Every finding on record at st anne's retirement community

Based on clinical record review, review of information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 24 residents (Resident 9).Findings include: Review of Resident 9's annual MDS (Minimum Data Set - periodic assessment of resident needs) dated October 22, 2025, section J1900 - Number of Falls since Admission/Entry or Reentry or Prior Assessment revealed that Resident 9 had one major injury. A major injury Includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries as per the Resident Assessment Instrument. Review of Resident 9's progress note of October 20, 2025, indicated resident was found on the floor in the bathroom. 911 was called to transport the resident to the hospital. Review of information submitted October 21, 2025, to the Department of Health revealed only observed injury was a 2.5 centimeter laceration to the occiput (back of the head or skull) region of the scalp. Laceration was stapled and resident returned to the facility. Interview with licensed staff E3 on December 22, 2025, at 1:30 p.m. revealed that the laceration was coded as a major injury because it involved the head. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of one resident. (Resident 1)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included pneumonia due to pseudomonas (lung infection caused by bacteria), other chronic pain (persistent pain lasting or recurring for an indefinite period) and chronic respiratory failure with hypoxia (is a long-term condition where lungs cannot adequately exchange gases, leading to persistently low oxygen levels in the blood). Review of Resident 1 physician's orders dated December 15, 2025, revealed an order for 'Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for severe pain'. Review of Resident 1's care plan revealed the resident has chronic pain with interventions for staff to 'identify other factors that may enhance pain such as body position, tight clothing, anxiety or other emotional issues, etc. Provide relief as able'.Review of the Medication Administration Records for December 2025, revealed that the Resident 1 received the as needed narcotic (Oxycodone HCl) on December 5, 2025, to December 22, 2025, without documented evidence that non-pharmacological interventions were attempted prior to administration. During an interview on December 24, 2025, at 10:30am., the Assistant Director of Nursing confirmed that the Oxycodone HCl was administered to Resident 1 and failed to provide documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for one of 12 residents reviewed (Resident 2).Findings include:Review of facility policy, Enhanced Barrier Precautions, reviewed February 27, 2025, indicated that the facility will have the appropriate signage on how to communicate to staff which residents require the use of enhanced barrier precautions (EBP). The following will list EBP criteria: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multidrug-resistant organism.Observation on December 23, 2025, at 9:00 a.m. revealed Resident 2 with tube feeding running. Observations of Resident 2's room on all days of the survey failed to reveal evidence of EBP signage or personal protective equipment. Review of Resident 2's physician's orders revealed that the resident was receiving an enteral feed (tube feeding - soft tube which delivers liquid nutrition directly into the gastrointestinal tract).Interview with licensed staff Employee E4 on December 24, 2025, at 10:05 a.m. confirmed that Resident 2 would meet the criteria for EBP due to the tube feeding and that EBP was not in place for Resident 2.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of facility policy and procedure, observation, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure infection control and prevention was implemented during a COVID-19 outbreak on two of two units observed (First and Second Floor Unit). Findings include: Review of facility policy and procedure titled Response to an Outbreak of COVID-19, revised November 20, 2023, revealed Identification of a single new case (resident or staff) 14 days after the last known case would meet the criteria for a new outbreak and prompt the need for an outbreak response. Further review of this policy revealed Managing exposed residents and employees as part of the unit-based or facility-wide response: Employees working in COVID rooms/areas must wear full PPE, including a full-face shield (goggles are not acceptable) gown, gloves and N-95. Further review of this policy revealed For full outbreak, on day 1-10, staff caring for residents in the yellow zone should use full PPE (gloves, gowns, eye protection using a full-face shield, and N-95. The facility experienced a COVID-19 outbreak beginning on November 20, 2023 and continuing through December 7, 2023. This outbreak consisted of a total of thirty-three (33) residents. Interview with Nursing Home Administrator and Director of Nursing on December 4, 2023, at 9:00 a.m. revealed that all staff and visitors must wear full PPE (personal protective equipment) on both the first floor and second floor nursing units due to the COVID-19 outbreak. This interview further revealed that staff were to remove PPE prior to leaving a COVID-19 positive resident's room and wash the face shield for reuse. Observation on December 4, 2023, at 11:17 a.m. on the second-floor nursing unit revealed a dietary aide preparing meal trays with a face shield pulled to the top of the staff person's head. Observation on December 4, 2023, at 11:24 a.m. on the second-floor nursing unit revealed Employee E4 exit a COVID-19 positive resident room and enter a resident room with COVID-19 negative residents without changing any PPE. This observation further revealed Employee E4 exit the COVID-19 negative room, remove the PPE gown and walk up the hallway to dispose of the gown without donning another gown. Observation on December 4, 2023, at 11:27 a.m. revealed Physical Therapist Employee E5 exit a COVID-19 positive resident room without removing PPE and walked in the hallway to the elevator area and removed the PPE at the elevator area. Observation on December 4, 2023, at 11:33 a.m. on the second-floor nursing unit revealed housekeeping Employee E7 remove PPE gown after cleaning a COVID-19 positive room, don a new gown at the housekeeping cart without washing hands or face shield. Housekeeping Employee E7 returned to the housekeeping cart and proceeded to continue to empty trash in the spa room without washing hands and/or washing face shield or changing mask or face shield. Observation on December 4, 2023, at 12:04 p.m. in the second-floor elevator revealed CNA Employee E6 enter the elevator wearing a gown and proceed to the first floor and exit the elevator on the first floor wearing the PPE gown that was worn on the second floor. Interview with CNA Employee E6 revealed employee was going to lunch. Observation on December 5, 2023, at 8:54 a.m. revealed facility physician sitting at the nurses' station desk wearing N-95 mask and goggles but no face shield. Observation on December 5, 2023, at 11:38 a.m. revealed a visitor at the second-floor elevator entrance preparing to exit the unit wearing a surgical mask and no other PPE, Visitor stated I didn't know there was COVID here. Observation on December 5, 2023, at 11:42 a.m. revealed a staff member returning from lunch; walked to the nurses' station in a surgical mask, no N-95 mask and no face shield. Employee donned N95 at the nurses' station. Observation on December 5, 2023, at 11:49 a.m. revealed staff member arrive on the second-floor nursing unit with no PPE Staff person entered the assisted dining room with no PPE then walked down the hall to the linen cart for a gown; re-entered the assisted dining room with mask and gown but no face shield. Staff person then exited the assisted dining room and walked down a second hallway and returned to the dining room without wearing the required face shield. Observation on December 5, 2023, at 11:55 a.m. revealed a staff person assisting a resident to eat in the assisted dining room without wearing the required face shield. Observation on all days of the survey revealed donning and doffing of all PPE occurring in the same location at the entrance to the second-floor elevator area. Interview with Licensed Employee E8, infection preventionist on December 6, 2023, at 1:30 p.m. revealed the facility was aware of breaches in infection control protocol due to low staffing. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on December 7, 2023, at 10:00 a.m. Review of Resident 53's clinical records revealed resident tested positive for COVID (An infectious disease caused by a virus named SARS-CoV-2) on November 26, 2023, and was on contact isolation (Used when a patient has an infectious disease that may be spread by touching either the patient or other objects that patient has handled). In addition to standard precautions Observation of Resident 53's door revealed signage indicating as follows: For all staff - Contact and Droplet Precaution in addition to standard precautions. The same signage also revealed Before entering the room, perform hand hygiene, put on a gown, put on a mask, put on protective eyewear, perform hand hygiene, and put on gloves. On leaving the room, dispose of gloves, dispose of gown, perform hand hygiene, remove protective eyewear, dispose of the mask, and perform hand hygiene. Observation was conducted on December 4, 2023, at 12:08 p.m of meal service. Unlicensed employee E3 was observed entering Resident 53's room with a gown, mask, and face shield. Employee E3 assisted the resident with setting up meals and touching the resident and the table. Employee E3 was observed leaving Resident 53's room and then went to assist another resident who was negative for COVID without changing their gown and performing hand hygiene. Employee E3 was observed leaving the room and assisted two other residents on the same unit without changing gowns. At 12:14 p.m., Employee E3 was observed leaving the C- Unit with the same gown then came back at 12:16 p.m. and proceeded to assist two other residents. Interview with Employee E3 was conducted on December 4, 2023, at 12:18 p.m. Employee E3 confirmed not changing PPE (Personal Protective Equipment) after assisting Resident 53, a positive COVID resident before leaving the room and assisting other residents who were negative for COVID. Employee E3 stated, I forgot [resident name] was COVID-positive. The above information was discussed with the Nursing Home Administrator on December 7, 2023, at 9:45 a.m. The facility failed to ensure, that infection control and prevention were practiced on the First floor Unit. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 2/10/23. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 2/10/23.

