein/4 oz.), adding Fortified Foods TID with meals, adding Prosource 30 ml BID (100 kcal, 10 gm protein/30 ml) and Vitamin C 500 mg BID. Also recommend continued weekly weight monitoring. Nutrition Goals: Nutrient Intake->75% nutrient and hydration needs met Weight Maintenance with no significant weight changes, gradual weight gains favorable. Review of resident R1's food intake percentage for the month of January 2026 reveal that on January 9, 2026, resident had zero food intake on for breakfast, lunch and dinner. on January 11, 2026, Resident R1 consumed 26-50% of breakfast, 76-100% of lunch and 26-50% of dinner. On January 12, 2026, Resident R1 consumed 26-50% of breakfast and lunch and had zero food intake for dinner. On January 14, 2026, Resident R1 consumed 26-50% of breakfast and dinner and consumed 51-75% of lunch. on January 16, 2026, Resident R1 consumed 26-50% of breakfast, lunch and dinner. On January 17, 2026, Resident had zero food intake for breakfast, lunch and dinner. On January 18, 2026, Resident R1 had zero food intake for breakfast, consumed 51-75% of lunch and 76-100% of dinner. On January 19, 2026, Resident R1 had zero food intake for breakfast and dinner and consumed 76 to 100% of dinner. On January 21, 2026, Resident R1 had zero food intake for breakfast and dinner and consumed 51-75% of lunch. On January 22, 2026, Resident R1 refused breakfast, lunch and consumed 51-75% of dinner. On January 23, 2026, there was no entry for breakfast and lunch and refused dinner. Further review of Resident R1's clinical record revealed no document evidence that Resident R1 was weighed every week since January 8, 2026, until he was discharged from the facility on January 24, 2026. Further, there was no documented evidence that dietitian conducted further evaluation, monitoring of Resident R1's weight, food and caloric intake, since January 8, 2026, until he was discharged from the facility on January 24, 2026. Interview with facility Administrator Employee E1 conducted on March 3, 2026, at 10:48AM revealed that the facility did not have a regular dietician at the time and that the facility had just recently hired a full-time dietician. Interview with full time Dietitian, Employee E3 conducted on March 3, 2026, at 10:50 AM confirmed that there was no further weight taken on Resident R1 after January 8, 2026, further Employee E3 also confirmed that the dietitian did not have any documented evidence of any intervention to address Resident R1's poor appetite. 28 Pa. Code 111.27 Nutritional assessment 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.10(c) Resident care plan

Based on the review of clinical record, facility investigation, review of policies and procedures, and interviews with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to unlocked elevator providing access to a door that resident was able to leave the facility. (Resident R1). This deficiency was identified as past non-compliance.Findings Include:Review of facility policy Safety and Supervision of Residents, dated July 2017, revealed Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and facility- wide commitment to safety at all levels of the organization.Review of facility policy Wandering and Elopements, dated March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Review of information dated January 21, 2026, submitted by the facility on January 22, 2026 revealed Resident R1 left the Center and was seen by staff getting on a Septa bus near the entrance to the Center. He was approached by staff and assisted back to the Center without an issue.Review of Resident R1's clinical record revealed admission date of January 18, 2026, with a diagnosis of dementia and difficulty walking.Review of Resident R1's clinical record revealed that resident has a BIMS (Brief Interview for Mental Status) of 15, indicating resident is cognitively intact. Review of Resident R1's progress notes, dated January 18, 2026, revealed Resident awake alert and oriented x 1-2 with forgetfulness, able to recall long-term events, doesn't remember what was said 30 mins to 1 hour ago.Review of Resident R1's Elopement/ Wandering Risk Evaluation, dated January 18, 2026, revealed that resident was at moderate risk for elopement.Interview with Employee E1, Nursing Home Administrator, and tour of the facility on January 28, 2026 at 10:05 a.m. revealed that Resident R1 was on a locked unit, however with new construction of dialysis suite, the elevator was accessible to residents. Resident R1 entered the elevator and took the elevator to the unoccupied dialysis suite hallways. Resident R1 pushed on emergency exit door until it opened and exited the building with jacket on. Resident R1 was observed walking towards bus station and the staff member was able to redirect the resident and returned to the facility.On January 20, 2026 following the incident, the facility immediately implemented the following corrective actions:On 1/20/2026, Resident R1 was returned to the center by staff. An interim pain and skin assessment was completed with no abnormalities noted. A detailed statement was obtained from [Resident R1]. The physician and responsible party were notified.On 1/20/2026, The Assistant Director of Nursing on January 20th completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably.On 1/20/2026, a lookback of all residents that have three identifiers (independently ambulatory, dementia diagnosis and cognitive impairment) triggered were reviewed and assessed for further safety measures.On 1/20/2026, nursing administration reviewed all resident EHR for accurate elopement/wandering evaluations, orders for every shift placement checks, daily function tests and care plans. Elopement book found at reception desk was reviewed to ensure that all residents identified as elopement risks were current and resident identifiers were available.On 1/20/2026, review of Center elopement drills for completeness and staff participation. Plant Operations provided elopement drills held monthly for the last quarter.Initiated on 1/20/2026 and 100% on 1/21/2026, RN supervisors were educated on completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/ designee.Initiated on 1/20/2026 and 100% on 1/21/2026, Staff educated on signs and symptoms that may indicate a risk for elopement.Initiated on 1/20/2026 and 100% on 1/21/2026, Staff educated on leave of absence process which includes the nurse signing the resident out at the nursing station and calling reception/ security to notify of approval to leave center and/or premises.Initiated on 1/20/2026 and 100% on 1/21/2026, Reception/security educated on leave of absence process which includes the nurse signing the resident out at the nursing station and calling reception/security to notify of approval to leave center and/ or premises.Initiated on 1/20/2026 and 100% on 1/21/2026, staff educated on abuse/ elopement/ missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premise and the surrounding areas, notification processes including [NAME] Police Department.Initiated on 1/20/2026 and 100% on 1/21/2026, staff educated on elopement drills including how often and expected responses.On 1/20/2026, Door audit completed by [NAME] President of PA Operations. Any variances were addressed.Initiated on 1/20/2026 and 100% on 1/21/2026, professional staff were educated on the need to further assess patients/residents with three identifiers (independently ambulatory, dementia diagnosis and cognitive impairment.Completed on 1/20/2026, elevator usage will be restricted to an operator with a key.On 1/20/2026, Nursing Home Administrator and Director of Nursing, educated on job description and responsibility to ensure resident safety.Ongoing compliance will be monitored by:Auditing census compared to headcount every 4 hours for 7 days then every shift for 14 days then daily for 30 days.Interviewing one staff nurse and one reception/security staff to ensure that there is knowledge and understanding of the LOA process daily for 14 days.Daily assurance that the elevator is in the locked position until the facility is able to get the elevator locked in place with code.All ongoing compliance audits/ interviews will be reviewed at the QAPI Meetings monthly for further recommendations and further actions required.This deficiency was identified as past non-compliance. 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 clinical record reviews, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to provide foot care and treatment for one of eight residents reviewed. (Resident R1)Findings include: A review of the policy and procedures titled medication and treatment orders dated July 2016 revealed that orders for medications and treatments will be consistent with the principles of safe and effective writing. The policy indicated that only authorized licensed practitioners, or individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the clinical record. The policy also said that verbal orders must be recorded immediately in the resident's clinical record. The order must include prescriber's last name, credentials and date and time of the order. A review of the policy and procedure titled consultant physician services dated February 2023 revealed that the consultant physician services must be inwriting and signed by the attending physician. After completion of the consult, the consultant physician was to provide the facility with a consultation report which was to include any orders, recommendations or follow-up actions. The policy indicated that consultation reports were filed in the resident's clinical record. The policy said that the orders from the consultant physician were to be entered into the resident's clinical record by the nursing staff Clinical record review revealed that Resident R1 was admitted to the facility on [DATE]. The resident was admitted to the facility for rehabilitation and nursing care post-surgical TMA traumatic amputation of left foot and left tendon Achilles lengthening. Clinical record review revealed that the consulting podiatrist (a physician that specializes in the diagnosis, treatment and surgical care of the foot, ankle and related structures of the leg) evaluated Resident R1 on July 10, 2025. The podiatrist removed the staples from the surgical site, advised the facility staff to work with Resident R1 and the physical therapy department to work at encouraging weight bearing, as tolerated to the left foot. The podiatrist report also indicated that Resident R1 required a diabetic shoe with filler, as adaptive equipment to meet her foot care needs for eventual ambulation. The podiatrist requested that the nursing staff assist Resident R1 in obtaining a diabetic shoe that would be custom fitted to meet her foot care needs for returning to ambulation status. Clinical record review revealed no documented evidence that an appointment and transportation was made for Resident R1 to be fitted for the adaptive equipment (diabetic shoe with filler) as assessed by the podiatrist on July 10, 2025. The podiatrist again evaluated Resident R1 on July 24, 2025, and requested that the resident be fitted for a diabetic shoe with filler. Observations of Resident R1 at 1:00 p.m., on July 28, 2025, revealed that the resident was not wearing any adaptive equipment for the left foot. Resident R1 was observed seated in a wheelchair and using it to ambulate on July 28, 2025. Clinical record review revealed a physical therapy progress note dated July 15, 2025, indicating Resident R1 was demonstrating hopping on her right foot with a roller walker and staff supervision. During an interview with Resident R1 at 1:30 p.m., on July 28, 2025, the resident reported that the physical therapy department trialed her with a boot that was painful to wear. Clinical record documentation by the occupational therapist on July 18, 2025, indicated that the resident was complaining of aching, throbbing, discomfort of her left foot, while wearing the trialed boot. Interview with Resident R1 at 1:45 p.m., on July 28, 2025, confirmed that she was not afforded the opportunity to use the custom-made diabetic shoe with filler that the podiatrist recommended on July 10, 2025. Interview with the physical therapist assistant, Employee E3, registered nurse, Employee E4 and social worker, Employee E5 at 11:00 a.m., on July 28, 2025 confirmed that Resident R1 was not afforded the opportunity to obtain the adaptive equipment (custom fitted diabetic shoe with filler) as recommended by the consulting podiatrist on July 10, 2025 to meet the foot care needs of this resident, for walking and ambulation. Interview with the social worker, Employee E5 at 10:30 a. m., on July 28, 2025, revealed that Resident R1 was formerly living in an assisted living and that the resident wished to return to living in the community at that home. The assisted living building had stairs/steps that Resident R1 would have to use for safe evacuation in an emergency. Interview with the physical therapist assistant on July 28, 2025 revealed that Resident R1 required the custom fitted diabetic shoe with filler, as requested by the podiatrist to be trialed with ambulation, steps and stairs before discharge into the community assisted home where she had resided. 28 PA. Code 211.10(c)(d) Resident care policies 28 PA. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records, and family member and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for two of three residents reviewed. (Residents R2 and R3). Findings include: Review of facility policy on Confidentiality of information and personal privacy with most recent revision date of October 2017, revealed that under section Policy Statement; our facility will protect and safeguard resident confidentiality and personal privacy. Under section Policy interpretation and implementation #1, the facility will safeguard the personal privacy and confidentiality of all residents and medical records. #4. Access to resident's personal and medical records will be limited to authorized staff and business associates. Interview with complainant revealed that when her husband Resident R1 was discharged home, medical records belonging to 2 other residents were included in her husband's discharge papers. Further complainant revealed that the medical records belonged to Residents R2 and R3. Review of documents provided by complainant via text message during a telephone interview with complainant conducted on April 17, 2025, at 9:02 AM, revealed two documents belonging to 2 residents (Residents R2 and R3). Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] and discharged to home on March 28, 2025. Review of Resident R2's document revealed a heading Admission Record further, the document contained Resident R2's full name admitted , address, telephone number, sex, date of birth, citizenship, nae of contact persons with their contact information and Resident R2's medical diagnoses. Review of Resident R3's document revealed a heading Admission Record further, the document contained Resident R3's full name admitted , address, telephone number, sex, date of birth, citizenship, nae of contact persons with their contact information and Resident R2's medical diagnoses. Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses of but not limited to Non-traumatic Intracerebral Hemorrhage, Essential Hypertension. Review of Resident R3's clinical record revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses of Anoxic Brain Damage, Tracheostomy Status, Chronic Respiratory Failure. Interview with Director of Nursing Employee E1 confirmed that Resident R2 and Resident R3 were residents at the facility. Further Employee E2 also confirmed that the clinical records that were sent together with Resident R1's discharge papers were Resident R2 and Resident R3's face sheet. Further Employee E2 revealed that Resident R2 and Resident R3's medical records should have not been sent with another resident 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.5(b) Clinical Records.