Based on clinical record review and staff interviews it was determined that the facility failed to ensure the residents code status for one out of 24 residents reviewed (Resident 173). Findings include: Review of the clinical record revealed the resident was admitted to the facility on [DATE]. Further review revealed that the resident was sent to the hospital on November 25, 2023 for new symptoms of Congested Heart Failure (CHF-Heart does not pump blood effectively). The resident was readmitted to the facility on [DATE]. Review of Resident 173's clinical record revealed a POLST (Pennsylvania -Orders for Life Sustaining Treatment) was signed on November 3, 2023, stating the resident was a Do Not Resuscitate (DNR). Review of the physician orders revealed the DNR was not current. Interview with the Director of Nursing on December 7, 2023 at 9:40 a.m. revealed when the resident went to the hospital all physician orders were discontinued. Further interview revealed upon readmission of resident resident, on November 30, the DNR order was not restarted. The facility failed to ensure the resident's right to formulate an advance directive for Resident 173. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 201.29(j) Resident rights.

Based upon review of facility policy and procedure, interview, and clinical record review, it was determined the facility failed to provide toileting services as requested to one resident resulting in a fall for one of seven residents reviewed (Resident 53). Findings include: Review of facility policy and procedure titled Fall Management Program, reviewed August 25, 2022, revealed Risk Assessment - formal/documented assessment tool that identifies those residents at risk and the degree that they are at risk by assessing past history and present condition; assessments done on admission, readmission, quarterly, and when there is a significant change in condition. Further review of this policy and procedure revealed Preventative measures/interventions - decrease environmental risks, obstacles and clutter. Further review of this policy and procedure revealed Post fall investigation/guidelines/management: toilet schedule; review of bowel/bladder patterns. Review of Resident 53's Admission Falls Risk assessment dated [DATE], revealed a score of 11 indicating Resident 53 was at risk for falls. Review of Resident 53's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated September 29, 2022, revealed Resident 53 required the extensive assistance of one staff member for toileting. Further review of Resident 53's Admission MDS revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating cognitive impairment. Review of Resident 53's current plan of care revealed Resident 53 was at risk for falls and family was to notify the facility when leaving after visiting. Interview with Resident 53's family member on January 31, 2023, at 2:00 p.m. revealed on Thursday, November 24, 2022, after visiting with Resident 53, family member notified staff that she was leaving the facility and that Resident 53 needed to be toileted. The staff member indicated to the family member that they were leaving in 15 minutes. This interview further revealed that shortly after leaving the facility family member received a phone call that Resident 53 had fallen and was being sent to the hospital. Review of Resident 53's progress notes dated November 24, 2022, revealed found on floor of bathroom. Left leg is painful and she is unable to move it. Provider notified and gave orders to send to ER [acute care facility] for eval.[evaluation] POA [power of attorney] updated. Further review of Resident 53's progress notes dated November 29, 2022, revealed Resident arrived to room [ROOM NUMBER] in stable condition from [acute care facility]. [Resident] had an ORIF [open reduction internal fixation] of [resident] left femur [large bone located in upper leg]. Interview with the Nursing Home Administrator and Director of Nursing on February 3, 2022, at approximately 1:00 p.m. revealed the facility was not always able to promptly address toileting needs and the assumption was that Resident 53 toileted himself/herself due to his/her lack of safety awareness. The facility failed to ensure Resident 53 was toileted as requested, requiring Resident 53 to attempt to toilet himself/herself resulting in a fall in the bathroom which resulted in a fractured femur requiring surgery for repair. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely address a significant weight loss for one of eight residents reviewed (Resident 56). Findings include: Review of facility policy, Weight Monitoring Protocol, reviewed October 5, 2022, indicated that if significant unplanned weight loss of 5% in one month or 10% in six months, the following steps are taken: a. Nursing will reweigh the resident to check accuracy the next day but no more than 48 hours, b. If weight is accurate, notify the physician, c. Residents with significant weight changes will be weighed weekly for 4 weeks and referred for dietician monitoring, d. POA/Responsible Party to be notified of significant weight changes, e. Care plan to be updated as needed. Review of Resident 56's clinical record revealed a weight of 110.1 pounds on November 3, 2022. Weight and reweight recorded on December 6, 2022, was 98.5 pounds (loss of 11.6 pounds or 10.5%. Review of nursing progress note of December 13, 2022, indicated weight noted. Further review of the clinical record revealed weekly weights were not obtained and the next weight obtained was 101.9 pounds on December 30, 2022. Review of Weight Loss Monitoring Note of December 30, 2022, indicated ongoing weight loss and recommended resident be weighed weekly for four weeks. Follow up weights were obtained on January 3, 2023 of 97.4 pounds, January 17, 2023 of 97.5 pounds, and February 1, 2023 of 95.0 pounds. Interview with Employee E3 on February 3, 2023, at 10:30 a.m. revealed that the dietitian was not aware of the significant weight loss and confirmed weekly weights should have been initiated at that time. Employee E3 also confirmed that weekly weights were obtained consistently after the recommendation on December 30, 2022. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based upon clinical record review, it was determined that the facility failed to provide education regarding the COVID-19 vaccine to resident and/or resident representatives prior to receiving/declining the COVID-19 vaccination for one of 24 residents reviewed (Resident 43). Findings include: Review of Resident 43's clinical record failed to reveal evidence that education regarding the COVID-19 vaccination was provided to Resident 43 or Resident 43's representative prior to Resident 43's representative declining the vaccination. Interview with the Nursing Home Administrator and Director of Nursing on February 3, 2023 at 1:00 p.m. failed to produce evidence that Resident 43 and/or their representative were provided educational material regarding the COVID-19 vaccination prior to Resident 43 and/or their representative declining the vaccination. 28 Pa. Code 201.18(a)(b)(1) Management

Based upon observation and resident and staff interviews, it was determined that the facility failed to protect resident rights regarding visitation. Findings include: Observation of signage at the facility entrance on January 18, 2022 at 9:30 a.m. revealed that the facility was denying visitation to residents due to a GI (gastrointestinal) virus. The signage further revealed that review of the visitation closing would be held on January 18, 2022. Observation of signage at the facility entrance on January 18, 2022 at 2:30 p.m. revealed that the closing of visitation would continue until January 20, 2022 at which time another review would be held. Observation of meals on January 18, January 19, and January 20, 2022 revealed all residents ate meals in their rooms with no residents being permitted to eat in any of the dining rooms in the facility. Interview with the Nursing Home Administrator during Entrance Conference on January 18, 2022 at 10:00 a.m. revealed that the facility had stopped visitation to residents on December 28, 2021 due to an unidentified GI virus. Review of the facility's Outbreak Case - Patient Line List revealed that one resident had symptoms of vomiting on December 27, 2021 and one resident had symptoms of vomiting on December 28, 2021. Further review of the Line List revealed one staff person had symptoms on December 27, 2021, one staff person had symptoms on December 30, 2021 and one staff person had symptoms on December 31, 2021. Further review of the Patient Line List revealed four specimens were sent to the state laboratory for testing. Review of a laboratory test result dated January 11, 2022 revealed one resident tested positive for norovirus (GI virus). The sample was obtained January 11, 2022 and resulted January 18, 2022. Interview with the Nursing Home Administrator on January 19, 2022 at 1:00 p.m. revealed that at the virus peak, six residents on one unit on the second floor of the facility had exhibited signs and symptoms of the virus. Interview with Resident 28 on January 19, 2022 at 12:23 p.m. revealed Resident 28 tearful related to the restriction of visitation. Further interview with Resident 28 revealed Resident R28 was to have a meeting with spouse, financial advisor and her son but that she was informed she would not be able to attend due to visitation restrictions. Resident 28 further revealed residents were restricted to their rooms and not allowed to visit with other residents on the same floor/unit/hallway, in the facility. Interview with Resident 36 on January 19, 2022 at 11:30 a.m. revealed Resident 36 was to be discharged to Personal Care on January 17, 2022. The interview further revealed that Resident 36 was told that return to Personal Care could not occur until the facility re-opened due to the virus. Resident 36's last covered day for Medicare was January 1, 2022. Interview with Resident 36 further revealed that Resident 36 never had the GI virus and all meals had to be consumed in resident rooms because no one was allowed to go to the dining room. Interview with Employee E3 on January 20, 2022 at 1:00 p.m. revealed Resident 36 was to have a home visit with therapy to Personal Care. The scheduled home visit did not occur between January 1, 2022 and January 20, 2022 due to concern for possible GI virus transmission. The interview further revealed that no employee or resident was permitted to enter and exit personal care community from December 28, 2021 until the time of the interview, therefore a home visit and discharge could not occur for Resident 36. Observation of signage at facility entrance on January 20, 2022 revealed that the facility was open to visitation as of January 20, 2022. Further review of the Line Listing report revealed that the last date that a resident had symptoms was January 12, 2022. The facility had been closed from December 28, 2021 to January 20, 2022 to visitation. The above information was conveyed to the Nursing Home Administrator on January 21, 2022 at approximately 1:00 p.m. 28 Pa. Code 201.29(a) Resident Rights