Based on observations, interview with staff and residents and review of facility provided documentation, it was determined that facility did not ensure residents received the necessary services to maintain personal hygiene and mobility for five out of 18 residents reviewed (Resident R35, R40, R65, R233, R13) Findings include: Review of facility's policy 'Activities of Daily Living (ADL), Supporting,' revised March 2018, indicates that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking) Review of East side 7-3 shower schedule and skin checks revealed that Resident R35, in room [ROOM NUMBER]-A, was scheduled for shower on Tuesday, March 18, 2025 and Friday, March 21, 2025. Interview with nurse aide, Employee E4, on Monday, March 24, 2025, at 12:15 pm, confirmed that Resident R35 did not receive scheduled showers on March 18, 2025 and March 21, 2025; review of documentation of electronic documentation related to showers with Employee E4, confirmed Resident R35 did not receive scheduled showers. Interview with Resident R35 on March 24, 2025 at 10:30 am, revealed concern of not receiving a shower since admission. Further interview with nurse aide, Employee E4 revealed Resident R40, in room [ROOM NUMBER]-A, did not receive scheduled shower on Monday, March 24, 2025 due to facility being short staffed. Interview with Resident R65 on March 24, 2025 at 12:18 pm, revealed concern of not receiving shower since admission. Review of R65's scheduled shower days indicated she is scheduled for showers on Mondays/Thursdays. Review of R65's 'Task:Shower/Bath on Monday 7-3,' documentation revealed she did not receive shower on Monday, March 24, 2025. Further review of electronic documentation related to showers with Employee E4 revealed Resident R233, room [ROOM NUMBER]-A, did not receive scheduled shower on Monday, March 24, 2025. Observations of Resident R13 on March 24, 2025 at 11:30 pm, in room [ROOM NUMBER]-A, revealed Resident R6 in bed complaining about facility being short staffed with no staff available to help her out of bed. 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, review of clinical record, and staff interview, it was determined that the facility failed to ensure that appropriate pain management was provided to a resident consistent with standards of professional practice for four of 18 residents reviewed (Residents R79, R290, R292 and R293). Findings include: Review of the facility Policy on Pain management revealed that the purpose of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address. The underlying causes of pain under section General Guidelines: #1 The Pain Management program is based on facility wide commitment to appropriate assessment and treatment of pain, based and professional standards of practice, the comprehensive care plan and the residents' choices related to pain. Management. #2 being management is defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals. #3 being management is multidisciplinary care process that includes the following: #b. Recognizing the presence of pain #c. Identifying the characteristics of pain. #d. Addressing the underlying causes of pain. #e. Developing and implementing approaches to pain management. #g. Monitoring the effectiveness of interventions. and #h. Modifying approaches as necessary. #5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassess as indicated and to relieve his attained. Under a section Implementing Pain Management Strategies: #1. Establish a treatment regimen that is specific to the resident based on consideration of the following. #a. The resident's medical condition. #b. Current medication regimen. #c. History of addiction or opioid use disorder. #d. Nature, severity and cause of pain. #e. Course of illness. #f. Treatment goals. #3. Pharmacological interventions (i.e. analgesics) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident (i.e. drowsiness Increased risk of following loss of appetite). #4. When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects and potential overdose. #a. Any resident who uses opioid for long term management of chronic pain is at risk for opioid overdose. #b. due to the risk of fatal respiratory depression, opioids and benzodiazepines are not administered together unless a clinical indication for the residents documented and the resident is carefully monitored. #c. Staff are trained in the use of naloxone for opioid overdose. #5. The following are considered when establishing the medication regimen. #c. Combining long-acting medications with PRN for breakthrough pain. #d. Combining non-narcotic analgesics with narcotics, opioids, analgesics. #f. Reducing or preventing anticipated adverse consequences of medications (i.e. bowel regimen to prevent constipation related to opioid analgesics) #6. The medication regimen is implemented as ordered. The results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications. Interview with DON (Director of Nursing) Employee E2 conducted on March 27, 2025 at 11:00 AM revealed that they use the numeric pain scale in assessing pain as follow: 0-no pain, 1-3- mild pain, 4-6-moderate pain,7-10-severe pain. Review of clinical records for Resident R79 revealed that she was admitted to the facility on [DATE], and had diagnoses of asthma and shortness of breath. According to her discharge Minimun Data Set (MDS- assesment of resident's care needs), dated January 5, 2025, the resident was discharged from the facility on January 5, 2025 to an acute care hospital. Review of the resident admission note dated January 4, 2025, at 9:47 p.m. revealed that the resident had been admitted for SOB (shortness of breath) and leg pain, and that she was AAOx4 (awake, alert and oriented to person, place, time and situation, i.e. able to correctly identify self, current location, what the current time and/or date is, and what is currently happening). At 10:51 p.m., an additional progress note stated pain treated with PRN (as needed) medication w/ positive effect. Awaiting med delivery from pharmacy. Review of the resident's Medication Administration Record (MAR) revealed orders for both Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for discomfort/pain, and Tramadol HCl Oral Tablet 50 MG . Give 1 tablet by mouth every 12 hours as needed for pain. Further, the MAR showed that acetaminophen (Tylenol) was signed out as administered by licensed nurse, Employee E10, for a moderate pain level of 4/10 on January 4, 2024 at 10:49 p.m. A progress note entered on January 5, 2025, at 1:45 a.m., stated resident was complaining of pain and was given Tylenol on the previous [shift]. Resident stated she don't want to stay at the facility and call 911 and was transferred to [the] hospital. In an interview with the Director of Nursing, Employee E2, on March 27, 2025, at 2:00 p.m., it was confirmed that the resident had left the facility due to inadequate pain relief and the unavailability of her prescribed Tramadol. Review of Resident R290's clinical record revealed that Resident R290 was admitted to the facility on [DATE], with diagnoses of Effusion of Right Knee, Injury of Right Ankle, Age Related Osteoporosis Review of Resident R290's pain care plan revealed that Resident R290 had acute pain and/or potential for pain r/t (related to) Fracture Date Initiated: 03/20/2025, Goals: will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Date Initiated: 03/20/2025 Target Date: 06/13/2025, Intervention: Administer analgesia as per orders. Observe for effectiveness and signs and symptoms of side effects. Report abnormal findings to practitioner. Document findings and interventions., evaluate the effectiveness of pain management interventions, report abnormal findings to practitioner, document findings and interventions, and monitor/record the presence of pain every shift and PRN. Further review of resident R290's clinical record revealed that Resident R290 had orders for: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for Discomfort/pain Total Dose 650mg *DO NOT EXCEED 3 GRAMS per 24 HOURS* -Start Date03/20/2025 with a -D/C (discontinued) Date 03/22/2025, Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain -Start Date 03/20/2025 @5:45 p.m., Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain-Start Date 03/21/2025 at 11:45 a.m. Further review of the physician's orders revealed that the order for Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for discomfort/pain did not have any parameters on pain intensity and Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain-Start Date 03/21/2025 at 11:45 a.m. did not have parameters on pain intensity. Review of Resident R290's March 2025 MAR (medication administration record) revealed that Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for Discomfort/pain total Dose 650 mg was administered on March 20, 2025 at 9:40 p.m.for a pain scale of 7, on March 21, 2025 at 4:46 a.m. for a pain scale of 4, on March 21, 2025 at 6:25 p.m. for a pain scale of 8, on March 22, 2025 at 12:38 a.m. for a pain scale of 7. Further review of Resident R290's MAR revealed that the Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain -Start Date 03/20/2025 at 5:45 p.m. was not administered to Resident R290 on March 20, 2025 at 9:40 p.m. when Resident R290 had a pain scale of 7, was not given on March 21, 2025 at 4:46 a.m. when Resident R290 had a pain scale of 4, was not given on March 21, 2025 at 6:25 p.m. when Resident R290 had a pain scale of 8, and was not given on March 22, 2025 at 12:38 a.m. when Resident R290 had a pain scale of 7. Interview with Resident R290 conducted on March 25,2025 at 10:37 a.m. during the tour of the facility revealed that Resident R290 complained that her pain medications were not given in a timely manner because the staff was unable to access her pain medication which was stored in a machine. Staff told her that they did not have the code and that they are waiting for it and that they will give her the medication as soon as they receive the code. Interview with Licensed nurse, Employee E3 conducted on March 25, 2025, at 9:41 a.m. revealed that when residents are admitted with an order for controlled pain medication, they must first obtain a script from the physician or nurse practitioner. If the physician or the Nurse Practitioner is not in the facility such as when resident is admitted after hours or on the weekend, the nurse has to contact them, wait for the script, once the script is in place in the electronic medical record, they then print it, then fax it over to the pharmacy, sometimes they have to call the pharmacy to make sure someone will process it, then they have to wait for the pharmacy to send the verification code, once the verification code is received, the nurse then has to get another licensed nurse to pull the medication from the Pyxis (automatic medication delivery system) because two nurses is required to pull medication from the machine. Further Employee E3 revealed that the process could take some time and that sometimes residents gets upset because they want their pain medications. Interview with DON Employee E2 conducted on March 25, 2025 at 12:48 p.m. confirmed that the physician's orders revealed that the order for Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for discomfort/pain did not have any parameters on pain intensity and Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain did not have parameters on pain intensity. Review of Resident R292's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Fracture of the neck of the left femur, Osteoarthritis. Further review of Resident R292's clinical record revealed a physician's order for: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for Discomfort/pain Total Dose 650mg *DO NOT EXCEED 3 GRAMS per 24 HOURS*-order date 3/19/25 and Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain management-order date 3/19/25. Review of the physician's order for Acetaminophen and Oxycodone for pain revealed that both orders did not specify the level of pain for which the pain medication are to be administered for. Review of Resident R292's March 2025 