Based upon review of facility policy and procedure, observation and interview it was determined that the facility did not use transmission based precautions to protect residents from a virus that caused a facility-wide visitation closure for approximately one month. Findings include: Review of facility policy and procedure titled Infection Prevention and Control Program, revised June 4, 2021 revealed transmission-based precautions will be utilized, in addition to Standard Precautions, when the route of transmission is not completed interrupted using Standard Precautions alone. Observation of signage at the facility entrance on January 18, 2022 at 9:30 a.m. revealed that the facility was denying visitation to residents due to a GI (gastrointestinal) virus. The signage further revealed that review of the visitation closing would be held on January 18, 2022. Observation of signage at the facility entrance on January 18, 2022 at 2:30 p.m. revealed that the closing of visitation would continue until January 20, 2022 at which time another review would be held. Observation of meals on January 18, January 19 and January 20, 2022 revealed all residents ate meals in their rooms with no residents being permitted to eat in any of the dining rooms in the facility. Interview with the Nursing Home Administrator during Entrance Conference on January 18, 2022 at 10:00 a.m. revealed that the facility had stopped visitation to residents on December 28, 2021 due to an unidentified GI virus. Review of a laboratory test result dated January 11, 2022 revealed Resident 17 tested positive for norovirus (GI virus). The sample was obtained January 11, 2022 and resulted January 18, 2022. Observation of all nursing units in the facility failed to reveal evidence that transmission-based precautions were in use. Interview with Employee E4 on January 21, 2022 at 12:30 p.m. regarding Resident 17's care plan revealed that during the course of the GI outbreak only standard precautions were used. The interview further revealed that no transmission-based precautions (i.e. contact precautions) were used during the outbreak that caused the facility to undergo visitor and dining restrictions. The above information was conveyed to the Nursing Home Administrator on January 21, 2022 at approximately 1:00 p.m. The facility failed to use transmission-based precautions during a GI virus outbreak which resulted in a facility shut-down to visitation and dining services. 28 Pa. Code 201.18(b)(1) Management

Based on observations and review of the facility menu, it was determined that the facility failed to provide and serve food items listed on the posted menu for two of two units (1st and 2nd floors). Findings include: Observations of the lunch meal on (MONTH) 13, 2019, at 12:00 p.m. revealed staff were serving pot roast or crab cakes. Review of the POS [REDACTED]. Observations of the lunch meal on (MONTH) 14, 2019, at 12:05 p.m. revealed staff were serving turkey divan or cranberry chicken. Review of the POS [REDACTED]. Observations of the lunch meal on (MONTH) 15, 2019, at 12:09 p.m. revealed staff were serving hungarian goulash or shrimp stir fry. Review of the POS [REDACTED]. Interview with the Food Service Director on (MONTH) 15, 2019, at 12:11 p.m. confirmed that the posted menus were incorrect and were for a different week of the menu cyce. 28 Pa Code 201.18(b)(3) Management Previously cited 4/20/18

Based on review of facility policy and procedure and clinical record review, it was determined the facility failed to notify residents' physicians of changes in weight for two of nine residents reviewed (Resident #17 and Resident #43). Findings include: Review of facility policy and procedure titled Weight Monitoring Protocol, revised (MONTH) 2019 revealed Weight Changes - CNA (nursing assistant) to notify charge nurse of weight changes; weight loss or weight gain - 5 pounds in one month and weight change of 3 pounds in 1 month in resident weighing 99 pounds or less. If significant unplanned weight loss of five percent in one month or 10 percent in six months is found the following steps are taken: a) Nursing will reweigh the resident to check accuracy the next day but no more than 48 hours; b) If weight is accurate, notify the physician; c) Resident with significant weight changes will be weighed weekly for 4 weeks and referred for dietician monitoring. Review of Resident #17's [DIAGNOSES REDACTED]. Review of Resident #17's active plan of care revealed Resident #17 is at risk for compromised nutritional status related to disease processes and advanced age with interventions including monitor weights and notify physician of weight change as appropriate. Review of Resident #17's Weight List revealed that on (MONTH) 21, 2019 Resident #17's weight was 132.5 pounds. Further review of Resident #17's Weight List revealed that on (MONTH) 28, 2019 Resident #17's weight was 153.8 pounds indicating a 21.3 pound weight gain within seven days. Further review of Resident #17's Weight List revealed that a re-weight was obtained on (MONTH) 29, 2019 and Resident #17's weight was confirmed at 153 pounds. Review of Resident #17's clinical record revealed that the physician was no notified of the increase in weight until (MONTH) 21, 2019 which revealed (Resident) has 20.9 lb. weight gain since (MONTH) 21, 2019. (Resident) does not report SOB (shortness of breath) but fine crackles noted in lung bases, history pHTN (pulmonary hypertension - high blood pressure in the arteries in the lungs). Harsh murmur noted at mitral valve, no chest pain. +4 [MEDICAL CONDITION] (swelling with pitting) in bilateral (both sides) legs, redness noted on posterior legs from knee to ankle. (Resident) reports pain and numbness in b/l (bilateral) legs. +1 pulse in b/l feet. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 18, 2019 at approximately 2:00 p.m. confirmed that the facility failed to notify Resident #17's of Resident #17's 21.3 pound weight gain. Review of Resident #43's [DIAGNOSES REDACTED]. Review of Resident #43's Weight List revealed Resident #43's weight on (MONTH) 4, 2019 was 92.4 pounds. Further review of Resident #43's Weight List revealed Resident #43's weight on (MONTH) 9, 2019 was 86.6 pounds indicating a 5.8 pound weight loss, 6.28% in one month. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 18, 2019 at approximately 2:00 p.m. confirmed that the facility failed to notify Resident #43's physician of Resident #43's weight loss. 28 Pa. Code 211.5(f) Clinical Records Previously cited 4/20/18 28 Pa. Code 211.10(c) Resident Care Policies Previously cited 4/20/18 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 4/20/18

Based on resident interview, review of clinical record, documentation provided by the facility, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 21 residents reviewed. (Resident #44). Findings include: During a group interview on (MONTH) 14, 2019 at approximately 1:30 p.m. revealed Resident #44 felt he was mishandled by staff and complained of swelling on his left arm. Review of Resident #44's [DIAGNOSES REDACTED]. Review of Resident #44's Initial Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 18, 2019 revealed Resident #44's Brief Interview for Mental Status (BIMS) score of 7 which indicated moderate cognitive impairment. Review of Resident #44's clinical record revealed a nursing note dated (MONTH) 7, 2019, stating at bedtime left arm swelling noted. Area 24 cm x 12 cm from mid forearm to above elbow; red, warm, and fluid filled. Further review of the clinical record revealed a phsycian's order stating to have an ultrasound of the left arm performed to rule out [MEDICAL CONDITION] vs. hematoma (bruise). Review of facility investigation of injury of unknown origin revealed a start date of (MONTH) 7, 2019 and that additional follow-up information was to be completed within 24 hours of the discovered condition which included staff statements. Further review of the documentation revealed that one statement was not collected until (MONTH) 13, 2019. Interview with the Nursing Home Administrator on (MONTH) 19, 2019, at approximately 11:00 a.m. revealed that the staff interviews were not completed in a timely manner. The facility failed to completed a through investigation for a bruise and sweeling identified on Resident #44's left arm in a timely manner. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited: 4/20/2018 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited: 4/20/2018 28 Pa. Code 201.29(a)(d) Resident Rights Previously cited: 4/20/2018 28 Pa. Code 211.5(f) Clinical Records Previously cited: 4/20/2018

Based on clinical record review, it was determined that the facility failed to ensure that changes in residents' weight status were supervised by a physician for two of nine residents reviewed (Resident #17 and Resident #43). Findings include: Review of Resident #17's [DIAGNOSES REDACTED]. Review of Resident #17's active plan of care revealed Resident #17 is at risk for compromised nutritional status related to disease processes and advanced age with interventions including monitor weights and notify physician of weight change as appropriate. Review of Resident #17's Weight List revealed that on (MONTH) 21, 2019 Resident #17's weight was 132.5 pounds. Further review of Resident #17's Weight List revealed that on (MONTH) 28, 2019 Resident #17's weight was 153.8 pounds indicating a 21.3 pound weight gain within seven days. Further review of Resident #17's Weight List revealed that a re-weight was obtained on (MONTH) 29, 2019 and Resident #17's weight was confirmed at 153 pounds. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 18, 2019 at approximately 2:00 p.m. confirmed that Resident #17's physician failed to timely address and supervise Resident #17's 21.3 pound weight gain. Review of Resident #43's [DIAGNOSES REDACTED]. Review of Resident #43's Weight List revealed Resident #43's weight on (MONTH) 4, 2019 was 92.4 pounds. Further review of Resident #43's Weight List revealed Resident #43's weight on (MONTH) 9, 2019 was 86.6 pounds indicating a 5.8 pound weight loss, 6.28% in one month. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 18, 2019 at approximately 2:00 p.m. confirmed that Resident #43's physician failed to supervise Resident #43's weight loss. 28 Pa. Code 211.5(f) Clinical Records Previously cited 4/20/18 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 4/20/18

Based upon clinical record review, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of five residents reviewed (Resident #69). Findings include: Review of Resident #69's clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident #69's physician's orders [REDACTED]. Review of Resident #69's Initial MDS (Minimum Data Set- assessment of resident care needs) assessment dated (MONTH) 26, 2019, revealed a BIMS (Brief Interview of Mental Status) of 00 which indicated severe cognitive impairment. Review of Resident #69's (MONTH) 2019 Medication Administration Record [REDACTED]. There was no further documentation to explain why both medications were administered simultaneously. Further review of Resident #69's (MONTH) 2019 MAR indicated [REDACTED].m There was no further documentation to explain why both medications were administered simultaneously. An interview was conducted with the Nursing Home Administrator on (MONTH) 18, 2019 at approximately 11:45 a.m. revealed that there was no further documentation stating why these two medications were administered at the same time. 42 CFR §483.45(d) Unnecessary Drugs Previously cited 4/20/2018 28 Pa. Code 211.5(f) Clinical Records Previously cited 4/20/2018 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 4/20/2018

Based on observations and review of facility menu, it was determined that the facility failed to provide and serve food items listed on the menu for one of two units. (Memory Support) Findings include: Review of facility menu, revealed that on week 1 residents were to be served Herb Baked Chicken Leg on Wednesday (MONTH) 18, (YEAR) for lunch. Observations of nursing staff taking residents meal orders on (MONTH) 18, (YEAR) at 11:45 a.m. revealed that the residents in the Memory Support unit were told that they would not be receiving a chicken leg even though that was on the menu a chicken breast would be served instead. An interview with dieatry staff, Employee E4 on (MONTH) 18, (YEAR), at approximately 12:45 p.m. revealed that often times the menu did not match what the resident were served. Interview with Director Dining Services, Employee E5 at approximately 10:20 a.m. on (MONTH) 19, (YEAR), indicated that the menus posted were facility wide and the Memory Support residents were not served a chicken leg historically, but rather a chicken breast (unless specifically ordered by the resident and or family) due to choking concerns. 28 Pa Code 201.18(b)(3) Management Prevously cited 3/31/17 28 Pa. Code 211.6 (a) Dietary services

Based on observation, family and staff interviews, it was determined that the facility failed to provide sufficient dining services staff to ensure that resident meals were served timely in one of two facility dining rooms. (Memory Support unit) Findings include: An interview conducted with Resident #1's family on (MONTH) 17, (YEAR) at approximately 5:05 p.m revealed that meals were taking a long time to be served. Observations conducted of the lunch meal of (MONTH) 18, (YEAR) in the Memory Support unit revealed that Resident #23 was brought to the dining ara at approximately 11:45 a.m. and service began approximately 11:50 a.m. One dietary aide, Employee E4 was observed plating the lunch meal. Further observations of the noon meal revealed at approximately 12:24 p.m. facility staff waiting for orders for the resident's (approximately 13 residents) meals to be completed. The last meal was served to Resident #23 at approximately 12:45 p.m. (a one hour wait). Resident #55 was offered vanilla or chocolate ice cream at 12:30 p.m. An interview conducted with Resident #55 at 12:42 p.m. revealed that he had not received his ice cream. Further observations of the lunch meal revealed that the resident was not served ice cream until 12:45 p.m, 15 minutes after it was offered to the resident. An interview was conducted with dietary staff, Employee E4 on (MONTH) 19, (YEAR) at approximately 9:27 a.m. revealed that usually there were two dietary aides for each meal to complete the plating of the meals. Employee E4 further stated that they have been running a little short recently. During an interview with Nursing Home Administrator (NHA) on (MONTH) 19, (YEAR), at 1:00 p.m. NHA revealed the time in which the residents wait to be served should not be an hour. 28 Pa Code 211.6 (c) Dietary services. 28 Pa. Code 201.18(e)(6) Management