MAR revealed that on March 20, 2025, Resident R292 had a pain level of 2 and was given Acetaminophen Tablet 325 MG Give 2 tablet by mouth. Interview with DON Employee E2 conducted on March 27, 2025, at 11:00 AM confirmed that there were no parameters indicated for Acetaminophen and Oxycodone. Review of Resident R293's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Low Back Pain, Sciatica. Review of Resident R293's clinical record revealed physician's orders for: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for Discomfort/pain Total Dose 650mg *DO NOT EXCEED 3 GRAMS per 24 HOURS*-Start Date 02/02/2025 with a discontinued date of Date 02/07/2025 1015, Ibuprofen Oral Tablet 600 MG (Ibuprofen) Give 1 tablet by mouth every 6 hours as needed for moderate pain for 30 Days-Start Date 02/02/2025 with a discontinued date of 02/28/2025 and Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain-Start Date 02/27/2025 with a discontinued date of 03/03/205. Review of the physician's order for Acetaminophen and Tramadol for pain revealed that both orders did not specify the level of pain for which the pain medication are to be administered for. Review of Resident R293's MAR for February 2025 revealed that Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 8 hours as needed for Discomfort/pain was administered to Resident R293 on February 5, 2025, at 10:28 a.m. for pain scale of 5 and on February 6, 2025, for pain level of 5 (pain level of 4-6 is equivalent to moderate pain). Further Ibuprofen Oral Tablet 600 MG (Ibuprofen) Give 1 tablet by mouth every 6 hours as needed for moderate pain was administered to Resident R293 on February 2, 2025, for pain level of 7 (pain level of 7-10 is equivalent to severe pain) and was administered on February 26, 2025, for pain level of 3 (pain level of 1-3 is equivalent to mild pain). Further, Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain was administered on February 28, 2025, for pain level of 5. Interview with DON Employee E2 conducted on March 27, 2025, at 11:00 a.m. confirmed that the order for Acetaminophen and Tramadol for pain did not have any parameters. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services

Based on review of facility provided documentation and interview with residents and staff, it was determined that facility did not ensure there is sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs based on 43 out of 50 grievances reviewed for months of March 2025, February 2025, January 2025, December 2024, October 2024. Findings include: Review of facility's policy 'Answering the Call Light,' indicates that procedure's purpose is to ensure timely response to residents' requests . staff are to answer the resident call system as soon as possible Interview with nurse aide, employee E4, on Monday, March 24, 2025 revealed that residents do not receive scheduled showers due to facility being short staffed. Interview with Resident R67, on Monday, March 24, 2025 revealed that he had an unwitnessed fall I his room due to waiting for assistance for a long time after pressing the call bell. Review of R67's progress notes, dated March 23, 2025 at 9:15 am, revealed that unwitnessed fall from bed to floor while transferring himself from bed to chair. Interview with Resident R14 on March 24, 2025 at 10:45 am, revealed concern about low weekend staffing and late response when using a call bell system. Interview with Resident R13 on March 24, 2025 revealed concern that there is insufficient nursing staff to assist her out of bed in the morning. Interview with Resident R235, on March 24, 2025 revealed concern of staying in bed soiled for extended period of time due to late response from nursing staff when using call bell system. Review of facility provided documentation revealed four grievances submitted for month of October, 2024 related to late response to call bells. Further review of grievances revealed one grievance was submitted for month of December 2024 related to late response to call bells. Further review of grievances revealed five grievances were submitted for month of January 2025 related to late response to call bells. Further review of grievances revealed 14 grievances submitted for month of February 2025 related to late response to call bells. Further review of grievances revealed 16 grievances submitted for month of March 2025 related to late response of call bells. Review of 'PBJ Staffing Data Report,' for fiscal year quarter 4, 2024 (July 1- September 30) indicates 'excessively low weekend staffing' was identified. Findings confirmed with facility's Administrator and Director of Nursing. 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a)(3) Management

Based on observations, review of clinical records, review of facility policy, interview with residents and staff, it was determined that facility did not ensure to implement enhanced barrier precautions for four residents (Residents R14, R5, R70, R77), ensure that infection control standards were maintained during wound care for one resident, (Residenr R22), and did not ensure that tuberculosis testing was administered on entry to the facility as required for one resident (Resident R190) out of 18 residents reviewed. Findings include: Review of facility provided policy 'Enhanced Barrier Precautions,' revised March 2024, states Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms to residents, and signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (personal protective equipment) require; PPE is available outside of the resident rooms. Review of Resident R14's clinical record on May 26, 2025, revealed an active physician's order for enhanced barrier precautions related to wounds. Observations of R14's environment of Monday, March 24, 2025, revealed no evidence of EBPs door post or PPE outside the resident's room. Review of Resident R5's clinical record, on Wednesday, March 26, 2025, revealed an active physician order for EBPs for peg, wounds and foley. Observations of R5's physical environment on Monday, March 24, 2025, revealed no evidence of EBP's door post or PPE outside resident's room. Review of Resident R70's clinical record on March 25, 2025, revealed an active physician order for EBP's for central line. Observations of R70's physical environment on Monday, March 24, 2025, revealed no evidence of EBP's door post or PPE outside resident's room. Review of R77's clinical record on March 25, 2025, revealed an active physician order for EBP's related to wounds. Observations of R77's physical environment, on March 24, 2025, revealed no evidence of EBP's door post or PPE outside resident rooms. Findings confirmed with facility's assistant director of nursing, employee E3, on Monday, March 24, 2025, day shift. Review of clinical documentation for Resident R22 revealed a physician order for Right hip wound- Cleanse with 1/4 strength Dakin's, apply honey fiber, cover with foam [dressing]- daily and as needed every day shift, dated March 4, 2025. Observation of wound care for Resident R22 was conducted on March 26, 2025, at 9:40 a.m. After removal of the resident's soiled dressing, licensed nurse, Employee E6 was observed to remove her gloves and proceed to open a package of sterile gauze and apply Dakin's solution to it without performing hand hygiene and applying new gloves first. Hand hygiene was not performed, and gloves were then applied, and the wound was cleansed. Gloves were then removed, and Employee E6 again opened sterile packaging for a bordered foam dressing and Manukahd (a medical honey saturated alginate used to absorb excess moisture from the wound and inhibit bacterial growth) without performing hand hygiene or applying new gloves. Hand hygiene was not performed, and gloves were then applied before continuing with wound care. Interview with Employee E6 on March 26, 2025, at 9:53 a.m. confirmed that she did not perform hand hygiene and apply gloves prior to opening sterile packaging of wound treatment supplies. Interview with the Director of Nursing, Employee E2, on March 26, 2025, at 12:15 p.m. confirmed that nurses are to wear clean gloves when opening wound care supplies and should perform hand hygiene immediately upon removal of soiled gloves. Review of clinical documentation for Resident R190 revealed that he was admitted to the facility on [DATE]. His recorded diagnoses did not include a history of tuberculosis (TB, a highly transmissible respiratory bacteria which can cause cough, bleeding and death). Review of his Medication Administration Record (MAR) for the month of February revealed a physician order for TB testing which read, Tubersol Solution 5 UNIT/0.1ML (Tuberculin PPD) Inject 0.1 milliliter intradermally one time only for first PPD test . Administer within 24 hours of admission. The order was dated February 21, 2025, and scheduled to be administered on either February 21, or 22, 2025. It was not signed as administered in the record. Review of the immunization record revealed no documentation of the test being administered in February 2025. No additional records were provided by the facility to indicate that the test was performed as required. Interview with the Director of Nursing, Employee E2, on March 26, 2025, at 12:15 p.m. confirmed that it is the expectation of the facility that TB testing be performed on all residents without history of TB within 24 hours of admission. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop comprehensive care plan for one of eighteen residents reviewed related to weight changes, and one resident related to long-term antibiotic use (Residents R2 and R43). Findings Include: Review of clinical documentation for Resident R2 revealed that she was admitted to the facility on [DATE], and had diagnoses which included, infection and inflammatory reaction due to unspecified internal joint prosthesis. Further review revealed a physician order for an antibiotic which read Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for joint infection chronic- no stop date. Review of progress notes for Resident R2 revealed a note from Registered Nurse Practitioner, Employee E8, dated March 26, 2025, which stated Left prosthetic joint infection- continue Bactrim DS (chronic). Review of the care plan for Resident R2 revealed no care plan had been developed regarding long-term antibiotic use for a chronic joint infection. Interview with the Director of Nursing, Employee E2, on March 27, 2025, at 2:00 p.m. confirmed that a care plan should have been developed for Resident R2's long-term antibiotic use for her chronic joint infection, but that it had not been. Observation conducted on March 26, 2025, at 8:52 a.m. during tracheostomy care on Resident R43, revealed that Resident R43's teeth were observed with yellowish, greenish substance on resident's upper and lower incisors. Review of Resident R43's clinical record revealed that Resident R43 was admitted to the facility on [DATE], with diagnoses including, but not limited to, Anoxic Brain Damage, Tracheostomy Status, and Gastro Esophageal Reflux Disease. Further review of Resident R43's clinical record revealed that there was no documented evidence that resident was seen by dentist. Review of Resident R43's annual MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated March 18, 2025, Section GG0130, Self-Care, subsection B, Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment, was coded 01 indicating that Resident R43 was Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity). Further review of Resident R43's clinical record revealed that there was no care plan addressing Resident R43's oral/dental hygiene deficits. Interview with the Director of Nursing, Employee E2 conducted March 27, 2025, at 10:38 a.m., confirmed that Resident R43 did not have an oral/dental care plan in place. Further, Employee E2 revealed that she is now inputting the oral/dental care plan in. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner for one of 18 records reviewed (Resident R81). Findings include: Review of clinical documentation revealed that Resident R81 was admitted to the facility on [DATE], and had diagnoses including, of malignant neoplasm (cancer) of the prostate. Review of the resident's MDS (Minimum Data Set, a periodic assessment of resident care needs) dated February 27, 2025, he died in the facility on February 27, 2025. Review of his physician orders revealed an order for DNR (Do Not Resuscitate), and an order for DNH (Do Not Hospitalize), both dated [DATE]. Review of his POLST (Pennsylvania Order for Life Saving Treatment, a document in which an individual expresses their wishes for end-of-life situations, such as whether or not they wish for CPR to be performed in the event that their heart stops) revealed that they wished for CPR (Cardio Pulmonary Resuscitation) to be withheld and that they wished for comfort measures only rather than life saving or sustaining treatments. Review of the care plan for Resident R81 revealed a care plan focus dated [DATE], which stated The resident has the following advanced directives on record: FULL CODE indicating that the resident wished for life saving and sustaining treatment to be initiated in the event of an emergency. Interview with the Director of Nursing, Employee E2, on [DATE], at 2:00 p.m., confirmed that the resident had wished for life saving and sustaining treatment to be withheld, and that the care plan should have been updated at the time of his change in code status. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on clinical record review, and interviews with staff, it was determined that the facility did not ensure that standards of practice for pressure ulcer treatment were followed related to a physician not being informed of a missed wound treatment for one of 18 records reviewed (Resident R59). Findings include: Interview with the representative of the County Ombudsman Program, Employee E9, on March 26, 2025, at 2:10 p.m., revealed that Resident R59 had stated to her that his wound care had not been done on March 25, 2025, and that the nurse had told him it was due to not having access to the supplies. Review of the resident's March 2025 Treatment Administration Record (TAR) showed that March 25, 2025, the evening shift treatment to the resident's sacrum was documented as code 22, which the TAR indicated meant treatment not given. Review of the notes revealed that a note written by Employee E5, which indicated that the reason for not administering the treatment was not available. No explanation was provided in the note as to why the treatment was not available. No note was found to indicate that the physician was notified that the treatment had not been performed. In an interview on March 27, 2025, at 10:05 a.m. the Director of Nursing, Employee E2, stated that she was aware that the treatment had not been done, and confirmed that in the event that a treatment cannot be completed for any reason, staff is expected to inform the physician. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluation was completed for one nurse aide out of five nurse aides trainings reviewed (Employee E7) Findings include: Review of facility policy 'Performance Evaluations,' revised on September 2020, indicates that ' a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probation period , and at least annually thereafter. Review of facility provided performance evaluations on Thursday, March 27, 2025 revealed that nurse aide, Employee E7 was hired on May 10, 2023; her last performance evaluation was on November 7, 2023. Finding confirmed with facility's Director of Nursing. 28 Pa Code 201.19(2) Personnel policies and procedures

Based on review of clinical records, facility documentation and policy, and interviews with staff, it was determined the facility failed to provide adequate supervision to Resident R1 with a history of wandering, and at risk for elopement. This failure resulted in an Immediate Jeopardy situation to Resident R1 who eloped from the facility, crossed a high traffic street and was found by a member of the community in a lot across from the facility entrance, for one of four residents reviewed at risk for elopement (Resident R1). The deficiency was identified as Immediate Jeopardy past non-compliance. Findings include: Review of the facility's policy titled, Wander Management and Elopement Prevention updated March 2022, states, The facility will maintain the safety of residents who wander and/or are at risk for elopement. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will implement a wander management system device as part of the plan of care. Resident care plan will include specific interventions to ensure safe wandering and prevent elopement. The wander management system device will be used in conjunction with other resident specific interventions for the management of unsafe wandering. When implementing a wander management system device, the staff will implement routine checks for placement each shift and functionality daily. Identified issues with wander management system device placement or functionality will be immediately addressed with replacement of the device. Review of Resident R1's clinical record revealed an admitted [DATE], diagnosed with Unspecified Dementia (progressive degenerative disease of the brain), severe without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, and abnormal finding on diagnostic imaging of skull and head not elsewhere classified. Review of Resident R1's admission Minimum Data Set (MDS- assessment of residents' needs), dated July 17, 2024, revealed the resident had no impairments to his upper and lower body and had the ability to walk at least 150 feet with supervision or touch assistant (verbal cues) and needed partial/moderate assistance (helper does less than half the effort) for activities of daily living. Review of Resident R1's admission evaluation dated, July 11, 2024, assessed the resident as an elopement risk, indicating that the resident was cognitively impaired with poor decision-making skills, diagnosed with dementia, and ambulating independently without the use of an assistive devise. The same evaluation assessed the resident's behaviors, indicating that the resident showed signs of being easily distracted; had periods of altered perception or awareness of his surroundings; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function that varied over the course of the day; wandered; abusive and resisted care and ambulated with an unsteady gait. Due to Resident R1's risk of elopement, on August 12, 2024, orders were obtained for the resident to wear a Wander Guard Bracelet (device that is place on ankle or wrist that activates the locking mechanism on doors to the outside of the facility) instructing to check the function and placement of the bracelet every shift. A care plan was also developed that included interventions to engage the resident in activities to decrease wandering, and to evaluate the resident's desire to leave. Review of documentation submitted to the Department of Health indicated that on, August 29, 2024, at approximately 6:30 p.m., two charge nurses from different units discussed the whereabouts of Resident R1; at the same time someone in the community called to inform the facility that Resident R1 was found off the facility's property, across the street. The same report noted that the resident did not have the wander guard in place when he was found. Review of Resident R1's facility incident report revealed on August 29, 2024, on the 11-7-night shift, Licensed Practical Nurse, Employee E4, checked and documented the wander guard for placement and realized Resident R1 was not wearing it. During an interview with Licensed Practical Nurse (LPN), Employee E4 on September 11, 2024, at approximately 2:30 p.m. stated the resident was sleeping and did not want to wake him. Before the end of the shift the nurse checked for placement and did not see the wander guard. She documented in the resident's electronic medication administration record an X for not being able to verify placement and left the facility without telling the supervisor. The nurse continued to say I thought someone would see the note, but I was re-educated. I know now to immediately report to a supervisor if a wander guard is missing from a resident. Continued review of facility documentation and observation and interview with the Director of Nursing (DON) on September 10, 2024, at 2:00 p.m. revealed the facility investigation determined Resident R1 was last seen at 6:10 p.m. and the facility felt the resident left the unit through closed double doors. The facility investigation revealed the armature of the door loosened when the resident used force to pull on the door. The DON explained the doors now have been replaced with a Mag lock (an electromagnetic force to stop doors from opening). The facility surmised the resident then proceeded to pass the reception desk at a time when no one was supervising the area, walked out the front door, through the parking lot, then crossed a high traffic- two lane street and was later found nearby. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on September 11, 2024, at 1:59 p.m. The facility failed to ensure adequate supervision was provided to Resident R1 who was diagnosed with dementia and was at risk for elopement. Resident R1 was able to eloped from the facility, and crossed a high traffic street. The facility provided their immediate action plan on September 11, 2024, which they had begun implementing on August 29, 2024 immediately after the incident occurred, to address the failure of providing inadequate supervision for an ambulatory resident who displayed signs of wandering, and elopement. The facility's plan of correction included the following: 1. The resident is not currently at the Center. The resident returned to the Center from the hospital with an abrasion to right knee. All other studies were within normal limits. Completed on August 30, 2024. 2. RN Supervisor on August 29th completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably, Variances identified included discharged residents. Completed on August 29, 2024. 3. Immediate Actions/Education -The Nursing Administrator reviewed all resident EHR (Electronic Health Record) for accurate elopement/wandering evaluations, orders for every shift placement checks, daily function tests and care plans. Elopement books found at reception desk and on every unit were reviewed to ensure that all residents identified as elopement risks were current and resident identifiers were available. Completed on August 29, 2024. -Nursing Staff were educated on if they find an identified resident without an elopement device, supervision is established for the resident, another device is located and applied. If the device cannot be reapplied, 1:1 supervision is maintained. The DON/designee will be notified immediately. Achieved 94% on 8/30/2024. The remainder will be educated PRIOR to the next shift scheduled. Remainder completed on 9/4/2024. -Review of Center elopement drills for completeness and staff participation. Plant Operations provided elopement drills held monthly for the last quarter. Completed 8/30/2024. -RN supervisors were educated on completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee. Achieved 100% on 8/30/2024. -Reception/off shift staff were educated on the process of each visor receiving a badge that must be returned prior to door being open and visitor leaving the premises, Achieved 94% on 8/29/2024. The reminder will be educated PRIOR to the next shift scheduled. Remainder completed on 9/4/2024. -Staff educated on elopement/missing person policy and procedures including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas notification process including local police department. Achieved 94% on 8/30/2024. The remainder will be educated PRIOR to the next shift. Scheduled, Remainder completed on 9/4/2024. -Staff educated on elopement drills including how often and expected response. Achieved 94% on 8/30/2024. The remainder will be educated PRIOR to the next shift scheduled. Remainder completed on 9/4/2024. Reception staff were educated on the need for constant supervision of the front reception area. The RN supervisor/designee is to be notified of relief prior to leaving area. Achieved 100% on 8/30/2024. -The double door leading out of unit will be modified to include a mag lock on both doors. Parts have been ordered and will be added/installed upon receipt. Double doors were monitored via 1:1 until mag locks were installed on 9/6/24. All the training above will be added to our general orientation schedule for all future new employees. Completed 8/30/2024. 