Based on review of clinical record review and documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 21 residents reviewed. (Resident #57). Findings include: Review of Resident #57's [DIAGNOSES REDACTED].). Review of Resident #57's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 12, (YEAR) revealed Resident #57's Brief Interview for Mental Status (BIMS) score of 9 which indicated cognitive impairment. Further reviewof Resident #57's MDS revealed that Resident #57 usually understood and section B0800 title Ability ot Understand others was coded as usually understands. Review of facility investigation of injury of unknown origin completed on (MONTH) 9, (YEAR) at 8:30 a.m. noted that an area of ecchymosis (bruise) measuring 3.0 x 1.0 was identified under the resident's left eye. Further review of facility's investigation revealed that no interviews were conducted with staff who provided care to Resident #57 to confirm the cause/source of the resident' left eye bruise. Interview with the Nursing Home Administrator on (MONTH) 19, (YEAR), at approximately 11:00 a.m. revealed that staff members were not interviewed due to a statement by Resident #57's that she was rubbing her eye. The facility failed to completed a through investigation for a bruise identified on Resident #57's left eye. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited: 3/31/2017 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited: 3/31/2017 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records

Based on clinical record review and staff interview, revealed that the facility failed to ensure that pharmacist recommendations of medication changes were reviewed by the attending physician timely for two of 21 residents reviewed. (Resident #91 and Resident #98). Finds include: Review of Resident #91's clinical record revealed resident was admitted to facility on (MONTH) 26, (YEAR) with the following [DIAGNOSES REDACTED]. Review of Resident #91's clinical record revealed a pharmacist's recommendation addressed to attending physician dated (MONTH) 22, (YEAR) indicating Consider changing the arthritis pain relief 650 mg (milligrams) with administration instructions of 1 tablet at bedtime to [MEDICATION NAME] 325 mg to be given as 2 tablets at bedtime. Further review of consultant pharmacist communication to physician revealed that physician reviewed, signed, recommended changed on (MONTH) 4, (YEAR) which was 14 days after pharmacist initiated recommendation. Review of Resident #98's clinical record revealed resident was admitted on (MONTH) 16, (YEAR). Review of the pharmacist medications review dated (MONTH) 22, (YEAR) with the following recommendation; could [MEDICATION NAME] (anti anxiety medication) PRN (as needed) dose be decreased? Further review of consultant pharmacist review revealed that the physician reviewed, approved, and signed dosage reduction recommendation on (MONTH) 5, (YEAR), 13 days from original recommendation by consultant pharmacist. Interview with licensed staff, Employee E3, licensed staff, on (MONTH) 20, (YEAR) at approximately 12:01 p.m. confirmed that physician failed to respond timely to medication changes recommended by the consultant pharmacist. 28 Pa. Code 211.5(f) Clinical records Previously Cited 3/31/17 28 Pa. Code 211.10(c) Resident care policies Previously cited 3/31/17 28 Pa. Code 211.12(c) Nursing services Previously Cited 3/31/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously Cited 3/31/17

Based on clinical record review, it was determined that the facility failed to ensure that physician's orders were followed and/or clarified regarding administration of pain medication and failed to accurately assess pain levels prior to the administration of pain medication for three out of 21 residents reviewed ( Resident # 31, Resident #96, and Resident # 103). Findings include: Review of Resident #31's clinical record revealed [DIAGNOSES REDACTED]. Review of physician's orders for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed an order for [REDACTED].#3 (narcotic pain medication used to treat pain) tablet 300-30mg, give one tablet by mouth every eight hours as needed for pain. Review of Resident # 31's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Resident #31's Medication Administration Record [REDACTED]. Further review of Resident #31 (MONTH) (YEAR) MAR indicated [REDACTED] The facility failed to obtained clarification from the resident's attending physcian of the severity of the resident's level of pain for the appropriate administration of the as needed pain medications [MEDICATION NAME] 325 milligrams and [MEDICATION NAME]-[MEDICATION NAME] #3. Review of Resident #96's clinical record revealed [DIAGNOSES REDACTED]. Review of physician's orders for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed an order for [REDACTED]. The facilty failed to obtained clarification from the resident's attending physcian of the severity of the resident's level of pain for the appropriate administration of the as needed pain medications [MEDICATION NAME] 50 mg and [MEDICATION NAME] 325 mg. Review of Resident #96's Medication Administration Record [REDACTED]. Review of Resident #103's clinical record revealed a [DIAGNOSES REDACTED]. Review of physician's orders for (MONTH) (YEAR), and (MONTH) (YEAR), revealed an order for [REDACTED]. of pain for the appropriate administration of the as needed pain medications Tylenol 325mg and [MEDICATION NAME] HCL 5mg. Review of Resident #103's Medication Administration Record [REDACTED].m 28 Pa Code 211.10(c) Resident care policies Previously Cited 3/31/17 28 Pa Code 21.12(d)(1)(5) Nursing services Previously Cited 3/31/17