4. Ongoing Compliance will be monitored by: -Auditing census compared to headcount every 4 hours for 3 days then every 8 hours for 3 days then every shift for 14 days then daily. -Random audit of five visitors to ensure compliance to pass system two times daily for 14 days then daily. The facility action plan was accepted on September 11, 2024, at 4:48 p.m. and identified as past non-compliance. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on August 29, 2024, revealing 94% was accomplished on the first day, and fully complete on September 6, 2024. On September 11, 2024, interviews with nursing staff and staff from multiple departments revealed they were able to verbally demonstrate their knowledge of the elopement trainings and verbally proved they understood the importance of following the facility's policies and procedures to ensure the safety of the residents. The Immediate Jeopardy was lifted on September 11, 2024 at 4:48 p.m. 28 Pa. Code 211.10(c) Resident Care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for one of two nursing units. This failure placed residents on the North Side nursing unit exposed to unsafe hot water temperature and at risk of serious injury from a burn. This failure resulted in an Immediate Jeopardy situation. (North side nursing unit) Findings: Review of facility policy on Safety of Water Temperatures, under section Policy Statement revealed that tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Under section Policy Interpretation and Implementation: Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 F (Fahrenheit) or the maximum allowable temperature per state regulation. #1. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. #2. Maintenance will conduct periodic tap water temperature checks. And records the water temperatures in a safety log. #3. If at any time, water temperature feels excessive to the touch (Example hot enough to be painful or cause reddening of the skin after removal of the hand from the water) Staff will report these findings to the immediate supervisor. Observation and water temperature checks on the North Side nursing unit were conducted with the [NAME] President for Plant Operations, Employee E3 on July 1, 2024, from 9:03 a.m. to 10:09 a.m. in Resident rooms 19, 20, 21, 22, 23, 24, 25, 26, 27, 28,129, 30. The hot water temperature at the hand sink were above as follows: hand sink water temperature in Room# 19 was 113 degrees Fahrenheit hand sink water temperature in Room# 20 was 113 degrees Fahrenheit hand sink water temperature in Room# 21 was 124 degrees Fahrenheit hand sink water temperature in Room# 22 was 117 degrees Fahrenheit hand sink water temperature in Room# 23 was 127 degrees Fahrenheit hand sink water temperature in Room# 24 was 127 degrees Fahrenheit hand sink water temperature in Room# 25 was 131 degrees Fahrenheit hand sink water temperature in Room# 26 was 109 degrees Fahrenheit hand sink water temperature in Room# 27 was 129 degrees Fahrenheit hand sink water temperature in Room# 28 was 128 degrees Fahrenheit hand sink water temperature in Room# 29 was 127 degrees Fahrenheit hand sink water temperature in Room# 30 was 129 degrees Fahrenheit Interview with the [NAME] President for Plant Operations, Employee E3 conducted at the time of each observation confirmed all water temperature test results. Observation of the North side boiler room conducted on July 1, 2024, at 11:13 am with the [NAME] President for Plant Operations, Employee E3 and Director of Plant Operations, Employee E4 revealed that the mixing valve thermometer located next to the boiler was set at 118 degrees Fahrenheit. Interview with the [NAME] President for Plant Operations, Employee E3 in the presence of Director of Plant Operations, Employee E4 conducted at the time of the observation revealed that after the water temperature on the North side was identified as above acceptable limits, he immediately went down to check the mixing valve temperature. Further the [NAME] President for Plant Operations, Employee E3 confirmed that when he checked the mixing valve thermometer on the North side mixing valve, the thermometer reading was 130 degrees Fahrenheit. The [NAME] President for Plant Operations, Employee E3 revealed that he then immediately adjusted the mixing valve to temperature to 118 degrees Fahrenheit. Interview with Regional [NAME] President for Plant Operations, Employee E5 also conducted at the time of the observation revealed that, when there is a high volume of water usage, the water temperature in the resident's rooms and other patient area would go down and when there is low volume of water usage, the water temperature in the resident's rooms and other patient areas would go up. Observation of the East side boiler room conducted on July 1, 2024, at 11:31 a.m. revealed that the boiler's knob was set at 130 degrees Fahrenheit. Further observation revealed that there was no thermometer anywhere near the boiler. Interview with the [NAME] President for Plant Operations, Employee E3 conducted at the time of the observation confirmed that the temperature setting was at 130 degrees Fahrenheit. Interview with the [NAME] President for Plant Operations, Employee E3 conducted at the time of the observation revealed that the mixing valve was located on the ceiling of the boiler room approximately 5 feet away from the boiler. Observation revealed that there was no thermometer anywhere in the boiler room ceiling. Continued interview with the [NAME] President for Plant Operations, Employee E3 and Director of Plan Operations, Employee E4 confirmed that there was no thermometer for the east side boiler mixing valve. Further, Employee E3 also revealed that the mixing valve temperatures were checked once a day. Employee E3 also revealed that he would adjust the mixing valve in the east side boiler and that he would go to the east unit and check the water temperature in the resident area. Review of facility water temperature log revealed that water temperature was only checked randomly on Mondays to Fridays. Review of facility water temperature log from April 29, 2024 to June 28, 2024, revealed that the facility checked the water temperatures for eight random resident room per day for the following dates April 29, 2024; May 1, 3, 6, 8, 10, 13, 14, 15, 17, 20, 22, 24, 27, 29 and 31, 2024; June 4, 5, 7, 10, 12, 14, 17, 19, 21, 24, 26 and 28, 2024. Interview with [NAME] President for Plant Operations, Employee E3 revealed that he conducts a random water temperature check Mondays to Fridays. Interview with Director of Nursing, Employee E2 conducted on July 1, 2024, at 12:08 p.m revealed that residents in the following rooms were able to use the hand sink in their rooms: Rm# 19A, Rm#20 A and B, Rm# 21A, Rm# 22A and B, Rm# 23A, Rm# 25B, Rm# 26A, Rm# 27A, Rm#28A, and Rm#29 A and B Interview with nursing staff conducted on July 1, 2024, at approximately 12:20 p.m. revealed 11 out of 12 nursing staff interviewed did not know what the safe water temperature was to use safely for residents. Based on the above findings Immediate Jeopardy related to the safety of the residents was identified for failure to ensure that safe hot water temperatures were maintained at the residents hand sink on the North Side nursing units. The Nursing Home Administrator was provided with the Immediate Jeopardy template on July 1, 2024, at 1:31 p.m. and an immediate action plan was requested. The following action plan was received and accepted on July 1, 2024. 1. Plant operations immediately worked to regulate the temperature at the mixing valve for the north side of the center. The east side of the center was noted to not have a temperature gauge. The plumber immediately called and responded. The temperatures will be monitored. In all the shower rooms and care areas. If the temperature is found to be greater than 110 F, the ship supervisor will be notified, and staff will cease to use the water until the temperature returns to 110 F or lower. 2. Planned operations completed a full house audit of hot water temperatures at the hand sinks in all resident rooms to ensure safe water temperatures. Completed July 1, 2024. 3. Immediate Action/Education. Nursing administration rounded on each resident to ensure that all are comfortable and were not affected by elevated water temperatures. (Completed. July 1, 2024) All shower rooms were inspected to ensure a thermometer was present for staff testing prior to showers, and in resident care areas. (Completed July 1, 2024) Care staff have been educated on the process for taking a water temperature prior to showering. Currently 90.7%. (as of July 2) All others will be educated prior to next shift. Center staff shall have been educated on the process for monitoring for temperatures that are excessive to the touch in residence sinks and non-resident areas. Currently, 90.9% (as of July 2) remaining staff will be educated on their next scheduled shift. Plant operations staff will be educated on the process for daily water temperatures, including recording and notification of administration if outside the acceptable range. (Completed July 2, 2024. Except for one employee on vacation). A temperature gauge will be installed on the mixing valve of the East Unit hot water heater to allow for accurate temperature monitoring of water prior to leaving the boiler room. (Installation was completed on July 2, 2024) 4. Ongoing compliance will be monitored by: monitoring of the water temperatures completed by the Maintenance Department will be completed on a random sampling of eight resident rooms, three times a day on all units for two weeks, then two times a day for two weeks, then daily ongoing. Any variances will be addressed and reported to the Monthly QA Committee. A random questionnaire will be completed with three staff members daily on the process for taking a water temperature, as well as the acceptable temperature range. The questionnaire will be completed daily for two weeks, then three times a week for two weeks. Then weekly for two weeks. All variances will be immediately addressed and reported to the monthly QA. Committee. Review of facility hot water temperatures audits conducted by the facility on July 1, 2024, revealed that hot water temperatures did not exceed 110 degrees Fahrenheit. Follow-up observation of the North side boiler conducted on July 2, 2024, 1:20 p.m. with Director of Plant Operations, Employee E4 revealed that mixing valve temperature reading was 109 degrees Fahrenheit. Follow-up observation of the East side boiler conducted July 2, 2024, at 1:23 p.m. with Director of Plant Operations, Employee E4 revealed that a mixing valve thermometer has been installed. Further, the mixing valve thermometer reading was 102 degrees Fahrenheit. Follow-up observation and hot water temperature checks conducted on July 2, 2024, 1:20 p.m. with Director of Plant Operations, Employee E4 on the North Unit nursing unit. at the resident hand sink for rooms 19, 20, 21,122, 23,124, 25, 26, 27, 28, 29, 30, Tub room#1, Tub room [ROOM NUMBER], East side rooms 101, 102, 114, Central Bath shower#1 and shower #2, revealed that water temperatures did not exceed 110 degrees Fahrenheit. Follow-up interview with 18 clinical staff conducted on July 2, 2024, revealed that all 18 clinical staff were knowledgeable on the facility's policy on Safety on Water Temperatures. Following verification of the implementation of the facility's immediate action plan, the Immediate Jeopardy was lifted on July 2, 2024, at 4:09 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to ensure that two of 32 residents reviewed were free of neglect during transfers from one surface to another (Resident R13 and Resident R80). This failure resulted in actual harm to Resident R13 who did not received the appropriate level of assistance during a transfer from bed to wheelchair and sustained a laceration to right calf requiring eight sutures. Findings include: Review of facility policy and procedure Abuse Prevention Program undated revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. Further review of the facility policy stated that the facility develops and implement policies and procedures to aid the facility in preventing abuse, neglect or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility policy, Lifting Machine, Using a Mechanical undated, revealed that, At least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of Resident R13 clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R13's quarterly Minimum Data Set (MDS- assessment of care needs), dated January 15, 2020, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that the resident was cognitively intact. The MDS assessment further revealed that the resident required extensive assistant of two person for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair). The resident was not steady when moved from a seated to standing position or for surface to surface transfer (for transfer between bed and wheel chair). Review of the resident's care plan revised October 23, 2019 revealed that the resident was at risk for falls due to a decrease in balance, decrease range of motion, strength and endurance. Interventions included for the resident to be transfer with a sliding board with assistance of two person. Review of facility documentation dated January 22, 2020, at 11:30 a.m. revealed that the social worker went to get Resident 13 for her care conference. Social worker found Resident R13 in her wheelchair with a pool of blood on the floor next to her. Resident R13 was unaware of what had happened. Nursing was informed and upon assessing resident, a large laceration on right calf was noted. A pressure dressing was applied. The resident's physician was notified and the resident was sent to hospital for evaluation. Resident R13 returned to the facility after receiving eight sutures to close the laceration on the right calf. Review of facility investigation into the incident sustained by Resident R13 revealed that Resident R13 was a two person transfer with sliding board. At the time of the incident the resident was transferred with the assist of one staff person from bed to wheelchair. Resident R13 has reduced sensation in right lower extremity and was unaware that the lower extremity brushed against wheelchair. Further review of a written statement obtained by the facility revealed an interview with nursing assistant, Employee E17, who indicated I did her wash up and put her in her chair. I got in front of her knee to knee and grabbed the pants and did the pivot and sat her in her chair. She did not say anything. I set up her table in front of her table with her perfume and mirror. I told her I would bring back some ice water. Facility staff asked Employee E17, what does it say on the transfer sheet? Employee E17 replied, Now I know she is a two person transfer. Further review of the interview revealed When you come on shift do you get report? Employee E17 replied, I come in early and ask the nurse if there is anything new? Any new patients? Any changes? And they always tell me what is going on. When you fill out the ADL log, do you write in transfer status? Employee E17 stated, I just do it the way I do. On that sheet, there is a block to indicate transfer status 1, 2 or 3 Employee E17 stated, I don't look at that. Further review of facility investigation revealed Resident R13's statement, I was being transferred out of bed by cna (nursing assistant) and my right leg twisted and bumped the side of the bed. My leg hurt when it happened. I guess I said ouch. Further review of the facility investigation confirmed that Resident R13 required eight sutures. Review of the facility's report submitted to the Department of Health revealed that the facility substantiated that neglect did occur since nursing assistant, Employee E17 failed to review Resident 13's transfer status. Interview conducted on October 25, 2021, at 2:00 p.m. with Resident R13 revealed that the resident could not accurately recall the incident related to the skin tear. Interview on October 25, 2021, at 3:00 p.m. with the Nursing Home Administrator (NHA) and the Senior Director of Operations, Employee E12, revealed that the facility was under different ownership at the time the incident occurred and that they were unable to provide any information or insight into the event. The NHA stated that there were currently no nursing staff working at the facility who were employed at the time of the incident. The NHA further stated that care plans were located in a binder by room number in the conference room during the previous administration and transfer status was located in a plastic frame in each resident's room. Review of Resident R80's Functional Screening Assessment, dated August 26, 2019, revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required a maximum assistant of 2 persons with decline in functional status over the previous month. The physical therapist recommended the use a hoyer (mechanical) lift for transfers due to the resident decline in function. Review of Resident R80's nursing note, dated September 13, 2019, at 11:20 p.m. indicated that licensed nursing staff were called to the resident's room by nurse aide staff. The nurse aide asked the licensed nurse to observe the resident's right frontal temple area, a large soft tissue hematoma (an abnormal collection of blood outside of blood vessels) was noted. The brusing was noted to be purple and dark blue. The resident reported having pain, was provided with pain medication and transferred to the hospital via 911 (Emergency Medical Services) for evaluation. Review of hospital records, dated September 14, 2019, revealed that Resident R80 was evaluated for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was subsequently returned to the facility. Review of facility documentation, dated September 14, 2019, revealed a written statement from nurse aide, Employee E14, who indicated in her statement that she put Resident R80 in bed using a hoyer lift by herself without any assistance from other staff persons. Continued review of facility documentation, dated September 17, 2019, revealed that during an interview between nurse aide, Employee E14 and facility administration staff, Employee E14 confirmed that she used a hoyer lift and transferred Resident R80 to bed alone without assistance. Employee E14 indicated that she knew that the correct policy for using a hoyer lift required two staff persons and that she did the transfer by herself because she wanted to get my people done and that other staff were busy. Interview on October 25, 2021, at 1:01 p.m. with the Nursing Home Administrator (NHA) and the Senior Director of Operations, Employee E12, revealed that the facility was under different ownership at the time the incident occurred and that they were unable to provide any information or insight into the incident. The NHA stated that there were currently no nursing staff working at the facility who were employed at the time of the incident. The NHA confirmed that nurse aide, Employee E14 was an agency nurse aide and the facility currently did not use any agency staff. The NHA was unable to provide any trainings or skills reviews for Employee E14. The NHA was also unable to provide any in-services or corrective actions that were taken by the facility in response to the incident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code: 201.29(d) Resident rights. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy and procedures, clinical records, incident reports, facility documentation, and staff interviews, it was determined that the facility failed to protect four of 16 residents reviewed (Residents R67, R64, R63, and CL1) from neglect, which resulted in actual harm and an Immediate Jeopardy for two resident's (Residents R67 and R63). Findings include: Review of facility policy and procedure, titled, Neglect, Mistreatment, Abuse of Resident and Misappropriation of Resident Property, revised, March, 2017, indicated, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident R67's clinical revealed a physician order dated, September 1, 2017, which indicated the following diagnosis; [MEDICAL CONDITION] disorder, (neurological disorders that cause brief episodes of spasms and/or unresponsiveness) and corticobsal degeneration, (is a rare neurological disease associated with progressive brain degeneration). Further review of Resident R67's clinical record revealed an Annual MDS, (Minimum Data Set - periodic assessment of needs), dated, July 23, 2017, which indicated that Resident R67, transfer status - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position, was indicated to be total dependence with two or more persons for physical assist. Review of Resident R67's Careplan dated, February 1, 2017, indicated that Resident R67 is a high risk for falls, because of medical [DIAGNOSES REDACTED]. Review of Resident R67's clinical record revealed a nursing progress note dated, March 3, 2017, written at 2:35 p.m. by a Licensed nurse, indicating, Called to room [ROOM NUMBER], observed Resident R67, laying on floor in front of the hoyer lift. CNA said Resident R67, slid out of sling and fell to the floor. Medical Doctor and R67's husband made aware and 911 called. Right shoulder noted to have an abrasion and back to red in color. Review of TAR, (Treatment Administration Record - a form that indicates what type of care and services are to be completed for a Resident). Review of Resient R67's TAR, indicated, Transfer status of 2 with a hoyer (a mechanical lift that transfers one from one place to another). An interview with the Director of Nursing, on September 12, 2017, at 11:20 a.m. revealed that on August 14, 2015, Resident R67, was identified as needing a hoyer lift for all transfers, and has remained a hoyer lift with 2 since August 14, 2015. Interviews with Employee's E5, E6, and E7, all CNA's assigned to the E Nursing Unit, on September 12, 2017, at 1:40 p.m., where Resident R67's room is located, indicated in the ADL, (Activities of Daily Living Book - which indicates what type of care needs to be done for each resident, such as type of transfer), tells you the type of transfer that is to be performed for each Resident on the unit. Review of the facility policy and procedure related to Hoyer Lifts, undated, indicated, that two staff persons are to be present when a resident is being transferred via a Hoyer lift. Review of the owner's manual, for LF1030 Hydraulic Patient Lift/LF1040 Electric Patient Lift, indicates, for transferring the patient from a chair to wheelchair and vice versa, It is recommended that two (2) attendants be used when transferring a patient to and from a wheelchair. An interview with the Director of Nursing on September 12, 2017, again at 11:20 a.m. confirmed that it is the facility policy and procedure, that when a resident is being transferred via a Hoyer Lift, that two staff person's be present. A review of the facility Incident Report, dated, March 3, 2017, completed by Employee E3, Licensed Nurse, indicated, Resident R67, fell from Hoyer Lift during the transfer from bed to recliner chair. Further review of the Incident Report revealed interview questions and answers, completed by the Nursing Home Administrator and Employee E4, Certified Nurses Aide, on March 3, 2017. The questions and answers, revealed that Employee E4, CNA, completed the Hoyer Lift transfer, independently on March 3, 2017, at 2:15 p.m An interview with the Nursing Home Administrator on September 11, 2017, at 11:20 a.m. confirmed that Employee E4, Certified Nurses Aide, improperly transferred Resident R67, from bed to recliner chair, by operating Hoyer Lift, independently, without