Based on observation, review of clinical record, review of facility policies and procedure and staff interview it was determined that the facility failed to ensure care and services were in place for one resident with pressure ulcers of 20 residents (Resident E7) Findings include: Review of facility's policy titled " Pressure Ulcers " revised March 17, 2011 revealed its policy to continue to assess a resident for maintenance of good skin integrity and its goal is to prevent pressure ulcers from occurring. It revealed skin assessment would be done with the weekly bath, also that the dietician would be notified. It included a lower extremity assessment and as part of the treatment, to identify risk factors, areas of the body at risk, bowel and bladder assessment and pain assessment. Review of the Impaired Skin policy #66 revealed for lower extremity wound, location included medial malleolus (inner aspect of ankle) and under heel. Review of the facility ' s policy for wound care protocol revised May 15, 2014 revealed the dietician would be notified for nutritional assessment and follow up. Review of Resident E7 ' s Admission Minimum Data Set (MDS - an assessment of resident care needs and status) dated January 28, 2014 revealed that the resident was alert and oriented had [DIAGNOSES REDACTED]. Review of Resident E7 ' s nursing notes dated May 19, 2014 revealed that the resident was readmitted into the facility from the hospital. Readmission orders [REDACTED]. Review of the resident ' s Braden Scale ( a tool for predicting Pressure Sore Risk ) dated May 19 and June 13, 2014 revealed scores of 15 and 16 respectively depicting that the resident was at mild risk for developing pressure ulcer. Nurses notes dated May 27, 2014 at 5:15 a.m. stated Left knee brace checked frequently throughout the shift. Nurses noted dated May 27, 2014 at 9:00 a.m. stated open are left lateral ankle , 3 centimeters x 3 centimeters. Area cleansed. Physician order/fax communication dated May 27, 2014 stated please assess skin left leg 3 cm x 3 cm open area left lateral ankle. Do you agree with my findings of a stage II pressure area related to left knee immobilizer? occupational therapy in to assess brace. Order to cleanse area with normal saline, no sting to periwound (surrounding tissue) with Cuticern [MEDICATION NAME] for protection. To change every Tuesday and Friday and as needed until healed. Review of Resident E7 ' s Orthopedic consult dated May 27, 2014 revealed that the resident had been troubled with some hamstrings spasms which caused his knee to go into flexion. The consult revealed that the resident was getting some skin breakdown in the left ankle area where the brace was digging into the resident. It revealed that the knee brace was not needed anymore as it was doing more harm than good with skin breakdown. Review of nursing notes revealed that the resident was transferred to the hospital on May 28, 2014 and readmitted into the facility on [DATE]. Review of nursing assessment for skin and body dated June 1, 2014 revealed that the resident had a cast in the left lower leg. There was no documentation to indicate a follow up of the left ankle pressure area found May 27, 2014 before transfer to the hospital and upon resident's readmission into the facility on [DATE]. Review of therapy notes dated June 2, 2014 revealed that the resident had a left lower plaster cast with a left lateral malleoli (inner aspect of ankle) CUT OUT secondary to skin issues. Review of Resident E7 ' s Pressure Ulcer documentation sheet revealed that there was no documentation of the left ankle wound from May 27, 2014 upon discovery until June 16, 2014. Pressure ulcer documentation dated June 16, 2014 revealed that the resident had an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (separation of dead tissue from living tissue, and/or eschar (dry scab, tan brown or black in wound bed). The ankle wound measured 1.5 centimeters X 0.2 centimeters 100 % slough and unknown depth. The date of onset was listed as June 16, 2014. There was no documentation to indicate if the left ankle wound with a start date of June 16, 2014 was the same left ankle wound with a start date of May 27, 2014. There was also no documentation that any treatment was applied to the area until June 17, 2014 (The Resident's cast was removed on June 13, 2014.) Further review of physician's order [REDACTED]. Nursing notes dated June 3, 2014 revealed that the resident had complained of severe sharp left heel pain and a fax was sent to the orthopedic doctor. Nursing notes dated June 4, 2014 revealed resident reported constant and sharp left heel pain. Review of physician fax documentation revealed that the fax was signed on June 6, 2014 by orthopedic specialist and no comments were made. However the resident was seen by the orthopedic doctor on June 5, 2014. Review of the office visit form revealed reason for visit was constant, severe, sharp pain on the resident ' s left heel however the orthopedic documentation indicated that the left ankle wound was healing well and cast would be removed in two weeks and no note addressing constant, severe, sharp pain on the resident ' s left heel. Review of nursing notes dated June 7, 2014 revealed left leg pain controlled with as needed pain medications. Nursing notes dated June 8, 2014 revealed Resident E7 reports 10 out of 10 (highest pain level) left heel pain. Nursing notes dated June 9, 2014 at 7:45 a.m. revealed resident medicated for left heel discomfort 9 out of 10 and physician notified by fax of left heel discomfort and increased confusion. There was no documentation to indicate Resident E7 ' s attending physician was informed of the constant severe sharp pain indicated above until June 9, 2014. Nursing notes dated June 10, 2014 revealed that the resident was seen by the physician. Nursing notes dated June 13, 2014 revealed that the resident complained of pain 9 out of 10 at the back of the left leg where the cast edge meets the leg and underneath the cast and also that the as needed [MEDICATION NAME] Immediate Release (narcotic pain relief) was not effective. Physician/ Fax communication dated June 13, 2014 revealed that the resident complained of pain 9 out of 10 at the back of the left leg as needed [MEDICATION NAME] immediate release was not effective and [MEDICATION NAME] (narcotic pain relief) was also not effective. A new order was obtained to contact Ortho for an appointment today (6/13/2014) for severe pain. Physical Therapy notes dated June 13, 2014 revealed that the knee brace was removed and not reapplied. The note stated the resident's left heel had a sore which had a dark scabbed area and that nursing was notified. Review of nursing notes dated June 13, 2014 at 10 p.m. revealed that the resident had a 3 centimeters x3 centimeters dark discoloration in the left heel. Review of treatment administration record (TAR) revealed orders dated June 14, 2014 for No sting to both heels. Review of Pressure Ulcer documentation dated June 16, 2014 revealed that the resident had an unstageable left heel pressure ulcer date of onset June 13,2014 that measured 5 centimeters by 5.8 centimeters, 100 % necrotic eschar area (dead tissue) at the bottom of the left heel and very painful. Review of dietary documentation dated June 2, 2014 revealed that the resident had no pressure areas noted and failed to include skin issues that the resident had in the ankle areas. Protein requirements were documented as 58 to 73 grams per kilogram. Review of dietary notes dated June 10, 2014 stated left elbow open (questionable stage 3), increased nutrient needs related to increased needs for healing. Protein needs was increased to 93 grams per kilogram. Interview with licensed nurse, Employee E7 during the initial tour of the facility on February 23, 2015 at approximately 1:15 p.m. revealed that the left heel wound was healed. Observation of Resident E7's heel on February 26, 2015 at 11:35 a.m. revealed that the resident's left heel had a dark blackish area, the employee indicated that the dark blackish area was found yesterday (February 26, 2015). Interview with the Director of Nursing and licensed nurse, Employee E4 on February 25, 2014 at approximately 4 p.m. confirmed that there was no wound documentation available for the wound in the left lateral ankle between June 1, 2014 and June 16, 2014 when the resident was readmitted from the hospital. Interview with the Director of Nursing and Employee E4 on February 26, 2014 at 9:20 a.m. revealed no reason why the resident ' s primary care physician was not notified about Resident E7 ' a heel pain until June 10, 2014 and could not explain how the ankle wound and the resident ' s heel pain were not addressed by the Ortho specialist during fax communication and visit on June 3 and June 5, 2014. The facility failed to ensure adequate and timely care and services were in place for Resident E7 with pressure ulcers resulting in actual harm to Resident E7. 28 Pa. Code 201.18(a)(b)(1)(3) Management. 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/27/2014 28 Pa. Code: 211.10(c)(d) Resident care policies Previously cited 3/27/2014 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 3/27/2014

Based on review of facility policy, review of clinical record and staff interviews, it was determined that the facility failed to provide timely emergency treatment and physician notification when physician unavailable in order to provide one of 21 residents with timely needed care and services resulting in delayed transfer to the hospital for one resident who sustained actual harm and a [MEDICAL CONDITION] (Resident A15). Findings include: Facility policy entitled, "Change in a Resident's Medical Condition or Status" revised on December 22, 2008, indicated the facility shall promptly notify the resident, attending physician, and power of attorney/responsible party of changes in resident's medical condition and/or status. The nurse will notify the resident's attending physician when: The resident is involved in any accident or incident which results in an injury, which has the potential of requiring physician interventions. Under "physician notification guidelines" indicated that falls consisting of hip pain should be reported immediately. The guidelines refer to fractures with any suspected serious injury (e.g. fracture), any hip pain. Fractures with obvious/deformity obtain physician order [REDACTED]. Inform physician: Do Not wait for facility in-house x-ray department. Facility policy entitled, "Fall Management Program" revised on April 5, 2010, indicated a Fall Management Program is in place for ongoing resident safety. The policy included, under #5. Post fall investigation/guidelines/management: Assess resident and give appropriate emergent care and initiate interventions and review pain assessment. Review of Resident A15's physician's orders [REDACTED]. Review of the nurses' notes dated March 10, 2014 at 8:45 a.m, indicated Resident A15 was found on the floor in front of toilet 1.5 cm x 1/5 cm skin tear right elbow. POA and Physician notified. Nurses note dated March 10, 2014 at 10:00 a.m. stated " Resident reporting Right hip and upper thigh discomfort. Right leg is straight with no external rotation. can bend knee when asked withour discomfort. Physician updated". Review of facility documentation dated March 12, 2014 related that on March 10, 2014 at 10:00 a.m. fax was sent to physician. At 11:30-11:45 a.m. no response from physician, called and spoke to secretary to inform physician resident reporting pain right hip. Family visiting. After lunch, had not received any response from physician. Voice mail left (March 10, 2014) Review of physician orders [REDACTED]. Review of the facility's timeline documentation of Resident A15's March 10, 2014 incident related that Resident A15 complained of pain in right hip and upper thigh on March 10, 2014 at 09:48 and two tylenol were administered per physican orders. Timeline documentation at 1:00 p.m. stated resident observed resting comfortably in bed, no statements of pain. Timeline documentation at 1:20 p.m. stated tylenol administered. Timeline documentation at 7:30 p.m. stated resident sleeping comfortable. Timeline documentation at 7:48 p.m. stated tylenol administered by med nurse. Review of the Medication Administration Record [REDACTED].m and the pain scale was 7 indicating pain. Interview with facility administration on March 27, 2014 indicated that the 6 tablets of [MEDICATION NAME] listed as given March 10, 2014 were administered throughtout the day and not all together on March 10, 2014. Facility documentation indicated that on March 10, 2014 resdent's physician was notified by fax of resident's complaint of right hip pain at 9:48 a.m. Facility documentation dated March 11, 2014 related that an order was received for right hip x-ray at 3:15 p.m on March 10, 2014. Nurses notes dated March 10, 2014 at 3:35 p.m. stated x-ray called to do a right hip xray. Nurses notes at 8:45 p.m. stated x-ray here Right hip x-ray being obtained. Nurses notes at 10:00 p.m. stated result of right hip x-ray called to physician. Nurses' noted at 10:p.m. stated orders received to send resident to hospital. Nurses' notes dated March 10, 2015 at 10:50 p.m. stated resident sent to the hospital. The facility failed to ensure that Resident A15 was timely transferred to the hospital post complaint of hip pain after a fall on March 10, 2014. The resident first complained of right hip pain March 10, 2014 at 10:00 a.m. and was transferred to the hospital on March 10, 2014 at 10:50 p.m. (12 hours 50 minutes after first complaining of pain). The facililty failed to follow their policy relating to change in resident condition when a change in condition had the potential for physician intervention that included any suspected serious injury, any hip pain. The facility failed to obtain an order to sent resident to the ER as soon as posible. Do not wait for facility in-house x-ray. The facility failed to ensure that messages left for the physician were responded to by the physician. The facility was notified on March 11, 2014 at 3:30 a.m. was admitted to Lancaster General Hospital with a [DIAGNOSES REDACTED]. The facility failed to provide appropriate treatment to a resident with a [DIAGNOSES REDACTED]. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.5 (f) Clinical records. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (c) Nursing services. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 4/11/13