a second staff person present, resulting in Resident R67, sliding thru the sling (patient lift slings are easy for caregiver to use and provide secure support to the patient during the transfer). Nursing Home Administrator further indicated, because of the improper transfer Resident R67, sustained an abrasion to the back of right shoulder, back was redned which resulted in Resident R67, being transported by 911, to local hospital for evaluation and treatment. Further review of Resident R67's Careplan, related to Falls updated, March 3, 2017, indicated, as a result of the improper transfer that occurred on March 3, 2017, the intervention put into place to prevent such an occurrence from occuring again, would be, Will provide inservice to all care personnel, (CNA's and Nursing), to ensure correct positioning of Hoyer Lift sling, checking for safety prior to initiating transfer with lift. Return demonstration will be required by staff being inserviced. The policy for 2 person transfer when using Hoyer lift will be reviewed. Review of Nursing Assistants Daily Schedules indicated that Employee E4, CNA, was assigned to care for Resient R67, on March 3, 2017. Further review of the Nursing Assistants Daily Schedules, indicates at the very bottom of the sheet, Check Transfer/ADL Book. Review of the ADL sheet for Resident R67, for March 3, 2017, indicated, Transfer Status of 2 - Hoyer. Review of ADL sheet for March 3, 2017, revealed that Employee E4, CNA, signed this section acknowledging that Resident R67, was a Transfer Status of 2 - Hoyer. Continued review Nursing Assistants Daily Schedules indicated that Employee E4, CNA, was assigned to Resident R64, on March 3, 2017, who was also identified as Transfer Status of 2 - Hoyer. Employee E4, CNA, remained assigned to Resident R64, on the following dates, March 6, 7, 8, 11, 12, 13, 16 and 17, 2017. Review of Employee E4, CNA's personnel record revealed a hire date of January 26, 2012. Employee E4's hire date was confirmed in an interview with Employee E8, Director of Human Resources, on September 13, 2017, at 1:45 p.m Review of Abuse and/or Neglect Training records revealed that Employee E4, CNA, received Abuse Training on June 5, 2013 and again on June 11, 2014. An interview with the Director of Nursing, on September 13, 2017, at 1:15 p.m. revealed that there was no documentation available to review indicating that Employee E4, CNA, received Abuse and/or Neglect Training, at the time of hire, (1/26/12), during the years of 2015, 2016 and thus far for 2017. During the same interview the Director of Nursing further indicated not having any documentation available to indicate since hire, when Employee E4, received Hoyer Lift training/inservicing. Director of Nursing further indicated that Hoyer Lift training/inservicing is required on a yearly basis for all direct care staff, like Employee E4. Review of the facility inservicing for the event that occurred on March 3, 2017, related to Hoyer Lift transfers, revealed, that the inservicing occurred on March 16 and 17, 2017. Review of the sign in sheet for March 16, 2017, indicated that only 6 staff person's including Employee E4, CNA, who did the improper transfer were inserviced on proper Hoyer Lift transfers. On March 17, 2017, and additional three employee's, all CNA's were inservices on proper Hoyer Lift technique. An interview with Director of Nursing on September 12, 2017, at 8:40 a.m. confirmed that only 9 staff person's were inserviced, related to the event that occurred on March 3, 2017. Director of Nursing further indicated that, The nine staff persons inserviced, work on the E - wing and all work during the 7 - 3 shift. During the same interview Director of Nursing indicated that on March 3, 2017, to date, the facility employee's 14 full time RN's, 7 full time LPN's and 17 full time CNA's and 26 CNA's on an as needed basis. Director of Nursing also indicated that the facility employee's 4 partime RN's and 10 as needed RN's, 3 partime LPN's and 2 as needed LPN's and 3 partime CNA's. Director of Nursing and Nursing Home Administrator, confirmed during an interview on September 12, 2017, at 10:30 a.m. that only 9 of approximately 88 staff persons that work under nursing received the inservicing about Hoyer Lift transfers as indicated in Resident R67's Careplan. Director of Nursing and Nursing Home Administrator further indicated during the same interview that Employee E4, CNA, who performed inappropriate Hoyer Lift transfer with Resident R67, continued to work for 8 days, before receiving inservicing on Hoyer Lift transfers and continued to transfer Residents by using the Hoyer Lift. During the same interview the Nursing Home Administrator reviewed the Nursing Assistant Dialy Schedules, for March 3 through March 17, 2017, with the Surveyor and identified Resident R64, has a Resident that requires Hoyer Lift transfer with two staff person's and further indicated that Employee E4, CNA, was assigned to Resident R64, on March 3, 6, 7, 8, 11, 12,13, 16 and 17, 2017. Nursing Home Administrator again confirmed that Employee E4, did not receive inservicing in a timely fashion. The facility failed to ensure that one Employee received annual Abuse training and Hoyer Lift inservicing on a yearly basis, from the time of hire. The facility also failed to ensure that inservicing was completed for all care staff that would complete a Hoyer Lift transfer after an incident occurred related to an improper Hoyer Lift transfer. Review of facility policy and procedure titled Condition Change, dated March, 1997, reviewed/revised April, 2015 stated To observe, record and report any condition changes to the physcian so proper treatment may be implemented. Any sudden and/or marked adverse change in vital signs, symptoms and/or behavior exhibited by a resident. Any unusual occurrence involving a resident such as a fall, injury or condition change. A review of Resident CL1 's clinical record revealed physcian orders that indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the residents Admission Minimum Data Set (MDS- a periodic review of the resident needs) dated July 5, 2017, a BIMS ( Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from BIMS assessment suggest the following guidelines: 13-15 cognitively intact: 8-12 moderately impaired: 0-7 severe impairment) score of 13 indicating that the resident was cognitively intact. Further review revealed that the resident had extensive assistance of two staff for bed mobility, transfers, toileting and bathing and had impairment on one side lower extremities that included the hip, knee, ankle and foot. A transfer sheet dated August 12, 2016 through August 30, 2016 noted that Resident CL1 was an assist of 2 staff members for transfers. Review of an electronic event submitted on September 1, 2016, revealed that on August 30, 2016 at 10:30 a.m. Resident CL1 twisted his left leg while being transferred from his bed to the wheelchair by a nurse aid, Employee E9, had pulled the wheelchair back, that Resident CL1 called out My leg, my leg, that the nurse aide repositioned the leg. A written statement from Employee E9, nurse aid, stated that the chair was next to the bed, put the walker in front of Resident CL1, and assisted him up, to pivot to the chair, that the resident had reported pain. Review of a statement written by Employee E10, rehabilitation aid, dated August 30, 2016, regarding the event, revealed that after the resident was placed in the wheelchair Employee E10 transported him to the occupational therapy shower room, that Resident CL1 had reported that he had pain in his leg to Employee E10. The written statement further revealed that Employee E15, certified occupational therapy assistant, had given the resident a shower, that resident CL1 had also reported pain in during the shower, that Employee E10 told Employee E15 that the resident had twisted his leg when he was transferred from the bed to the wheelchair. A PB-22(Pennsylvania Bulletin-required report of alleged resident abuse/neglect investigations) dated August 30, 2016, stated that during physical therapy he told the therapist his knee had been bent back more than it should have been, that the therapist reported this to the nurse who went to investigate and was delayed because the resident was eating lunch. A nursing progress note dated August 30, 2016 at 11:00 a.m. stated that the resident had told the therapist that the leg had become hyper extended when moved in his wheelchair. Facility documentation regarding the event noted that Resident CL1 had received ice from the therapy department and that the Resident had gone to a follow up orthopedic appointment accompanied by family. A review of the facility investigation revealed that there were no statements obtained from the physical therapist, the certified occupational therapy assistant, the nurse or any other staff that had interacted with Resident CL1 at the time of the event. The facility did not include any information regarding why staff had not immediately notified nursing of the incident or why they continued the transfer of the resident and the shower. In addition, there was no evidence available for review at the time of the survey that staff had completed an assessment of the Resident's injury prior to sending the resident out. Review of inservicing documentation completed September 4, 2016 through September 10, 2016 revealed that approximately 81 staff member were educated regarding body mechanics, risk of injury to staff and residents, tips for moving and lifting residents, transfer techniques with slide board and tips for carrying and unloading. Employee E13, Director of Rehabilitation, stated in an interview on September 13, 2017 at approximately 2:00 p.m. that she had given the inservices, that reporting changes in resident condition had not been included in any of the inservices or following plan of care for transfers. A review of an orthopedic consultation dated August 30, 2016, revealed that the resident had a supracondylar(break in the bone at the knee) femur fracture, that the resident would need an ORIF/plate and screws(surgical repair of the injury). The facility failed to insure that a complete and thorough investigation of an incident resulting in harm to a resident who was transferred with the assist of one staff instead of two and that a serious change in condition that had not been reported by multiple staff members as the policy directed. Review of Resident R63's quarterly MDS dated [DATE] revealed that the resident had severe cognitive (mental function) impairment and needed extensive assistance with care needs and included the [DIAGNOSES REDACTED]. Review of Resident R63's nursing progress notes dated September 5, 2017 revealed that the nurse aide discovered a bruise under the residents left breast and on the left arm. Review of the facility's investigation revealed that on September 5, 2017 at 7:45 p.m. the nurse aide discovered the bruise and reported to the nurse. The report was not completed with the size and character of the bruise. The report did not evaluate how the resident was transferred as possible cause of the bruise. The report also did not include statements of the nursing staff who previously provided nursing care to determine when the bruise actually occurred. There was no investigation to rule out abuse. An interview with the director of nursing services on September 14, 2017 at 11:30 a.m. confirmed this finding and stated there was no policy and procedure available for how to investigate incidents and accidents. A review of the facility Polices and Procedures titled Neglect, Mistreatment, Abuse of Resident and Misappropriation of Resident Property, dated, January, 2010, revised March, 2017, stated that All matters such as suspicious bruising of residents, occurrences, patterns, trends that may constitute abuse are to be reported. An investigation into the matter will begin promptly after being reported. A review of the facility Polices and Procedures titled Incident Report on all Bruises of Unknown Origin, undated, stated It is the policy of Harlee Manor to complete an incident report on all bruises of unknown origin.The investigation is imitated in timely manner and the necessary procedures are carried out. A review of Resident R64 's clinical record revealed physcian orders that indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the residents Admission Minimum Data Set (MDS- a periodic review of the resident needs) dated July 5, 2017 revealed that the resident rarely or never was able to be understood and rarely or never was able to understand others. A BIMS ( Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from BIMS assessment suggest the following guidelines: 13-15 cognitively intact: 8-12 moderately impaired: 0-7 severe impairment) score of 15 indicating that the resident was severly cognitively impaired. Further review revealed that the resident had total dependence on two staff for transfers, toileting and bathing and had impairment of both upper extremities that included the shoulder, elbow, wrist and hand. The resident was non-ambulatory and was incontinent of bowel and bladder. Review of facility documentation dated June 10, 2017, 7:40 p.m. stated that the Resident R64 had a bruise on the left elbow that measured 5 centimeters by 6 centimeters(approximately 2 inches by 2.5 inches), that the bruise had been discovered when the Resident was about to be transferred to bed, that the cause of the bruise was unknown. There was no evidence available for review at the time of the survey to indicate that a complete and comprehensive investigation had been completed of the injury such as a description of the bruised area that included the shape and color of the area and statements from staff on previous nursing shifts. Review of facility documentation dated June 19, 2017, 8:30 p.m. stated that Resident R64 had a bruise on the right lateral(on the side) breast that was purple in color and measured 5 centimeters by 8.5 centimeters(approximately 2 inches by 3.5 inches), that the bruise had been discovered when the Resident was about to be undressed for bed, that the cause of the bruise could have been the mechanical lift. One statement was obtained from the nurse aid who first noted the bruised area. There was no evidence available for review at the time of the survey to indicate that a complete and comprehensive investigation had been completed of the injury such as obtaining statements from staff on previous nursing shifts, staff demonstration of the transfers with the mechanical lift to evaluate staff performance or that staff education regarding transfers had been completed. The facility failed to complete comprehensive investigations of two injuries of unknown origin to rule out abuse. 28 Pa. Code 201.20(a) Staff development 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to provide adequate monitoring and supervision for two of residents, (Residents CL1 and R67). reviewed which resulted in actual harm to one resident (Residents CL1). Findings include: Review of facility policy and procedure titled Condition Change, dated March, 1997,Reviewed/Revised April, 2015 stated To observe, record and report any condition changes to the physcian so proper treatment may be implemented. Any sudden and/or marked adverse change in vital signs, symptoms and/or behavior exhibited by a resident. Any unusual occurrence involving a resident such as a fall, injury or condition change. A review of Resident CL1 's clinical record revealed physcian orders that indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the residents Admission Minimum Data Set (MDS- a periodic review of the resident needs) dated July 5, 2017, a BIMS ( Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from BIMS assessment suggest the following guidelines: 13-15 cognitively intact: 8-12 moderately impaired: 0-7 severe impairment) score of 13 indicating that the resident was cognitively intact. Further review revealed that the resident was 69 inches tall, weighed 170 pounds, required extensive assistance of two staff for bed mobility, transfers, toileting and bathing and had impairment on one side lower extremities that included the hip, knee, ankle and foot. A transfer sheet dated August 12, 2016 through August 30, 2016 noted that Resident CL1 was to be transferred with the assistance of 2 staff members. Review of an electronic event submitted on September 1, 2016, revealed that on August 30, 2016 at 10:30 a.m. Resident CL1 twisted his left leg while being transferred from his bed to the wheelchair by a nurse aid(one staff member instead of two), Employee E9, had pulled the wheelchair back, that Resident CL1 called out My leg, my leg, that the nurse aide repositioned the leg. Employee E9 in a written statement dated August 30, 2016 stated that she got Resident CL1 ready to go to the shower in Occupational Therapy, that the chair was next to the his bed, that she put the walker in front of Resident CL1, assisted him up to pivot to the chair, that he did not say anything except pain, that she pushed the wheelchair into the hall, that the footrests were not on the wheelchair. Review of a statement written by Employee E10, rehabilitation aid, dated August 30, 2016, regarding the event, that E10 stated during the transfer I went to get clothes and he started screaming my leg, my leg, I asked what's going on. In addition, the statement noted that Employee E10 transported Resident CL1 to the occupational therapy shower room and had reported that he had pain in his leg to Employee E10, that the wheelchair did not have leg rests on it. The written statement further revealed that Employee E15, certified occupational therapy assistant, had given the resident a shower, that resident CL1 had also reported pain in during the shower, that Employee E10 told Employee E15 that the resident had twisted his leg when he was transferred from the bed to the wheelchair. A PB-22(Pennsylvania Bulletin-required report of alleged resident abuse/neglect investigations) dated August 30, 2016, stated that during physical therapy Resident CL1 told the therapist his knee had been bent back more than it should have been, that the therapist reported this to the nurse who went to investigate, which was delayed because the resident was eating lunch and when the nurse returned the resident had left the faciltiy for a follow up orthopedist appointment. The physical therapist, Employee E11, stated in an interview on September 13, 2017 at 1:30 p.m. that the resident had reported pain in the left leg, that she had gotten him out of the chair and onto the mat to assess his leg, notified nursing staff of the report of pain. In addition, Employee E11 stated that residents always get leg rests with transport. A nursing progress note dated August 30, 2016 at 11:00 a.m. stated that the resident had told the therapist that the leg had become hyper extended when moved in his wheelchair. Facility documentation regarding the event noted that Resident CL1 had received ice from the therapy department and that the Resident had gone to a follow up orthopedic appointment accompanied by family. A review of the facility investigation revealed that there were no statements obtained from the physical therapist, the certified occupational therapy assistant, the nurse or any other staff that had interacted with Resident CL1 at the time of the event. A review of an orthopedic consultation dated August 30, 2016, revealed that the resident had a supracondylar(break in the bone at the knee) femur fracture, that the resident would need an ORIF/plate and screws(surgical repair of the injury). A nursing note dated August 31, 2016 at 5:00 p.m. stated that the physcian had ordered to send the Resident to the emergency room today, instead of tomorrow for surgery, that the resident left at 6:00 p.m. by ambulance. Review of Resident R67's clinical revealed a physician order dated, September 1, 2017, which indicated the following diagnosis; seizure disorder, (neurological disorders that cause brief episodes of spasms and/or unresponsiveness) and corticobsal degeneration, (is a rare neurological disease associated with progressive brain degeneration). Further review of Resident R67's clinical record revealed an Annual MDS, (Minimum Data Set - periodic assessment of needs), dated, July 23, 2017, which indicated that Resident R67, transfer status - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position, was indicated to be total dependence with two or more persons for physical assist. Review of Resident R67's Careplan dated, February 1, 2017, indicated that Resident R67 is a high risk for falls, because of medical [DIAGNOSES REDACTED]. Review of Resident R67's clinical record revealed a nursing progress note dated, March 3, 2017, written at 2:35 p.m. by a Licensed nurse, indicating, Called to room 123, observed Resident R67, laying on floor in front of the hoyer lift. CNA said Resident R67, slid out of sling and fell to the floor. Medical Doctor and R67's husband made aware and 911 called. Right shoulder noted to have an abrasion and back to red in color. Review of TAR, (Treatment Administration Record - a form that indicates what type of care and services are to be completed for a Resident). Review of Resient R67's TAR, indicated, Transfer status of 2 with a hoyer (a mechanical lift that transfers one from one place to another). An interview with the Director of Nursing, on September 12, 2017, at 11:20 a.m. revealed that on August 14, 2015, Resident R67, was identified as needing a hoyer lift for all transfers, and has remained a hoyer lift with 2 since August 14, 2015. Interviews with Employee's E5, E6, and E7, all CNA's assigned to the E Nursing Unit, on September 12, 2017, at 1:40 p.m., where Resident R67's room is located, indicated in the ADL, (Activities of Daily Living Book - which indicates what type of care needs to be done for each resident, such as type of transfer), tells you the type of transfer that is to be performed for each Resident on the unit. Review of the facility policy and procedure related to Hoyer Lifts, undated, indicated, that two staff persons are to be present when a resident is being transferred via a Hoyer lift. Review of the owner's manual, for LF1030 Hydraulic Patient Lift/LF1040 Electric Patient Lift, indicates, for transferring the patient from a chair to wheelchair and vice versa, It is recommended that two (2) attendants be used when transferring a patient to and from a wheelchair. An interview with the Director of Nursing on September 12, 2017, again at 11:20 a.m. confirmed that it is the facility policy and procedure, that when a resident is being transferred via a Hoyer Lift, that two staff person's be present. A review of the facility Incident Report, dated, March 3, 2017, completed by Employee E3, Licensed Nurse, indicated, Resident R67, fell from Hoyer Lift during the transfer from bed to recliner chair. Further review of the Incident Report revealed interview questions and answers, completed by the Nursing Home Administrator and Employee E4, Certified Nurses Aide, on March 3, 2017. The questions and answers, revealed that Employee E4, CNA, completed the Hoyer Lift transfer, independently on March 3, 2017, at 2:15 p.m An interview with the Nursing Home Administrator on September 11, 2017, at 11:20 a.m. confirmed that Employee E4, Certified Nurses Aide, improperly transferred Resident R67, from bed to recliner chair, by operating Hoyer Lift, independently, without a second staff person present, resulting in Resident R67, sliding thru the sling (patient lift slings are easy for caregiver to use and provide secure support to the patient during the transfer). Nursing Home Administrator further indicated, because of the improper transfer Resident R67, sustained an abrasion to the back of right shoulder, back was reddened which resulted in Resident R67, being transported by 911, to local hospital for evaluation and treatment. The facility failed to provide adequate supervision to two Residents during care which resulted in actual harm to one Resident CL1. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services